Spring 2020 - Volume 24 Number 2

Original Research

CME Association Between Peripheral Blood Oxygen Saturation (SpO2)/Fraction of Inspired Oxygen (FiO2) Ratio Time at Risk and Hospital Mortality in Mechanically Ventilated Patients
Jason Y Adams, MD, MS; Angela J Rogers, MD, MPH; Alejandro Schuler, MS, PhD; Gregory P Marelich, MD; Jennifer M Fresco, MD; Sandra L Taylor, PhD; Albert W Riedl, MS; Jennifer M Baker, MA; Gabriel J Escobar, MD; Vincent X Liu, MD, MSc
This retrospective, observational cohort study of mechanically ventilated patients at 21 community and 2 academic hospitals demonstrated that in 28,758 derivation cohort admissions, every 10% increase in SpO2/ FiO2 time at risk (SF-TAR) was associated with a 24% increase in adjusted odds of hospital mortality. The SF-TAR can identify ventilated patients at increased risk of death, offering modest improvements compared with single SpO2/FiO2 and P/F ratios. This longitudinal, noninvasive, and broadly generalizable tool may have particular utility for early phenotyping and risk stratification.

Aspirin Use, Compliance, and Knowledge of Anticancer Effect in the Community
Gurpreet Singh Ranger, MD; Cindy McKinley-Brown, RN; Emma Rogerson; Krystal Schimp-Manuel
Little is known about the use of aspirin in our community. Among aspirin users (n = 137), mean age was 65.8 years. Most (76.6%) received an 81-mg daily dose of aspirin. Compliance was 25.6% and was associated with diabetes mellitus. Only 9.5% were aware of the medication’s anticancer effect. Among nonusers (n = 383; mean age 53.3 years) only 4.7% knew of the anticancer effect, and more likely to be women younger than 40 years, and have comorbidities or polypharmacy.

Identifying Patients with Rare Disease Using Electronic Health Record Data: The Kaiser Permanente Southern California Membranous Nephropathy Cohort
Amy Z Sun, MD; Yu-Hsiang Shu, PhD; Teresa N Harrison, SM; Aviv Hever, MD; Steven J Jacobsen, MD, PhD; Michelle M O’Shaughnessy, MD; John J Sim, MD
A retrospective cohort study (6/1999-6/2015) was performed among 4723 patients with kidney biopsy results; they were manually reviewed and designated membranous nephropathy (MN) or non-MN. One year after biopsy, the sensitivity and specificity of an MN diagnosis were 86% and 76%, respectively, but the positive predictive value was 26%. The authors’ findings suggest that ICD-9 diagnosis codes might be a convenient tool to identify patients with MN using electronic health record and/or administrative claims information. Codes selected from supervised learning achieved better overall performance, suggesting the potential of developing data-driven methods.

Challenging the Surgical Axiom: Albumin Level Does Not Reliably Predict Development of Wound Complications in Patients Undergoing Body Contouring
Efstathios Karamanos, MD; Pridvi Kandagatla, MD; Howard Wang, MD; Arielle Hodari Gupta, MD; Aamir Siddiqui, MD
Hypoalbuminemia has traditionally been associated with a poor nutritional status and subsequent high incidence of postoperative wound complications in surgical patients. All 4496 patients undergoing body contouring (2015-2017) were identified using the American College of Surgeons National Surgical Quality Improvement Program database. Wound complications developed in 202 patients (4.5%). Albumin levels were not associated with the development of wound complications, nor with the need for a repeated operation, with readmission, or with the total hospital length of stay.

