Kaiser Permanente Stockton Medical Offices

By ignoring the root causes of disease and neglecting to prioritize lifestyle measures for prevention, the medical community is placing people at harm. Advanced nations, influenced by a Western lifestyle, are in the midst of a health crisis, resulting largely from poor lifestyle choices. Epidemiologic, ecologic, and interventional studies have repeatedly indicated that most chronic illnesses, including cardiovascular disease, cancer, and type 2 diabetes, are the result of lifestyles fueled by poor nutrition and physical inactivity.In this article, we describe the practice of lifestyle medicine and its powerful effect on these modern instigators of premature disability and death. We address the economic benefits of prevention-based lifestyle medicine and its effect on our health care system: A system on the verge of bankruptcy. We recommend vital changes to a disastrous course. Many deaths and many causes of pain, suffering, and disability could be circumvented if the medical community could effectively implement and share the power of healthy lifestyle choices. We believe that lifestyle medicine should become the primary approach to the management of chronic conditions and, more importantly, their prevention. For future generations, for our own health, and for the Hippocratic Oath we swore to uphold ("First do no harm"), the medical community must take action. It is our hope that the information presented will inspire our colleagues to pursue lifestyle medicine research and incorporate such practices into their daily care of patients. The time to make this change is now.

INTRODUCTION: Approximately 4% of NSCLC harbor BRAF mutations, and approximately 50% of these are non-V600 mutations. Treatment of tumors harboring non-V600 mutations is challenging because of functional heterogeneity and lack of knowledge regarding their clinical significance and response to targeted agents. METHODS: We conducted an integrative analysis of BRAF non-V600 mutations using genomic profiles of BRAF-mutant NSCLC from the Guardant360 database. BRAF mutations were categorized by clonality and class (1 and 2: RAS-independent; 3: RAS-dependent). Cell viability assays were performed in Ba/F3 models. Drug screens were performed in NSCLC cell lines. RESULTS: A total of 305 unique BRAF mutations were identified. Missense mutations were most common (276, 90%), and 45% were variants of unknown significance. F468S and N581Y were identified as novel activating mutations. Class 1 to 3 mutations had higher clonality than mutations of unknown class (p < 0.01). Three patients were treated with MEK with or without BRAF inhibitors. Patients harboring G469V and D594G mutations did not respond, whereas a patient with the L597R mutation had a durable response. Trametinib with or without dabrafenib, LXH254, and lifirafenib had more potent inhibition of BRAF non-V600-mutant NSCLC cell lines than other MEK, BRAF, and ERK inhibitors, comparable with the inhibition of BRAF V600E cell line. CONCLUSIONS: In BRAF-mutant NSCLC, clonality is higher in known functional mutations and may allow identification of variants of unknown significance that are more likely to be oncogenic drivers. Our data indicate that certain non-V600 mutations are responsive to MEK and BRAF inhibitors. This integration of genomic profiling and drug sensitivity may guide the treatment for BRAF-mutant NSCLC.

BACKGROUND: Knee dislocations from minor trauma have been reported sparsely in the literature. The consensus is that these injuries tend not to be associated with neurovascular compromise. PURPOSE: To present a series of atraumatic knee dislocations in obese and morbidly obese patients and to compare operative versus conservative treatment. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This study included 19 patients (21 knees) who presented with knee dislocation from a low-velocity or ultra low-velocity incident. Charts, radiographs, and magnetic resonance images (MRIs) were reviewed, and patients were reviewed based on their latest follow-up. We included patients in our database from 2001 to 2011 and compared knees of patients who had ligament repair or reconstruction (9 total knees) verses nonoperative treatment (12 total knees). Range of motion, activity levels, and knee laxity information were collected as outcome measures to compare operative and nonoperative results. RESULTS: The mean age at presentation was 30.3 years (range, 15-74 years), with 5 men and 14 women. The average body mass index (BMI) was 41.4 kg/m(2) (range, 30-64.4 kg/m(2)), with an average follow-up of 31 months (range, 12-72 months). Five patients (27%) had a popliteal artery injury, and 7 (44.4%) had a peroneal nerve injury at presentation. Four had a vascular repair, 1 had an amputation, and 3 of 7 patients had return of peroneal nerve. Ligament reconstruction was performed on 9 individuals. The average operating time for ligament reconstruction was 183% of that with injury-matched normal-weight patients. Eight operative patients who complied with therapy had an average range of motion of 91.4° (range, 60°-110°). The nonoperative patients had an average range of motion of 60.45° (range, 0°-120°). Two of these patients later required a total knee arthroplasty (3 total knee arthroplasties overall). CONCLUSION: Knee dislocations from minor falls occur in obese patients and are often accompanied by neurovascular complications. While surgical reconstruction is more time consuming and more difficult than that in normal-weight individuals, it may be preferable to nonoperative treatment.

