Summer 2021 - Volume 25 Number 3



An Intervention to Tag Findings Suspicious for Lung Cancer on Chest Computed Tomography Has Good Sensitivity and Number Needed to Diagnose

Jennifer R Dusendang, MPH; Lori C Sakoda, PhD; Thomas H Urbania, MD; Sora Ely, MD; Todd Osinski, MD; Ashish Patel, MD; Lisa J Herrinton, PhD

Among patients who obtained an index chest computed tomography (CT) exam from January 2015 to July 2017 without an exam in the previous 2 years, we computed the frequency of lung cancer diagnosis within 120 days of CT in relation to each #PUL tag. For #PUL5, we computed sensitivity, specificity, positive and negative predictive values, and number needed to diagnose. We also performed chart review to assess why some patients diagnosed with lung cancer were not tagged #PUL5.

Measuring Greater Patient­-Provider Continuity in a Clinic-First Family Medicine Residency Curriculum

Kathleen J Paul, MD, MPH; Brandon H Hidaka, MD, PhD; Paul Ford, MS; Carl Morris, MD, MPH

Continuity is valued by patients, clinicians, and health systems for its association with higher-value care and satisfaction. Continuity is a commonly cited reason for entering primary care, but it is difficult to achieve in residency settings. We sought to determine the effect of transitioning from a traditional block (13 4-week rotations per year) to a clinic-first (priority on outpatient continuity) curriculum on measures of continuity in our family medicine residency.

Three Learning Organizations in Cataract Surgery: The Example of Intracameral Antibiotic Injection

Neal H Shorstein, MD; Per Montan, MD; Aravind Haripriya, MD; Mats Lundström, MD; Lisa Herrinton, PhD

The recent systematic adoption of intracameral antibiotic injection during cataract surgery in Sweden, India, and the United States serves as a model for the successful transitioning of local, quality-improvement initiatives to organizationwide implementation. Although the delivery of eye care in the three countries is distinctly organized with differing governances and technological infrastructure, each contains elements of a learning organization.

High-Flow Nasal Cannula Use in Children with Bronchiolitis in a Community Hospital Setting: Evaluation of Safety, Flow Limits, and Intensive Care Unit Transfers

Patrick J Van Winkle, MD; Allen M Castro, BS; Shareemae A Salvador-Lloyd, RN; Janet M GilbertLambert, RRT; Qiaoling Chen, MS

High-flow nasal cannula oxygen therapy is being used in pediatric wards at increasing rates, including community hospitals that do not have a pediatric intensive care unit. This study describes the use of high-flow nasal cannula in a pediatric ward at a community hospital, evaluating safety, flow limits, and outcomes for children transferred to a pediatric intensive care unit.

A Novel, Structured Fellow Training Pathway for Robotic-Assisted Sacrocolpopexy

Tatiana Catanzarite, MD, MAS; Jasmine Tan-Kim, MD, MAS; John N Nguyen, MD; Sharon Jakus-Waldman, MD; Shawn A Menefee, MD

We developed a novel education pathway for robotic-assisted sacrocolpopexy (RASC) fellows and compared step-specific and total operative times for RASC performed by Female Pelvic Medicine and Reconstructive Surgery attendings to those in which fellows performed part or all of the RASC. We further aimed to compare complication and readmission rates by fellow involvement.

Patterns of Care and Treatment Outcomes for Outpatient Daptomycin-Containing Regimens in Osteomyelitis

Thomas Delate, PhD, MS; Julia K Nguyen, PharmD; Jonathan T Truong, MD; Fang Niu, MS; Arman Haghighatgoo, PharmD

Use of daptomycin at doses ≥ 6 mg/kg for treatment of osteomyelitis is increasing in clinical practice; unfortunately, limited data are available to guide optimal dosing and duration. The objective of this study was to assess daptomycin dosing and duration regimens for osteomyelitis treatment.

