Fall 2014 - Volume 18 Number 4

Original Research and Contributions

Mindfulness-Based Stress Reduction in an Integrated Care
Delivery System: One-Year Impacts on Patient-Centered
Outcomes and Health Care Utilization
Tracy McCubbin, MD; Sona Dimidjian, PhD; Karin Kempe, MD, MPH;
Melissa S Glassey; Colleen Ross, MS; Arne Beck, PhD

Mindfulness-based stress reduction (MBSR) programs have demonstrated clinical effectiveness for both mental and physical health conditions. Less research exists on health services utilization, self-efficacy, or work productivity outcomes. A prospective single cohort design evaluated an 8-week MBSR program for 38 Kaiser Permanente Colorado members with chronic pain, chronic illness, or stress-related problems. Repeated measures analyzed at 8 weeks and 1 year showed significant improvements in self-reported mental and physical function, pain, psychological symptoms, and self-efficacy, but not in work productivity. There were also significant decreases at 1 year for visits to: primary care, specialty care, and the Emergency Department, and for hospital admissions.

Improving Appropriate Use of Pulmonary Computed Tomography Angiography by Increasing the Serum D-Dimer Threshold and Assessing Clinical Probability
Sydney Char; Hyo-Chun Yoon, MD, PhD

A retrospective review was conducted of all patients undergoing pulmonary computed tomography angiogram during 2 separate 12-month intervals: 1 before the implementation of an increased D-dimer threshold and recommendation for formal clinical probability assessment, and the other after regional implementation. The prevalence of pulmonary embolism detected by computed tomography angiography increased from 4.7% to 11.7%, but only 4% of patients had a formal clinical probability assessment recorded in their electronic medical record.

Testing for Meningitis in Children with Bronchiolitis
Michael Stefanski, MD, MPH; Ronald Williams, MD, FAAP, FACP; George McSherry, MD; Joseph Geskey, DO, MBA

The authors present a retrospective, case-control study of hospitalized infants younger than age one year diagnosed with viral bronchiolitis who underwent lumbar puncture as part of an evaluation for meningitis. The presence of apnea, cyanosis, meningeal signs, positive urine culture results, and young age were factors found to be preliminarily associated with the performance of a lumbar puncture in the setting of bronchiolitis. Young age was the only significant clinical factor found after multivariable regression; no other demographic, clinical, laboratory, or radiologic variables were found to be significant.

Impact of Implementing Glycated Hemoglobin Testing for Identification of Dysglycemia in Youth
Vinutha Vijayadeva, PhD; Gregory A Nichols, PhD

At both Kaiser Permanente Hawaii and Kaiser Permanente Northwest, fasting plasma glucose testing was significantly more common in 2009 and HbA1C testing was more common in 2012, but the characteristics of the overall population did not change. At both sites, the characteristics of youth at risk of diabetes changed substantially with a much greater proportion being female and children younger than age 10 years. The size
and composition of the population of youth identified with diabetes was not affected.

Most Common Dermatologic Topics Published in Five High-Impact General Medical Journals, 1970-2012: Melanoma, Psoriasis, Herpes Simplex, Herpes Zoster, and Acne
Young M Choi; Aram A Namavar, MS; Jashin J Wu, MD

Internists frequently diagnose herpes simplex, herpes zoster, and acne, which are also common dermatologic topics published. The authors conducted an independent search of the Thomson Reuters' Science Citation Index for common dermatologic topics, limited to the period 1970 to 2012. The five most common dermatologic topics published in five high-impact general medical journals were melanoma, psoriasis, herpes simplex, herpes zoster, and acne.      