A solution-focused approach to brief psychotherapy can be a useful and respectful model for delivery of services, particularly in a managed care setting. Or the model can be misinterpreted and misused in a way that may resemble “solution-forced” psychotherapy. This paper will present the major rules of solution-forced therapy and provide clinical case examples which highlight this model. It is hoped that consideration of solution-forced methods will encourage clinicians to refine their knowledge and hopefully avoid errors. The authors will also explore possible reasons for the occurrence of solution-forced therapy.

Identification of modifiable behaviors is important for pediatric weight management and obesity prevention programs. This study examined obesogenic behaviors in children with obesity in a Northern California obesity intervention program using data from a parent/teen-completed intake questionnaire covering dietary and lifestyle behaviors (frequency of breakfast, family meals, unhealthy snacking and beverages, fruit/vegetable intake, sleep, screen time, and exercise). Among 7956 children with BMI ≥ 95th percentile, 45.5% were females and 14.2% were 3–5, 44.2% were 6–11, and 41.6% were 12–17 years old. One-quarter (24.9%) were non-Hispanic white, 11.3% were black, 43.5% were Hispanic, and 12.0% were Asian/Pacific Islander. Severe obesity was prevalent (37.4%), especially among blacks, Hispanics, and older children, and was associated with less frequent breakfast and exercise and excess screen time, and in young children it was associated with consumption of sweetened beverages or juice. Unhealthy dietary behaviors, screen time, limited exercise, and sleep were more prevalent in older children and in selected black, Hispanic, and Asian subgroups, where consumption of sweetened beverages or juice was especially high. Overall, obesity severity and obesogenic behaviors increased with age and varied by gender and race/ethnicity. We identified several key prevalent modifiable behaviors that can be targeted by healthcare professionals to reduce obesity when counseling children with obesity and their parents.

John Hughlings Jackson proposed a mechanism of neurologic compensation based on his theory of cerebral localization. According to Hughlings Jackson, there are three levels of evolution of the nervous system. Each element of each level contains a complete representation of the next lower level. Each element of the middle and highest levels contain a representation of the entire body, weighted for a particular part of the body. If the nervous system is damaged so that an area heavily weighted for a particular part of the body is destroyed, less heavily weighted areas are immediately activated according to their weighting. This activation partially compensates for the function of the destroyed tissue. As time passes, the weighting of representation in the unaffected areas changes, amplifying the degree of recovery. Recent clinical studies and PET cerebral blood flow studies show that various ipsilateral and contralateral areas are activated in recovery. The activated areas reside in what Hughlings Jackson would call the middle and highest evolutionary levels. Modern clinical and neurophysiologic observations are therefore consistent with Hughlings Jackson's theory of compensation.

BACKGROUND: John Hughlings Jackson (1835-1911) in London was critical in advancing the concept of cerebral localization. Hughlings Jackson, however, did not work in a vacuum. Silas Weir Mitchell (1829-1914), in Philadelphia, published several clinical observations related to localization. OBJECTIVE: To examine Weir Mitchell's clinical observations on sensory localization, to determine whether they influenced Jacksonian neurology, and to elucidate the private relationship between the two men. METHODS: The authors reviewed published (fictional and scientific writings of Weir Mitchell and scientific writings of Hughlings Jackson) and archival sources (Weir Mitchell's unpublished autobiography and Hughlings Jackson's unpublished correspondence with Weir Mitchell). RESULTS: In the 1860s, Weir Mitchell, through his work on phantom limb syndrome and other nerve injuries, made oblique references to the central representation of body parts, specifically with regard to sensation. Hughlings Jackson had an interest in somatotopic representation in the nervous system and repeatedly cited Weir Mitchell's work in support of his ideas. The two shared several patients, met at least once in London, and carried on a friendly correspondence. CONCLUSIONS: Weir Mitchell's observations on sensory localization were well known to Hughlings Jackson, who cited them in seminal articles on cortical localization. Their correspondence provides an example of trans-Atlantic scientific and clinical communication at the time that neurology emerged as a distinct clinical discipline.