Understanding Patient and Clinical Stakeholder Perspectives to Improve Adherence to Lung Cancer Screening

Karen J Wernli, PhD; Leah Tuzzio, MPH; Sarah Brush, BA; Kelly Ehrlich, MS; Hongyuan Gao, MS; Melissa L Anderson, MS; Lorella Palazzo, PhD

We identified clear gaps in adherence to lung cancer screenings, organizational and clinical barriers to care, and design features for patient-centered interventions to improve lung cancer screening in the United States.

A Retrospective Analysis of Intracranial Pressure Monitoring and Outcomes in Adults After Severe Traumatic Brain Injury at Kaiser Permanente Trauma Centers

Kaveh Barami, MD, PhD; Jessica Pemberton, MSN; Amit Banerjee, MD; Jason London, MD, PhD; William Bandy, MD

Intracranial pressure (ICP) monitoring may not impact in-patient mortality or long-term outcomes at Level II trauma centers. Improved outcomes may be more related to identifying patients who may benefit from ICP-guided therapy rather than simply increasing the overall use of it. Our pattern of care and outcomes is comparable to Level I trauma centers and our findings may serve as a benchmark for future studies.

Complex Trauma Care Pathway: Results of a 12-Month Pilot

Josephine Bilbao Bourke, LCSW, LICSW; Jordan Dobrovolny, LCSW, LICSW; Melanie Eaton, LCSW; Theresa Ferrante, LCSW, MPA:HA; Megan Smith, LPC

The Complex Trauma Care Pathway shows promising clinical efficacy and should be evaluated using a more rigorous design. Further research should also explore the relationship between the pathway or similar interventions and chronic disease management, overall health care utilization, and suicide risk.

Potential Role of Cardiopulmonary Exercise Testing as an Early Screening Tool for Patients With Suspected Pulmonary Hypertension Including Exercise-Induced Pulmonary Hypertension: Results From a Retrospective Analysis

Zulfiqar Qutrio Baloch, MD; Shabber Agha Abbas, MD; Rohan Madhu Prasad, DO; Amin M Elamin, MD, FACP; MD, FACC

The primary goal of our retrospective, case-control study was to evaluate the ability of cardiopulmonary exercise testing to screen for underlying exercise-induced pulmonary hypertension in symptomatic patients who had a negative stress test and elevated right-ventricular systolic pressure on echocardiogram. We also evaluated long-acting nitrates and ranolazine as medication challenges.

A Pilot Study on the Awareness and Knowledge of Adverse Childhood Experiences Science and Trauma-Informed Care Among Medical School Students

Jere Tan, BS; Shanta R Dube, PhD, MPH

Childhood trauma is widespread and contributes to clinical, behavioral, and social health consequences. Despite over two decades of research from the Centers for Disease Control and Prevention and Kaiser Permanente Adverse Childhood Experiences (ACEs) study, ACEs science is still not fully integrated into medical school curriculum. We conducted a pilot study to assess the level of awareness about ACEs and trauma-informed care curriculum among medical students.

Is the Preparticipation Physical Examination Replacing the Annual Well Child Examination Among Student Athletes?

Eldra W Daniels, MD, MPH; Cayce A Onks, DO, MS, ATC; Robert A Gallo, MD; Matthew L Silvis, MD

The majority of student athletes complete both a well-child examination and a preparticipation physical examination (PPE) annually. Parents believe screening electrocardiograms are effective in preventing sudden cardiac death and that the PPE can prevent injuries from occurring. Parents also believe the PPE can serve as an opportunity to discuss mental and substance abuse, which is consistent with the most recent PPE monogram. An educational handout should be provided to parents regarding the goals of the PPE.

Caudal Epidural Injections in Lumbar Spinal Stenosis: Comparison of Nonimage, Ultrasonography-, and Fluoroscopy-Guided Techniques. A Randomized Clinical Trial

Frideriki Poutoglidou, MD; Dimitrios Metaxiotis, MD, PhD; Angelo V Vasiliadis, MD, PhD; Dimitrios Alvanos, MD; Anastasios Mpeletsiotis, MD, PhD

Caudal epidural injections are widely used in the treatment of lumbar spinal stenosis. Imaging modalities, such as fluoroscopy and ultrasonography, are frequently employed to confirm proper needle placement and prevent possible complications. This prospective, randomized study aims to compare the efficacy of nonimage-, ultrasonography-, and fluoroscopy-guided caudal epidural injections for the management of lumbar spinal stenosis.

