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Permanente Journal

Nicole Hahn, Kelsey E Palmer, Shilpa Klocke, Thomas Delate
INTRODUCTION: For patients with a less-active (fewer relapses or complete recovery from relapses, less radiologic burden of disease, or no or limited disease-related disability) relapsing form of multiple sclerosis (MS), interferon (IFN) beta-1b subcutaneous is similar in efficacy to IFN beta-1a intramuscular and subcutaneous. The purpose of this study was to assess the impact of patient interchange from an IFN beta-1a to IFN beta-1b. METHODS: This was a retrospective, pre-post study of adult patients with relapsing MS who underwent interchange from an IFN beta-1a to IFN beta-1b between April 15, 2014, and April 30, 2015...
August 30, 2018: Permanente Journal
Fareed Ahmed, Sidra Asad Ali
This is a story of a medical intern whose cascade of baffling thoughts about pursuing a career finally led to a gratifying conclusion. This young intern is easily swayed by the opinions of others, but circumstances proved that the field he chose was the one he was made for. This is a story of determination and belief in one's ability, which gave the power to fight against the odds.
August 30, 2018: Permanente Journal
Gerald Levy, Jiaxiao M Shi, T Craig Cheetham, Nazia Rashid
CONTEXT: Hyperuricemia is an independent risk factor for progression of kidney disease. OBJECTIVE: To determine whether lowering serum uric acid level (sUA) to below 6 mg/dL (target) improves mild to moderate chronic kidney disease (CKD) and whether CKD stage influences the benefit of lowering sUA to target. DESIGN: Retrospective epidemiologic cohort study conducted over 8 years. Estimated glomerular filtration rate (eGFR) was required in the 6 months preceding the index date (defined as first occurrence of sUA < 7 mg/dL), and at least 1 sUA and eGFR were required during follow-up...
August 30, 2018: Permanente Journal
Nandini Bakshi
No abstract text is available yet for this article.
August 27, 2018: Permanente Journal
Efstathios Karamanos, Arielle Hodari Gupta, Cletus Nor Stanton, Adhnan Mohamed, Joe H Patton, Nathan Schmoekel
CONTEXT: Clostridium difficile-associated infection (CDAI) can result in longer hospitalization, increased morbidity, and higher mortality rates for surgical patients. The impact on trauma patients is unknown, however. OBJECTIVE: To assess the effect of CDAI on trauma patients and develop a scoring system to predict CDAI in that population. METHODS: Records of all trauma patients admitted to a Level I Trauma Center from 2001 to 2014 were retrospectively reviewed...
August 27, 2018: Permanente Journal
Nardine Saad Riegels, Emily Asher, Joseph R Cartwright, Jessica L Chow, Elaine D Lee, Matthew Nordstrom, Allison N Schneider, Madeline D Schwarz, Margot Zarin-Pass, Lindsay A Mazotti
INTRODUCTION: Physician communication is critical to patient care. However, integration of sound communication practice with clinical workflows has proven difficult. In this quality improvement initiative, medical students used the rapid improvement model to test interventions that could enhance patients' perception of listening by physicians as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems survey. METHODS: Literature review and process analysis yielded 42 potential interventions, of which 24 were feasible for implementation...
August 1, 2018: Permanente Journal
Lewei Duan, Aniket A Kawatkar
CONTEXT: Many patients with ductal carcinoma in situ (DCIS) receive treatment that is too extensive. OBJECTIVE: To take a holistic approach in comparing the effectiveness in cancer prevention between mastectomy and breast-conserving surgery (BCS) for patients with DCIS. DESIGN: Female Kaiser Permanente Southern California members who underwent surgery for treatment of single primary DCIS from 2004 to 2014 were identified by the Kaiser Permanente Southern California cancer registry and HealthConnect database...
July 31, 2018: Permanente Journal
Mitsuro Chiba, Kunio Nakane, Masfumi Komatsu
No abstract text is available yet for this article.
July 31, 2018: Permanente Journal
Georgia Dedemadi, Shota Takano
CONTEXT: Posterior tibial nerve stimulation is a new second-line treatment for refractory fecal incontinence. OBJECTIVE: To assess the efficacy of bilateral transcutaneous posterior tibial nerve stimulation (BTPTNS) for treatment of fecal incontinence in Japanese patients and its impact on quality of life. DESIGN: A prospective observational-interventional study was conducted from May 2015 to June 2017 in patients with fecal incontinence in whom conservative treatment had failed...
July 31, 2018: Permanente Journal
Lisa J Herrinton, G Thomas Ray, Jeffrey R Curtis, Jashin J Wu, Bruce Fireman, Liyan Liu, Robert Goldfien
BACKGROUND AND OBJECTIVES: Comparative safety studies typically use hierarchical treatment categories that lump monotherapy and combination therapy. The consequence of this approach on study results is not clear. For example, studies of tumor necrosis factor inhibitors usually lump users regardless of whether they are using the drug alone or in combination with other agents. This study explored the importance of lumping vs splitting users of monotherapy and combination therapy. We also explored whether the timing of disenrollment from Health Plan membership was informative as an outcome variable when interpreting unmeasured, time-varying confounding...
