Fall 2021 - Volume 25 Number 4

TABLE OF CONTENTS

ORIGINAL RESEARCH ARTICLES

An Expanded Role for the Medical Assistant in Primary Care: Evaluating a Training Pilot.

Marlaine Figueroa Gray, PhD; Katie Coleman, MSPH; Callie Walsh-Bailey, MPH; Samantha Girard, PhD, RN; Paula Lozano, MD, MPH

A predominantly virtual 12-week program built the skills and confidence of medical assistants in proactive population management; health coaching; and collaboration and communication. This program shows the promise of a virtual approach that to training that identifies, trains, and recognizes high-potential medical assistants.

Life Expectancy Trends Among Integrated Health Care System Enrollees, 2014–2017

Anthony Finch, MS; M Cabell Jonas, PhD; Kevin Rubenstein; Eric Watson, BA; Sundeep Basra, MPH; Jose Martinez, BS; Michael Horberg, MD, MAS, FACP

From 2014 to 2017, the overall population of Kaiser Permanente Mid-Atlantic States had life expectancy at birth varying between 84.6 and 85.2 years compared with the CDC-reported national average of 78.6 to 78.9 years. While the CDC dataset reported shows a 3.5- to 3.7-year life expectancy gap between non-Hispanic White and Black populations, in this population, the gap was significantly smaller.

Comprehensive, Multimodal, Interdisciplinary Approach to Chronic Non-Cancer Pain Management in a Family Medicine Clinic: A Retrospective Cohort Review.

Edward Kwon, MD; Christopher Stange, MD; Katy Reichlin, DO; Hamilton Vernon, DO; Akira Miyanari, MD; Elizabeth Bier, DO; Hind Beydoun, PhD, MPH; Virginia Kalish, MD

The complexity of chronic non-cancer pain in the setting of regulatory efforts to curb opioid usage presents a novel challenge for the medical community, and much of this burden falls on primary care clinics. The authors retrospectively quantified the reduction of opioid usage by patients in a multimodal, interdisciplinary, primary care clinic for chronic pain.

Comanagement of Rashes by Primary Care Providers and Dermatologists: A Retrospective Study.

Sangeeta Marwaha, MD; Jennifer R Dusendang, MPH; Stacey E Alexeeff, PhD; Eileen Crowley, MD; Michael Haiman, MD; Ngoc Pham, MD; Melanie J Tuerk, MD; Danny Wudka, MIDS; Michael Hartmann, MS, MA; Lisa J Herrinton, PhD

The demand for managing skin disease is high, and dermatologists are in short supply. To better understand how rashes and other skin conditions are comanaged by primary care providers and dermatologists, the authors estimated the frequency with which primary care providers sought consultation with or referral to dermatology and the proportion of patients who had a follow-up dermatology office visit in the following 90 days.

Attitudes and Knowledge Regarding Health-Promoting Behavior in Families Facing Food Insecurity.

Andrea Nederveld, MD, MPH; Phoutdavone Phimphasone-Brady, PhD; Bridget Marshall, DNP; Elizabeth Bayliss, MD, MSPH

Food insecurity is common in families with young children. People experiencing food insecurity have worse health outcomes related to behaviors (such as obesity and diabetes management) than people who are food secure. This study explores strategies that parents on limited incomes use to feed their children, their understanding of nutrition for their children, and the social factors contributing to or alleviating food insecurity.

System-Level Variation in Multiple Sclerosis Disease-Modifying Therapy Utilization: Findings From the Multiple Sclerosis Continuous Quality Improvement Research Collaborative.

Laetitia A N'Dri, PharmD; Dexter D Waters, MSPH; Karen Walsh, DHSc, MS, MBA; Falguni Mehta, MS, MBA; Brant J Oliver, PhD, MS, MPH, APRN-BC for the MS-CQI Investigators

This study contributes initial evidence concerning system-level variation in the utilization of disease-modifying therapies in people with multiple sclerosis. The results suggest a lack of standardization in the management of disease-modifying therapies. Continued research and improvement efforts targeting system-level performance could improve outcomes for people with multiple sclerosis.

Using Trauma-Informed Care in Practice: Evaluation of Internal Medicine Resident Training and Factors Affecting Clinical Use.