The Relationship Between Racial/Ethnic Concordance and Hypertension Control

Francesca Adriano, MD; Raoul J Burchette, MS; Alyson C Ma, PhD; Alison Sanchez, PhD; Mindy Ma, PhD

Given the increase in health care costs due to hypertension on the economy, understanding high blood pressure control is warranted, particularly as it pertains to racial and ethnic disparities. To understand the relationship between hypertension control and racial and ethnic concordance, we investigated whether concordance between a patient’s race and ethnicity and that of the individual’s provider is a predictor of high blood pressure control.

Description and Early Results of the Kaiser Permanente Southern California COVID-19 Home Monitoring Program

Dan Ngoc Huynh, MD; Alyssa Millan, MPH; Earl Quijada, MD; Deborah John; Shariq Khan; Tadashi Funahashi, MD

The Southern California region of Kaiser Permanente developed a COVID-19 home monitoring program as an alternative to hospital admission to decrease hospital bed days and mitigate the adverse effects of a surge. To date over 15,000 patients have been enrolled and approximately 10% have been escalated to hospital care for timely treatment.


Dermatological and Ophthalmological Inflammatory, Infectious, and Tumoral Tattoo-Related Reactions: A Systematic Review

Juliana Muñoz-Ortiz, MD; Mariana Teresa Gómez-López, MD; Paula Echeverry-Hernández, MD; Mario Federico Ramos-Santodomingo, Medical Student; Alejandra de-la-Torre, MD, PhD

This literature review found a close relationship between the application of tattoos on dermatological and ophthalmological tissues and the possible risk of immunological, neoplasms, and infectious complications. Dermatologists and ophthalmologists should be aware of the consequences caused by even small amounts of ink applied on skin and eyes, generating the need for strict regulations on its use.

“Outpatient Management” of Pulmonary Embolism Defined in the Primary Literature: A Narrative Review

Judy Shan, BS; Dayna J Isaacs, MPH; Harjot Bath, MD; Elizabeth J Johnson, MD; Dani Julien, BS; David R Vinson, MD

Evidence for the effectiveness and safety of outpatient management of low-risk patients with acute pulmonary embolism continues to mount. However, lack of definitional clarity may hinder understanding of this emerging management strategy and impede translation into clinical practice.

In Search of Medical Professionalism Research: Preliminary Results from a Review of Widely Read Medical Journals

J Harry Isaacson, MD; Deborah Ziring, MD; Fred Hafferty, PhD; Adina Kalet, MD, MPH; Dawn Littleton, PhD, MLS; Richard M Frankel, PhD

Professionalism is a core concept in medicine. The extent to which knowledge about professionalism is anchored in empirical research is unknown. We conducted an exploratory literature review to characterize professionalism research published in widely read medical journals, identify knowledge gaps, and describe their sources of funding.

Cerebral Venous Sinus Thrombosis in Inflammatory Bowel Disease: A Review of Published Case Reports

Aishah Ibrahim Albakr, MD; Noor AlMohish, MBBS

Cerebral venous sinus thrombosis (CVST) is a rare extraintestinal manifestation of inflammatory bowel disease (IBD), with a high risk of poor clinical outcomes in patients with delayed diagnoses. This study aimed to highlight the critical nature of CVST complications in IBD and the challenges associated with managing concurrent conditions.


Management of Erythrodermic Psoriasis Through Ayurveda: A Case Report

Vikraman Syamala Abhilesh, BAMS; Changuli Krishna Bhat Prathibha, MD (Panchakarma); Puthanmadom Venktramana Sharma Anandaraman, MD (Panchakarma), PhD

Psoriasis is a noninfectious chronic inflammatory skin disorder, characterized by well-defined erythematous plaques with silvery scales. In an ayurvedic perspective, we can compare this disease with kitibha kushta (a type of skin lesion) as most of its signs and symptoms mimic that of erythrodermic psoriasis.

