Summer 2018 Edition of the Permanente Journal Now Available


The latest Permanente Journal is now available for download, and includes a variety of peer-reviewed articles and studies on topics from the impact of body-mass index on postconcussion symptoms in teenagers to a rare case of endogenous endophthalmitis.

This edition also includes a study co-written by Michael Kanter, MD, chief quality officer of The Permanente Federation, that looks at results of a survey of Permanente physicians at the Southern California Permanente Medical Group, asking them about time spent on direct patient care and the appropriateness of care provided in an effort to understand potential waste in health care.

Read more about what’s inside this quarter’s Journal and click on articles of interest below. Or you can download the PDF for the complete edition.

Original Research and Contributions

CMERelapse Prevention in Ulcerative Colitis by Plant-Based Diet Through Educational Hospitalization: A Single-Group Trial
Mitsuro Chiba, MD, PhD; Kunio Nakane, MD, PhD; Tsuyotoshi Tsuji, MD, PhD; Satoko Tsuda, MD; Hajime Ishii, MD, PhD; Hideo Ohno, MD; Kenta Watanabe, MD; Mai Ito, MD; Masafumi Komatsu, MD, PhD; Koko Yamada, RD; Takeshi Sugawara, MD

No known published study has focused on a plant-based diet in the treatment of ulcerative colitis (UC). In a prospective study of 60 patients with mild UC or UC in remission who did not need immediate treatment (29 initial-episode cases and 31 relapse cases), the cumulative relapse rates at 1, 2, 3, 4, and 5 years of follow-up were 2%, 4%, 7%, 19%, and 19%, respectively. Relapse rates after educational hospitalization providing a plant-based diet were far lower than those reported with medication. Educational hospitalization is effective at inducing habitual dietary changes.

Marijuana’s Influence on Pain Scores, Initial Weight Loss, and Other Bariatric Surgical Outcomes 
Frank L Bauer, MD; William T Donahoo, MD; Harris W Hollis Jr, MD; Adam G Tsai, MD; Brian J Pottorf, MD; Jason M Johnson, DO; Lori J Silveira, PhD; Farah A Husain, MD

Pain management can be challenging following bariatric surgery, and obese patients tend to increase opioid use after undergoing surgery. Data were collected for 434 consecutive patients undergoing weight reduction surgeries (5/2014-7/2015) among whom 36 (8.3%) reported marijuana (MJ) use. Perioperative opioid requirements were significantly higher in the MJ-user group despite lower subjective pain scores (3.70 vs 4.24). The difference in opioid requirements suggests an interaction between MJ use and opioid tolerance or pain threshold. The percentage of total body weight loss, improvement in medical comorbidity, and incidence of postoperative complications at 90-day follow-up were not affected by MJ use in this cohort analysis.

CMEPotentially Preventable Hospital and Emergency Department  Events: Lessons from a Large Innovation Project
Leif I Solberg, MD; Kris A Ohnsorg, RN, MPH; Emily D Parker, PhD, MPH;Robert Ferguson; Sanne Magnan, MD, PhD; Robin R Whitebird, PhD; Claire Neely, MD; Emily Brandenfels, MD, MS; Mark D Williams, MD; Mark Dreskin, MD; Todd Hinnenkamp, RN; Jeanette Y Ziegenfuss, PhD

There are few proven strategies to reduce the frequency of potentially preventable hospitalizations and Emergency Department visits. Of the studied events, 28 percent were considered to be potentially preventable (39 percent of Emergency Department visits and 14 percent of hospitalizations) and 4.6 percent of patients had 40 percent of events. Only type of insurance coverage; patient lack of resources, caretakers, or understanding of care; and inability to access clinic care were more frequent in those with preventable events. Neither disease control nor ambulatory care-sensitive conditions were associated with potentially preventable events.

