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Effect of a region-wide incorporation of an algorithm based on the 2012 international consensus guideline on the practice pattern for the management of pancreatic cystic neoplasms in an integrated health system

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World Journal of Clinical Cases 2018年第13期6卷 624-631页

作者： Andrew Khoi Nguyen Agathon Girgis Timnit Tekeste Karen Chang Mopelola Adeyemo Armen Eskandari Emilio Alonso Priyanka Yaramada Charles Chaya Albert Ko Edmund Burke Isaiah Roggow Rebecca Butler Aniket Kawatkar Brian S Lim School of Medicine University of California Department of Gastroenterology Kaiser Permanente Riverside Medical Center Department of Surgery Kaiser Permanente Riverside Medical Center Department of Research and Evaluation Southern California Permanente Medical Group

AIM To examine the practice pattern in kaiser permanente southern california(KPSC), i.e., gastroenterology(GI)/surgery referrals and endoscopic ultrasound(EUS), for pancreatic cystic neoplasms(PCNs) after the regionwide dissemination of the PCN management *** Retrospective review was performed; patients with PCN diagnosis given between April 2012 and April 2015(18 mo before and after the publication of the algorithm) in KPSC(integrated health system with 15 hospitals and 202 medical offices in southern california) were ***2558(1157 pre-and 1401 post-algorithm) received a new diagnosis of PCN in the study period. There was no difference in the mean cyst size(pre-19.1 mm vs post-18.5 mm, P = 0.119). A smaller percentage of PCNs resulted in EUS after the implementation of the algorithm(pre-45.5% vs post-34.8%, P < 0.001). A smaller proportion of patients were referred for GI(pre-65.2% vs post-53.3%, P < 0.001) and surgery consultations(pre-24.8% vs post-16%, P < 0.001) for PCN after the implementation. There was no significant change in operations for PCNs. Cost of diagnostic care was reduced after the implementation by 24%, 18%, and 36% for EUS, GI, and surgery consultations, respectively, with total cost saving of 24%.CONCLUSION In the current healthcare climate, there is increased need to optimize resource utilization. Dissemination of an algorithm for PCN management in an integrated health system resulted in fewer EUS and GI/surgery referrals, likely by aiding the physicians ordering imaging studies in the decision making for the management of PCNs. This translated to cost saving of 24%, 18%, and 36% for EUS, GI, and surgical consultations, respectively, with total diagnostic cost saving of 24%.

关键词： Pancreatic cyst Algorithm incorporation Pancreas Optimization of resource utilization Fukuoka criteria Sendai criteria Pancreatic cancer Intraductal papillary mucinous neoplasm Practice management Algorithm

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Microscopic colitis:A large retrospective analysis from a health maintenance organization experience

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World Journal of Gastroenterology 2009年第25期15卷 3122-3127页

作者： Kevin T Kao Benito A Pedraza Amy C McClune David A Rios Yi-Qiong Mao Robert H Zuch Michael H Kanter Sony Wirio Chris N Conteas Department of Gastroenterology Kaiser PermanenteLos Angeles Medical Center Los Angeles California 90027United States Department of Internal Medicine Kaiser Permanente Los Angeles Medical Center Los Angeles California 90027 United States Department of Pathology Southern California Kaiser Permanente Medical Group California 90027 United States

AIM： To examine the demographic data on a large multi-ethnic population of patients with microscopic colitis （MC） in southern california and to determine the association of MC with inflammatory bowel disease （IBD） and colorectal cancer. METHODS： All patients diagnosed with MC by co- Ionic biopsy from 1996-2005 were identified utilizing a pathology database. All biopsies were reviewed by experienced pathologists utilizing standard histologic criteria. Patients＇ medical records were reviewed and data regarding patient age, co-morbidities, sex, ethnic- ity, and medications were analyzed. An age- and sex- matched standard control group was also generated. Chi-square test was used to evaluate the associations of co-morbidities between lymphocytic colitis （LC）, col- lagenous colitis （CC） and the control group. RESULTS： A total of 547 cases of MC were identified, 376 patients with LC and 171 patients with CC. The fe- male/male ratio was 3：1 in CC and 2.7：1 in LC patients. Celiac disease （P 〈 0.001）, irritable bowel syndrome （IBS）（P 〈 0.001）, and thyroid diseases （P 〈 0.001） were found to have a higher occurrence in MC com- pared to the control group. No statistical differences in the occurrence of colorectal cancer, diabetes and IBD were found between the MC group and the control group. CONCLUSION： This is the largest group of patients with MC known to the authors that has been studied to date. Conditions such as celiac disease, IBS, and thyroid diseases were found to be related to MC. Fur- thermore, neither an increased risk of colorectal cancer nor IBD was associated with MC in this study.