Elevated Hemoglobin and Macrocytosis: A Neglected Association to Become a Diagnostic Tool (A Case Report)

Leonid L Yavorkovsky, MD, PhD

The landmark value of mean corpuscular volume in the diagnosis and classification of anemias was established more than a century ago. In contrast, the importance of mean corpuscular volume assessment in patients with elevated hemoglobin and hematocrit is not often appreciated. This case describes a patient who exhibited long-standing macrocytosis, which contributed to elevated hemoglobin and hematocrit levels, thus mimicking a diagnosis of polycythemia vera.

Case Report: Primary Duodenal Melanoma With Brain Metastasis

Sonha Nguyen, MD; Naila Khan, MD; Christine Duong, MD; Mary Le, MD; Vishal Ranpura, MD

While the most common primary tumor involving the duodenum is an adenocarcinoma, primary malignant melanomas arising in the small intestine are exceedingly rare and remain a controversial clinical entity. We present a unique case of primary duodenal melanoma with brain metastasis successfully managed by surgical excision, stereotactic radiation, and adjuvant immunotherapy.

Case Report of High-Grade Atrioventricular Block and Takotsubo Cardiomyopathy

Rohan Prasad, DO; Mohammad Fahad Salam, MD; Shaurya Srivastava, DO; FNU Samreen, MD; Zulfiqar Qutrio Baloch, MD

Takotsubo cardiomyopathy is a condition with a good long-term prognosis. However, when the Takotsubo cardiomyopathy is due to a life-threatening arrhythmia, such as atrioventricular block, several considerations must be made regarding treatment. A 71-year-old female with a history of ischemic stroke presented after a syncopal episode. Clinicians should understand this rare but fatal complication as these patients need pacemakers and beta blockers.

When You Cannot Go With the Flow: A Case Report of May-Thurner Syndrome

Adnan Khan, MD; Jeffrey Wang, MD; Leslea Brickner, MD; Nirmala Ramalingam, MPP; Nicole Tran, MD, PhD

May-Thurner syndrome is caused by extrinsic compression of the left iliac venous system, most commonly between an overlying right iliac artery and 5th lumbar vertebra, and it is seen mainly in women between 20 to 50 years old. This compression may be asymptomatic but can lead to the formation of venous thrombi causing left lower extremity pain and swelling.

Free Bone Cement Fragments Leading to a Locked Knee 3 Years After Medial Unicompartmental Knee Arthroplasty: A Case Report

Michelangelo Palco, MD; Roberto Caminiti, MD; Filippo Familiari, MD; Roberto Simonetta, MD

Unicompartmental knee arthroplasty (UKA) is a reliable alternative to total knee arthroplasty (TKA) in patients with isolated medial knee osteoarthritis. Rare complications are the limitation of knee movement and a clicking sensation associated to cement extrusion, both after UKA and TKA. We describe the case of a patient who required arthroscopic removal of free bone cement fragments 3 years after a minimally invasive UKA.

Conus Medullaris Infarction in a Patient With Familial Mediterranean Fever: A Case Report

Zoe Robinow, BS; Kathleen Barnett, BS; John Geraghty, MD

Spontaneous spinal cord infarctions are infrequent, especially in the conus medullaris region. An estimated 1.6 to 7.2 spinal cord infarctions occur per 100,000 individuals yearly, with a slightly higher occurrence in females than males. Affected patients can develop lasting sequelae. Conus medullaris infarction is a particularly rare presentation in patients with familial Mediterranean fever.

Duodenal Metastasis in Triple-Negative Invasive Ductal Breast Carcinoma With Negative Mammography: A Case Report and Review of the Literature

Naila A Khan, DO; Sonha T Nguyen, MD; Phildrich G Teh, MD; Vishal N Ranpura, MD; Taruna Bhatia, MD

Breast cancer metastasis to the gastrointestinal tract is uncommon and duodenal involvement is exceptionally rare. Those cases that do metastasize are reported to be lobular, with ductal carcinomas comprising only a small percentage of reported cases. We present a unique case of a patient with duodenal metastasis as the first sign of metastatic breast cancer.