Immunotherapy Outcomes in Advanced Melanoma in Relation to Age
Krishna Joshi, MD; Dinesh Atwal, MD; Rahul Ravilla, MD; Yadav Pandey, MD; Naveen Yarlagadda, MD; Sunil Kakadia, MD; Issam Makhoul, MD; Laura Hutchins, MD; Fade Mahmoud, MD
Older age is a melanoma risk factor. Elderly individuals are likelier to have immunosenescence, which could help melanoma cells escape immune surveillance. The authors retrospectively identified patients with stage IV melanoma who received at least 1 dose of ipilimumab, pembrolizumab, nivolumab, or combined ipilimumab and nivolumab. In 29 patients (age < 65 years) and 31 patients (age > 65 years), time to progression was comparable, as well as overall survival and overall immunotherapy-related adverse events. Aging does not seem to affect response to checkpoint inhibitors. Elderly patients with metastatic melanoma should be treated similarly to younger patients.

Awareness of Heterotopic Ossification in Total Joint Arthroplasty: A Primer
Michelle J Lespasio, DNP, JD, ANP; AJ Guarino, PhD
Heterotopic ossification (HO) is the presence of normal bone in soft tissue where bone should not exist. Acquired HO related to total joint arthroplasty (TJA) of the hip and knee forms outside the joint capsule and can be a challenging condition when it impairs the essential healing process after elective surgery. Ultimately, patients with clinically relevant HO after elective TJA may require additional treatment, including medication, radiation therapy, manipulation under anesthesia, surgical excision of the HO, and possibly revision TJA

Effects on Medical Students of Longitudinal Small-Group Learning about Breaking Bad News
Edlaine Faria de Moura Villela, PhD; Luana Kronit Bastos; Wanderson Sant’ana de Almeida; Andressa Oliveira Pereira; Matheus Silva de Paula Rocha; Fábio Morato de Oliveira, PhD; Valdes Roberto Bollela, PhD
An exploratory study using a qualitative approach was done at a Brazilian public university’s medical school (30 medical students per semester). Two focus groups in 2018 (15 per group) before and after training—a 6-month (4 h/wk) course. Preintervention, only 30% of the students were aware of the importance of breaking bad news and of the existence of specific protocols to guide physicians in these situations. Postintervention, 90% understood the importance and applied protocols in their practice.

Fostering Partnerships with the Safety Net: An Evaluation of Kaiser Permanente’s Community Ambassador Program in the Mid-Atlantic States
Lorella Palazzo, PhD; Juno Matthys; Craig Sewald, MPA; Natasha Arora, MS; Maggie Jones, MPH; Jacqueline Bradley, MSN, MSS, CRNP; Sallie Eissler, RN, MSN, CPNP; Mindy R Rubin; Tanya M Edelin; Maya Nadison, PhD, MS
From 2013 to 2017, Community Ambassadors (CAs) filled 32.8 full-time equivalent positions and conducted 294,436 patient encounters in 19 clinics. In certain years and for subsets of clinics, CAs performed above average on 2 high-priority quality measures: Cervical cancer screening and diabetes (blood glucose) control. Interviews with 15 CAs, 15 health centers leaders, and 7 Kaiser Permanente (KP) Mid-Atlantic States staff members revealed that CAs improved patient access, clinic capacity, and care quality, and also exported KP best practices and supported KP’s community relations

Prostate Cancer and Asbestos: A Systematic Review and Meta-Analysis
Frédéric Dutheil, MD, PhD; Laetitia Zaragoza-Civale, MD; Bruno Pereira, PhD; Martial Mermillod, PhD; Julien S Baker, PhD; Jeannot Schmidt, MD; Fares Moustafa, MD, PhD; Valentin Navel, MD
The authors included 33 studies with 15,687 cases of prostate cancer among 723,566 individuals. Asbestos exposure, and respiratory inhalation, increased the risk of prostate cancer. Both environmental and occupational exposure increased the risk of prostate cancer. The risk was higher in Europe, without significant results in other continents.

A Novel Instrument for Integrated Measurement and Assessment of Intrinsic Motivation, Team Climate, and Burnout in Multidisciplinary Teams
Maya Khazei; Ali Rafik Shukor, M Biotech, MSc
There is increasing recognition of the importance of intrinsic motivation, team dynamics, and burnout in multidisciplinary teams striving to achieve the Quadruple Aim. An online survey was administered to a 38-member multidisciplinary team working at an urgent primary care center in Vancouver, Canada. Only 8% of 25 respondents met the threshold level of burnout, with no respondents indicating severe or complete burnout. These ratings align with the scores for team climate and intrinsic motivation.

