The Permanente journal

Online ISSN: 1552-5775
Print ISSN: 1552-5767
Publications
Treatment scheme for intradermal administration of ERC-1671 vaccine for patients with recurrent glioblastoma multiforme after failure to respond to bevacizumab therapy a a ERC-1671 doses A to C contained approximately 1 × 10 6 dinitrophenol-modified allogeneic tumor cells and 1 × 106 dinitrophenol-modified allogeneic tumor lysates from Donors 1 to 3, respectively. Dose D contained approximately 1 × 10 6 dinitrophenol-modified autologous tumor cells and approximately 1 × 10 6 dinitrophenol-modified autologous tumor lysates from the patient. Cy = cyclophosphamide (50 mg/m 2 ) orally; GM-CSF = granulocyte-macrophage colony-stimulating factor (sargramostim).
Histopathologic analysis of tumor specimens from surgery and autopsy. Specimens show progression of Ki-67 (bottom row) from high-power magnification (middle row, 20x ) to low-power magnification (top row, 10x ) after administration of 2 cycles of vaccination (March and July 2012), decreasing further after completion of vaccination, as evidenced by autopsy specimen in December 2012 (far-right column) staining with hematoxylin-eosin (H&E).
Magnetic resonance image (MRI) of the brain showing the tumor size before resection (A, E), after resection (B, F), end of vaccination Cycle 1 (C, G), end of Cycle 2 (D, H), end of Cycle 3 (I, J), and end of Cycle 4 (K, L). The MRI shows a slow increase in fluid-attenuated inversion recovery (FLAIR) signal (top row) and contrast enhancement (bottom row) over time (x-axis, in month/day/year format).
Histopathologic examination of tumor samples and immunohistochemical staining. Trichrome stain of specimen at diagnosis (A), at first recurrence (B), and at autopsy showing collagen deposition in close relationship to blood vessels (C).
Artist’s depiction of vaccination process. Tumor cells and tumor cells’ lysate components are injected into the patient, taken up by antigen-presenting cells, and presented to B and T lymphocytes (top). This produces an immune response with activated T cells, which later exude through the capillary endothelial wall into the glioblastoma mass and attack the tumor cells carrying similar antigens (bottom). 
Glioblastoma multiforme (GBM) is a highly aggressive tumor, which recurs despite resection, focal beam radiation, and temozolomide chemotherapy. At recurrence, the only second-line treatment approved by the US Food and Drug Administration is bevacizumab (Avastin). To date, no single agent has shown to extend the life of patients with progressive malignant gliomas after bevacizumab failure. Once the tumor recurs during bevacizumab therapy, it is universally fatal, with death occurring within a few weeks. ERC-1671 is an experimental treatment strategy, which uses the patient's own immune system to attack the tumor cells. We report preliminary data on the first human administration of ERC-1671 vaccination, under a single-patient, compassionate-use protocol, to a patient with progressive, bevacizumab-resistant GBM. Treatment involved sequential administration to the patient of GBM tumor cells and cell lysates combined from three different donors with GBM, followed by the patient's own tumor cells and lysates. The patient survived for ten months after the vaccine administration without any other adjuvant therapy and died of complications related to his previous chemotherapies. The tissues collected after two vaccination cycles and at the time of death showed a robust immune response and no viable tumor. These preliminary data strongly indicate that ERC-1671 could be effective in the treatment of progressive malignant gliomas. On the basis of these preliminary data, we are planning a larger study to assess the efficacy of ERC-1671 in the treatment of patients with recurrent GBM.
 
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.
 
Context: General practitioners frequently encounter skin diseases and are accustomed to diagnosing the most common dermatologic conditions. Objective: We sought to determine the most common dermatologic topics published in five high-impact general medical journals (New England Journal of Medicine, The Lancet, the Journal of the American Medical Association, British Medical Journal (now The BMJ), and Annals of Internal Medicine). Design: We conducted an independent search of the Thomson Reuters’ Science Citation Index for common dermatologic topics, limited to the period 1970 to 2012. Main outcome measure: Total number of publications dealing with each dermatologic topic considered. Results: The five most common dermatologic topics published were melanoma, psoriasis, herpes simplex, herpes zoster, and acne. Melanoma and psoriasis were the top two dermatologic topics published in each journal except for Annals of Internal Medicine. Conclusions: Internists frequently diagnose herpes simplex, herpes zoster, and acne, which are also common dermatologic topics published. Although internists infrequently diagnose melanoma and psoriasis, they are major topics for general medical journals because of their increased community awareness, major advancements in therapeutic research, and their nondermatologic manifestations.
 
A retrospective review of the Journal of the American Academy of Dermatology and the Archives of Dermatology was performed using the MEDLINE database for all original research articles published between 1970 and 2010. The frequency of research into acne vulgaris and rosacea decreased from 24% to 5.1%, psoriasis research increased from 17.6% to 26.5% (most likely because of the discovery of biologics), and skin cancer research increased from 4% to 48% (paralleling the increasing incidence of skin cancer).
 