关键词： Collagenous colitis Inflammatory bowel disease Lymphocytic colitis Microscopic colitis

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To scan or not to scan:Use of transient elastography in an integrated health system

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World Journal of Hepatology 2023年第3期15卷 419-430页

作者： Libby Stein Rasham Mittal Hubert Song Joanie Chung Amandeep Sahota Department of Internal Medicine Kaiser Permanente Los Angeles Medical CenterLos AngelesCA 90027United States Department of Transplant Hepatology Kaiser Permanente Los Angeles Medical CenterLos AngelesCA 90027United States Research and Evaluation Kaiser Permanente Southern CaliforniaLos AngelesCA 91101United States

BACKGROUND Non-invasive tests,such as Fibrosis-4 index and transient elastography(com-monly FibroScan),are utilized in clinical pathways to risk stratify and diagnose non-alcoholic fatty liver disease(NAFLD).In 2018,a clinical decision support tool(CDST)was implemented to guide primary care providers(PCPs)on use of FibroScan for *** To analyze how this CDST impacted health care utilization and patient *** We performed a retrospective review of adults who had FibroScan for NAFLD indication from January 2015 to December 2017(pre-CDST)or January 2018 to December 2020(post-CDST).Outcomes included FibroScan result,laboratory tests,imaging studies,specialty referral,patient morbidity and *** We identified 958 patients who had FibroScan,115 before and 843 after the CDST was *** percentage of FibroScans ordered by PCPs increased from 33%to 67.1%.The percentage of patients diagnosed with early F1 fibrosis,on a scale from F0 to F4,increased from 7.8%to 14.2%.Those diagnosed with ad-vanced F4 fibrosis decreased from 28.7%to 16.5%.There were fewer laboratory tests,imaging studies and biopsy after the CDST was *** there were more specialty referrals placed after the CDST was implemented,multivariate analysis revealed that healthcare utilization aligned with fibrosis score,whereby patients with more advanced disease had more *** few patients were hospitalized or *** This CDST empowered PCPs to diagnose and manage patients with NAFLD with appropriate allocation of care towards patients with more advanced disease.

关键词： Non-alcoholic fatty liver disease Transient elastography FibroScan Clinical decision support tool Health care utilization Primary care

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Implementation science for the adductor canal block:A new and adaptable methodology process

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World Journal of Orthopedics 2021年第11期12卷 899-908页

作者： Nikhil Crain Chun-Yuan Qiu Stephen Moy Shawn Thomas Vu Thuy Nguyen Mijin Lee-Brown Diana Laplace Jennifer Naughton John Morkos Vimal Desai Bowman Gray center for Medical Education Wake Forest School of MedicineWinston-SalemNC 27103United States Perioperative Service and Anesthesiology Kaiser Permanente Medical CenterBaldwin ParkCA 91706United States Department of Anesthesiology Baldwin Park Medical CenterSouthern California Kaiser Permanente Medical GroupBaldwin ParkCA 91706United States Johns Hopkins University The Johns Hopkins University School of MedicineBaltimoreMD 21205United States

BACKGROUND Following the successful Perioperative Surgical Home(PSH)practice for total knee arthroplasty(TKA)at our institution,the need for continuous improvement was realized,including the deimplementation of antiquated PSH elements and introduction of new *** To investigate the transition from femoral nerve blocks(FNB)to adductor canal nerve blocks(ACB)during *** Our 13-month study from June 2016 to 2017 was divided into four periods:a three-month baseline(103 patients),a one-month pilot(47 patients),a three-month implementation and hardwiring period(100 patients),and a six-month evaluation period(185 patients).In total,435 subjects were *** within 30 postoperative days were extracted from electronic medical records,such as physical therapy results and administration of oral morphine equivalents(OME).RESULTS Our institution reduced FNB application(64% to 3%)and increased ACB utilization(36% to 97%)at 10 *** in the ACB group were found to have increased ambulation on the day of surgery(4.1 vs 2.0 m)and lower incidence of falls(0 vs 1%)and buckling(5% vs 27%)compared with FNB patients(Pmonitoring were deemed key facilitators of our program’s *** patient populations and additional orthopedic procedures are recommended for future study.

