Spring 2011 - Volume 15 Number 2

Original Research and Contributions

Identifying Opportunities for a Medical Group to Improve Outcomes for Patients with Coronary Artery Disease and Heart Failure: An Exploratory Study
Courtney Jordan Baechler, MD, MSCE; Thomas E Kottke, MD, MSPH
The potential impact of optimizing care for patients age 40-75 years treated for coronary artery disease and heart failure, by a multispecialty group between August 2007 and July 2008, was calculated using deaths that might be prevented or postponed if optimal care was achieved. The greatest opportunity to prevent or postpone deaths—70% of the total opportunity—lies with optimizing care for ambulatory patients. Optimizing care for patients hospitalized for acute myocardial infarction with or without ST-segment elevation on ECG would prevent or postpone only 2% of deaths.

A New Model of Well-Child Care: Implications for Resource Costs and Dissemination
Debra P Ritzwoller, PhD; Anna Sukhanova, MA; Arne L Beck, PhD; David Bergman, MD
Demographic and health care utilization data associated with 14,910 pediatric enrollees, ages newborn to 5 years, enrolled at Kaiser Permanente Colorado were used to simulate the change in costs attributable to an innovative high-performance model of Well-Child Care. Simulation models and sensitivity analyses suggest it is likely to be relatively resource cost neutral in a managed care system, allowing for efficient reallocation of resources to higher-risk children.

When Rapport Building Extends Beyond Affiliation: Communication Overaccommodation Toward Patients with Disabilities
Ashley P Duggan, PhD; Ylisabyth S Bradshaw, DO, MS; Natalie Swergold; Wayne Altman, MD, FAAFP
Physician rapport with patients is described as a vital component of relationship-centered care, but rapport-building communication behaviors may exceed boundaries and instead indicate patronizing behavior toward patients with disabilities. Videotaped interactions between third- and fourth-year medical students (N = 142) and standardized patient educators with physical disabilities were qualitatively analyzed. Results suggest six primary themes: baby talk, kinesic movement, vocalics, relationship assumptions, emotional divergence from patient disclosure, and inconsistency with patient emotional cues.

Adverse Reactions Associated with Therapeutic Antibiotic Use after Penicillin Skin Testing
Eric Macy, MD, MS; Ngoc J Ho, PhD
This study presents electronic medical record data from a large cohort on the incidence of new antibiotic "allergy" after all outpatient therapeutic antibiotic use in all the individuals who had penicillin skin testing at a medical center from January 1, 2000 through December 31, 2004. This gives a real world picture of the incidence and severity of new antibiotic "allergy" in patients with a history of penicillin "allergy."

Birth Outcomes Among Low-Income Women - Documented and Undocumented
Bich Ngoc Dang, MD; Louise Van Dessel, BS, MBA; June Hanke, RN, MSN, MPH; Margo A Hilliard, MD, MPH
In January 2007, Texas expanded the Children's Health Insurance Program (CHIP) to include perinatal care for the unborn children of undocumented low-income women. In a retrospective cohort study of 10,763 pregnant women (CHIP) and 4614 (Medicaid) who delivered between January 1 and August 31, 2008, Hispanic women had the lowest preterm and low-birth-weight rates (6.6% and 5.8%), and non-Hispanic black women had the highest (11.3% and 12.4%).

Can Patient Factors Predict Early Discharge After Pyloromyotomy?
Steven L Lee, MD, FACS, FAAP; Rebecca Stark, MD
The authors conducted a retrospective review of pyloromyotomies performed within a six-year period to determine whether patient factors could predict length of hospitalization in patients with pyloric stenosis. Of 230 patients, 58% were discharged within 24 hours, 31% between 24 and 48 hours, and 11% after 48 hours. Patients with lower weight and a longer preoperative hydration period had an increased risk of prolonged hospitalization.

Inpatient Palliative Care Consults and the Probability of Hospital Readmission
Craig Nelson, PhD, CLS; Pushkar Chand, MD; Julie Sortais, LCSW; Joseph Oloimooja, MDiv; Gina Rembert, RN
On retrospective review of electronic medical records for 200 consecutive patients referred to an Inpatient Palliative Care Service (IPCS) between November 2006 and February 2010, the new consultation with a team (a physician, bioethicist, social worker, registered nurse, and hospital chaplain) versus the consultation with only the IPCS registered nurse showed a decrease in readmissions to the hospital per patient per six months after consultation from 1.15 to 0.7 admissions per patient.

Reducing Antipsychotic Polypharmacy Among Psychogeriatric and Adult Patients with Chronic Schizophrenia
Yen-Li Goh, MD; Kok Han Seng, MD; Alex Su Hsin Chuan, MD; Hong Choon Chua, MD
In phase 1 of a project conducted with inpatients with chronic schizophrenia, the average chlorpromazine-equivalent dose per day in psychogeriatric patients was reduced from 375 mg to 170 mg. In phase 2 with adult patients, there was a reduction in both the average number of antipsychotics from 2.9 to 2.27, and an average chlorpromazine-equivalent dose per day from 1523 mg to 1246 mg, with no documented relapse within six months of implementation of both the projects.

