VOLUME 12 NO. 4 — FALL 2008 12 NO. 4 — FALL VOLUME VOLUME 12 NO. 4 — FALL 2008 12 NO. 4 — FALL VOLUME Fall 2008 Volume 12 No. 4 a peer-reviewed journal of medical science, social science in medicine, and medical humanities Original Articles 4 Associations of Psoriatic Arthritis and Cardiovascular Conditions in a Large Population 9 Augmentation of Conventional Medical Management of Moderately Severe or THE PERMANENTE JOURNAL THE PERMANENTE JOURNAL Severe Asthma with Acupuncture and Guided Imagery/Meditation 15 Early Discharge Study for Premature Infants: Singapore General Hospital 20 Counseling and Wellness Services The Permanente Journal Integrated with Primary Care: Fall 2008 A Delivery System That Works Volume 12 No. 4 25 Are Foot Abnormalities More ISSN 1552-5767 Common in Adults with Diabetes? Printed on recycled paper. A Cross-Sectional Study in Basrah, Iraq Review Articles 32 The Role of B-Type and Other Natriuretic Peptides in Health and Disease 45 Prognostic Factors for Long-Term Survival PRSRT STD after Glioblastoma 500 NE Multnomah St, Suite 100 US POSTAGE Portland, Oregon 97232 PAID PORTLAND OR Commentary PERMIT NO 1452 65 Information Technology Innovation Change Service Requested Narrative Medicine 77 Labyrinths Find Their Way onto Hospital Grounds as Paths to Healing www.kp.org/permanentejournal Fall08cvrPDX.indd 1 8/15/08 11:53:13 AM Fall 2008/ Volume 12 No. 4 ORIGINAL ARTICLES TPJ 2007 “Service Quality Awards” — 4 Associations of Psoriatic Arthritis Institute for Healthcare Improvement Mission: The Permanente Journal is and Cardiovascular Conditions in 19th Annual National Forum on Quality published for physicians, practitioners, a Large Population. Improvement in Health Care and nurses to create and to deliver superior Svetlana Kondratiouk, DO; 15 Early Discharge Study for Premature health care through the principles and Natalia Udaltsova, PhD; Arthur L benefits of Permanente Medicine. Infants: Singapore General Hospital. Klatsky, MD Yeo Cheo Lian, MD; Selina Ho Kah Permanente Medicine is preventive, Among a multiethnic population Ying, MD; Cheong Chiu Peng, RN; innovative, evidence-based, population of 76,465 men and women, none Tay Yih Yann, RN care practiced by a multispecialty group, of the 99 persons with a con- At Singapore General Hospital, prema- using an electronic health and medical firmed outpatient diagnosis of ture infants had a median birth weight record, and focused on patient psoriatic arthritis exhibited more of 1210 g. Discharge traditionally oc- relationships and outcomes. atherothrombotic disease (coro- curred when infants were medically fit nary and cerebrovascular) or dia- and weighed 2000 g. The length of betes mellitus than two control hospital stay was reduced 59.8%, pri- Circulation: 30,000 print readers per groups, but all 99 persons did marily by improved discharge planning, quarter, and accessed by 500,000 unique have an increased prevalence of revised guidelines (mean discharge at Web readers in 2007 from all 160 countries systemic hypertension and heart 1915 g), and nurses’ active preparation of the world. failure, and a higher mean body of parents psychologically and mentally mass index. for care of their babies at home. 9 Augmentation of Conventional 20 Counseling and Wellness Services Medical Management of Integrated with Primary Care: Moderately Severe or Severe A Delivery System That Works. Asthma with Acupuncture and Ken Van Beek, LMSW; Steve Duchemin, Guided Imagery/Meditation. PA-C; Geniene Gersh, MA, LLP; Susanne Lewis Mehl-Madrona, MD, PhD Pettigrew, PA-C; Pamela Silva; Barb Luskin On the cover: Patients with moderately severe By colocating behavioral health “At Angelique” or severe asthma who, when counselors and nutritionists along- (24”x 30”) by visiting a complementary and side primary care physicians. Grand Fred M Freedman, alternative medicine clinic, Valley Health Plan established the MD, is an oil selectively chose to add a com- national benchmark for patients us- on canvas of a bination of acupuncture and Paris café scene. ing ambulatory services for mental guided imagery/meditation to It is painted health, and ranked first in Michigan from a photo their maximal medical man- on all six HEDIS “effectiveness of Dr Freedman shot at Angelique, a café in Paris agement, experienced respira- care” measures for behavioral health. known for its hot chocolate and dessert pastries. The tory improvement—decreased One result was a 54% decrease in photograph was taken from a balcony overlooking symptoms, decreased Emer- mental health hospitalization. Up to the front window tables. In this painting, Dr gency Department visits, and 70% of primary care visits are driven Freedman wanted to try a loose painting style decreased number of days of by psychosocial