关键词： Total knee arthroplasty Femoral nerve block Adductor canal block Physical therapy Oral morphine equivalent Action-related information gap

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Protocol for electrophysiological monitoring of carotid endarterectomies

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The Journal of Biomedical Research 2010年第6期24卷 460-466页

作者： Hong Liu Anthony M Di Giorgio Eric S Williams William Evans Michael J Russell Department of Anesthesiology University of california Davis Medical CenterSacramentoCA 95817USA Active Diagnostics Inc.DavisCA 95616USA kaiser permanente Sacramento Medical center SacramentoCA 95825USA Aaken Laboratories Inc.DavisCA 95616USA

Near zero stroke rates can be achieved in carotid endarterectomy （CEA） surgery with selective shunting and electrophysiological *** false negative rates as high as 40% have been *** sought to determine if improved training for interpretation of the monitoring signals can advance the efficacy of selective shunting with electrophysiological monitoring across multiple centers,and determine if other factors could contribute to the differences in *** and raw beta band （12.5-30 Hz） electroencephalogram （EEG） and median and tibial nerve somatosensory evoked potentials （SSEP） were monitored in 668 CEA cases at six surgical centers.A decrease in amplitude of 50% or more in any EEG or SSEP channel was the criteria for shunting or initiating a neuroprotective protocol.A reduction of 50% or greater in the beta band of the EEG or amplitude of the SSEP was observed in 150 *** patient showed signs of a cerebral infarct after *** shunting based on EEG and SSEP monitoring can reduce CEA intraoperative stroke rate to a near zero level if trained personnel adopted standardized *** also found that the rapid administration of a protective stroke protocol by attending anesthesiologists was an important aspect of this success rate.

关键词： intraoperative monitoring somatosensory evoked potentials electroencephalogram carotid endarterectomy carotid

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De novo ADGRV1 variant in a patient with ictal asystole provides novel clues for increased risk of SUDEP

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Acta Epileptologica 2023年第2期6卷 118-126页

作者： Tuo Ji Aaron W.Downs Luong Dorris Ning Zhong SQZ Biotechnologies WatertownMA 02472USA Morrissey College of Arts and Sciences Boston CollegeChestnut HillMA 02467USA College of Medicine California Northstate UniversityElk GroveCA 95757USA Pediatric and Adolescent Medicine Residency of Mayo Clinic MNRochesterUSA Department of Neurology Kaiser Permanente Sacramento Medical CenterSacramentoCA 95825USA North Valley Comprehensive Epilepsy Program Kaiser Permanente Sacramento Medical CenterSacramentoCA 95825USA

Background Various cardiac and autonomic manifestations are frequently reported during *** the seizure-related arrhythmia,ictal tachycardia is the most common,followed by ictal bradycardia,with ictal asystole being the *** occurrence of ictal asystole may obscure the clinical presentation and delay the diagnosis,representing a life-threatening presentation of epilepsy,with an elevated risk of sudden unexpected death in epilepsy patients(SUDEP).These cardiac abnormalities are being increasingly recognized as the key to elucidating the mechanisms of *** presentation We present a 35-year-old man with a history of focal-onset seizures with impaired consciousness since his mid-20 *** developed different types of seizures for 2 years,described as tonic seizure and atonic seizure(drop attack).During such clinical events,he suffered from falls and cardiac ***,thorough cardiac electrophysiology and imaging workup failed to reveal a cardiac *** video electroencephalograph(EEG)monitoring was performed,and ictal bradycardia and ictal asystole were discovered.A cardiac pacemaker was implanted,and at 3-year follow-up,the patient did not suffer more atonic seizures,or *** tests discovered a de novo variant of Adhesion G Protein-Coupled Receptor V1(ADGRV1),which may provide a clue for the patient’s ictal asystole and the increased risk of *** Considering the important impact of ictal bradycardia and asystole on the morbidity and potential mortality of epileptic patients,it is important to simultaneously utilize EEG and electrocardiogram to confirm the *** case report highlights the link between the de novo variant of ADGRV1 and the ictal bradycardia/asystole phenotype and implicates the importance of genetic testing in adult epilepsy patients.