CMEUnderstanding Waste in Health Care: Perceptions of Frontline Physicians Regarding Time Use and Appropriateness of Care They and Others Provide 
John P Caloyeras, PhD; Michael H Kanter, MD; Nicole R Ives, MHA; Chong Y Kim, PhD; Hemal K Kanzaria, MD; Sandra H Berry, MA; Robert H Brook, MD, ScD

In a cross-sectional online survey of all Southern California Permanente Medical Group physicians primarily providing clinic-based care (1034), 61 percent of respondents indicated that 15 percent of their time spent on direct patient care could be shifted to nonphysicians, and between 10 percent and 16 percent of care provided was equivocal or inappropriate. It is apparent that within at least one health care system, the opportunity to increase value through task shifting and avoiding inappropriate care is more narrow than commonly perceived on a national level.

Impact of Body Mass Index on Postconcussion Symptoms in Teenagers Aged 13 to 18 Years 
Harry Bramley, DO; Kathryn C Foley, MD; Ronald Williams, MD; Mechelle M Lewis, PhD; Lan Kong, PhD; Matthew Silvis, MD

In a retrospective chart review at a regional concussion program located at an academic medical center, medical records of all patients aged 13 to 18 years treated from 3/2006-1/2012 were reviewed with 252 patients meeting the inclusion criteria of sports-related concussion and having body mass index data. There was no statistically significant difference in recovery time between obese and overweight patients and others. After concussion, irritability and impulsivity may be more likely than headaches in overweight and obese patients.

Comparative Effectiveness of Surgical Options for Patients with Ductal Carcinoma In Situ: An Instrumental Variable Approach
Lewei Duan, MS; Aniket A Kawatkar, PhD

Many patients with ductal carcinoma in situ (DCIS) receive treatment that is too extensive. Of qualified subjects, 72.2 percent underwent breast-conserving surgery and 27.8 percent underwent mastectomy. No significant benefit was observed with a more aggressive surgical procedure in preventing DCIS recurrence or cancer progression in a diverse population. Many patients with DCIS could benefit from breast-conserving surgery with preservation of their body image. Breast conservation followed-up with cancer surveillance is a rational approach to ensure effective care for patients with DCIS.

Listening Beyond Auscultating: A Quality Initiative to Improve Communication Scores in the Hospital Consumer Assessment of Health Care Practitioners and Systems Survey
Nardine Saad Riegels, MD; Emily Asher, MD, MS, MPH, MPA; Joseph R Cartwright, MD, MEd; Jessica L Chow, MD, MPH, MS; Elaine D Lee, MD; Matthew Nordstrom, MD; Allison N Schneider, MD; Madeline D Schwarz, MD; Margot Zarin-Pass, MD; Lindsay A Mazotti, MD

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. Literature review and process analysis yielded 42 potential interventions by medical students. The final intervention used a structured reminder embedded in the electronic health record to direct physicians to begin interviews by eliciting patient concerns, which included pain symptoms (28 percent), disease or treatment course (16 percent), and discharge planning (10 percent). In the Hospital Consumer Assessment of Healthcare Providers and Systems survey, physician listening scores rose from 73.6 percent (2014) to 77 percent (2015).

Efficacy of Bilateral Transcutaneous Posterior Tibial Nerve Stimulation for Fecal Incontinence
Georgia Dedemadi, MD, PhD, FACS; Shota Takano, MD, PhD

Bilateral transcutaneous posterior tibial nerve stimulation (BTPTNS) is a new second-line treatment for refractory fecal incontinence. Twenty-two patients (median 64 years, range 26-81) with a male:female ratio of 9:13 completed BTPTNS. Mean episodes of fecal incontinence were significantly reduced from 4.7 to 1.5. An improvement of 50 percent or better in episodes of fecal incontinence was achieved in 77.2 percent of patients. The median Wexner score significantly decreased from 10.2 to 6.9. The median fecal incontinence quality of life score improved from 2.7 to 3.1 (p = 0.06), and significant improvement was seen in the embarrassment domain (2.2 vs 2.8). Resting and squeezing anal pressures revealed no significant changes.