July 19, 2018: Permanente Journal
Ahmed Z Obeidat, Nadia Al-Khun
A neurology fellow describes an emotionally draining workday beginning with a long commute delayed by a scene of accidental death. During patient rounds, the day continued with misery as this physician watched and declared brain death in two patients. Opioids took away the life of a young, loving father from his growing family. Opioids robbed an unborn child from seeing her mother. Opioids made this physician feel helpless and caused him to think, Why is this happening? How to stop it? And when does it end? This narrative essay illustrates, with words and art, the need to stamp out the opioid epidemic...
July 19, 2018: Permanente Journal
John P Caloyeras, Michael H Kanter, Nicole R Ives, Chong Y Kim, Hemal K Kanzaria, Sandra H Berry, Robert H Brook
BACKGROUND: Approximately 30% of total US health care spending is thought to be "wasted" on activities like unnecessary and inefficiently delivered services. OBJECTIVES: To assess the perceptions of clinic-based physicians regarding their use of time and appropriateness of care provided. DESIGN: Cross-sectional online survey of all Southern California Permanente Medical Group partner and associate physicians (N = 1034) who were primarily providing clinic-based care in 1 of 4 geographically and operationally distinct Kaiser Permanente Southern California Medical Centers...
July 19, 2018: Permanente Journal
Aakanksha Goel, Rahul Insa, Manish Kumar Gaur, Pankaj Kumar Garg
INTRODUCTION: Local treatment of metastatic cystosarcoma phyllodes is classically viewed with skepticism because it does not provide survival benefit. When these advanced tumors ulcerate, they reduce quality of life dramatically because of associated pain, infection, malodor, massive discharge, and bleeding. CASE PRESENTATIONS: Two patients with metastatic cystosarcoma phyllodes presented to our hospital with recurrent disease featuring foul-smelling, ulcerated chest wall masses that caused physical pain and social exclusion...
July 19, 2018: Permanente Journal
Kate Dubé, Reena Gupta, Marianna Kong, Margae Knox, Thomas Bodenheimer
Continuity of care is a challenge in primary care residency teaching clinics. Resident physicians have competing inpatient and outpatient responsibilities and often spend only 1 to 2 half-days per week in the clinic. Their clinic schedules are often pieced together after the needs of inpatient and specialty rotations are met. Similarly, faculty clinicians often balance limited clinic time with teaching, research, or administrative responsibilities. Seeking approaches to improve continuity of care, we visited 23 internal medicine, family medicine, and pediatric residency clinics across the US...
July 19, 2018: Permanente Journal
Frank L Bauer, William T Donahoo, Harris W Hollis, Adam G Tsai, Brian J Pottorf, Jason M Johnson, Lori J Silveira, Farah A Husain
INTRODUCTION: Pain management can be challenging following bariatric surgery, and patients with obesity tend to increase opioid use after undergoing surgery. This report quantifies marijuana (MJ) use and its relationship to pain and other surgery-related outcomes in a population from a state that has legalized MJ. METHODS: Data were collected for consecutive patients undergoing weight reduction surgeries between May 1, 2014 and July 31, 2015. Demographics, preoperative comorbidities, medications, and perioperative opioid use were analyzed...
July 19, 2018: Permanente Journal
Shobana Kubendran, Jennifer Duong, Fanglong Dong, Amy Lueking, Darren Farley
CONTEXT: Results from chromosome testing after spontaneous abortion (SAB) or intrauterine fetal demise (IUFD) are useful in patient counseling; however, results can be inconclusive when cell cultures for chromosomes are unable to grow from products of conception. Chromosomal microarray analysis (CMA) can analyze DNA from nonviable fetal tissue. OBJECTIVE: To examine whether establishing a genetic testing protocol for karyotype and CMA on SAB and IUFD tissues increases diagnostic yield...
July 19, 2018: Permanente Journal
Lindsey C Shipley, S Trevor Taylor, Christina Grimsley, Kevin Stoffer, Jack Goldstein
INTRODUCTION: Hantavirus is an RNA virus that is transmitted to humans by inhalation of aerosolized excrement from infected rodents. This case report demonstrates the value of taking a thorough social history and highlights the challenges associated with early diagnosis of this viral infection. CASE PRESENTATION: We highlight a case of suspected hantavirus infection with subtle gastrointestinal and pulmonary symptoms that challenged the initial diagnosis. DISCUSSION: Efforts are needed to improve clinical recognition and rapid detection of hantavirus infections, to reduce associated mortality...
July 19, 2018: Permanente Journal
Satvinder S Bakshi
No abstract text is available yet for this article.
July 19, 2018: Permanente Journal
Sarah Beekley
No abstract text is available yet for this article.
July 19, 2018: Permanente Journal
G Todd Alonso, Raquel Hink, Michael R De Georgeo, Katherine Vidal, Sarah Thomas, David Swaschnig, Gail Spiegel, Susan Owen, Jessica Thurston, Laura Pyle, Robert Slover
CONTEXT: Our pediatric diabetes center initiated insulin pump therapy for more than 250 patients with type 1 diabetes in 2014, but onboarding was inefficient. OBJECTIVE: To decrease time from the decision to initiate pump therapy to the ambulatory encounter after pump start (lead time) for new pump users from 132.5 days to less than 110 days within 5 months. DESIGN: Define, Measure, Analyze, Improve, Control method. We identified key problems: Long wait for training classes, unclear metrics, complicated scheduling, and nonstandardized processes...
July 12, 2018: Permanente Journal
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