关键词： Ictal asystole Drug resistant epilepsy ADGRV1 SUDEP

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Retinal emboli

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World Journal of Ophthalmology 2014年第4期4卷 124-129页

作者： Michelle J Kim Donald S Fong kaiser permanente southern california eye monitoring center Baldwin Park CA 91706United States

Retinal emboli are opacities identified in retinal arterioles and are often incidental findings on ophthalmic examination. They are generally composed of cholesterol, platelet-fibrin, or calcium and are thought to arise from carotid arteries, coronary arteries, or cardiac valves. In the general population, the estimated prevalence is 0.2% to 1.3%, and the estimated incidence is 0.9% to 2.9%. The transient nature of retinal emboli likely explains the variations between and within these reported figures. The strongest risk factor for retinal emboli is smoking, which has been reported consistently across many studies. Other likely risk factors include older age, hypertension, male sex, total cholesterol, coronary artery disease, and history of coronary artery bypass grafting. The presence of multiple risk factors, as is common in many patients, confers a higher risk for retinal emboli. Several studies suggest that retinal emboli predict an increase in stroke-related, all-cause, and possibly cardiovascular mortality. Due to these sequelae, patients often undergo further workup, most commonly carotid ultrasonography. However, given the low prevalence of significant carotid disease in patients with retinal emboli, further workup, such as carotid ultrasound, should be reserved for those with risk factors for carotid disease. All patients would benefit from medical optimization and coordinated care with the primary care physician.

关键词： Retinal emboli Hollenhorst plaque Stroke Carotid disease Cardiovascular disease

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Eight-week ledipasvir/sofosbuvir in non-cirrhotic, treatment-na?ve hepatitis C genotype-1 patients with hepatitis C virus-RNA < 6 million: Single center, real world effectiveness and safety

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World Journal of Gastroenterology 2017年第26期23卷 4759-4766页

作者： Nyan L Latt Beshoy T Yanny Derenik Gharibian Rita Gevorkyan Amandeep K Sahota Division of Gastroenterology and Hepatology Mayo Clinic College of Medicine Division of Gastro-enterology and Hepatology Kaiser Permanente Los Angeles Medical Center Pharmacy Operations Office Kaiser Permanente Los Angeles Medical Center Department of Clinical Operations Kaiser Permanente Southern California

AIM To evaluate sustained viral response(SVR) of 8-wk ledipasvir/sofosbuvir therapy among non-cirrhotic, genotype-1 hepatitis C virus(HCV) patients with RNA < 6 million IU/m *** We performed a retrospective cohort study to examine SVR rates, predictors of treatment failure and safety analysis of 8-wk ledipasvir/sofosbuvir(LDV/SOF) therapy among non-cirrhotic, genotype 1 HCV patients with viral load < 6 million IU/m L. Primary outcome was an achievement of SVR at 12 wk after treatment. Secondary outcomes were identifying predictors of treatment failure and adverse events during *** Total 736 patients: 55% males, 51% Caucasians and 65% were genotype 1a. Non-cirrhotic state of 53% was determined by clinical judgment(imaging, AST, platelet count) and 47% had documented liver fibrosis testing(biopsy, vibration-controlled transient elastography, serum biomarkers). Overall SVR12 was 96%. No difference in SVR12 was seen between patients whose non-cirrhotic state was determined by clinical judgment and patients who had fibrosis testing. Age groups, gender, ethnicity and genotype 1 subtype did not predict SVR. Non-cirrhotic state determined by clinical judgment based on simple, non-invasive tests were not associated with lower SVR [OR = 1.02, 95%CI: 0.48-2.17, P = 0.962]. The AUROC for hepatitis C RNA viral load was 0.734(P < 0.001, 95%CI: 0.66-0.82). HCV RNA 2.2 million IU/m L was identified as the cutoff value with sensitivity 73% and specificity 64%. HCV RNA < 2.2 million IU/m L was associated with significantly higher SVR 98% with OR = 0.22(95%CI: 0.1-0.49, P < 0.001) compared to SVR 92% in HCV RNA ≥ 2.2 million IU/m L. No death or morbidities were *** Our outcomes validate safety and effectiveness of 8-wk LDV/SOF therapy in non-cirrhotic, untreated HCV genotype 1 patients with HCV RNA < 6 million IU/m L.