Capturing Risk Associated with Childhood Adversity: Independent, Cumulative, and Multiplicative Effects of Physical Abuse, Sexual Abuse, and Family Violence on Mental Disorders and Suicidality
Kathryn Wiens, MSc; Jennifer Gillis, MSc; Ioana Nicolau, MSc; Terrance J Wade, PhD

Special Reports

CME Adverse Childhood Experiences (ACEs) and Community Physicians: What We’ve Learned
Brian R Stork, MD, FACS; Nicholas John Akselberg; Yongmei Qin, MD, MS; David C Miller, MD, MPH
Most physicians surveyed (81%) reported they had never heard of the ACE questionnaire. Even fewer (3%) reported using the questionnaire in clinical practice. Most physicians (55.5%) reported no personal history of ACEs. Physicians reporting a history of childhood trauma reported a wide range of ACE scores (1-9). Women reported a statistically higher number of ACEs. Physicians in this study reported a lower prevalence of ACEs than the population they serve.

Working to Acheive the Quadruple Aim
Nancy Gin, MD; Patrick Courneya, MD
Quality improvement activities are essential to achieving the Institute for Healthcare Improvement’s Quadruple Aim of improving the health of our patients and members, enhancing members’ care experiences, reducing costs, and attaining joy and meaning for our physicians and care teams in the workplace. These activities are also essential in creating a learning health care system.

Kaiser Permanente 2020 National Quality Conference

Review Articles

CME Comprehensive Outpatient Management of Low-Risk Pulmonary Embolism: Can Primary Care Do This? A Narrative Review
David R Vinson, MD; Drahomir Aujesky, MD, MS; Geert-Jan Geersing, MD, PhD; Pierre-Marie Roy, MD, PhD
The authors undertook a narrative review of the literature on the outpatient management of acute pulmonary embolism (PE) from 1/1950-7/2019, focusing on the site of care. No studies evaluated PE management in primary care or general practice settings. The site-of-care decision was made with in the Emergency Department or Specialty Clinic. The authors see no formal reason why a trained primary care physician could not provide comprehensive care for select patients with low-risk PE. The obstacles would be access to advanced pulmonary imaging and time constraints of practice.

Primary Breast Carcinoma of the Vulva Metastatic to Lymph Nodes and Bones: A Case Report and Literature Review
Aneesha Ananthula, MD; Blake Lockwood, MD; John Savage, MD; Sharp Malak, MD; Chien Chen, MD; Issam Makhoul, MD; Angela Pennisi, MD
Primary breast carcinoma can occur at ectopic sites. in a 47-year-old premenopausal woman, a vulvar adenocarcinoma was positive for estrogen receptor and negative for progesterone receptor and human epidermal growth factor receptor 2/neu. For a diagnosis of primary breast cancer of the vulva, a thorough metastatic workup should be performed, with attention directed toward detecting a breast primary disease to confirm the vulvar lesion is the primary site.

Negative-Pressure Wound Therapy to Reduce Wound Complications after Abdominoperineal Resection
Rebecca Gologorsky, MD; Shruti Arora; Anahita Dua, MD, MS, MBA
The authors performed a systematic review (PubMed database 1990-2019) including English-language studies using incisional negative-pressure wound therapy (NPWT) for closed wounds from abdominoperineal resection in malignancy cases (5 studies with 76 patients). Their findings showed reduced rates of surgical site complications with the use of incisional NPWT. Another 2 studies describing the use of prophylactic NPWT to expedite secondary closure of the surgical wound followed by incisional wound therapy were separately categorized and included 8 patients, none of whom experienced wound complications


CME Pharmacist Medication Management of Adults with Attention Deficit: An Alternative Clinical Structure
Rex Huang, MD; Samuel J Ridout, MD, PhD; Brooke Harris, PhD; Kathryn K Ridout, MD, PhD; Kavitha Raja, MD
Attention-deficit/hyperactivity disorder (ADHD) is one of the most common psychiatric conditions in youth. This disorder can persist into adulthood, with an estimated prevalence of 4.4% to 5.2% in the US. This program created a standardized protocol for assessment, referral, and follow-up of adult patients with ADHD, with close monitoring and titration of controlled medications, systematic use of screening measures, and a stimulant treatment contract. We believe this program offers a solution to a component of this growing problem, and other clinical sites would benefit from such a program.