Binny Chokshi, MD, MEd; Ellen Goldman, EdD

Trauma-informed care (TIC) acknowledges that childhood traumas can profoundly affect health outcomes, and it aims to creates a safe, nurturing medical environment. TIC curricula in graduate medical education are limited, and assessments of their application in practice are lacking.

Factors Influencing Patient Satisfaction With Care and Surgical Outcomes for Total Hip and Knee Replacement.

Margaret C Wang, PhD, MPH; Priscilla H Chan, MS; Elizabeth W Paxton, MA, PhD; Jim Bellows, PhD; Kate Koplan, MD, MPH; Violeta Rabrenovich, MHA; Jeff Convissar, MD; Nithin C Reddy, MD; Christopher D Grimsrud, MD, PhD; Ronald A Navarro, MD

Patient-centered quality improvement in total joint replacement care requires thinking of care across the entire episode, including before and after the hospital stay for surgery, in addition to perioperative care. The actionable factors identified from this study can be incorporated into total joint replacement care to improve patient satisfaction with overall care and surgical results.

Rates of Acute Myocardial Infarction During the COVID-19 Pandemic.

Matthew T Mefford, PhD; Jaejin An, PhD; Nigel Gupta, MD; Teresa N Harrison, SM; Steven J Jacobsen, MD, PhD; Ming-Sum Lee, MD; Paul Muntner, PhD; Chileshe Nkonde-Price, MD; Lei Qian, PhD; Kristi Reynolds, PhD, MPH

Early in the pandemic, stay-at-home orders and the fear of acquiring COVID-19 may have led to an avoidance of care for medical emergencies, including acute myocardial infarction (AMI). The authors evaluated whether a decline in rates of AMI occurred during the COVID-19 stay-at-home orders.

Psychological Predictors of Weight Loss Based on Participants' Predispositions: Obesity Treatment Implications.

James J Annesi, PhD, FAAHB, FTOS, FAPA

Treatments for obesity focused on improving self-regulation, self-efficacy, and mood have demonstrated promise for maintaining weight loss, but they could be improved if tailored to subjects' psychological predispositions.

Oral Health Care: A Missing Pillar of Total Health Care?

Nancy P Gordon, ScD; David M Mosen, PhD, MPH; Matthew P Banegas, PhD, MPH

Oral health is an important component of overall health, and preventive dental care is essential for maintaining good oral health. However, many patients face significant barriers to preventive dental care. We examined prevalence of, and factors associated with, no recent preventive dental care in an adult health plan population.

Outcomes of a Medically Supervised Fasting Module on Healthy Females in a Controlled Residential Environment: A Brief Report.

Dhananjay Arankalle, BNYS, MPH; Gulab Rai Tewani, BNYS; Pradeep MK Nair, BNYS, MSc; Jon Wardle, MPH, PhD

Numerous reports are available on the beneficial effects of fasting on various disease conditions. Despite mounting evidence on the benefits of fasting, little is known about its physiological effects in humans as most of the studies on physiological effects are done in animals.

Comparison of a Kidney Replacement Therapy Risk Score Developed in Kaiser Permanente Northwest vs Estimated Glomerular Filtration Rate in Advanced Chronic Kidney Disease Using Decision Curve Analysis.

Ken J Park, MD; Jose G Benuzillo, MA, MS; Erin Keast, MPH; Micah L Thorp, MPH, DO; David M Mosen, PhD; Eric S Johnson, PhD

The use of kidney replacement therapy in the prediction models guiding arteriovenous fistula referrals for advanced chronic kidney disease is unknown. We aimed to compare a hypothetical approach using a kidney replacement therapy prediction model developed in Kaiser Permanente Northwest with the estimated glomerular filtration rate for arteriovenous fistula referrals.

REVIEW ARTICLES

Robotic Versus Laparoscopic Surgery for Rectal Cancer: A Comprehensive Review of Oncological Outcomes.