Study subject demographics 
Penicillin skin test results by year of test 
Background: Data on the rate of positive penicillin skin test (PenST) results over time in large populations are rare. The factors that influence positive PenST results are incompletely understood. Objectives: We sought to correlate demographic variables to the rate of positive PenST results over time in a large group of patients with a history of penicillin allergy. Methods: RESULTS from the first test for all patients tested for penicillin allergy in the Kaiser Permanente Health Care Program in San Diego County, CA, between 1995 and 2007 are reported. All patients were tested with penicillin, penicilloyl-poly-lysine, penilloate, penicilloate, and amoxicillin. Results: There were 255 positive PenST results in 3469 individuals. The rate of positive PenST results declined from >10% to <5% during the 13 years studied. The positive PenST result rate could be accounted for by the year of testing (R(2) = 0.56; p = 0.003) without any significant contribution from the patient's age or the time since reaction (TSR). If the TSR was ≤13 years, the relative risk of a positive PenST result was 2.1 (95% confidence interval = 1.6-2.8). If the study subject's age was ≤38 years, the relative risk of a positive PenST result was 2.1 (95% confidence interval = 1.6-2.7). Females reported higher rates of penicillin allergy history than males did (11% compared with 6.6%; p < 0.0001), but there were no significant sex differences in the rate of positive PenST results. Conclusions: There has been a steady decline in the proportion of positive PenST results between 1995 and 2007, independent of study subject age and TSR. Increasing age and increasing TSR were associated with a lower rate of positive PenST results.
 
Total Clostridium difficile colitis cases 
Objective: We studied antibiotic use prior to the onset of Clostridium difficile colitis (CDC) and time interval between onset of gastrointestinal symptoms and diagnosis for two historical time periods with separate comparisons for inpatients and outpatients to determine whether time to diagnosis had decreased and whether previous metronidazole use is associated with CDC. Method: We performed a retrospective chart review of adult patients (those 18 years or older) with positive findings on Clostridium difficile (CD) stool toxin tests performed at a Kaiser Permanente Southern California medical center. Independent assessments were compared for 1997-1998 and for 2004 time periods. These assessments used similar enrollment and exclusion criterion. Study populations were evaluated for previous antibiotic use and to determine time from clinical presentation of symptoms to diagnosis of CDC during each of the time periods, with assessments made separately for inpatients and outpatients. Results: Findings showed a reduction in the average time from symptom presentation to diagnosis among outpatients with CDC from 17 days in the first time period (1997-1998) to ten days during the second time period (2004). No significant difference in the average time from symptom presentation to diagnosis of CDC was evident among inpatients (5.33 days for 1997-1998 and 6.00 days for 2004). Multiple antibiotic use prior to diagnosis of CDC was evident among both outpatients and inpatients in this study. Metronidazole had been used prior to the onset of CDC in approximately 15% of cases. Conclusion: The time from symptom onset to a CDC diagnosis decreased by seven days between the 1997-1998 and 2004 time periods among outpatients in this health care setting. Previous metronidazole use appeared to be associated with some cases of CDC.
 
eEncounter survey measures 
Use of Personal Health Link by PCPs. 
Reasons patients e-mailed their PCP. Rx = prescriptions. 
Timeliness of PCP response. 
Patient description of potential action if e-mail encounter had not been available 
MyChart is one of the new, innovative features of Kaiser Permanente (KP) HealthConnect—the comprehensive, integrated, organizational, and personal electronic health and medical record. MyChart, an Epic Systems Corporation (Verona, WI) product, is a secure member Web site where registered patients can view portions of their medical record, and exchange secure messages with their primary care physician (PCP) and other recently visited clinicians. The KP Northwest (KPNW) Region, in Portland, Oregon, was the first KP Region to implement MyChart. Starting in late 2002, KPNW initiated a pilot project of MyChart as a stand-alone Web address in two medical offices.1 KPNW named this feature Personal Health Link (PHL). By early 2005, all adult primary care physicians and affiliated clinicians (both groups are PCPs in this paper) were trained and set up to use PHL. Patients who registered for PHL could send secure e-mail messages directly to their primary care clinician, incurring no copayment or fees. MyChart is now available to KP patients in all Regions, except Ohio, through KP HealthConnect online at www.kp.org.
 
Between November 2004 and January 2005, the Institute for Culturally Competent Care (ICCC) conducted a needs assessment survey to identify perceived needs for education and training in the area of culturally competent care, as well as preferred methods to receive that education and training. Among targeted recipients were physicians, physician assistants, osteopaths, nurse practitioners, nurses, pharmacists, and dieticians. The Colorado Region opted out of the assessment survey because it was preparing to conduct its own survey in the near future. The Southern California and Northwest Regions participated through representatives because each Region had recently conducted similar surveys. Respondents were almost exclusively physicians (MDs). The possible reasons for this include: 1) key regional diversity contacts had primarily MD e-mail lists and/or are accustomed to surveying physicians; 2) the lack of appropriate contacts with access to RN e-mail lists; 3) historically, RNs are less likely to respond to these types of survey requests; and 4) RN Union concerns.
 
Pregnant women are at increased risk of severe influenza-related complications and hospitalizations and are a priority group for influenza vaccination. To examine coverage of seasonal and pandemic influenza A (H1N1) vaccines in pregnant women in a managed care setting, from 2008 to 2012. Retrospective cohort study of 10,145 pregnant women. H1N1 and seasonal influenza vaccination rates. Seasonal influenza vaccine coverage increased from 38% to 63% between the 2008-2009 and 2010-2011 seasons, and then dropped to 61% in 2011-2012. Vaccine coverage was higher in women considered at high risk of influenza complications, increasing from 43% in 2008-2009 to 71% in 2010-2011, before decreasing to 69% in 2011-2012. H1N1 vaccine coverage was greater than seasonal influenza coverage in 2009-2010 in the overall pregnant population (61% vs 53%) and in the high-risk group (64% vs 59%). We observed statistically significant differences in vaccination rates by trimester, gravidity, maternal age, and race/ethnicity. Vaccination rates increased significantly from 2008 to 2011, then dropped slightly in 2011-2012. Continued efforts are needed to ensure adequate vaccination coverage in this high-risk population.
 