Prevalence of Hypovitaminosis D and Its Association with Comorbidities of Childhood Obesity
Ronald Williams, MD, FAAP, FACP; Marsha Novick, MD; Erik Lehman, MS       

We conducted a retrospective chart review from 155 obese children aged 5 to 19 years who attended the Penn State Children's Hospital Pediatric Multidisciplinary Weight Loss Program from November 2009 through November 2010. Under the latest Institute of Medicine definitions, vitamin D deficiency (< 20 ng/mL) and insufficiency (20-29 ng/mL) was present in 40% and 38% of children, respectively. African-American race, winter/spring season, hyperinsulinemia, elevated systolic blood pressure, urban location, and total numbers of comorbidities were significantly associated with hypovitaminosis D (< 30 ng/mL). Obese children should be considered for routine vitamin D screening.

A Pilot Study Comparing Anatomic Failure after Sacrocolpopexy with Absorbable or Permanent Sutures for Vaginal Mesh Attachment
Jasmine Tan-Kim, MD, MAS; Shawn A Menefee, MD; Quinn Lippmann, MD, MPH; Emily S Lukacz, MD, MAS; Karl M Luber, MD; Charles W Nager, MD

The authors reviewed the medical records of 193 women who underwent sacrocolpopexy with 2 different types of sutures attaching polypropylene mesh to the vagina: delayed absorbable sutures (median follow-up, 43 weeks) and permanent sutures (median follow-up, 106 weeks). Failure rates for the 45 subjects in the delayed absorbable group and 148 subjects in the permanent suture group were similar and not statistically different in any compartment: apical, anterior, or posterior. Delayed absorbable monofilament suture appears to be a reasonable alternative to permanent suture for mesh attachment to the vagina during sacrocolpopexy.

Differences in Perceived Difficulty in Print and Online Patient Education Materials
Michael Farnsworth, MA

Patients are often intimidated by the task of reading patient education materials, perceiving the materials' difficulty levels as prohibitive, even when they do not exceed the patients' reading abilities. Some first-year college students perceived online patient education materials to be more difficult to read than print-based ones—even when the reading level of the patient education materials was similar. Patients' perceptions of the difficulty of patient education materials influenced their ability to effectively learn from those materials.

Special Report

Behavior Medicine Specialist
Phillip Tuso, MD, FACP, FASN

A behavioral medicine specialist is a psychologist who works in the medical home with the primary care physician. The key to achieving Total Health will be to transform the current health care system from a focus on treating disease to a focus on preventing disease. This transformation will require complex behavior change interventions and services not usually provided in the medical home. The behavioral medicine specialist will bring the knowledge and experience used to treat mental illness into the medical home to help the primary care physician improve the care of all patients in the medical home.

Special Report

Mindful Mood Balance: A Case Report of Web-Based Treatment of Residual Depressive Symptoms
Jennifer Felder, MA; Sona Dimidjian, PhD; Arne Beck, PhD; Jennifer M Boggs, MSW; Zindel Segal, PhD

Residual depressive symptoms are associated with increased risk for relapse and impaired functioning. Although there is no definitive treatment, Mindfulness-Based Cognitive Therapy (MBCT) has been shown to be effective, but access is limited. Mindful Mood Balance (MMB), a Web-based adaptation of MBCT, was designed to address this care gap. The authors describe a composite case that is representative of the course of intervention with MMB and its implementation in a large integrated delivery system. MMB may be a cost-effective and scalable option in primary care for increasing access to treatments for patients with residual depressive symptoms.

Special Report

Thinking about Thinking and Emotion: The Metacognitive Approach to the Medical Humanities that Integrates the Humanities with the Basic and Clinical Sciences
Quentin G Eichbaum, MD, PhD, MPH, MFA, MMHC, FCAP

The explosion in medical knowledge has exceeded the capacity of the individual human brain to absorb the entirety of this knowledge. This suggests we can no longer expect medical students to continue simply memorizing facts. Instead, we must develop in students a competency as flexible thinkers and agile learners so they can adeptly deal with new knowledge, complexity, and uncertainty in a rapidly changing world. Such a competency would entail not only cognitive but also emotional skills essential for the holistic development of their professional identity. This article will argue that metacognition—"thinking about thinking (and emotion)"—offers the most viable path toward developing this competency.

