Fall 2015 - Volume 19 Number 4

Original Research and Contributions

Study of the Use of Lipid Panels as a Marker of Insulin Resistance
to Determine Cardiovascular Risk

Ruth Ann Bertsch, MD, PhD, FACP; Maqdooda A Merchant, MSc, MA
The authors followed 103,646 members aged 50 to 75 years without cardiovascular disease or diabetes in a community health plan. Subjects were categorized as insulin sensitive or insulin resistant on the basis of triglyceride and high-density lipoprotein cholesterol (HDL-c) in the index year. The primary outcome was ischemic heart disease. Insulin resistance, as manifested by a high triglyceride/HDL-c ratio, was associated with cardiovascular outcomes more than other lipid metrics, including low-density lipoprotein cholesterol, which had little concordance.

Right-Side Colon Ischemia: Clinical Features, Large Visceral Artery Occlusion, and Long-Term Follow-Up
George F Longstreth, MD, FAGA, FACG; Robert J Hye, MD, FACS
Large visceral artery occlusion (LVAO) could underlie right-side colon ischemia (RSCI) but is little known. In a retrospective observational study in an integrated health care system, 19 of 49 patients underwent surgery—5 of 6 developed RSCI in hospital following surgical procedures and 14 of 43 had RSCI before hospitalization. Among 44 survivors (median follow-up of 5.19 years) 5, including 3 of 15 operated cases, had symptomatic LVAO and underwent angioplasty and stent placement. Patients with RSCI may have symptomatic LVAO; therefore, we advise they undergo careful query for symptoms of abdominal angina and routine visceral artery imaging.

Effect of Structured Touch and Guided Imagery for Pain and Anxiety in Elective Joint Replacement Patients—A Randomized Controlled Trial: M-TIJRP
John Brent Forward, MD, FACP, ABIHM; Nancy Elizabeth Greuter, RN, LMT, NCTMB, CCAP; Santa J Crisall, RN, MA, NP-C, PsyD; Houston F Lester, MS
At a community hospital, 225 male and female patients, aged 38 to 90 years, undergoing elective total hip or knee replacement were randomly assigned to 1 of 3 groups (75 patients in each): "M" technique (M, a registered method of structured touch), guided imagery, or usual care. M showed the largest predicted decreases in both pain and anxiety between groups. There was no significant difference in narcotic pain medication use between groups. Patient satisfaction survey ratings were highest for M, followed by guided imagery.

Patient Satisfaction after Thoracoscopic Sympathectomy for Palmar Hyperhidrosis: Do Method and Level Matter?
Amy Cheng, MD; Hege Johnsen, MD; Michael Y Chang, MD
Although surgery is widely recognized as the best treatment for palmar hyperhidrosis (PH), the technique is based on surgeon preference. In a retrospective medical chart review, 635 patients underwent bilateral thoracoscopic procedures for PH between 1995 and 2010, and 210 (33%) responded to the questionnaires. Sixteen surgeons performed 108 sympathicotomies, 83 sympathectomies, and 19 ligations with titanium clips. Mean follow-up was 5.5 years. Most patients reported relief of their PH and were satisfied with surgical intervention, regardless of method used.

An Education Program for Patient Self-Management of Warfarin
Kathleen M Jenner, PharmD, BCPS, CACP; Brandon J Simmons, PharmD, BCPS, CACP; Thomas Delate, PhD; Nathan P Clark, PharmD, FCCP, BCPS; Deanna Kurz; Daniel M Witt, PharmD, FCCP, BCPS
Developing and administering a warfarin Patient Self-Management (PSM) education program for those with atrial fibrillation was feasible. There was improvement in PSM competency (34.9% to 95.3%) and high levels of self-reported comfort (100% prepared to self-manage warfarin and 93% comfortable changing doses on their own).

Safely Increase the Minimally Invasive Hysterectomy Rate: A Novel Three-Tiered Preoperative Categorization System Can Predict the Difficulty for Benign Disease
Esteban Andryjowicz, BScPhm, MD, FACOG; Teresa B Wray, MD, FACOG; V Reinaldo Ruiz, MD, FACOG; Sara Noroozkhani, MD, FACOG; Sandra Crowder, MD, FACOG; Jeff M Slezak
A nonlaparotomic route is recommended for hysterectomy for benign indications. All hysterectomies for benign disease performed at a Medical Center in 2012 were reviewed. Of 576 hysterectomies performed for benign disease, 89% were minimally invasive hysterectomies with a 3% complication rate and 4% readmission rate. Using of 4 preoperative parameters, the average operating time for hysterectomy for benign disease can be predicted. A higher hysterectomy category predicts a more difficult surgery.