Jessica Lam, MD; Michael S Tam, MD; R. Luke Retting, MD; Elisabeth C McLemore, MD

The treatment of rectal cancer is complex and involves specialized multidisciplinary care, though the tenet is still rooted in a high-quality total mesorectal excision. The robotic platform is one of many tools in the arsenal to assist with dissection in the low pelvis. This article is a comparison of oncologic outcomes for robotic versus laparoscopic rectal cancer resection, with a particular focus on total mesorectal excision.

Practical Management of New-Onset Urticaria and Angioedema Presenting in Primary Care, Urgent Care, and the Emergency Department.

Eric Macy, MD, MS, FAAAAI

A new episode of urticaria (hives) and/or angioedema can be an anxiety-inducing event for patients as well as physicians seeing them in primary care, urgent care, or the emergency department. These episodes are easy to manage and virtually never life-threatening. Acute idiopathic urticaria is treated with high dose, nonsedating antihistamines, acute avoidance of alcohol and nonsteroidal anti-inflammatory drugs, and time.

CASE REPORTS

Phrenic Nerve Palsy Following Radiation Therapy for Patient With Breast Cancer.

Akhil Sharma, DO; Fazal Raziq, MD; Tyler Kemnic, DO; Rohan Prasad, DO

Radiotherapy used after breast-conserving surgery has been shown to decrease local recurrence while minimizing side effects. Peripheral neuropathy remains a common and well known complication of radiotherapy for breast cancer but it is rarely associated with phrenic nerve palsy after treatment. The authors present the case of a 66-year-old female with the first reported incidence of phrenic nerve palsy due to radiotherapy for breast cancer.

Stepwise Treatment With Plant-Based Diet and Medication for Patient With Mild Ulcerative Colitis.

Mitsuro Chiba, MD, PhD; Tsuyotoshi Tsuji, MD, PhD; Hideo Ohno, MD; Masafumi Komatsu, MD, PhD

Inflammatory bowel disease is a lifestyle disease mainly mediated by a westernized diet. A plant-based diet to counter the westernized diet can induce remission without medication in a subset of mild cases of ulcerative colitis. In this case report, the authors describe how medication can be provided when induction of remission is not achieved solely with the diet.

Pleuroperitoneal Hernia in an Adult Patient.

Mario R Rodríguez, MD; Juan S González, MD; Karen L Alfonso, MD; Paula A Becerra, MD; María C Gaviria, MD; Andés Felipe Herrera Ortiz, MD

Pleuroperitoneal hernia symptoms in adults most commonly affect the gastrointestinal and respiratory tracts. Diagnosis is performed by computed tomography or magnetic resonance imaging, in which a diaphragmatic defect can be seen. Treatment is based on surgical repair of the diaphragmatic defect, and the surgical approach chosen may vary according to the surgeon's expertise.

Rare Cardiac Papillary Fibroelastoma: Right Atrial, Non-Valvular, Large, Symptomatic With Pulmonary Embolism.

Rohan M Prasad, DO; Abdul-Fatawu Osman, MD; Christopher C Garces, MD; Robert Gumbita, MD; Ahmed Elshafie, MD; Pranay Pandrangi, MD; Michael Kehdi, MD

Primary cardiac tumors are rarely seen in the general population and only a subset are classified as cardiac papillary fibroelastoma. A 59-year-old female who presented with unresponsiveness and cardiac arrest required four rounds of cardiopulmonary resuscitation and intubation. Laboratory investigations showed uncompensated respiratory acidosis, hyperkalemia, and elevated troponins. A chest computed tomography angiogram illustrated an acute right pulmonary embolism and a right atrial filling defect.

Successful Use of Glycoprotein IIb/IIIa Inhibitor Involving Severely Ill COVID-19 Patient.

Patrick Joseph Merrill, MD, FACP; R Mark Bradburne, MD, FACCP

This case report shares a successful outcome involving a patient with severe COVID-19 viral pneumonia utilizing a novel therapeutic approach with the glycoprotein IIb/IIIa inhibitor eptifibatide.

COMMENTARIES

Reframing the Conversation Around Physician Burnout and Moral Injury: "We're Not Suffering From a Yoga Deficiency."