Online OnlyImproving the Insulin Pump Initiation Process for Pediatric Patients with Type 1 Diabetes through Application of Lean Quality Improvement Methods
Raquel Hink, PA-C, MSPH; Raquel Hink, PA-C, MSPH; Michael R De Georgeo, PhD; Katherine Vidal; Sarah Thomas; David Swaschnig, CPNP-C, CDE; Gail Spiegel, MS, RD, CDE; Susan Owen, RN, CDE; Jessica Thurston, MS; Laura Pyle, PhD; Robert Slover, MD

A pediatric diabetes center initiated insulin pump therapy for more than 250 patients with type 1 diabetes in 2014, with an objective to decrease time from the decision to initiate pump therapy. During this project, 229 patients initiated the pump-start proces. with 31 pump nonstarters. Nonstarters had a longer diabetes duration (median = 3.43 vs 2.05 years). A high proportion of patients not starting pump therapy was discovered.

Online OnlySentiment, Contents, and Retweets: A Study of Two Vaccine-Related Twitter Datasets 
Elizabeth B Blankenship, MPH; Mary Elizabeth Goff, MPH; Jingjing Yin, PhD; Zion Tsz Ho Tse, PhD; King-Wa Fu, PhD; Hai Liang, PhD; Nitin Saroha, MS; Isaac Chun-Hai Fung, PhD

Social media platforms are important channels through which health education about the utility and safety of vaccination is conducted. A stratified random sample (1425) of 142,891 #vaccine tweets (2/2010-11/2016) and all 201 tweets with 100 or more retweets from 194,259 #vaccineswork tweets (1/2014-4/2015) were manually coded. Among 325 links in antivaccine tweets, social media links were common: Twitter (44; 14.9 percent), YouTube (25; 8.4 percent), and Facebook (10; 3.4 percent). Among highly retweeted #vaccineswork tweets, the most common theme was childhood vaccinations (40 percent; 81/201); global vaccination improvement/efforts (21 percent; 42/201); and vaccines can prevent outbreaks and deaths (29 percent; 58/201). Engaging social media key opinion leaders to facilitate health education about vaccination in their tweets may allow for reaching a wider audience online.

Online OnlyAn Observational Study of Cardiovascular Risks Associated with Rheumatoid Arthritis Therapies: A Comparison of Two Analytical Approaches 
Lisa J Herrinton, PhD; G Thomas Ray, MBA; Jeffrey R Curtis, MD, MS, MPH; Jashin J Wu, MD; Bruce Fireman, MA; Liyan Liu, MD, MSc; Robert Goldfien, MD

Comparative safety studies typically use hierarchical treatment categories that lump monotherapy and combination therapy. This study explored the importance of lumping vs splitting users of monotherapy and combination therapy. Analysis of nine drug categories that split monotherapies from combination therapy was easier to interpret, although confidence intervals were wider. Analysis of drug treatment in relation to disenrollment provided useful information with which to assess study validity.

Online OnlyImplementing a Protocol to Optimize Detection of Chromosome Abnormalities in Cases of Miscarriage or Stillbirth at a Midwestern Teaching Hospital 
Shobana Kubendran, MBBS, MS, CGC; Jennifer Duong, MPH; Fanglong Dong, PhD; Amy Lueking, MD; Darren Farley, MD

A protocol of reflexing to chromosomal microarray analysis or proceeding directly with chromosomal microarray analysis gives a higher diagnostic yield in the genetic evaluation of spontaneous abortion or intrauterine fetal demise. Institutions should consider implementing a genetic testing protocol to improve diagnostic yield. Our study results emphasize the importance of proceeding directly to microarray analysis and give support for current clinical recommendations for genetic testing after fetal demise.