Incentive-Based Primary Care: Cost and Utilization Analysis
Marcus J Hollander, MA, MSc, PhD; Helena Kadlec, MA, PhD
This study used Canadian Ministry of Health administrative data for Fiscal Year 2010-2011. After controlling for patients' age, sex, service-needs level, and continuity of care (ie, attachment to a general practice), the incentives reduced the net annual health care costs for patients with hypertension, chronic obstructive pulmonary disease, and congestive heart failure, but not for diabetes. The incentives were also associated with fewer hospital days, fewer admissions and readmissions, and shorter lengths of hospital stays for all 4 groups.

Anxiety's Impact on Length of Stay Following Lumbar Spinal Surgery
Hollis Floyd; Mazen Sanoufa, MD; Joe Sam Robinson, MD
The authors retrospectively reviewed the medical records of 307 patients who consecutively underwent elective lumbar decompression and fusion surgery from October 1, 2010 through September 30, 2013. This study suggests that those with a diagnosis of anxiety who are medicated for the condition have a longer length of stay than those with no diagnosis of anxiety, and who are not medicated for the condition. This could be because when these patients are required to be nil per os for 12 hours before surgery it leaves them vulnerable to states of anxiety.

Special Report

Navigating the Next Accreditation System: A Dashboard for the Milestones
Samir Johna, MD; Brandon Woodward, MD
In July 2014, all residency programs accredited by the Accreditation Council for Graduate Medical Education were enrolled in the new Next Accreditation System. The authors used existing electronic goals and objectives for each rotation coupled with appropriate end-of-rotation evaluations reflecting the specialty-specific milestones. A resident's final, overall performance was visually represented on a plot graph. The novel dashboard proved simple to use and reduced the time for each resident evaluation to 5 to 10 minutes.

Special Report

SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): Revised Publication Guidelines from a Detailed Consensus Process
Greg Ogrinc, MD, MS; Louise Davies, MD, MS; Daisy Goodman, DNP, MPH; Paul Batalden, MD; Frank Davidoff, MD; David Stevens, MD
Since the publication of Standards for QUality Improvement Reporting Excellence (SQUIRE 1.0) guidelines in 2008, the science of the field has advanced considerably. SQUIRE 2.0 is intended for reporting the range of methods used to improve health care, recognizing that they can be complex and multidimensional. It provides common ground to share these discoveries in the scholarly literature (www.squire-statement.org). This is a simultaneous publication with BMJ Quality and Safety.

Costs and Utilization of Operating Rooms in a Public Hospital in Trinidad, West Indies
Seetharaman Hariharan, MBBS, MD, FCCM; Deryk Chen, MBBS, FRCA, MBA
This quantitative observational study was conducted to determine the costs and utilization of Operating Rooms (ORs) in a public hospital in Trinidad, West Indies, for two one-year periods using a top-down model. The adapted cost-block model was used to evaluate the costs of ORs in a public hospital and can be used from the government's expenditure perspective. Because the cost of running the ORs was enormous, efficiency had to be improved to minimize waste.

Review Articles

Primary Epithelial Neuroendocrine Tumors of the Retroperitoneum
Ahmed Dehal, MD; Sean Kim, MD; Aamna Ali, MD; Thomas Walbolt, DO
Neuroendocrine tumors are either epithelial or neural in origin. Neuroendocrine tumors of the retroperitoneum are mostly metastatic. Primary epithelial neuroendocrine tumors of the retroperitoneum are exceedingly rare. The authors describe the case of a retroperitoneal tumor that was discovered incidentally during exploratory laparotomy for small-bowel obstruction. The literature is reviewed and discussed. To date, this is only the fifth reported case.

Case Reports

High-Dose Viscum album Extract Treatment in the Prevention of Recurrent Bladder Cancer: A Retrospective Case Series
Tido von Schoen-Angerer, MD, MPH; Johannes Wilkens, MD; Gunver S Kienle, MD; Helmut Kiene, MD; Jan Vagedes, MD, MA
Viscum album extract (European mistletoe), containing immune-active compounds with dose-dependent cytotoxic activity, is being used as an adjuvant cancer treatment in Europe. Few studies have been done with high-dose, fever-inducing Viscum album treatment. The authors retrospectively analyzed the case notes of patients with resectable bladder cancer who underwent initiation of high-dose Viscum album treatment at their clinic between January 2006 to December 2012. High-dose Viscum album showed a possible beneficial effect in 5 of 8 patients. No tumor progression was observed. Treatment was generally well tolerated and no patient stopped treatment because of side effects.