Sneha Mantri, MD, MS; Karen Jooste, MD, MPH; Jennifer Lawson, MD; Brian Quaranta, MD, MA; John Vaughn, MD

The conceptual model of burnout is failed work–life balance, wherein increasing administrative burdens or systemic policies chip away at physician resilience. The recommended treatment is the rest cure: detach from clinical duties, take a vacation, refresh, and reset. Yet despite an explosion of lunchtime yoga classes and mindfulness meditation apps, burnout continues to worsen across all medical specialties.

Open Access Fees: A Barrier to Scholarly Activity Among Neurology Trainees.

Keng Lam, MD; Annette Langer-Gould, MD, PhD

The open access publishing model provides readers of all backgrounds access to articles free of charge. To cover the costs of open access, many journals now charge substantial article processing fees. This has inadvertently created yet another barrier for trainees to engage in scholarly activity. The authors describe the issue, review the literature, and provide suggestions for addressing this barrier, with a focus on the neurology specialty.

Challenges in Managing Isolated Subsegmental Pulmonary Embolism.

David R Vinson, MD; Dayna J Isaacs, MD, MPH; Etsehiwot Taye, MD; Mahesh J Balasubramanian, MD

This commentary explores the critical elements in the management of adults with isolated subsegmental pulmonary embolism. A healthy 47-year-old woman was diagnosed by her primary care physician with acute subsegmental pulmonary embolism and referred to the emergency department for definitive care.

Low-Tech High-Value(s) Care: No Patient Left Behind.

Maria Alcocer Alkureishi, MD, FAAP; Wei Wei Lee, MD, MPH; Gena Lenti, MD; Zi-Yi Choo, BS; Jonah Benning-Shorb, BS; Rachel Grob, PhD; Martha E Gaines, JD, LLM; Richard Frankel, PhD, FACH

From a quality and cost perspective, the lack of visual cues during telephone consultations can lead to inferior care in some scenarios. New data suggests that the telephone can be equally as effective as video in achieving visit resolution for certain common conditions such as eye infections, skin conditions, and allergies. Does high-tech always mean high value and if not, why is that, and why does it matter?

Retraction Notice

Erratum

TABLE OF CONTENTS

ORIGINAL RESEARCH ARTICLES

1 An Expanded Role for the Medical Assistant in Primary Care: Evaluating a Training Pilot. Marlaine Figueroa Gray, PhD; Katie Coleman, MSPH; Callie Walsh-Bailey, MPH; Samantha Girard, PhD, RN; Paula Lozano, MD, MPH

A predominantly virtual 12-week program built the skills and confidence of medical assistants in proactive population management; health coaching; and collaboration and communication. This program shows the promise of a virtual approach that to training that identifies, trains, and recognizes high-potential medical assistants.

10 Life Expectancy Trends Among Integrated Health Care System Enrollees, 2014–2017. Anthony Finch, MS; M Cabell Jonas, PhD; Kevin Rubenstein; Eric Watson, BA; Sundeep Basra, MPH; Jose Martinez, BS; Michael Horberg, MD, MAS, FACP

From 2014 to 2017, the overall population of Kaiser Permanente Mid-Atlantic States had life expectancy at birth varying between 84.6 and 85.2 years compared with the CDC-reported national average of 78.6 to 78.9 years. While the CDC dataset reported shows a 3.5- to 3.7-year life expectancy gap between non-Hispanic White and Black populations, in this population, the gap was significantly smaller.

18 A Comprehensive, Multimodal, Interdisciplinary Approach to Chronic Non-Cancer Pain Management in a Family Medicine Clinic: A Retrospective Cohort Review. Edward Kwon, MD; Christopher Stange, MD; Katy Reichlin, DO; Hamilton Vernon, DO; Akira Miyanari, MD; Elizabeth Bier, DO; Hind Beydoun, PhD, MPH; Virginia Kalish, MD

The complexity of chronic non-cancer pain in the setting of regulatory efforts to curb opioid usage presents a novel challenge for the medical community, and much of this burden falls on primary care clinics. The authors retrospectively quantified the reduction of opioid usage by patients in a multimodal, interdisciplinary, primary care clinic for chronic pain.