Special Report

Continuity of Care in Residency Teaching Practices: Lessons from “Bright Spots” 
Kate Dubé, MSW; Reena Gupta, MD; Marianna Kong, MD; Margae Knox, MPH; Thomas Bodenheimer, MD, MPH

The authors visited 23 internal medicine, family medicine, and pediatric residency clinics across the US. This article highlights strategies to optimize continuity of care pioneered by 3 “bright spot” residency teaching clinics with high-continuity performance. The strategies include adopting a strong continuity culture and patient scheduling algorithms that prioritize continuity, appointing a team continuity anchor, and/or reorganizing resident and faculty schedules to maximize continuity.

Review Article

The Effect of Abnormal Vitamin D Levels in Athletes
Jakub Sikora-Klak, MD; Steven J Narvy, MD; Justin Yang, MD; Eric Makhni, MD; F Daniel Kharrazi, MD; Nima Mehran, MD

Vitamin D is a lipophilic prohormone integral to musculoskeletal, autoimmune, oncologic, cardiovascular, and mental health. Most American adults have inadequate levels of vitamin D. Even among athletes, there is a high prevalence of vitamin D deficiency, which may place competitors at risk of stress fractures, illness, and delayed muscle recovery. This review is to describe the epidemiology of vitamin D deficiency and its effects on athletic performance and musculoskeletal health.

Case Reports

Obstructive Uropathy and Sepsis Caused by an Inguinoscrotal Bladder Hernia: A Case Report 
Seena Safavy, MD; Emmanuel Mitsinikos, MD; Bradford Tropea, MD; Allen Chang, MD; Hetal Patel, MD

Inguinoscrotal bladder hernia is a very rare pathology, occurring in up to 4 percent of all inguinal hernias in the general population. We present a case of an inguinoscrotal bladder hernia causing obstructive uropathy and sepsis in a 59-year-old obese man who presented with left-sided flank and abdominal pain that radiated to his left groin. It is prudent to first stabilize the patient via decompression of the upper urinary tract and antibiotics before herniorrhaphy.

Metastatic Angiosarcoma of the Scalp Presenting with Cystic Lung Lesions: A Case Report and Review of Cystic Lung Diseases
Antonette A Ajayi, MD, MPH; Stephanie V Commins, MTchgLn; David E Clarke, MD, FCCP

An 83-year-old woman presented with a scalp lesion that was initially thought to be caused by scalp trauma but was later found to be an angiosarcoma. The authors discuss the common presentation of cutaneous angiosarcomas and their tendency to metastasize to the lung and to present as cystic lesions. They review the common conditions that can cause cystic changes in the lungs.

Endogenous Group A Streptococcal Endophthalmitis  in a Healthy 42-Year-Old Man: A Case Report
Tan Duong, MD; Shahin Shahbazi, MD; Sung Lee, MD

Endogenous endophthalmitis is a rare condition that is caused by hematogenous spread of bacteria or fungi and is usually seen in patients with predisposed medical conditions. The authors report an unusual case of group A streptococcal infection causing endogenous endophthalmitis and septic arthritis in a healthy 42-year-old man.

Online OnlyPyeloduodenal Fistula in Xanthogranulomatous Pyelonephritis: A Series of Two Cases
Sara Dawoud, MBMS; Rachele J Solomon, MPH; Stephanie A Eyerly-Webb, PhD; Neil A Abrahams, MD; Fernando Pedraza, MD; Juan D Arenas, MD, MBA, FACS; Tjasa Hranjec, MD, MS-CR

Xanthogranulomatous inflammation (destruction and replacement of tissues with chronic inflammatory cells, including foamy histiocytes and hemosiderin-laden macrophages) may extend from the kidney to the overlying duodenum, creating a pyeloduodenal fistula. The authors present two cases with recurrent kidney infections who each ultimately received a nephrectomy and repair of their duodenal fistula.

