Spring 2015 - Volume 19 Number 2

Original Research and Contributions

The Panel Management Questionnaire: A Tool to Measure Panel
Management Capability

Elizabeth Ann Rogers, MD, MAS; Danielle Hessler, PhD; Kate Dube;

Rachel Willard-Grace, MPH; Reena Gupta, MD; Thomas Bodenheimer, MD, MPH; Kevin Grumbach, MD
Primary care practices are turning toward team-based strategies such as panel management, in which nonclinicians address routine preventive and chronic disease care tasks for a group of patients. No known validated instruments have been published for measuring panel management implementation. The authors developed the 12-item Panel Management Questionnaire (PMQ) measuring 4 domains. Data were assembled from self-administered cross-sectional surveys of 136 staff and 204 clinicians in 9 county and 5 university adult primary care clinics. Staff and clinician PMQ scores in each clinic were correlated. The clinic-level median PMQ score was positively associated with a composite clinic quality measure.

Hand-Assisted versus Straight-Laparoscopic versus Open Proctosigmoidectomy for Treatment of Sigmoid and Rectal Cancer: A Case-Matched Study of 100 Patients
Fazli C Gezen, MD; Erman Aytac, MD; Meagan M Costedio, MD; Jon D Vogel, MD; Emre Gorgun, MD
To assess the efficacy of laparoscopic proctosigmoidectomy for cancer treatment, 25 patients who underwent hand-assisted laparoscopic resection during the study period (9/2006 – 7/2012) were matched to 25 straight-laparoscopic and 50 open-surgery cases. The patients who underwent hand-assisted resection had higher rates of preoperative cardiac disease and hypertension than did the straight-laparoscopy and open-surgery groups. Straight-laparoscopic surgery seems to provide faster convalescence compared with open surgery and hand-assisted laparoscopic surgery.

Big Data, Miniregistries: A Rapid-Turnaround Solution to Get Quality Improvement Data into the Hands of Medical Specialists
Lisa J Herrinton, PhD; Liyan Liu, MD, MS; Andrea Altschuler, PhD; Richard Dell, MD; Violeta Rabrenovich, MHA; Amy L Compton-Phillips, MD
The cost to build and to maintain traditional registries for many dire, complex, low-frequency conditions is prohibitive. The authors used accessible technology to develop a platform that would generate miniregistries (small, routinely updated datasets) for surveillance, to identify patients who were missing elected utilization and to influence clinicians to change practices to improve care. The platform, tested in 5 medical specialty departments, enabled the specialists to rapidly and effectively communicate clinical questions, knowledge of disease, clinical workflows, and improve opportunities. Each miniregistry required 1 to 2 hours of collaboration by a specialist. Turnaround was 1 to 14 days.

Expanding Access to Care and Improving Quality in the Mid-Atlantic States Safety-Net Clinics: Kaiser Permanente's Community Ambassador Program
Jared Lane K Maeda, PhD, MPH; Jacqueline J Bradley, MSN, CRNP; Sarah R Eissler, MSN, CPNP; Marcia LoBrano, MD, MPH; Mindy R Rubin; Maritha Gay; Michael A Horberg, MD, MAS, FACP, FIDSA; Bernadette C Loftus, MD
The Community Ambassador Program (CAP) in the Mid-Atlantic States Region places Kaiser Permanente-employed nurse practitioners, midwives, and physician assistants to work in the safety-net clinics and share best practices through a long-term community collaboration. The authors conducted an evaluation of 18 safety-net clinics that participated in the CAP in 2012. The Community Ambassadors provided an estimated 32,249 encounters to 11,988 patients. Performance was at or near 90% for 2 adult quality measures (weight screening and tobacco use assessment). For breast cancer screenings, however, performance among the Community Ambassadors was much lower (48%). The program expanded access and improved quality of care.

Alcohol Intake, Beverage Choice, and Cancer: A Cohort Study in a Large Kaiser Permanente Population
Arthur L Klatsky, MD; Yan Li, MD, PhD; H Nicole Tran, MD, PhD; David Baer, MD, PhD; Natalia Udaltsova, PhD; Mary Anne Armstrong, MA; Gary D Friedman, MD, MS
The authors studied incident cancer risk from 1978 to 1985 and through follow-up in 2012 relative to light-to-moderate and heavy drinking and to the choice of alcoholic beverage in a cohort of 124,193 persons. With lifelong abstainers as referent, heavy drinking (≥ 3 drinks per day) was associated with increased risk of 5 cancer types: upper airway/digestive tract, lung, female breast, colorectal, and melanoma, with light-to-moderate drinking related to all but lung cancer.

Maintenance of Certification Part IV Quality-Improvement Project for Hypertension Control: A Preliminary Retrospective Analysis
Vallerie A Kolasinski, MPH, CHES; David W Price, MD, FAAFP
Fifty-two American Board of Family Medicine and 19 American Board of Internal Medicine certified physicians completed projects to increase the percentage of hypertensive patients on their patient panels who had controlled blood pressure. Mean panel blood pressure control improved from 79.49% to 84.64%. The choice of improvement option was not associated with the level of improvement or with the participant's perception of the workload related to completing the project.

Use of ERC-1671 Vaccine in a Patient with Recurrent Glioblastoma Multiforme after Progression during Bevacizumab Therapy: First Published Report
Daniela A Bota, MD, PhD; Daniela Alexandru-Abrams, MD; Chrystel Pretto, PhD; Florence M Hofman, PhD; Thomas C Chen, MD, PhD; Beverly Fu, NP; Jose A Carrillo, MD; Virgil EJC Schijns, PhD; Apostolos Stathopoulos, MD, PhD
Glioblastoma multiforme is a highy aggressive tumor that recurs despite resection, focal beam radiation, and temozolamide chemotherapy. ERC-1671 is an experimental treatment strategy that uses the patient's own immune system to attack the tumor cells. The authors report preliminary data on the first human administration of ERC-1671 vaccination under a single-patient, compassionate-use protocol. The patient survived for ten months after the vaccine administration without any other adjuvant therapy and died of complications related to his previous chemotherapies.