Results of optical coherence tomography (OCT) and fluorescein angiography in a man with diabetes. a  
Crude thiazolidinedione (pioglitazone and rosiglitazone) use within Kaiser Permanente Northern California in two contiguous years
The diabetes mellitus portion of the current Kaiser Permanente Northern California PHASE (Prevent Heart Attack and Stroke Everyday) program. Cr = creatinine; HF = heart failure; LFT = liver function test; NPH = neutral protamine Hagedorn (insulin); SMBG = self-monitoring of blood glucose; SQ = subcutaneous; ULN = upper limit of normal; bid = twice daily; hs = at bedtime; q2days = every 2 days.
Proposed antihyperglycemic strategy in the patient with type 2 diabetes mellitus and coronary artery disease.
Proposed antihyperglycemic strategy in the patient with type 2 diabetes mellitus and heart failure. a Secretagogues include the sulfonylureas and the nonsulfonylurea glinides. Certain sulfonylureas (eg, glyburide) may impair ischemic preconditioning and probably are best avoided in patients with active coronary insufficiency. b Metformin is no longer contraindicated in this setting and may be used cautiously, but only in stable, compensated heart failure patients with normal renal function and acid/base status. c Insulin can be added to or substituted for oral agents at any point in the disease course. When more advanced regimens are used, insulin secretagogues traditionally are discontinued. Because of the sodium-retaining properties of insulin, the lowest effective dose should be used, and the dose should be titrated carefully. Reprinted with permission from Inzucchi SE, McGuire DK. New drugs for treatment of diabetes: part II: Incretin-based therapy and beyond. Circulation 2008 Jan 29;117(4):574-84; Figure 2.  
A large number of cardiology clinical trials have mortality as an endpoint unless adequate surrogate endpoints are available. Although there are nine classes of agents used in the treatment of diabetes mellitus, none have shown a mortality benefit in clinical trials. The United Kingdom Prospective Diabetic Study was the first to suggest that metformin given for diabetes mellitus had a trend toward lowering mortality. The accidental discovery of peroxisome proliferator-activated receptors (PPARs) led to the introduction of the thiazolidinediones (TZD), a PPAR agent with a suggestion of a promise for the future. As the incidence of cardiovascular complications related to diabetes mellitus increases, there is a sense of urgency to produce antidiabetic medications that achieve not only nontoxic glycemic control but also improved cardiovascular outcomes. The goal of this review is to aid the clinician to appropriately assess the benefits and risks of TZD use when prescribing for patients.
 
After almost ten years of being regaled by Kaiser Permanente (KP) historian Steve Gilford's wonderful stories about Sidney Garfield, MD's four-year sojourn in the Mojave Desert (1933–38), where the young surgeon literally laid the foundation of what would become KP, I was well primed for the long-delayed pilgrimage. Finally, last November, I at last had a legitimate excuse to fly down to Anaheim and drive more than 100 miles east, past the rich oases of Palm Desert and Palm Springs and into the empty, awesome wastes of the Mojave, in search of KP's birthplace.
 
Conceptual model for the 21st Century Care Innovation Project 
Trend of office visits and telephone visits at the Nanaikeola Medical Office in Hawaii. 
Involving the Entire Care TeamAs the teams' gain a better understanding of caring for their whole panel, they are also trying to utilize all the members of their care team within their licensure to address unmet needs. Nurse Practitioners are taking a key role in providing group appointments and outreach for patients with multiple comorbidities. Nurses are making outreach calls regarding medication compliance and relaying lab results. Many MD/RN/MA teams are now located in close proximity, often in the same office, to exchange information more easily, which equips the team to more effectively handle questions and messages from patients.In addition, KP HealthConnect ensures all medical and health care is documented and available to team members when they need it. This has served to increase the competence and confidence level of everyone on the team.“Having a nurse share my office has really increased our team work. We can share information and I don't feel like I alone have the responsibility to provide care to my entire panel. I can count on any member of our team to pitch in. Everyone works at their highest scope of practice and potential,” states Dr Samir Patel from the Nanaikeola Team.Dr Shaw concurs, “We are sharing the workload. When there are complex health care issues to talk with the patient about, I make the call. When there are suggested tests and advice, others on the staff are making the calls. We all help patients get what they need. The big benefit of working as a team is to be able to do more with limited time and resources. We have the flexibility to double, sometimes triple, how many problems we can solve for patients.”Many of the teams are extending the traditional view of the care team beyond the MD, RN, LPN and MA, to include receptionists. At one facility, the Medical Intake Specialists (MIS), who greet and register patients, remind them of overdue preventive care needs and, with the patients' permission, schedule an appointment with the ancillary department on the spot. Teams are also experimenting with expanding team membership to integrate other caregivers, including pharmacists, phlebotomists, nutritionists, behavioralists, and call center agents.
 
the Practical, robust implementation and Sustainability Model (PriSM) 1 1 reprinted from: Feldstein ac, glasgow re. a Practical, robust implemenation and Sustainability Model (PriSM) for integrating research findings into practice. Jt comm J Qual Patient Saf 2008;34(4):228-43. 
Social network map of site a. 
Full social network map of site B. Figure 3a. Detail of social network map showing opinion leaders. 
Full social network map of site B. Figure 3a. Detail of social network map showing opinion leaders. 
We describe here the use of a conceptual framework for implementing and disseminating in a Health Maintenance Organization an evidence-based model of well-child care (WCC) that includes developmental and preventive services recommended by the American Academy of Pediatrics. Twenty-first Century WCC is a parent-centered, team-based, primary care model that combines online previsit assessments-completed by parents and caregivers regarding clinic-based weight, growth, and development assessments-with vaccinations and anticipatory guidance. Nurses, nurse practitioners, developmental specialists, and pediatricians all play roles in the WCC model. Patient and clinician interaction, health records, and resources are all facilitated through a Web-based diagnostic, management, tracking, and resource information tool. Implementation and dissemination concepts and their attendant practices and tools can reliably be used to augment strategic decisions about how to best disseminate and implement innovations in health care delivery. Unlike innovations that are embedded only in technical systems, validated models of team-based health care have multiple components that must be made compatible with complex sociotechnical systems. Interpersonal communication, work, coordination, and judgment are key processes that affect implementation quality. Implementation can involve tailoring to a particular site and customizing either the model or the organizational context to accommodate it.
 