Trauma-Informed Care in Pediatrics: A Developmental Perspective in Twelve Cases with Narratives
Joshua Strait, DO; Sean Meagher, MD
The dose-response relationship of adverse childhood experiences (ACEs) with chronic morbidities is recognized as prevalent. During pediatric residency training, the author implemented routine universal screening using ACE questionnaires. Clinical vignettes describe 12 cases. Addressing ACEs opened crucial conversations with some patients, which promoted efficacious, developmentally sensitive care. Implementing trauma-informed care in the pediatric setting, especially in training, is feasible and vital to understand the patient population. With clinical knowledge and experience in addressing ACEs, practitioners will empower patients and their families to improve health outcomes.

Mixed Serous and Clear Cell Adenocarcinoma of the Ovary Presenting with Symptomatic Hypercalcemia: A Case Report and Clinical Considerations
Julia L Boland; Darius Shahbazi; Stephen E Wang, MD; Shahin Z Shahbazi, MD

Case Reports

Rapid Induction Therapy for Opioid-Use Disorder Using Buprenorphine Transdermal Patch: A Case Series
Daniel Saal, MD; Frank Lee, MD
The authors present a case series involving a novel approach to transdermal induction of buprenorphine or buprenorphine-naloxone therapy that has been demonstrated in inpatient settings but not widely explored in the outpatient setting. A range of patients, from the highly medically complex to relatively straightforward cases, benefited and can be used without the patient having to experience withdrawal or wait to start treatment. This should reduce the risk of lack of return for follow-up as well as decrease the dropout rate caused by inability to tolerate withdrawal symptoms.

Drug-Induced Lupus, a One-time Hit or a Harbinger of Future Autoimmunity: A Case Report
David Kirakossian, MD; Pradipta Ghosh, MD
Drug-induced lupus (DIL) can comprise up to 10% of new lupus cases annually, and the list of medications associated with DIL is increasing. However, it can be difficult to recognize the connection between symptoms and a medication-induced autoimmune syndrome, which can lead to an invasive, costly workup. The case highlights how DIL should be on the differential when seemingly disparate symptoms develop in a patient receiving DIL-associated medications. Lupus is one of the “great imitators,” in which symptoms can be ascribed to many different underlying causes.

Evolving Treatment of Frontal Sinus Cholesteatoma: A Case Report
Nizar Tejani, MD; Rijul Kshirsagar, MD; Brian Song, MD; Jonathan Liang, MD
Cholesteatomas are lined by squamous epithelium, contain keratin debris, and can cause bony erosion. A 45-year-old man presented with a 1-week history of right eyelid and forehead swelling. Images revealed a right frontal sinus lesion of soft-tissue density with bony dehiscence along the superior orbit and posterior table, the frontal sinus contained keratin debris. The pathogenesis of frontal sinus cholesteatoma varies based on its cause (congenital vs acquired).

Primary Functioning Neuroendocrine Tumor of the Appendix with Hypoglycemia Syndrome: A Case Report and Review of Neuroendocrine Tumors
Peter F Layman, DO; Deborah Davis-Merritt, MD; Phillip Neff, MD

Primary Renal Carcinoid Tumor: Report of Two Cases
Ramzi Jabaji, MD; Tyler Kern, MD; Dejun Shen, MD; William Chu, MD; Madhur Merchant, MD

Graphic Medicine

Stories and poems written by clinicians in 15 minutes in writing workshops about meaningful moments in their work and life of practicing medicine. To better communicate health care experiences, our intention is to use graphic images with simple clinician or patient stories. Professional artists were asked to create a visual representation of the story.

