Winter 2013 - Volume 17 Number 1

Original Research and Contributions

Neighborhood-Level Hot Spot Maps to Inform Delivery of Primary Care
and Allocation of Social Resources

Ingestion of Magnetic Toys: Report of Serious Complication Requiring Surgical Intervention and a Proposed Management Algorithm
Jerry Tsai, MD; Donald B Shaul, MD; Roman M Sydorak, MD; Stanley T Lau, MD; Yasir Akmal, MD; Karen Rodriguez, RN, MN, CPNP-PC/AC
Increasing popularity of magnets as toys has led to their ingestion by children. A retrospective review of magnet ingestions treated over a 2-year period included 5 patients who presented with abdominal symptoms. Four of the 5 patients suffered serious complications, including bowel necrosis, perforation, fistula formation, and obstruction. All patients were successfully treated with laparoscopic-assisted exploration with or without endoscopy.

Effects and Linguistic Analysis of Written Traumatic Emotional Disclosure in an Eating-Disordered Population
Ashli M Gamber, MD; Susan Lane-Loney, PhD; Martha Peaslee Levine, MD
Writing about traumatic life events produced positive physical and psychological outcomes in various populations. Participants included 29 female patients from the Penn State Hershey Eating Disorders partial-hospitalization program. Individuals completing the disclosure writing used more negative emotion, insight, cognitive, function, and filler words along with decrease of tentative words. No correlating health benefits could be found. Eating-disordered populations, often alexithymic, may have difficulty engaging with the disclosure task.

Operational Challenges in Delivery of Charity Care Program for Diabetic Retinopathy Screening in an Urban Setting: A Quality-Improvement Study
Erica H Chedid, AM; Quin R Golden, MBA; Rama D Jager, MD, MBA, FACS
University of Chicago Medicine partnered with Chicago Family Health Center to screen uninsured and underinsured patients for diabetic retinopathy. They recalled patients with ungradable images for repeat imaging, had regular staff training, sent weekly e-mails to the physician champion to read images, sent reminder cards, and made preappointment and postappointment phone calls. The overall number of ungradable images decreased and show rates began to increase.

Improving Efficiency and Reducing Administrative Burden through Electronic Communication
Katlyn E Cook; Gail M Ludens; Amit K Ghosh, MD; William C Mundell, MD; Kevin C Fleming, MD; Andrew J Majka, MD
A standardized InBox was implemented at Mayo Clinic Division of General Internal Medicine. Sixteen of 28 individuals (57%) completed the preintervention survey. Twenty-eight clinicians participated in 2 separate 8-day pilot tests. The number of Inbox defects was substantially reduced from 37 to 7. Frequent InBox defects decreased from 25% to 10%. More than half of clinicians believed the standardized InBox positively affected their work and 100% reported no negative effect.

Quality and Cost Evaluation of a Medical Financial Assistance Program
Douglas A Conner, PhD; Arne Beck, PhD; Christina Clarke; Leslie Wright, MA; Komal Narwaney, MD, PhD; Neysa W Bermingham
A prospective cohort study of 308 medical financial assistance (MFA) program members were enrolled between May 2008, and May 2009. Use of services was analyzed with multiple regression, and costs of services with generalized linear models. MFA increased members' access to health services. Hospital costs were lower, but costs for clinic visits, pharmacy services, phone calls, and radiology services were significantly higher.

Breast Cancer Screening in an Insured Population: Whom Are We Missing?
Karin L Kempe, MD, MPH; Rebecca Sam Larson, PhD; Susan Shetterley; Andra Wilkinson
The authors retrospectively evaluated data from 47,946 women aged 52 to 69 years who had not undergone mammography. Nonwhite ethnicity increased risk of screening failure if black, Latina, "other," or missing race/ethnicity. A greater number of office visits in any setting was associated with greater likelihood of undergoing mammography. Increasing screening among women with missing race/ethnicity data, could improve mammography screening rates.

The Banner Psychiatric Center: A Model for Providing Psychiatric Crisis Care to the Community while Easing Behavioral Health Holds in Emergency Departments
Pat Little-Upah, MA; Chris Carson, MD; Robert Williamson, MD; Tom Williams, MC; Michael Cimino, MBA; Neena Mehta, MSN; Jeff Buehrle, MBA; Steve Kisiel
Banner Health, in Phoenix, AZ, provides individuals in a behavioral health crisis with an alternative to presenting to an Emergency Department (ED). By quickly moving patients out of the ED, their hold time was greatly reduced. The center provides access to psychiatric clinicians around the clock. Finally, disposition of patients into appropriate levels of care has freed up acute care Level 1 beds.

Televisitation: Virtual Transportation of Family
Bonnie Nicholas, RN, CNCC(C), CPTC
Televisitation is the virtual transportation of a patient's family to the bedside, regardless of the patient's location within an acute care setting. In Thunder Bay, Ontario, Canada, the health system embraces patient- and family-centered care. The important relationship between health outcomes and the psychosocial needs of patients and families has been recognized more recently. First Nations renal patients with family in remote communities were some of the earliest users of videoconferencing technology for this purpose.