Background: Although 7% of US adolescents have impaired fasting glucose, a precursor of type 2 diabetes, research has suggested that few interventions for obese adolescents at risk for diabetes have been effective. Therefore, pediatricians seek effective behavioral treatments for referral for this age group.Objective: We wanted to determine the effects of two different durations of nutritional and exercise treatments on changes in nutrition, physical activity, body mass index (BMI), and psychological predictors of BMI change in overweight and obese adolescents at risk for type 2 diabetes.Methods: We obtained data from 64 pediatrician-referred patients with diabetes risk factors (mean age, 14.1 years; BMI, ≥99th percentile.) Study participants were assigned to nutrition and exercise treatments for 12 weeks (n = 35) or 24 weeks (n = 29). A specific weight-loss goal was given only for the 24-week group.Results: Both treatments demonstrated significant within-group changes over 12 weeks in days per week of physical activity of at least 60 minutes, physical self-concept, general self, and overall mood. However, they failed to demonstrate significant 12-week increases in fruit and vegetable intake, decreases in sweetened-beverage consumption, or decreases in BMI. Between-group differences were found only in mood changes in favor of the 12-week treatment. In the 24-week treatment, BMI change from week 12 to week 24 was significantly better than corresponding normative data (d = 0.37). Physical self-concept, general self, and mood scores at week 12 explained a significant portion of the variance in BMI change (R2 = 0.13, p = 0.04).Conclusion: Nutrition education alone may be insufficient for nutrition behavior change. Behavioral treatment lasting longer than 12 weeks and having a specific weight-loss goal may be useful for BMI improvements, and attention to participants' self-concept and mood may be important treatment considerations.
 
“I've discovered the meaning of life, Bill!” the man sitting in my office exclaimed. His eyes saw worlds I could not imagine, and madness flickered in them like the light from distant stars. “The aliens told me! They told me, and it's okay!” John had informed me when he walked in that he had not taken his antimanic medication for six weeks because he knew he no longer needed it. I was rapidly assessing if he were a danger to himself or anyone else and trying to determine how I might contain him. Suddenly, he leaped to his feet. “I'm a time–space pilot!” he shouted exuberantly. I must have flinched, because he immediately apologized and sat back down. “I didn't mean to scare you, Bill, but it's just so exciting!” He turned his head briefly, distracted by a vision I was not privy to. Then he turned his attention back to me and riveted me with his gaze. Before I could react, he reached forward and grabbed my left hand, turned it palm up, and raised it to his eyes. He stared at it intently, as though the lines on my palm were the runes of some ancient and long-forgotten language that only he could translate. “You're my brother!” he shrieked. “We're twins! I knew it! I knew you were special too!” He released my hand and drew closer, lowering his voice to a deep conspiratorial tone. “Bill,” he whispered. “Bill, will you be my time–space copilot?” I was stunned. As I stumbled for words, he sat back in his chair with a broad smile on his face. I found myself thinking of the many sessions we had had together. John had been a very successful businessman before the development of his acoustic neuroma and the surgery that went awry. His brain had suffered an insult from which it could not completely recover. He was not suicidal or homicidal, but those gross measures of behavior could not capture his personal tragedy. He was no longer the supremely competent man he had been. The six-figure income, the wheeling and dealing, the travel to exotic locales were gone. His psychotic delusion gave meaning to what was a mere shell of his former life. Incorporating me into that delusion was the most precious gift he had to give me for my willingness to listen, to respect, and to challenge him. “John, I'm flattered that you think of me so highly, that you would offer me such a privilege. But I really think you need to be on your medication again. You haven't seen your psychiatrist for a couple of months. Would you mind if I brought her in?” “Sure, Bill,” he answered, almost with relief. “I have to talk to her too. Bring her in.” That incident happened at Kaiser Permanente (KP) Skyline Medical Offices in Salem, OR, in the late 1990s, and I have thought about it many times since. The patient's name is not John, but his story is true. With a drink or two and the right audience, it can be a very funny story, an example of the M*A*S*H-type humor that most clinicians use at one time or another. At another level, it can be a very touching and troubling story, a striking example of how that most prominent organ of our humanity, the brain, can betray us so utterly. What kind of world is this that we inhabit, often so thoughtlessly? How thin is the ice of that “hard reality” that we skate on?
 