Review Articles

A Business Case for Tele-Intensive Care Units
Alberto Coustasse, DrPh, MD, MBA, MPH; Stacie Deslich, MA, MS; Deanna Bailey, MS; Alesia Hairston, MS; David Paul, DDS, PhD

A tele-intensive care unit (tele-ICU) uses telemedicine, in an intensive care unit (ICU) setting, to care for critically ill patients by off-site clinical resources. This literature review examined a large number of studies of implementation in hospitals. The evidence supporting cost savings was mixed. Implementation of a tele-ICU system was associated with cost savings, shorter lengths of stay, and decreased mortality. However, two studies suggested increased hospital cost after implementation. Intensivists working these systems are able to more effectively treat ICU patients, providing better clinical outcomes for patients at lower costs compared with hospitals without a tele-ICU.

Case Studies

Vasal Injury During Inguinal Herniorrhaphy: A Case Report and Review of the Literature
Lawrence Flechner, MD, PhD; James Smith, MD, MS; Patrick Treseler, MD, PhD; John Maa, MD

An injury to the vas deferens during inguinal herniorrhaphy from possible tethering of the vas has not, to our knowledge, previously been described in the surgical literature. We report a case of iatrogenic injury of the vas deferens that occurred during elective hernia repair in a 28-year-old man who had previously sustained blunt trauma to the abdomen and pelvis.

Reverse Pseudohyperkalemia in a Patient with Chronic Lymphocytic Leukemia
Taurino Avelar, MD

A man, age 78 years, with a history of chronic lymphocytic leukemia presented to clinic for evaluation of a cough. This case report highlights the importance of distinguishing cases of true hyperkalemia from pseudohyperkalemia and reverse pseudohyperkalemia.

An Incidental Discovery of Low-Grade Appendiceal Mucinous Neoplasm
Aaysha Kapila, MD; Jennifer Phemister, MD; Pranav Patel, MD; Chakradhar M Reddy, MD; Ravindra Murthy, MD; Mark F Young, MD

A 65-year-old man with a history of hyperplastic polyps underwent a surveillance colonoscopy, which revealed a large, smooth cystic bulge at the appendicular orifice. Subsequently, a computed tomography of the abdomen with contrast revealed an appendiceal mucocele measuring 13.3 x 4.5 cm.

Latrodectus Envenomation in Greece
Garyfallia Nikolaos Antoniou, MSc; Dimitrios Iliopoulos, PhD; Rania Kalkouni, MD; Sofia Iliopoulou, MSc; Giorgos Rigakos, MD; Agoritsa Baka, MD

During the summer period 2011-2012, seven widow spider bites in Greece were reported to the Hellenic Center for Disease Control and Prevention. Widow spiders (in the genus Latrodectus) are found all over the world. Antivenin was administered to four patients upon the request of their physicians. The most important goal for all of these patients is early pain relief.


Healthy Behavior Change in Practical Settings
Scott Young, MD

The core principle of implementing healthy behavior change is making the healthy choice the easy choice. Putting this motto into practice requires removal of barriers to live a healthy lifestyle. It is important to look at the bigger picture when helping patients reach optimal health, looking closely at exercise levels and home life. Environmental factors cause strain and present challenges also. The Care Management Institute and Kaiser Permanente are changing default behaviors so optimal lifestyles become the norm, rather than the exception.

Letters to the Editor

Narratives In Medical Education: The Next Steps

Plant-Based Diets in Crohn's Disease

Book Review

The Doctor Crisis
Jack Cochran, MD and Charles Kenney
Review by Edward Ellison, MD

Soul of the Healer

Okavango Evening
David Clarke, MD

The Snorer
David A Dumbrell

Morning Mist
Brad Christian McDowell, MD

Moose Antlers of Eielson
Sally J Cullen, MD, MS

On the Cover

Backlit Aspens Near Monitor Pass, California 2012
Stuart Hahn, MD 


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