25 Comanagement of Rashes by Primary Care Providers and Dermatologists: A Retrospective Study. Sangeeta Marwaha, MD; Jennifer R Dusendang, MPH; Stacey E Alexeeff, PhD; Eileen Crowley, MD; Michael Haiman, MD; Ngoc Pham, MD; Melanie J Tuerk, MD; Danny Wudka, MIDS; Michael Hartmann, MS, MA; Lisa J Herrinton, PhD

The demand for managing skin disease is high, and dermatologists are in short supply. To better understand how rashes and other skin conditions are comanaged by primary care providers and dermatologists, the authors estimated the frequency with which primary care providers sought consultation with or referral to dermatology and the proportion of patients who had a follow-up dermatology office visit in the following 90 days.

33 Attitudes and Knowledge Regarding Health-Promoting Behavior in Families Facing Food Insecurity. Andrea Nederveld, MD, MPH; Phoutdavone Phimphasone-Brady, PhD; Bridget Marshall, DNP; Elizabeth Bayliss, MD, MSPH

Food insecurity is common in families with young children. People experiencing food insecurity have worse health outcomes related to behaviors (such as obesity and diabetes management) than people who are food secure. This study explores strategies that parents on limited incomes use to feed their children, their understanding of nutrition for their children, and the social factors contributing to or alleviating food insecurity.

39 System-Level Variation in Multiple Sclerosis Disease-Modifying Therapy Utilization: Findings From the Multiple Sclerosis Continuous Quality Improvement Research Collaborative. Laetitia A N'Dri, PharmD; Dexter D Waters, MSPH; Karen Walsh, DHSc, MS, MBA; Falguni Mehta, MS, MBA; Brant J Oliver, PhD, MS, MPH, APRN-BC for the MS-CQI Investigators

This study contributes initial evidence concerning system-level variation in the utilization of disease-modifying therapies in people with multiple sclerosis. The results suggest a lack of standardization in the management of disease-modifying therapies. Continued research and improvement efforts targeting system-level performance could improve outcomes for people with multiple sclerosis.

46 Using Trauma-Informed Care in Practice: Evaluation of Internal Medicine Resident Training and Factors Affecting Clinical Use. Binny Chokshi, MD, MEd; Ellen Goldman, EdD

Trauma-informed care (TIC) acknowledges that childhood traumas can profoundly affect health outcomes, and it aims to creates a safe, nurturing medical environment. TIC curricula in graduate medical education are limited, and assessments of their application in practice are lacking.

53 Factors Influencing Patient Satisfaction With Care and Surgical Outcomes for Total Hip and Knee Replacement. Margaret C Wang, PhD, MPH; Priscilla H Chan, MS; Elizabeth W Paxton, MA, PhD; Jim Bellows, PhD; Kate Koplan, MD, MPH; Violeta Rabrenovich, MHA; Jeff Convissar, MD; Nithin C Reddy, MD; Christopher D Grimsrud, MD, PhD; Ronald A Navarro, MD

Patient-centered quality improvement in total joint replacement care requires thinking of care across the entire episode, including before and after the hospital stay for surgery, in addition to perioperative care. The actionable factors identified from this study can be incorporated into total joint replacement care to improve patient satisfaction with overall care and surgical results.

60 Rates of Acute Myocardial Infarction During the COVID-19 Pandemic. Matthew T Mefford, PhD; Jaejin An, PhD; Nigel Gupta, MD; Teresa N Harrison, SM; Steven J Jacobsen, MD, PhD; Ming-Sum Lee, MD; Paul Muntner, PhD; Chileshe Nkonde-Price, MD; Lei Qian, PhD; Kristi Reynolds, PhD, MPH

Early in the pandemic, stay-at-home orders and the fear of acquiring COVID-19 may have led to an avoidance of care for medical emergencies, including acute myocardial infarction (AMI). The authors evaluated whether a decline in rates of AMI occurred during the COVID-19 stay-athome orders.

69 Psychological Predictors of Weight Loss Based on Participants' Predispositions: Obesity Treatment Implications. James J Annesi, PhD, FAAHB, FTOS, FAPA

Treatments for obesity focused on improving self-regulation, self-efficacy, and mood have demonstrated promise for maintaining weight loss, but they could be improved if tailored to subjects' psychological predispositions.