Context: Nurses are the primary hospital caregivers. Increasing the efficiency and effectiveness of nursing care is essential to hospital function and the delivery of safe patient care.Objective: We undertook a time and motion study to document how nurses spend their time. The goal was to identify drivers of inefficiency in nursing work processes and nursing unit design.Design: Nurses from 36 medical-surgical units were invited to participate in research protocols designed to assess how nurses spend their time, nurse location and movement, and nurse physiologic response.Main Outcome Measures: Nurses' time was divided into categories of activities (nursing practice, unit-related functions, nonclinical activities, and waste) and locations (patient room, nurse station, on-unit, off-unit). Total distance traveled and energy expenditure were assessed. Distance traveled was evaluated across types of unit design.Results: A total of 767 nurses participated. More than three-quarters of all reported time was devoted to nursing practice. Three subcategories accounted for most of nursing practice time: documentation (35.3%; 147.5 minutes), medication administration (17.2%; 72 minutes), and care coordination (20.6%; 86 minutes). Patient care activities accounted for 19.3% (81 minutes) of nursing practice time, and only 7.2% (31 minutes) of nursing practice time was considered to be used for patient assessment and reading of vital signs.Conclusion: The time and motion study identified three main targets for improving the efficiency of nursing care: documentation, medication administration, and care coordination. Changes in technology, work processes, and unit organization and design may allow for substantial improvements in the use of nurses' time and the safe delivery of care.
 
Anonymous Teen Health Survey 
Unlabelled: Research Setting: The research for the study reported here was conducted in conjunction with the Biomedical and Health Sciences Internship for High School Students at the University of California, San Francisco, Department of Pediatrics. The eight-week intensive summer program promotes interest in science, medicine, and health among young people by introducing students to the professional world of science, broadly defined. Interns are expected to assist in a specific research project that addresses a scientific question. They participate in a variety of lectures and are exposed to faculty members, medical students, and college graduates working as research assistants in a rich academic and clinical research setting. This study was conducted within Kaiser Permanente (KP) of Northern California as part of a larger study aimed at increasing Chlamydia screening among sexually active adolescents. It was approved by Committee on Human Research, the institutional review board (IRB) for the University of California, San Francisco and the IRB for KP Northern California. Objective: There were two primary objectives of this study: first, we sought to identify where teenagers obtain information about sexual health; second, we examined whether aspects of a clinician's communication style with a teen during a health care visit were associated with the teen choosing that clinician as a primary source of sexual health information (as compared with parents, peers, teachers, the news media, and other sources). Results: Teens who perceived that their clinician communicated with respect and explained information in ways that they could understand were more likely to cite their clinician as a source of sexual health information. Having time alone (confidentiality) with a physician was also associated with teens' selection of a clinician as a primary information source. Whether the clinician asked about sex during the health care visit was significantly associated with males selecting the clinician as a primary source of sexual health information. An important finding, at least for males, because teens do not always bring up the topic.
 
Patient characteristics for STEMI Heart Alert cases (total 72 cases) 
Context: Prompt percutaneous coronary intervention (PCI) for patients with ST-segment elevation myocardial infarction (STEMI) can significantly reduce mortality and morbidity, although its effectiveness may be limited by delays in delivery. In March 2008, our hospital implemented a Heart Alert protocol to rapidly identify and treat patients with STEMI presenting to our Emergency Department (ED) with PCI, using strategies previously described to reduce door-to-balloon times. Before the Heart Alert protocol start date, patients with STEMI presenting to our ED were treated with thrombolysis.Objective: We evaluated data from patients with STEMI after one year of use of our Heart Alert protocol to determine protocol success on the basis of the percentage of patients for whom the recommended door-to-balloon times of ≤90 minutes were met. We examined factors involved in implementation of the protocol that contributed to these results.Design: We conducted a retrospective data and chart review for patients in the ED with STEMI who underwent PCI after a Heart Alert protocol activation between March 17, 2008, and March 17, 2009.Results: During the study period, our staff met the recommended door-to-balloon time of ≤90 minutes (mean door-to-balloon time, 57.3 ± 17.6 minutes) for 70 of 72 patients (97%) presenting to our ED with STEMI. Sixty-five of the 72 patients (90.3%) survived to hospital discharge.Conclusion: Initiation of a Heart Alert protocol at our hospital resulted in achievement of door-to-balloon times of ≤90 minutes for 97% of patients with STEMI. This achievement was obtained through careful preparation, training, and interdepartmental collaboration and occurred despite immediate conversion from a previous thrombolytic protocol.
 
Context: Glioblastoma multiforme (GBM) is an aggressive neoplasm, with controversy regarding treatment in elderly patients. Objective: To review outcomes of elderly patients aged ≥ 65 with newly diagnosed GBM treated with concurrent temozolomide and either standard-course radiotherapy (SRT) or abbreviated-course radiotherapy (ART). Design: Retrospective review from 2003 to 2012. Main outcome measure: Survival, comparing treatment regimens. One hundred patients received SRT (median dose = 60 Gy), and 29 received ART (median dose = 35 Gy). O6- methylguanine-DNA methyltransferase (MGMT) status was available for 26 SRT and 13 ART recipients. Results: Median age was 70 years. Median follow-up was 11 months. At analysis, 3 patients were alive. Multivariate analysis of the entire cohort found SRT (hazard ratio [HR] = 0.421, p = 0.0001), Karnofsky Performance Score of 70 or higher (HR = 1.894, p = 0.0031), and more extensive surgery (HR = 0.466, p = 0.0023) were associated with longer survival time, but age was not. Median time to death with SRT was 13 months versus 5.4 months with ART, but the latter had worse prognostic factors, including lower Karnofsky Performance Scores, fewer gross total resections, and higher recursive partitioning analysis class. Recipients of SRT with methylated MGMT promoter had a trend toward longer survival compared with unmethylated MGMT (p = 0.06), but ART recipients had shorter survival with MGMT methylation (p = 0.02). Conclusion: Elderly patients with multiple poor prognostic factors given ART had short survival times. Relative to other variables, MGMT status may not predict outcome for these patients.
 