Online OnlyPalliative Surgery for Metastatic Fungating Phyllodes Tumors: A Series of Two Cases
Aakanksha Goel, MBBS, MS; Rahul Insa, MBBS, MS; Manish Kumar Gaur, MBBS, MS; Pankaj Kumar Garg, MS, DNB, MCh

Local treatment of metastatic cystosarcoma phyllodes is classically viewed with skepticism because it does not provide survival benefit. Palliative resection allowed our patients to have good social and family support to the end. Palliative surgery plays an important role in alleviating suffering of patients having metastatic fungating cystosarcoma phyllodes and has the potential to improve their quality of life significantly.

Online OnlyInvasive Basal Cell Carcinoma of the Skin Treated  Successfully with Vismodegib: A Case Report
Ramez Awad, MD; Juan Camilo Barreto Andrade, MD; Heba Mousa, MD; Fade Mahmoud, MD

Basal cell carcinoma is the most common skin cancer. It is primarily a local disease, and it very rarely causes metastatic disease. Chemotherapeutic agents had limited success in management of metastatic disease until the introduction of vismodegib. In this case report of a 69-year-old man, we describe the presentation of a metastatic basal cell carcinoma that was not amenable to surgical resection or local treatment options and was treated successfully with vismodegib.

Online OnlyRats! Hantavirus: A Case Report of a Suspected Case in Eastern Tennessee 
Lindsey C Shipley, MD; S Trevor Taylor; Christina Grimsley; Kevin Stoffer; Jack Goldstein, MD

Hantavirus, an RNA virus, is transmitted to humans by inhalation of aerosolized excrement from infected rodents. The authors present a case of suspected hantavirus infection with subtle gastrointestinal and pulmonary symptoms that challenged the initial diagnosis. In a patient presenting with gastrointestinal prodromal symptoms followed by cardiopulmonary findings, physicians should pay special attention to that patient’s living conditions and maintain a high index of suspicion for hantavirus infection.

Image Diagnosis

Online OnlyImage Diagnosis: Plummer-Vinson Syndrome: An Unusual Cause of Dysphagia 
Puneet Chhabra, MD, DM; Hunny Khurana, MD

A 50-year-old woman was referred to our gastroenterology clinic for an upper gastrointestinal endoscopy for mechanical dysphagia, after 25 years of dysphagia predominantly to solids without any significant loss of weight or appetite. Barium swallow revealed a short segment-filling defect in the midcervical esophagus with narrowing and a jet effect of the barium passing distally to the lesion.

Online OnlyImage Diagnosis: Allergic Fungal Sinusitis
Satvinder S Bakshi, MS, DNB

The term “allergic fungal sinusitis” was introduced by Robson et al in 1989. Incidence depends on geographic location; most cases are in temperate regions and regions with high humidity. This condition is most commonly seen in immunocompetent adolescents and young adults. Theories on pathogenesis include hypersensitivity and T-cell-mediated reactions as well as a humoral immune response.

Health Care Communication

CMEThe Unmet Challenge of Medication Nonadherence
Fred Kleinsinger, MD

Medication nonadherence for patients with chronic diseases is extremely common, affecting as many as 40 percent to 50 percent of patients who are prescribed medications for management of chronic conditions such as diabetes or hypertension. A Cochrane review shows that multifactorial interventions are more effective. In at least one integrated health care system, Kaiser Permanente Northern California, a combination of approaches centered on the electronic health record has improved medication adherence rates to above 80 percent. Effective change will not happen until key players decide to take on this challenge and reimbursement systems are changed to reward health systems that improve medication adherence and chronic disease control.

How a “Nothingoma” Can Bring Joy to a Physician
Scott Abramson, MD

During our visit, I talked with Joanne and examined her. Everything was perfectly fine. I reviewed the MRI. It clearly showed an incidental, harmless finding, a “nothingoma.” As I reassured her and was making my exit, Joanne grasped my hand between hers.