关键词： Hepatitis C Sustained viral response Ledipasvir Cirrhosis Sofosbuvir

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肩难产:传统的危险因素是否为可靠的预测指标

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世界核心医学期刊文摘（妇产科学分册） 2005年第10期1卷 10-10页

作者： Ouzounian J.G Gherman R.B Steinke R 张丽娟 Department of Obstetrics and Gynecology Kaiser Permanente Medical Center 1011 Baldwin Park Blvd Baldwin Park CA 91706 United States.Dr

Objective: Our purpose was to determine the rate of associated risk factors for shoulder dystocia from a large cohort of patients delivered within our southern california perinatal program. Study design: A retrospective analysis was performed of patients delivered from January 1991 to June 2001. Patients with and without shoulder dystocia were identified from our computer- stored perinatal database and compared. Statistical methods used included: χ 2 test, t test, calculation of odds ratios, and Fisher exact test, as indicated. Results: Among the 267,228 vaginal births during the study period, there were 1,686 cases of shoulder dystocia (rate 0.6% ). Rates for operative vaginal delivery, diabetes, epidural use, multiparity, and postdatism were similar among cases with and without shoulder dystocia. The clinical triad of oxytocin use, labor induction, and birth weight greater than 4,500 g yielded a cumulative odds ratio of 23.2 (95% CI 17.3- 31.0) for shoulder dystocia, but its sensitivity and positive predictive value were only 12.4% and 3.4% , respectively. Conclusion: Historic obstetric risk factors for shoulder dystocia are not useful predictors for the event. Furthermore, although shoulder dystocia was observed more frequently with increasing birth weight, current limitations in estimating birth weight antenatally with accuracy preclude its practical use as a reliable predictor.

关键词：肩难产阴道分娩者队列研究过期妊娠分娩孕妇阴道手术催产素使用硬膜外麻醉精确检验阳性预测值

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Baricitinib plus Remdesivir for Hospitalized Adults with Covid-19

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四川生理科学杂志 2020年第4期42卷 451-451页

作者： Andre C Kalil From the University of Nebraska Medical center Omaha (A.C.K. L.L.) University of Texas Health San Antonio University Health and the South Texas Veterans Health Care System San Antonio (T.F.P. P.O.P. B.S.T.) UT Southwestern Medical Center Parkland Health and Hospital System (M.K.J.) and Baylor Scott and White Health (U.S.) Dallas and Baylor College of Medicine Houston (H.M.E.S.) — all in Texas Emory University (A.K.M. N.G.R. Y.S. V.C.M. V.D.C.) and Grady Memorial Hospital (V.D.C.) Atlanta and Atlanta Veterans Affairs Medical Center Decatur (V.C.M.) — both in Georgia the National Institute of Allergy and Infectious Diseases National Institutes of Health (K.M.T. V.G. R.T.D. M.P. G.A.D. W.D. S.U.N. L.E.D. J.H.B.) and the Infectious Disease Clinical Research Program Uniformed Services University of the Health Sciences (T.H.B.) Bethesda and Emmes (J.F. M.G. M.M.) and Clinical Monitoring Research Program Directorate Frederick National Laboratory (T.B.) Rockville — both in Maryland Duke University Durham NC (C.R.W. E.R.K. J.J.E.) Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán (G.M.R.-P.) and Instituto Nacional de Enfermedades Respiratorias (J.R.P.) Mexico City University of california Irvine Irvine (L.H. A.N.A. M.W.) Cedars–Sinai Medical Center Los Angeles (V.T.) University of California San Diego La Jolla (D.A.S.) University of California San Francisco San Francisco (A.F.L.) University of California Davis Davis (S.H.C.) and Stanford University Stanford (N.A.) — all in California University of Minnesota Medical School Minneapolis (S.K. J.B.) University of Florida Gainesville (N.M.I. M.-C.E.) University of Rochester Rochester NY (A.R.B.) National center for Infectious Diseases Tan Tock Seng Hospital Lee Kong Chian School of Medicine and Yong Loo Lin School of Medicine (D.C.L.) and Changi General Hospital (S.Y.T.) Singapore University of Massachusetts Medical School Worcester (R.W.F.) University of Virginia Charlottesville (P.E.H.J.

Background:Severe coronavirus disease 2019(Covid-19)is associated with dysregulated *** effects of combination treatment with baricitinib,a Janus kinase inhibitor,plus remdesivir are not ***:We conducted a double-blind,randomized,placebo-controlled trial evaluating baricitinib plus remdesivir in hospitalized adults with *** the patients received remdesivir(≤10 days)and either baricitinib(≤14 days)or placebo(control).The primary outcome was the time to *** key secondary outcome was clinical status at day 15.

关键词： placebo clinical des

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