75 Oral Health Care: A Missing Pillar of Total Health Care? Nancy P Gordon, ScD; David M Mosen, PhD, MPH; Matthew P Banegas, PhD, MPH

Oral health is an important component of overall health, and preventive dental care is essential for maintaining good oral health. However, many patients face significant barriers to preventive dental care. We examined prevalence of, and factors associated with, no recent preventive dental care in an adult health plan population.

84 Outcomes of a Medically Supervised Fasting Module on Healthy Females in a Controlled Residential Environment: A Brief Report. Dhananjay Arankalle, BNYS, MPH; Gulab Rai Tewani, BNYS; Pradeep MK Nair, BNYS, MSc; Jon Wardle, MPH, PhD

Numerous reports are available on the beneficial effects of fasting on various disease conditions. Despite mounting evidence on the benefits of fasting, little is known about its physiological effects in humans as most of the studies on physiological effects are done in animals.

89 Comparison of a Kidney Replacement Therapy Risk Score Developed in Kaiser Permanente Northwest vs Estimated Glomerular Filtration Rate in Advanced Chronic Kidney Disease Using Decision Curve Analysis. Ken J Park, MD; Jose G Benuzillo, MA, MS; Erin Keast, MPH; Micah L Thorp, MPH, DO; David M Mosen, PhD; Eric S Johnson, PhD

The use of kidney replacement therapy in the prediction models guiding arteriovenous fistula referrals for advanced chronic kidney disease is unknown. We aimed to compare a hypothetical approach using a kidney replacement therapy prediction model developed in Kaiser Permanente Northwest with the estimated glomerular filtration rate for arteriovenous fistula referrals.

REVIEW ARTICLES

95 Robotic Versus Laparoscopic Surgery for Rectal Cancer: A Comprehensive Review of Oncological Outcomes. Jessica Lam, MD; Michael S Tam, MD; R. Luke Retting, MD; Elisabeth C McLemore, MD

The treatment of rectal cancer is complex and involves specialized multidisciplinary care, though the tenet is still rooted in a high-quality total mesorectal excision. The robotic platform is one of many tools in the arsenal to assist with dissection in the low pelvis. This article is a comparison of oncologic outcomes for robotic versus laparoscopic rectal cancer resection, with a particular focus on total mesorectal excision.

104 Practical Management of New-Onset Urticaria and Angioedema Presenting in Primary Care, Urgent Care, and the Emergency Department. Eric Macy, MD, MS, FAAAAI

A new episode of urticaria (hives) and/or angioedema can be an anxiety-inducing event for patients as well as physicians seeing them in primary care, urgent care, or the emergency department. These episodes are easy to manage and virtually never life-threatening. Acute idiopathic urticaria is treated with high dose, nonsedating antihistamines, acute avoidance of alcohol and nonsteroidal anti-inflammatory drugs, and time.

CASE REPORTS

111 Phrenic Nerve Palsy Following Radiation Therapy for Patient With Breast Cancer. Akhil Sharma, DO; Fazal Raziq, MD; Tyler Kemnic, DO; Rohan Prasad, DO

Radiotherapy used after breast-conserving surgery has been shown to decrease local recurrence while minimizing side effects. Peripheral neuropathy remains a common and wellknown complication of radiotherapy for breast cancer but it is rarely associated with phrenic nerve palsy after treatment. The authors present the case of a 66-year-old female with the first reported incidence of phrenic nerve palsy due to radiotherapy for breast cancer.

115 Stepwise Treatment With Plant-Based Diet and Medication for Patient With Mild Ulcerative Colitis. Mitsuro Chiba, MD, PhD; Tsuyotoshi Tsuji, MD, PhD; Hideo Ohno, MD; Masafumi Komatsu, MD, PhD

Inflammatory bowel disease is a lifestyle disease mainly mediated by a westernized diet. A plant-based diet to counter the westernized diet can induce remission without medication in a subset of mild cases of ulcerative colitis. In this case report, the authors describe how medication can be provided when induction of remission is not achieved solely with the diet.Inflammatory bowel disease is a lifestyle disease mainly mediated by a westernized diet. A plant-based diet to counter the westernized diet can induce remission without medication in a subset of mild cases of ulcerative colitis. In this case report, the authors describe how medication can be provided when induction of remission is not achieved solely with the diet.