Exploring Empathy in the Face of Patient Anonymity and Professional Challenges and Barriers
Carina Mendoza, MD

This is a reflective short story addressing empathy through the eyes of Maria (fictitious patient), confronted with negotiating her first encounter at a medical facility, and through the actions of Dr Jones (fictitious physician) who, at a critical juncture, fails to engage empathically with her patient, donning the ubiquitous hospital gown. Maria’s story is a collage of multiple clerkship experiences of a fourth-year medical student, and of shared anecdotal accounts from patients and medical practitioners.


From Principles to Practice: Real-World Patient and Stakeholder Engagement in Breast Cancer Research
Sarah M Greene, MPH; Susan Brandzel, MPH; Karen J Wernli, PhD, MS

Kaiser Permanente Washington Health Research Institute (KPWHRI) developed a set of eight principles to guide how research teams should work with patients and other stakeholders to simultaneously achieve research aims and embrace this new paradigm in how research teams collaborate. With a goal of assisting other research teams, this article describes the genesis of the KPWHRI principles, their relevance to patient- and stakeholder-engaged research, and how these principles were brought to life in the context of a specific Patient-Centered Outcome Research Institute-funded project on surveillance imaging in women after a breast cancer diagnosis.

Narrative Medicine

Pigments and Medicine
Sarah Beekley, MD

A physician’s work is challenging, complicated, and sometimes even daunting. We heal, but we are also witnesses to tragedy and loss. Maintaining grace in this setting requires an active investment in community, self, and beliefs. And so, when I am not working, I paint.

Home-Based Palliative Care Program Relieves Chronic Pain  in Kerala, India: Success Realized Through Patient, Family Narratives
Aparna Sai Ajjarapu; Ann Broderick, MD, MS

The current project features the pain stories of six patients who received treatment from Pallium India, one of the most sophisticated palliative care programs in India that emphasizes holistic pain treatment. A Pallium India staff member asked questions about each patient’s pain experience. Pain narratives (with photographs) illustrate the substantial impact of Pallium India’s home visit program and the role of total pain assessment in delivering high-quality palliative care.

Cathartic Poetry: Healing Through Narrative
Richard Bruce Hovey, MA, PhD; Valerie Curro Khayat, MA; Eugene Feig

Most people are completely afraid of silence. —EE Cummings.
This article explores the efficacy of writing and reading poetry as a means to help people living with chronic pain to explore and express their narratives in their own unique way. One of the authors’ poetry is sent out almost weekly to the members of our pain support group as a method of sharing his own experiences of living with pain, as well as to support and to inspire hope in others. This article is a philosophical hermeneutic conversation about pain and poetry.

Balloons of Hope 
Ahmed Z Obeidat, MD, PhD; 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 the life of a young, loving father from his growing family. Opioids robbed an unborn child from seeing her mother. This narrative essay illustrates, with words and art, the need to stamp out the opioid epidemic.

100 Little Stories of Big Moments

Ode to a Dead Hawk
Robert Sigafoes, MD, Joe Infurnari

What brought you down today, my noble friend?
I found you motionless, lying at the base of the tree you loved.
Speckled tan and white and gray, resting on the brown, moist leaves,
As the cerulean sky faded high above you.

Leg Warmers
Nina Greenblatt, MD, Tandy Kunkle

Depression, panic nonstop. About bad weather in her brain, her strength and courage for coming in. We all laughed at needing warm clothes and an umbrella until the shitty “brain storm” passed.

Wynne Morrison, MD, MBE, Ty Ennis

Bits of life erode
And fall apart until the end.
Lying on a bathroom floor,
Syringe still clutched
In a blue hand.

Letter to the Editor

Lifestyle Medicine in Inflammatory Bowel Disease

Book Review

Turbo Metabolism: 8 Weeks to a New You
Review by Charles R Elder, MD, MPH, FACP

Soul of the Healer

Hena Jawaid, MBBS, FCPS

Visiting Monarch
Robert W Hogan, MD

Round the Mountain (Pack a Lunch)
Charlene Happel

Verse of the Coast: Yellow Tree
Shenshen Dou, MS

On the Cover

Grandmother’s Green Thumb
Sarah Beekley, MD