Follicular lymphoma (FL) is the second most common subtype of non-Hodgkin lymphoma. The disease usually affects older individuals, with the average age at diagnosis being 63.5 years. Only in 4% of cases is the disease diagnosed in individuals younger than age 40 years. The case presented in this report describes the diagnosis of FL in a 38-year-old woman and highlights the variability of this disease. Tumor grading, disease staging, and the Follicular Lymphoma International Prognostic Index score can be valuable aids in prognosis. Treatment consists of close observation or radiation therapy for early-stage disease, and rituximab with combination chemotherapy regimens for more advanced disease. Cure is rare. Treatment is predominately handled by oncologists, but these patients will likely first present to their primary care physicians. Symptoms can be subtle at times, so it is essential to be able to recognize them to provide the patient with timely treatment.
 
Abdominal aortic aneurysm (AAA) disease is a prevalent and highly morbid condition among older people in the US. There are currently no proven methods for reducing or eliminating enlargement in smaller preclinical aneurysms. Given their relatively slow increase in diameter (typically <0.4 cm/year), these smaller aneurysms offer a valuable window into the underlying pathophysiology of AAA disease. Through a Vascular Remodeling Specialized Center of Clinically Oriented Research program funded by the National Institutes of Health, we have established, in conjunction with Northern California Kaiser Permanente, a multidisciplinary research effort to efficiently identify and handicap suppressive therapeutic strategies for early AAA disease.
 
Thoracoabdominal computed tomography with angiographic study showing thrombosis of the distal aorta (coronal view). 
Almost complete aortic abdominal thrombosis on computed tomography with angiographic study (axial view). 
Distal spontaneous reperfusion of common iliac arteries and internal and external iliac arteries was observed (axial view). A no. 5 Fogarty embolectomy of the aortic bifurcation was performed; despite flow restoration, the patient did not survive. 
A 79-year-old woman with a medical history of hypertension and cardiac surgery for mitral valve repair was seen in the Emergency Department after falling to the floor in her bedroom. Acute abdominal aortic occlusion is an uncommon condition frequently resulting from saddle embolism or thrombus of an atherosclerotic plaque. Sudden neurologic symptoms can occur.
 
Incisional hernia is one of the most common complications of abdominal surgery, with a reported occurrence rate of up to 20% after laparotomy. The high incidence of hernia formation significantly contributes to both patient morbidity and health care costs. Although a variety of approaches have been described to repair these defects, historically the results have been disappointing. Recurrence rates after primary repair have been reported to range from 24% to 54%. The recent advent of laparoscopic ventral hernia repair (LVHR) has offered promising outcomes by combining tension-free repair using a prosthesis with minimally invasive techniques, lowering reported recurrence rates to <10%. This review discusses standardized, well-researched techniques that have contributed to the success of LVHR. We also discuss how these techniques have been modified for laparoscopic repair of suprapubic lumbar hernias, hernias near the iliac crest, and parastomal hernias. In addition, we review our own experience with LVHR in the context of the principles discussed.
 
Context/objective: Abdominal lipectomy is performed by plastic surgeons to provide symptomatic, functional, and cosmetic relief for patients with excess abdominal tissue. However, there are few clinical outcome studies looking at the utility of this procedure: this is the first prospective oucomes study. Design: Patients who underwent abdominal lipectomy at the Bellflower Medical Center during a 12-month period (September 2004 through September 2005) were prospectively studied. Data were collected at the preoperative visit, during surgery, and at the one-week, one-month, and six-month postoperative visits. Outcome measures: Complications, both major (requiring rehospitalization or reoperation) and minor (requiring local outpatient care) were identified. To evaluate the impact on our patients' perceived health and well-being as well as body image, we administered the Short Form-36 Health Survey (SF-36) and the Multidimensional Body-Self Relations Questionnaire (MBSRQ) to participants at their preoperative and six-month postoperative visits. Results: For the 72 patients enrolled in the study, the postoperative major complication rate was 5.6% (four patients) and the minor complication rate was 27.8% (20 patients); 98.3% were happy to have had the surgery. Two components of the MBSRQ, feelings of attractiveness and body area satisfaction, showed significant improvement (p < 0.0001 for each) at six-month postoperative testing. No component of the SF-36 reached statistical significance between pre- and postoperative testing. Conclusion: Because the complication rate for cosmetic abdominoplasty in our study did not significantly differ from rates reported for other studies, and given our data on perceived patient satisfaction and improvement in outcomes, our study validates the utility of abdominal lipectomy for patients with symptomatic lower abdominal pannus.
 
Osteitis pubis is the most common inflammatory condition of the pubic symphysis and may present as acute abdominal, pelvic, or groin pain. Osteomyelitis pubis can occur concurrently and spontaneously with osteitis pubis. Primary care physicians should consider these conditions in patients presenting with abdominal and pelvic pain. A thorough history, including type of physical activity, and a focused physical examination will be useful, and imaging modalities may be helpful. A biopsy and culture of the pubic symphysis will usually confirm the diagnosis. Treatment for osteitis pubis generally involves rest and anti-inflammatory medications. Failure with this conservative treatment should alert the physician to the possibility of osteomyelitis, which needs treatment with antibiotics. Prognosis for recovery is excellent with definitive diagnosis and treatment.
 