factors, with 25% of with a post-impressionistic color spectrum. hospitalization, while taking less patients having a diagnosable mental Dr Freedman is a Neurologist at the South Bay medications than before—and at disorder, and comorbidity occurring Medical Center. He enjoys painting in oil on can- a lower cost of care. in up to 80% of patients. vas and the inspiration for many of his paintings are scenes from his travels. Dr Freedman has done artwork all his life, including painting in oil and 25 Are Foot Abnormalities More Common gouache and etchings. He is retiring in Septem- in Adults with Diabetes? A Cross- ber and hopes to be able to pursue more travel, Sectional Study in Basrah, Iraq. photography, and art—all linked together as in this painting. Abbas Ali Mansour, MD; Samir Ghani Dahyak, MD 88 ABSTRACTS OF ARTICLES AUTHORED OR COAUTHORED In a study population of 100 patients BY PERMANENTE PHYSICIANS, with type 2 diabetes and 100 patients NURSES, AND INVESTIGATORS without diabetes, researchers found 13 foot abnormalities—prominent metatar- 90 ABSTRACTS FROM THE sal head, high medial arch, hammertoe, HMO RESEARCH NETWORK wasting, joint stiffness, amputation, 93 BOOK REVIEWS fissures, nail changes, ulcers, blisters, dryness, sclerosis, and dermopathy— The Permanente Journal statistically more frequent in study 500 NE Multnomah St, Suite 100 participants with diabetes; however Portland, Oregon 97232 only wasting, ulcer, and dryness were www.kp.org/permanentejournal strongly associated with diabetes. available online: www.kp.org/permanentejournal ISSN 1552-5767 See page 3 for details. The Permanente Journal/ Fall 2008/ Volume 12 No. 4 Fall08InCvr.indd 1 8/15/08 12:04:12 PM REVIEW ARTICLES NARRA TIVE CASE STUDY EDITORIAL STUDY 32 The Role of B-Type and Other 53 Diagnoses are Stereotypes: 70 Relationship of a Physician’s Well- Natriuretic Peptides in Health Go Where They Are. Being to Interactions with Patients: and Disease. Dustin L Larson Practices of the Highest Performing Ashok Krishnaswami, MD, FACC Physicians on the Art of Medicine What if clinicians accompanied Patient Survey. Tom Janisse, MD B-type natriuretic peptide (BNP) a homeless person for a day, as levels are specifically useful in the author did? Would they also In a trusting relationship, physi- differentiating the etiology of learn how to inquire about sensi- cians who, according to patient shortness of breath between left tive issues, high-risk behaviors, surveys, satisfy their patients best ventricular (LV) dysfunction, acute or lifestyle? Would they learn that described that as doctors they are congestive heart failure (CHF), individuals don’t fit stereotypes? “part of the medicine” through and pulmonary dysfunction with- several empathetic activities: out CHF. The primary responsibil- respect, attention and presence, ity of natriuretic peptides (NP) is CLINICAL MEDICINE listening, connection, reassurance SOUL OF the maintenance of sodium and 57 Image Diagnosis: Pulmonary and support, touch, knowledge, THE HEALER water homeostasis and vasomo- explanation and education. This Embolism. Original Visual Art tor tone. Both atrial NP and BNP medicine has a powerful thera- 19 “Sara’s Trees” decrease plasma volume and Image Diagnosis: Radial peutic treatment effect and is Stephen Weiss, MD blood pressure in response to an Head Fracture. responsible for physicians’ sense increased tension of the atrium or Image Diagnosis: Abdominal of feeling valued, making an 31 “College Avenue” ventricle, respectively, but reflect Aortic Aneurysm. important contribution, making a Pamela Fox LV function, mass, and load more Gus M Garmel, MD, FACEP, FAAEM difference, and creating personal 44 “449” than volume status. Three sets of radiographic and and professional well-being. Sal Iaquinta, MD 45 Prognostic Factors for Long-Term computed tomography images 52 “Mexican Marionette” Survival after Glioblastoma. depict pulmonary embolism (and NARRATIVE MEDICINE Evelyn Zlomke, RN, MPH Mohammad Sami Walid, MD, PhD popliteal venous source), radial head fracture, and leaking ab- 77 Labyrinths Find Their Way onto Original Literary Art Long-term survivors of glioblas- dominal aortic aneurysm. Hospital Grounds as Paths to 85 The Dance. toma are rare. Several variables Healing. Jim Gersbach Jonathon W Gietzen, besides tumor size and location Walking labyrinths, recently MS, PA-C determine a patient’s survival COMMENTARIES opened at Kaiser Permanente (KP) chances: age at diagnosis, where 86 True North. 60 The Changing Face Sunnyside and Antioch Medical younger patients often receive Mary Dowd, MD of HIV Infection. Center hospitals, are intended to more aggressive multimodal William J Towner, MD, FACP let those who enter find their way 87 In the Pod. treatment; functional status, along