Reducing the Use of Seclusion and Restraint in Psychiatric Emergency and Adult Inpatient Services  Improving Patient-Centered Care
Joyce B Wale, LCSW; Gary S Belkin, MD; Robert Moon, LMSW
Seclusion and restraint (S/R) use is associated with high rates of patient and staff in­juries and is a coercive and potentially traumatizing intervention. The New York City Health and Hospitals Corporation, operating 1117 adult inpatient psychiatric beds with 36,000 psychiatric emergency services visits, conducted a sequenced, intensive series of interventions (2007 to 2009) resulting in a substantial decline in the overall time spent in S/R, a reduced use frequency, and reduced patient injury.

Special Reports

Is Patient-Centered Care the Same As Person-Focused Care?
Barbara Starfield, MD, MPH
Person-focused care, based on accumulated knowledge of people, specifically focuses on the whole person. It refers to interrelationships over time, considers episodes as part of life-course experiences with health, views diseases as interrelated phenomena, often considers morbidity as combinations of types of illnesses (multimorbidity), and views body systems as interrelated. Tools to assess person-focused care are available and deserve more widespread use in primary care

Review Articles

Unconscious (Implicit) Bias and Health Disparities: Where Do We Go from Here?
John F Steiner, MD, MPH; Edward P Havranek, MD
Disparities in health care are of great concern, with much attention focused on the potential for unconscious (implicit) bias to play a role in this problem. This article provides a research roadmap that spans investigations of the presence of implicit bias in health care settings, identification of mechanisms through which implicit bias operates, and interventions that may prevent or ameliorate its effects. Concrete suggestions are offered for indi­viduals in different roles.

Case Study

Acute Hypersensitivity Syndrome Caused by Valproic Acid: A Review of the Literature and a Case Report
Robert G Bota, MD, MSG; Allein P Ligasan, RN; Tom G Najdowski, LCSW; Andrei Novac, MD
Valproic acid is an antiepilieptic medication used in the treatment of bipolar disorder. This literature review focuses on aromatic anticonvulsants (AA) and non-AA medications causing acute hypersensitivity syndrome, a less well-known complication. A case is presented of a woman, age 25 years, with a generalized rash, fever, liver and kidney involvement, and eosinophilia.

Clinical Medicine

Calcific Uremic Arteriolopathy: An Underrecognized Entity
Victoria Ann Kumar, MD
This condition often occurs with chronic kidney disease or end-stage renal disease. Diagnosis is based on clinical judgment and recognition of lesions, secondary to small-vessel calcification, that appear as painful necrotic eschars, ulcerations, indurated nodules, and treated with rigorous wound care, strict control of mineral metabolism with avoidance of calcium and vitamin D analogs, and pain control.

Image Diagnosis: Thoracic Aortic Dissection and Thoracic Aortic Aneurysm
Sundeep R Bhat, MD; Gus M Garmel, MD, FACEP, FAAEM
Although plain film chest radiograph may be used to screen, computed tomography angiography or traditional angiography are gold-standard tests and should be obtained in any stable patient for whom dissection is suspected. Complications include aortic valve insufficiency, dissection into coronary vessels, and dissection into the pericardial sac.

ECG Diagnosis: Complete Heart Block
Joel T Levis, MD, PhD, FACEP, FAAEM
Third-degree atrioventricular block, when more P waves than QRS complexes exist with no relationship between them, and the ventricular rate varies from 30-40 beats/minute, complicates 10% of acute myocardial infarctions, the most frequent unstable bradydysrhythmia. Permanent pacing (not atropine) is usually required as vagal stimulation is not the cause.


The Patient's Question-Unanswered
Mikel Aickin, PhD
Faced with a treatment choice for a newly diagnosed condition, the patient's question is "Which treatment will give me more benefit?" Although unanswerable, a question that may be is "What is the probability that I will do better on treatment A or B?" This article explores this philosophical question offering a method to recover real clinical research: the "almost perfect experiment," using a group of highly, closely matched pairs, each given treatment A or B.

Letters to the Editor

Alternate Model for Medical Education

Gastric antral vascular ectasia (watermelon stomach)

Narrative Medicine

Please Hear What I'm Not Saying: The Art of Listening in the Clinical Encounter
Mary T Shannon, MSW, MS
Near the end of Anne Fadiman's book, The Spirit Catches You and You Fall Down, a tragic account of two cultures at odds with each other, the author tells the story of a Hmong patient who was being referred to a specialist for further treatment and, instead of inquiring about the physician's skill or credentials, he asked, "Do you know someone who would care for me and love me?" It is an honest question that bears asking, and yet within its naked simplicity lies the deepest complexity. It is not the type of question one responds to quickly or without reservation, but it is one that deserves a thoughtful answer. It would not be incorrect to assume that beneath our own culture's fiercely held value of independence lies the very same question, for when all is said and done, isn't this what every person desires?

Soul of the Healer

"Pacific White-Sided Dolphins"
Stephen Henry, MD

"Oneonta Falls"
Daniel Rappaport, MD

Avron Daniller, MD, FACS, FRCS

Samir Johna, MD, FACS

On the Cover

Myrtle Beach Sunrise
John Davenport, MD


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