Foot abnormalities among study participants
Background: Altered foot biomechanics, limited joint mobility, and bony deformities with neuropathy, peripheral vascular disease, and infection have been associated with an increased risk of ulceration and amputation among patients with diabetes. The aim of our study was to estimate prevalence of foot abnormalities among Iraqis with diabetes and to see if they are more common than in a control population. Methods: We structured the study as a comparative outpatient clinic study. The study population consisted of 100 patients with type 2 diabetes and 100 patients without diabetes as the control group. The study was conducted between January 2006 and August 2007. The patients and study control subjects were selected from the outpatient clinic at Al-Faiha Hospital in Basrah, southern Iraq. All were adults of at least 40 years of age. Results: There were no differences between the two groups regarding sex, age, weight, qualifications, smoking status, marital status, or residency, but patients with diabetes had a higher body mass index and a higher socioeconomic status. No differences were found in the type of footwear worn or in occupation. Foot abnormalities associated with diabetes were prominent metatarsal heads, hammertoe, high medial arch, wasting, joint stiffness, amputation, fissures, nail changes, ulcer, and dermopathy on univariate analysis. With a multivariable model using logistic regression, only wasting (odds ratio [OR], 0.21; 95% confidence interval [CI], 2.16-11.33; p = 0.0002), ulcer (OR, 0.08; 95% CI, 1.12-134.59; p = 0.03), and dryness (OR, 0.11; 95% CI; 1.19-7.32; p = 0.01) remained significantly associated with diabetes. Conclusion: We checked for 17 foot abnormalities associated with diabetes and found that 13-prominent metatarsal head, high medial arch, hammertoe, wasting, joint stiffness, amputation, fissures, nail changes, ulcers, blisters, dryness, sclerosis, and dermopathy-were statistically more frequent in study participants with diabetes than in control study subjects without diabetes. In a logistic regression model, only wasting, ulcer, and dryness remained strongly associated with diabetes. A larger study is needed to see the relationship of these abnormalities with footwear worn, duration of wearing footwear, occupation, duration of diabetes, and insulin use.
 
Health care professionals are in a unique position to identify and to assist victims of human trafficking. Human trafficking today occurs both domestically and globally. It manifests in many forms, including adult and child forced labor, involuntary domestic servitude, adult and child sexual slavery, involuntary servitude, debt bondage, and child soldiers. This article offers insight into modern human trafficking and ways health care professionals can be activists.
 
Adult hematuria workup algorithm. C + S = culture and sensitivity; e-gfr = estimated glomerular filtration rate; HPF = high-power field; rbc = red blood cells; iVP = intravenous pyelogram; KUB = kidneys, ureter, bladder; NSAiDs = nonsteroidal anti-inflammatory drugs; RUS = renal ultrasound; U/A = urinalysis. 1 Urine specimens should be collected >48 hours after exercise. The U/A should be analyzed fresh if possible, by a standardized methodology to avoid the lysus of formed elements from heat for chemical breakdown. 2 After urologic evaluation is completed, re-referral for persistent microhematuria is not needed unless there is a change in clinical situation, such as the occurrence of gross hematuria or another sign or symptom suggestive of possible urologic pathology. 3 CT Urogram is defined as a two-phase study (noncontrast followed by postcontrast delay) and KUB reconstruction. When iVP is ordered, clinicians should take into consideration patient history of chronic illness (diabetes, heart failure, and other comorbidities), as well as a patient being on certain medications (metformin, NSAiDS, and others). 4 Patients receiving contrast should have a serum e-gfr testing performed prior to the procedure.  
The Kaiser Permanente Interregional Chiefs of Urology Service
Hematuria is one of the most common conditions confronting clinical urologists and is present in many genitourinary pathology conditions. Although researchers have studied hematuria symptoms in an effort to determine the best diagnostic pathway, the existing lack of scientific evidence has created variations in clinical practice. The literature does not provide enough evidence to significantly alter the need to assess these patients. Consequently, many patients with microscopic or gross hematuria undergo low-yield workups that include invasive testing and imaging with radiation. In 2007, a national group of Kaiser Permanente (KP) urology chiefs agreed that national practice recommendations were needed to address existing variations in the management and workup of hematuria. Using a KP guideline methodology, the group reached a consensus agreement on the following recommendations: 1) referral to urology is recommended for all people with gross hematuria or high-grade hematuria (>50 red blood cells per high-power field [RBCs/HPF]) on a single urinalysis (UA); 2) referral to urology and urologic evaluation is recommended for men or women with asymptomatic microscopic hematuria or symptomatic hematuria that produces >3 RBCs/HPF on two of three properly performed and collected urinalyses; and 3) voided urinary cytology should be eliminated from asymptomatic hematuria screening protocol. The test is not sensitive enough to obviate further workup if findings are negative, and elimination of this screening test is estimated to save millions of dollars across the US. Hematuria on a UA should be reported as 0 to 3 RBC/HPF, 4 to 10 RBC/HPF, 11 to 25 RBC/HPF, 26 to 50 RBC/HPF, >50 RBC/HPF, or gross hematuria. This approach will also reduce radiation exposure.
 
Objectives: To describe anatomic failure rates for sacrocolpopexy in groups receiving either delayed absorbable or permanent monofilament suture for mesh attachment to the vagina. Methods: We 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). Vaginal apical failure was defined as Point C greater than or equal to half of the total vaginal length. Anterior-posterior compartmental failures were defined as Point Ba and/or Point Bp more than 0 cm. Fisher exact and χ2 tests were used to compare failure rates. There were no documented suture erosions in the delayed absorbable monofilament suture group during the review period. Two patients in the permanent suture group were found to have permanent suture in the bladder more than 30 weeks after the index procedure. Results: Failure rates for the 45 subjects in the delayed absorbable group and 148 subjects in the permanent suture group were similar (4.4% vs 3.4%, p = 0.74) and not statistically different in any compartment: apical (0% vs 1.4%, p = 0.43), anterior (4.4% vs 2%, p = 0.38), or posterior (0% vs 1.4%, p = 0.43). Conclusions: Delayed absorbable monofilament suture appears to be a reasonable alternative to permanent suture for mesh attachment to the vagina during sacrocolpopexy. The use of delayed absorbable suture could potentially prevent complications of suture erosion into the bladder or vagina remote from the time of surgery.
 