An Unusual Presentation of Dengue Fever: Association with Longitudinal Extensive Transverse Myelitis
Laxmikant Ramkumarsingh Tomar, MD; Velmurugan Mannar, MD; Sonal Pruthi, MBBS; Amitesh Aggarwal, MD, MAMS, PGCC (Cardiology), FIACM
The authors describe a middle-aged man who presented with dengue fever and in whom weakness of his bilateral lower limbs and urinary incontinence developed on the third day of fever. Magnetic resonance imaging confirmed the diagnosis of longitudinally extensive transverse myelitis. Over a four-week course of corticosteroids with supportive management, the patient recovered without any residual neurologic deficit.

Clinical Medicine

ECG Diagnosis: Isolated Posterior Wall Myocardial Infarction
Joel T Levis, MD, PhD, FACEP, FAAEM
The ECG diagnosis of posterior wall myocardial infarction (MI) is difficult because no specific leads of the standard ECG directly represent this area. In addition, the lack of ST-segment elevation (as seen in typical ST-elevation MI) combined with misinterpreting the anterior ST-segment depressions as indicating ischemia rather than posterior infarction frequently lead to missing the diagnosis of posterior wall MI.

Isolated Pancreatic Histoplasmosis: An Unusual Suspect of Pancreatic Head Mass in an Immunocompetent Host
Avin Aggarwal, MD; Shashank Garg, MD
Histoplasmosis is endemic to the Mississippi and Ohio River valley regions in the US. It usually affects patients with underlying immunodeficiency but can also be seen in immunocompetent hosts. Isolated gastrointestinal involvement is uncommon.


Strategies to Increase Physical Activity
Phillip Tuso, MD, FACP, FASN
One key intervention to prevent preventable diseases and to make health care more affordable is to increase the percentage of Americans who are physically active. No single intervention will increase activity rates, but a group of interventions working together in synergy may be the stimulus needed to get Americans moving.

Research Letter: Sensor-Based Systems and the Objective Measure of Physical Activity
Phillip Tuso, MD, FACP, FASN
Similar to medication adherence, objective measures of physical activity may allow physicians to improve activity rates among individual patients and patient populations, which should improve health care outcomes. Sensor-based systems may become a best practice for objective measurement of physical activity and the management of physical activity programs. Given the ease of tracking with these new devices and the ability to upload information automatically, a sensor-based system has the potential to prevent preventable diseases and lower health care costs.

Nursing Research and Practice

Caring Science: Transforming the Ethic of Caring-Healing Practice, Environment, and Culture within an Integrated Care Delivery System
Anne Foss Durant, RN, MSN, NP, NEA-BC; Shawna McDermott, MBA; Gwendolyn Kinney, RN, MSN; Trudy Triner
The intent of this article is two-fold: 1) to provide context and background on how a professional practice framework was used to transform the ethics of a caring-healing practice, environment, and culture across multiple hospitals within an integrated delivery system; and 2) to provide evidence on how integration of Caring Science across administrative, operational, and clinical areas appears to contribute to meaningful patient quality and health outcomes.

Narrative Medicine

Primary Health Care and Narrative Medicine
John W Murphy, PhD
Key to the strategy to improve health care outlined at the Alma Ata conference in 1978 is citizen participation in every phase of service delivery. But a new epistemology, compatible with narrative medicine, is necessary so that local knowledge is elevated in importance and incorporated into the planning, implementation, and evaluation of health programs. In this way, relevant, sustainable, and affordable care can be provided. The aim of this article is to discuss how primary health care might be improved through the introduction of narrative medicine into planning primary health care delivery.

Book Review

The Lost Art of Retinal Drawing
Review by Mark Cohen, MD

Soul of the Healer

Umbrellas for Sale
Stuart Hahn, MD

Île d'Orléans, Quebec
Gerald Levy, MD, MBA

Heading Home
Cathleen VanBergen

Scarlet Macaws at a Mineral Lick, Tambopata National Reserve, Peru
Stuart Hahn, MD

On the Cover

The Wheel of Life
Daniela Alexandru Abrams, MD


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