Inpatient Palliative Care Consultation: Describing Patient Satisfaction
Pushkar Chand, MD; Teralyn Gabriel, MSW; Cathy L Wallace, RN; Craig M Nelson, PhD, CLS
This study identified and measured common patterns of patients' positive care experiences during inpatient palliative consultation. The codified responses revealed the perspectives of patients rather than predicting outcomes. Six areas of satisfaction included: treatment with dignity and respect, being better informed, excellent overall experience, treatment plan, respect of cultural beliefs and values, and pain and symptom control addressed.

Temporal Arteritis: Improving Patient Evaluation with a New Protocol
Michael Alberts, MD, PhD
The process of diagnosing temporal arteritis remains controversial. Although temporal artery biopsy has long been the standard evaluation tool, it has poor sensitivity. Implementing a new protocol—and adding specialist clinical evaluation and color duplex ultrasonography to the standard diagnostic workup—resulted in a 38% reduction in biopsies. The percentage of abnormal biopsy results rose from 8.5% at baseline to 24%, and no cases of the disease were missed.

Transprocessing: Neurobiologic Mechanisms of Change during Psychotherapy—A Proposal Based on a Case Report
Robert Bota, MD, MSG; Andrei Novac, MD
This article proposes transprocessing (as in "transduction" and "processing") to denote mechanisms by which the brain processes information in psychotherapy and develops solutions that have a lasting, curative effect. Psychotherapeutic changes of the brain reframe complex or multimodal memories, deconstructed and restored through memory mechanisms at the synaptic, cellular level. The authors propose three stages of transprocessing: 1) evaluation, 2) acquisition, and 3) contextualization.

Clinical Medicine

Images in Emergency Medicine: Phlegmasia Cerulea Dolens
Joel T Levis, MD, PhD, FACEP, FAAEM; Danny L Sam, MD, FACP
Phlegmasia cerulea dolens (PCD) is a rare form of massive venous thrombosis of the lower extremities associated with a high degree of morbidity including venous gangrene, compartment syndrome, and arterial compromise. PCD is characterized by sudden pain, swelling, purple ecchymosis, and arterial ischemia with loss of distal pulses, and tense, firm, tender skin.

ECG Diagnosis: Hyperkalemia
Joel T Levis, MD, PhD, FACEP, FAAEM
Diagnosis of hyperkalemia is usually based on laboratory studies. Typical electrocardiogram findings progress from tall, "peaked" T waves and a shortened QT interval to lengthening PR interval and loss of P waves, and then to widening of the QRS complex culminating in a "sine wave" morphology and death if not treated. Calcium can effectively block the effect of extracellular potassium elevation on cardiac myocytes within minutes.

Review Articles

Meta-Analysis of the Use of Narrative Exposure Therapy for the Effects of Trauma Among Refugee Populations
Nicolas Gwozdziewycs, MA; Lewis Mehl-Madrona, MD, PhD
Narrative therapies, used to treat the effects of trauma in refugees and to prevent psychiatric illness, help the person to tell his/her story until it no longer elicits anxiety. The average effect size for studies in which interventions were administered by physicians, graduate students, or both was 0.53, whereas the effect size for studies in which the counselors were themselves refugees was 1.02. Empowering lay counselors to treat their fellow refugees in future studies is warranted.

Case Studies

The Renal Palliative Care Program
Phillip Tuso, MD
A 75-year-old man with a 25-year history of type 2 diabetes presents for long-term treatment options. His estimated glomerular filtration rate is 16 mL per minute per 1.73 m2 of body-surface area. His history is remarkable for ischemic coronary artery disease, congestive heart failure, peripheral artery disease, mild dementia, and colon cancer. He has been admitted to the hospital 4 times in the last 6 months. How should his care be managed?

The Treatment of Angiocentric Glioma: Case Report and Literature Review
Daniela Alexandru, MD; Bijan Haghighi, MD; Michael G Muhonen, MD
Recognized since 2007, angiocentric glioma is a recently described tumor. This is the only case at the author's institution in 15 years. This review of the literature attempts to establish prognostic parameters from only 27 cases in the literature. The most common presenting symptom was seizures. Gross total resection of the lesion was curative, without need for radiation or chemotherapy.

Commentary

Transforming Care Delivery through Health Information Technology
Benjamin Wheatley
Electronic health record systems provide a complete patient record at the point of care and can alleviate some of the challenges of a fragmented delivery system, such as drug-drug interactions. Moreover, health IT identifies gaps in recommended treatment and provides clinical decision-support tools. In addition, the data can be used to monitor patient outcomes and identify potential improvements in care protocols.

Book Reviews

The Better End: Surviving (and Dying) on Your Own Terms in Today's Modern Medical World
Review by Richard D Della Penna, MD

Soul of the Healer

Aspens at Kenosha Pass
Brad Christian McDowell, MD

Carved Mandolin Top
John L Anderson

Namibia
Stuart Hahn, MD

Thrive with Five
Karen L Goodlett, MD

Skunk Cabbage
Stephen Henry, MD

Trillium
Stephen Henry, MD