Successful Conservative Management of a Rare Surgical Complication of Vascular Ehlers-Danlos Syndrome: A Case Report

Giuseppe Mangiameli, MD, PhD; Charles Al Zreibi, MD; Abderrahmen Ammar, MD; Alex Arame, MD; Françoise Le Pimpec-Barthes, MD, PhD

Vascular Ehlers-Danlos syndrome is a hereditary disorder of the connective tissue characterized by a reduction in production of Type III collagen. Clinical evolution of the disease is unpredictable because vascular lesions can occur everywhere in the body. Bruising, arterial and bowel fragility, and uterine fragility during pregnancy are the most common symptoms. We report an extra pleural hematoma, an unusual complication successfully treated with conservative management.


Cannabis Use Among Patients With Psychotic Disorders

Matthew E Hirschtritt, MD, MPH; Kelly C Young-Wolff, PhD, MPH; Daniel H Mathalon, MD, PhD; Derek D Satre, PhD

We provide a focused, clinically oriented overview of the epidemiology and characteristics of cannabis use among individuals with first-episode psychosis; evaluation of cannabis use; and treatment modalities, focusing on behavioral interventions suitable for outpatient primary-care settings.

Establishing Virtual Vital Signs in Older Adults

Eric A Lee, MD; Michael H Kanter, MD

COVID-19 forced all physicians to be telemedicine specialists, as virtual visits protect patients by minimizing exposure risks. A 2019 review suggested that quality of care was maintained in older adults using telemedicine. In contrast, another article suggested that antibiotics were prescribed inappropriately with telemedicine, suggesting inferior quality of care.

Pearls From a Clinician-Researcher in an Integrated Health Care Delivery System

Kate Michi Ettinger, JD; Vivian M Ettinger, RN; Marc G Jaffe, MD; David A Schroeder, MD, FACC; Joan C Lo, MD, FACP

This commentary profiles the career of Bruce Ettinger, MD, (1938–2020), a physician in The Permanente Medical Group who grew professionally as Kaiser Permanente Northern California expanded around him. During his career, Ettinger found avenues to remain humane, foster community, stimulate curiosity, and improve the quality of care for patients in his practice, regionally, and for larger patient populations.

True Stories: Facing COVID-19 With Courage and Humility

Patricia Lynn Dobkin, PhD

Physicians write stories for a variety of reasons. They describe victories or mourn the loss of a patient. They share insights gained from complex clinical encounters. Sometimes they reveal their own vulnerabilities or their patients’ tribulations. They work through confusion or inner conflicts by writing. They call attention to flaws in the health care system, and they imagine new ways of working with courage and humility.

Ethical Considerations Concerning Use of Percutaneous Endoscopic Gastrostomy Feeding Tubes in Patients With Advanced Dementia

Paul L Schneider, MD; Cynthia Fruchtman, JD; Joe Indenbaum, MD; Eszter Neuman, JD; Christine Wilson, JD; Terri Keville, JD

The insertion of percutaneous endoscopic gastrostomy tubes into patients with advanced dementia has become common practice despite evidence suggesting that the practice is not beneficial. The authors present a set of ethics guidelines on this subject, produced by the Joint Committee on Bioethics of the Los Angeles County Bar Association and the Los Angeles County Medical Association.

Vagus Nerve Stimulation for Tumor-Related Epilepsy: Does It Make Sense?

Keng Lam, MD; Jane Y Hwang, MD

Several antiepileptic drugs are available, but some patients can still go on to develop tumor-related refractory epilepsy. Due to its effectiveness, vagus nerve stimulation is becoming a popular option for those with medical refractory epilepsy but no brain tumor. We discuss the evidence for using vagus nerve stimulation for refractory tumor-related epilepsy and its challenges and research gaps moving forward.


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