Kaiser Permanente measures how often tobacco users are offered strategies to quit but not the success of such strategies. To compare tobacco abstinence rates for participants of the Kaiser Permanente Riverside (California) Medical Center's Freedom from Tobacco Class in 2008, before direct physician involvement, and in 2009, after direct physician involvement, and to compare other variables affecting these rates. In a retrospective study, participants were divided into two groups based on year of participation. Data were collected using electronic medical records and phone interviews. Tobacco use status between both groups at 1, 3, 6, and 12 months after the classes started and within groups by sex, number of classes attended, medication received, and class teacher. The 12-month abstinence rates were 27% in 2008 and 33% in 2009 (p = 0.3). The abstinence rate for men improved from 23% to 38% (2008 vs 2009; p = 0.05), whereas for women it was 30% vs 27% (p = 0.7). Abstinence rates decreased over time for the group as a whole (p < 0.001). Attendance of 6 or more classes was associated with higher abstinence rates. There was no significant impact on abstinence rates due to age, body mass index, class teacher, or medications used. Direct physician involvement improved men's but not women's abstinence rates among class participants. The relapse rate was significant over the first year after the class. Further research is needed to study the difference between sexes and the factors affecting relapse.
 
Here I present a medical narrative, as a catharsis, regarding Albert Camus’s The Myth of Sisyphus in an attempt to elude meaninglessness in my difficult everyday practice of critical care medicine. It is well documented that physicians who practice critical care medicine are subject to burnout. The sense of despair that occasionally overwhelms me prompted my rereading of Camus’s classic text and caused me to recount his arguments that life is meaningless unless one is willing to take a leap of faith to the divine or, alternately, to commit suicide. This set up the examination of his third alternative, acceptance of a life without prima facie evidence of purpose and meaning, a view that may truly have some bearing on my professional life in the intensive care unit.
 
What do you do when you smell alcohol on the breath of a coworker? For obvious—and not so obvious reasons—this question has greater significance for those in health care. The following are excerpts from my memoir of 12 years as a Navy physician. In the 70s and early 80s, I became interested in what is now called Addiction Medicine. This interest blossomed when I took a two-week course for health professionals on substance abuse at the Naval Hospital in Long Beach, CA under the leadership of Captain Joseph Pursch, MD, then Medical Director. Fresh from this two-week course, I returned to the Naval Hospital where I was stationed, now an “expert” on the diagnosis and treatment of alcoholism. A few months after my return, I had the opportunity to put into practice something I had learned in Long Beach.
 
Untreated perinatal substance abuse is associated with serious adverse maternal and neonatal outcomes. Historically, many barriers have prevented pregnant women from seeking treatment. Early Start (ES) breaks new ground by sidestepping these barriers with a fully integrated service delivery model.ES is the largest HMO-based prenatal substance-abuse program in the United States targeting all pregnant women seen at Kaiser Permanente Northern California (KPNC) prenatal clinics, currently screening more than 39,000 women each year. The program is based on the premise that substance abuse is a treatable disease and addresses it in a nonjudgmental, accepting manner. A substance-abuse counselor is located in each obstetrics clinic providing accessible one-to-one counseling to pregnant women screened at risk for alcohol, tobacco, or drug use as part of the routine prenatal care package offered to all patients.A 2006 ES study, sponsored by the Kaiser Foundation Research Institute, evaluated program effectiveness in terms of its impact on neonatal and maternal outcomes. Preliminary results that included 49,986 KPNC patients indicate that compared with pregnant women whose results on screening for substance use were positive but who were untreated, ES-treated women had significantly lower rates on a number of outcome measures.The originality and transferability of ES has led to both local and national recognition. Universal screening of all pregnant women with access to an integrated model of substance-abuse treatment should be the standard of care for every prenatal patient because of the significant benefits for mothers and their babies.
 
It is unclear if telepsychiatry, a subset of telemedicine, increases access to mental health care for inmates in correctional facilities or decreases costs for clinicians or facility administrators. The purpose of this investigation was to determine how utilization of telepsychiatry affected access to care and costs of providing mental health care in correctional facilities. A literature review complemented by a semistructured interview with a telepsychiatry practitioner. Five electronic databases, the National Bureau of Justice, and the American Psychiatric Association Web sites were searched for this research, and 49 sources were referenced. The literature review examined implementation of telepsychiatry in correctional facilities in Arizona, California, Georgia, Kansas, Ohio, Texas, and West Virginia to determine the effect of telepsychiatry on inmate access to mental health services and the costs of providing mental health care in correctional facilities. Telepsychiatry provided improved access to mental health services for inmates, and this increase in access is through the continuum of mental health care, which has been instrumental in increasing quality of care for inmates. Use of telepsychiatry saved correctional facilities from $12,000 to more than $1 million. The semistructured interview with the telepsychiatry practitioner supported utilization of telepsychiatry to increase access and lower costs of providing mental health care in correctional facilities. Increasing access to mental health care for this underserved group through telepsychiatry may improve living conditions and safety inside correctional facilities. Providers, facilities, and state and federal governments can expect increased savings with utilization of telepsychiatry.
 
Top-cited authors
Wansu Chen
  • Kaiser Permanente
Corinna Koebnick
  • Kaiser Permanente
Phil Tuso
  • Kaiser Permanente
Carole Bartolotto
  • Kaiser Permanente
Daniela Alexandru-Abrams
  • University of California, Irvine