Special Report
Breast Cancer Survivorship: A Comprehensive Review of Long-Term Medical Issues and Lifestyle Recommendations
Balazs I Bodai, MD, FACS; Phillip Tuso, MD, FACP, FASN
As breast cancer becomes a chronic condition rather than a life-threatening illness, survivors not only have the challenge of dealing with multiple long-term side effects of treatment protocols, but may also be forced to address the preexisting comorbidities of their therapies, which often include multiple other issues. It is imperative that the information available regarding survivorship issues be accessible in an organized and useful format. This article is a modest attempt to provide a comprehensive review of the long-term medical issues.

Special Report
Nutrition Reconciliation and Nutrition Prophylaxis: Toward Total Health
Phillip Tuso, MD, FACP, FASN; Sam Beattie, PhD
Malnutrition by definition may be an abnormality in either under- or overnutrition. Nutrition reconciliation means that all patients have their nutritional status reconciled on admission to and discharge from the hospital. Nutrition reconciliation is defined as the process of maximizing health by helping align an individual's current diet to the diet prescribed for him or her by the health care team. Nutrition prophylaxis is a proactive intervention to prevent a medical complication.

Case Reports

Ruptured Intracranial Lipoma—A Fatty Outburst in the Brain
Vinod Chaubey, MD; Ganesh Kulkarni, MD; Lovely Chhabra, MD
Intracranial lipomas are rare congenital lesions that occur because of abnormal differentiation of embryogenic meninges. These lipomas are usually seen incidentally on brain imaging, and are usually asymptomatic and do not require treatment. The authors present a case of ruptured intracranial lipoma, discovered in an elderly patient presenting with dizziness and episodes of falls.

Atrial Fibrillation and Cor Triatriatum Sinister: A Case Report
Hoa Jeannie Tran, MD; Robert Gordon, MD; Thomas Alloggiamento, MD, MS; Sukhvinder Kaur Nagi, MD, PhD; Ashok Krishnaswami, MD, MAS
A 29-year-old man presented to our hospital with palpitations, shortness of breath, and orthopnea. After being admitted, he progressed to cardiogenic shock and respiratory failure, which required ventilator support and cardioversion. Subsequent evaluation revealed a fibromuscular membrane across the left atrium, requiring urgent corrective surgery.

Rare Case of Myocardial Infarction in a 19-Year-Old Caused by a Paradoxical Coronary Artery Embolism
Jonathan Kei, MD, MPH; Jennifer Kiss Avilla, MD; Jeffrey J Cavendish, MD
This case focuses on a 19-year-old man who developed an inferior ST-segment elevation myocardial infarction as a result of a previously undetected large atrial septal defect. This cardiac anomaly facilitated the transport of a paradoxical embolism that occluded the right coronary artery.

Clinical Medicine

Image Diagnosis: Arachnoid Cyst
Andrew C Karnazes; Jonathan Kei, MD, MPH; Minh V Le, MD
A 14-year-old boy presented with 3 months of generalized headache that had increased in intensity and frequency with associated lightheadedness. Primary arachnoid cysts result from developmental abnormalities; more rare secondary cysts develop as a result of head injury, meningitis, tumors, or as a complication of brain surgery.


The First International Congress on Whole Person Care—A Report
Gary Huffaker, MD, MA; David Petrie, MD, FRCP; Joel Kreisberg, DC, CCH
This report on the First International Congress on Whole Person Care, sponsored by McGill University, is based on the experiences of two attending authors who developed a poster of Integral Theory that emphasized the importance of taking multiple perspectives in all areas of human inquiry to allow a "big picture" perspective on medicine. Interiors (thoughts, intentions, will) of both physician and patient are as important as the exteriors (measurable parameters, such as lab results) which are often emphasized.

Changing Medicine and Building Community: Maine's Adverse Childhood Experiences Momentum
Leslie Forstadt, PhD; Sally Cooper, MD; Sue Mackey Andrews
Physicians are instrumental in community education, prevention, and intervention for adverse childhood experiences. In Maine, a statewide effort is focusing on education about adverse childhood experiences and ways that communities and physicians can approach childhood adversity. This article describes how education about adversity and resilience can positively change the practice of medicine and related fields. It exemplifies the collective impact model by increasing community knowledge, affecting medical practice, and improving lives.

Nursing Research and Practice

Workplace Violence in the Emergency Department: Giving Staff the Tools and Support to Report
Julie Stene, MHA, MSN, RN; Erin Larson, MSN, RN; Maria Levy, RN; Michon Dohlman, MSN, RN
Workplace violence is increasing across the nation's Emergency Departments, and nurses often perceive it as part of their job. Reporting processes were inconsistent, and nurses often did not know what acts constitute violence and underreported it. A staff nurse-led workgroup developed an initial survey and a reporting tool, and education was provided. A posteducation survey documented the reporting of violent acts has increased, and staff perceived the Emergency Department to be a safer environment.

Book Review

40 Years in Family Medicine
Review by Robert W Hogan, MD

Soul of the Healer

Lake Bled
Samuel H Glassner, MD

Summer Storm at Myrtle Beach
John Davenport, MD, JD

Captive Souls
Philip R Brunner, MD, FAAP

Sol Duc Falls
David L Shenson, MD

On The Cover

The Breast Cancer Research Stamp


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