120 Pleuroperitoneal Hernia in an Adult Patient. Mario R Rodríguez, MD; Juan S González, MD; Karen L Alfonso, MD; Paula A Becerra, MD; María C Gaviria, MD; Andés Felipe Herrera Ortiz, MD

Pleuroperitoneal hernia symptoms in adults most commonly affect the gastrointestinal and respiratory tracts. Diagnosis is performed by computed tomography or magnetic resonance imaging, in which a diaphragmatic defect can be seen. Treatment is based on surgical repair of the diaphragmatic defect, and the surgical approach chosen may vary according to the surgeon's expertise.

124 Rare Cardiac Papillary Fibroelastoma: Right Atrial, Non-Valvular, Large, Symptomatic With Pulmonary Embolism. Rohan M Prasad, DO; Abdul-Fatawu Osman, MD; Christopher C Garces, MD; Robert Gumbita, MD; Ahmed Elshafie, MD; Pranay Pandrangi, MD; Michael Kehdi, MD

Primary cardiac tumors are rarely seen in the general population and only a subset are classified as cardiac papillary fibroelastoma. A 59-year-old female who presented with unresponsiveness and cardiac arrest required four rounds of cardiopulmonary resuscitation and intubation. Laboratory investigations showed uncompensated respiratory acidosis, hyperkalemia, and elevated troponins. A chest computed tomography angiogram illustrated an acute right pulmonary embolism and a right atrial filling defect.

128 Successful Use of Glycoprotein IIb/IIIa Inhibitor Involving Severely Ill COVID-19 Patient. Patrick Joseph Merrill, MD, FACP; R Mark Bradburne, MD, FACCP

This case report shares a successful outcome involving a patient with severe COVID-19 viral pneumonia utilizing a novel therapeutic approach with the glycoprotein IIb/IIIa inhibitor eptifibatide.

COMMENTARIES

131 Reframing the Conversation Around Physician Burnout and Moral Injury: "We're Not Suffering From a Yoga Deficiency." Sneha Mantri, MD, MS; Karen Jooste, MD, MPH; Jennifer Lawson, MD; Brian Quaranta, MD, MA; John Vaughn, MD

The conceptual model of burnout is failed work–life balance, wherein increasing administrative burdens or systemic policies chip away at physician resilience. The recommended treatment is the rest cure: detach from clinical duties, take a vacation, refresh, and reset. Yet despite an explosion of lunchtime yoga classes and mindfulness meditation apps, burnout continues to worsen across all medical specialties.

134 Open Access Fees: A Barrier to Scholarly Activity Among Neurology Trainees. Keng Lam, MD; Annette Langer-Gould, MD, PhD

The open access publishing model provides readers of all backgrounds access to articles free of charge. To cover the costs of open access, many journals now charge substantial article processing fees. This has inadvertently created yet another barrier for trainees to engage in scholarly activity. The authors describe the issue, review the literature, and provide suggestions for addressing this barrier, with a focus on the neurology specialty.

138 Challenges in Managing Isolated Subsegmental Pulmonary Embolism. David R Vinson, MD; Dayna J Isaacs, MD, MPH; Etsehiwot Taye, MD; Mahesh J Balasubramanian, MD

This commentary explores the critical elements in the management of adults with isolated subsegmental pulmonary embolism. A healthy 47-year-old woman was diagnosed by her primary care physician with acute subsegmental pulmonary embolism and referred to the emergency department for definitive care.

144 Low-Tech High-Value(s) Care: No Patient Left Behind. Maria Alcocer Alkureishi, MD, FAAP; Wei Wei Lee, MD, MPH; Gena Lenti, MD; Zi-Yi Choo, BS; Jonah Benning-Shorb, BS; Rachel Grob, PhD; Martha E Gaines, JD, LLM; Richard Frankel, PhD, FACH

From a quality and cost perspective, the lack of visual cues during telephone consultations can lead to inferior care in some scenarios. New data suggests that the telephone can be equally as effective as video in achieving visit resolution for certain common conditions such as eye infections, skin conditions, and allergies. Does high-tech always mean high value and if not, why is that, and why does it matter?

147 Retraction Notice

148 Erratum

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