This graphic submission is the dramatization of a true incident. It is intended to show the shock, surprise, sadness, guilt, futility and resignation I and many physicians feel in the face of the opioid crisis.

Abby Caplin, MD, MA

Footsteps on the Floating Dock
Michael Parchman, MD


Addressing the Health Needs of the Uninsured: One Community’s Solution
Lynne M Hutchison, DNP, FNP-BC; Raymond L Cox, MD, MBA
Volunteers in Medicine on Hilton Head Island, SC, provides free health care, with 28,000 eligible patient visits annually, for the underserved population. Self-funded through donations and charity events, it accepts no federal money. Patients are not asked to pay a fee for service. Most medical specialties are represented in the clinic, with partnerships in place for referrals for advanced procedures like surgery. All health care clinicians (physicians, nurses, dentists, mental health professionals) are volunteers.

Narrative Approaches to North American Indigenous People who Attempt Suicide
Lewis Mehl-Madrona, MD, PhD; Barbara Mainguy, MA, MSW
As a senior health care administrator, I was intrigued by ways to enhance the skills of a new physician leader to help others succeed. Emotional intelligence is a key characteristic, though skills and behaviors can be learned. Emerging leaders can: Listen to various points of view, develop a “let’s go see” attitude, gather all the facts before making a decision, train others to be leaders, embrace a spirit of adventure, and develop a knowledge of statistics and finance.

Insights for New Physician Leaders
Martha P Gilmore, MBA

Book Review

MD Aware: A Mindful Medical Practice Course Guide
Patricia Lynn Dobkin, PhD
It describes a course rolled out in 2015 that aims to reinforce positive qualities inherent in medical students that will help them maintain their enthusiasm for medicine and provide them with the means to hold onto their humanity.


Transition at TPJ
Stephen Tarnoff, MD, Editor in chief (interim)

Let’s Care for Those in Need—Today: Collaborating to Solve the Uninsured Crisis in America
Lee Jacobs, MD
In this issue of The Permanente Journal, 2 articles detail strategies for providing care to those in need. Given a choice of standing on the sidelines, listening and watching, these people acted. They chose to deal with todays’ realities—and to care for the uninsured. They are heroes—and like others across the country also acting. This major crisis must be addressed now. We need a countrywide safety-net movement, led by the health care community, driven by the crisis, and fueled by collaboration and compassion.

Multiples of Median Income: A Tool to Call out Drugs that are High Cost and Low Value
Thomas E Kottke, MD; Andrew R Zinkel, MD; Charles J Fazio, MD

Narrative Medicine

Narrative Approaches to North American Indigenous People Who Attempt Suicide
Lewis Mehl-Madrona, MD, PhD; Barbara Mainguy, MA, MSW
Case files from an academically affiliated, rural psychiatric practice focused on indigenous patients were reviewed for 54 indigenous patients who attempted suicide. Nine major successful strategies were: Introducing novel contradictory ideas to the beliefs people held about suicide, using stories to introduce that desired effects of suicide might not be forthcoming, including story to find means other than attempting suicide to reach the same, creating stories of a positive future, and finding ways to bring humor into the discussion. Of 29 patients in this narrative approach, 26 had no further suicide attempt. In a comparison population, 90% attempted again.

Haiku and Healing—Creating Connections
Brian Stork, MD

A House Call
Arsheeya Mashaw, MD

“Not Until I See My Other Doctor”
Henry Bair

“Of Course You Want To Die”
Maria Maldonado, MD

Letter to the Editor

Novel use of Apple Watch 4 to Obtain 3-lead Electrocardiogram and Detect Cardiac Ischemia

Soul of the Healer

Latifat Apatira, MD

Just Before Sunrise
Jorge A Ramirez, MD

Emery Boudreau

Pain, Seeking Relief
Kristina Alton

Shades of Purple and Yellow at Sunset
Michael House, LCSW

On the Cover

Jorge A Ramirez, MD


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