Spring - The Permanente Journal

Spring 2009

The Permanente Journal

Spring 2009 - Volume 13 Number 2

Original Articles

Short- and Long-Term Antireflux and Asthma Medication Use in Children After Nissen Fundoplication
Steven L Lee, MD, FACS, FAAP
Overall, study findings demonstrated a slight decrease in antireflux medication use after Nissen fundoplicaton. With respect to asthma medications, only older, neurologically healthy children decreased use in the short term (one year).

The Falling Rate of Positive Penicillin Skin Tests from 1995 to 2007
Eric Macy, MD; Michael Schatz, MD, MS; CK Lin, PhD; Kwun-Yee Poon, MS
Data on the rate of positive penicillin skin test (PenST) results over time in large populations are rare. Of 3469 individuals, 255 had positive PenST. The rate declined from >10% to <5% (13 years studied) accounted for by the year of testing without contribution from patient's age or time since reaction. Route and frequency of outpatient antibiotic use may explain this.

Developing Minimally Invasive Surgery Centers Within Kaiser Permanente: The Integrated Multidisciplinary Experience of Los Angeles
Gary W Chien, MD; Maher A Abbas, MD, FACS, FASCRS
Although there are unique issues for each specialty, many common issues, such as anesthetic considerations, organizing operating room teams, standardization of disposable products and electrosurgical units, testing and implementation of new equipment, postoperative care, education, simulation, training, and research are effectively and efficiently addressed through a multidisciplinary approach and complete integration.

An Exploratory Case Study: Effects of a Physician Organizational Socialization (Enculturation) Program
Richard Pitts, DO, DABEM, DABPM
Compelling study data—filling a literature void—shows that comprehensive enculturation improves physicians' effective entry into a medical group. Themes include: developed a strong sense of belonging; gained improved communication skills; gained multiple resources for success at home, and work; and developed friends called on later for clinical advice. 2008 David M Lawrence, MD: Chairman's Patient Safety Award

Northwest Simulation Center—Sharpens Clinical and Communication Skills for Individuals and Teams
Georgina Ottaviano, BSN, RN-BC; Carl Washington, MT, PSO, CPHQ
Many authorities have suggested that some variant of team training is likely to reduce human error in operating rooms, Emergency Departments, resuscitation teams and other settings within health care—where human interaction is common and where breakdowns in communication and teamwork can have critical consequences. The Kaiser Sunnyside Medical Center Regional Simulation Center achieves this end. 2008 Lawrence Patient Safety Award

Ohio Safety Action Teams
Cindy Ebner, RN, MSN, CPHRM, FASHRM
Following the implementation of a new process—"Images-to-Operating-Room"—a survey of all Safety Action Team (SAT) participants showed they knew more about building a reliable process, their job satisfaction increased, patient safety was improved, and the gains were sustained. The plan is to continue SATs which are readily transferable to other areas and facilities.

Review Article

Incidental Gallstones.
Jeffrey K Wang, MD; Shannon M Foster, MD; Bruce G Wolff, MD, FACS
Gallstones develop in approximately 10% to 15% of the US population. Complications arise at 1% per year in asymptomatic patients and 2% per year in symptomatic patients. Laparoscopic cholecystectomy has quickly become the gold standard in the US. The literature also advocates cholecystectomy for gallstones found incidentally during other abdominal procedures.

Case Studies

An Unusual Presentation and Etiology of Hypotension Seen in Nephrotic Syndrome
Anna-Maria Panagiotides, MD; Aviv Hever, MD; John J Sim, MD
The case discussed illustrates an unusual presentation of hypotension due to amyloid infiltration of the vasculature, leaving the patient susceptible to acute kidney injury even from what is generally considered mild diuresis. The kidneys are the most frequently affected organs in approximately 80% of patients with the disease. Cardiac dysfunction is the second most common presentation

An Unusual Cause of Elevated Values on Liver Function Tests in a Liver Transplant Patient
Ankur Jain, MD; Amandeep Sahota, MD; Najeeb S Alshak, MD; Jim K Tung, MD
Biliary obstruction and rejection are two of the most common causes of abnormal findings on liver function tests (LFTs) in patients who have already undergone liver transplantation. Here a post-transplant patient with jaundice, not previously vaccinated, had hepatitis B as the cause of his increased values on LFTs.

Clinical Medicine

Corridor Consult
Early and Accurate Diagnosis of Sudden Sensorineural Hearing Loss
Barry Rasgon, MD; Luke James Schloegel, MD
Sudden Sensorineural Hearing Loss is defined as a 30-dB hearing loss in three consecutive frequencies whose onset is less than three days. Most researchers agree it is likely to be of vascular, immunologic, or viral origin, and is regarded as an otologic emergency.

Commentary

Statement on behalf of the Kaiser Permanente Medical Care Program before the Committee on Health, Education, Labor, and Pensions; United States Senate on January 15, 2009

Investing in Health IT: A Stimulus for a Healthier America
John H Cochran, MD, FACS
Congress should explore investing in the nation's health care delivery system. KP HealthConnect securely connects 8.7 million people to their physicians, their health care teams, their personal health information, and the latest medical knowledge, leveraging the integrated approaches to health care available at KP. It's not just about digitizing the visit: it's about using visit data to inform and ultimately to transform care delivery.

Marketing, Media, Wishful Thinking, and Conflicts of Interest: Inflating the Value of New Medical Technology
Richard A Deyo, MD, MPH
"Advances"—autologous bone marrow transplantation, Vioxx, arthroscopic debridement—were expensive, marginal treatments that became widely used without adequate scientific evaluation or comparison to competing treatments. "Newly approved" does not necessarily mean new and improved. Marketing, politics, media, and advocacy sometimes trump scientific considerations. "Jumping the gun" before rigorous evaluation makes it hard to practice evidence-based medicine.

Editorial

Isn't it Time to Stop Accepting Handouts for our Educational Efforts?
KM Tan, MD
Commercial support for continuing education risks distorting educational content, invites bias, and endangers professional commitment to evidence-based decision making. The Permanente Medical Groups are leading a ban on commercial support for accredited organizations that provide continuing education, especially because it is not the size of the gift, but the gifting itself that creates the desire to reciprocate.

Dealing With Change: Using the Conditional Change Model for Clinical Research.
Mikel Aickin, PhD
Virtually all clinical medicine is about change. In clinical research one of the most frequently used approaches—to compare changes in a treated group with corresponding changes in a control group—fails to include the baseline measurement value in the analysis. Reasons to prefer the conditional change model over the t-test are: smaller error, similar groups, and less artifact. The Merging of the Work of Two Pioneers: Dr Weed & Dr Berwick

Attaining Comprehensive Health Care Improvement is Imperative
Lee Jacobs, MD
Two physicians are on journeys to improve health care. Lawrence Weed, MD (problem-oriented medical record) explores how practitioners process and apply information, using "knowledge couplers" for decisions based on quality data input rather than on recall. Donald Berwick, MD believes that the key to higher quality is understanding and improving 100 core work-flow processes covering 95% of all patient care. We need both approaches.

Narrative Medicine

A Fatal Form of Contentment
Catherine Hickie, MBBS
A 19th-century query in The Lancet into mass train travel noted vagrants as enjoying the pleasure of travel without having earned it through work—a "fatal form of contentment." The Internet has come with anxieties and fears just as the trains did. A 21st-century psychiatrist wonders if our hopes for new technology are that different from the hopes of the Victorians.