(1994). Hughlings Jackson's theory of cerebral localization. Journal of the History of the Neurosciences: Vol. 3, No. 3, pp. 153-168.

Breast necrosis is a rare complication following coronary artery bypass grafting, as the blood supply to the breast is abundant. Internal mammary artery (IMA) harvest has been cited as a risk factor for breast necrosis following cardiac procedures. We retrospectively reviewed 3 cases of breast necrosis following IMA harvest, performed a comprehensive literature review, and noted risk factors. Obesity, macromastia, diabetes, hypertension, and end-stage renal disease were present in all cases. Two of 3 patients had pathology suggestive of calciphylaxis. Despite a rich blood supply, breast necrosis following use of the IMA for cardiac revascularization may occur in a subset of patients. Our review suggests that obese patients with macromastia and end-stage renal disease may be at increased risk for breast necrosis following IMA harvest. As the prevalence of obesity increases, we may see an increase in this previously uncommon complication.

OBJECTIVE: Recently a number of new therapies have been introduced to treat psoriasis, but concerns have been expressed about their high cost. The purpose of this study was to determine whether most psoriasis treatments lie within the accepted range of cost-utility. METHODOLOGY: 32 patients with moderate to severe psoriasis were administered the Euro-Qol 5 Dimension (EQ-5D) survey to calculate their health state utility. Economic modeling was performed with a range of therapeutic costs applying the calculated utility score. Paired t-tests were used to calculate significance. RESULTS: At the conclusion of 2 weeks of therapy, the mean psoriasis area and severity index (PASI) improved 35% to 7.2 (p<0.001). The mean health state utility score on the EQ-5D improved 11.5% from 77.7 units before therapy to 86.7 units after therapy (p=0.007). CONCLUSION: A therapy that achieves at least a PASI 35 would be considered cost-effective by conventional standards if it does not exceed $33 600 in cost.

Type 1 hepatorenal syndrome (HRS) is characterized by rapid deterioration of renal function. We sought to assess native kidney function after combined kidney-liver transplant (CLKTx) performed for type 1 HRS. We performed a retrospective, cross-sectional, single-center study. All patients with Type 1 HRS who received a CLKTx at the University of California, San Francisco from 1997 to 2007 were screened for enrollment. Patients with a baseline estimated glomerular filtration rate (eGFR) ≥30 ml/min/1.73 m(2) were eligible. Twenty-three patients were identified and consented to receive a Technetium-99 m-mercaptoacetyltriglycine (MAG3) nuclear scan to measure the native kidney contribution to overall renal function. Only 4 of the 23 subjects (17.4%) demonstrated native renal function that consisted of a contribution ≥50% of total renal function. Several factors and comorbidities such as age, gender, race, duration of HRS, need for and duration of renal replacement therapy, need for pressors, urine sodium, proteinuria, and use of octreotide/midodrine were analyzed and not found to be significant in predicting native renal function. The assessment of post-transplant native renal function following CLKTx may allow for improved accuracy in identifying the patients in need of CLKTx, and thus allow for greater optimization of dual-organ allocation strategies in patients with concomitant liver and renal failure.

The work of John Hughlings Jackson (1835-1911) has attracted considerable attention among historians and philosophers of science because it set a conceptual framework for scientific neurology. In this paper we examine the notion, espoused by some modern writers, that his scientific work was motivated by a deep interest in metaphysics. There are two elements in the story—a youthful crisis of intention, and an alleged mature interest in formal metaphysical speculation. We use the term metaphysics to describe the extrapolation of a scientific theory beyond the phenomena it is intended to explain1. For example, Herbert Spencer's extension of evolutionary principles beyond biology into all manner of social and political realms is a form of metaphysical speculation. On this view of metaphysics, we argue, Hughlings Jackson's personal intentions were not at all metaphysical.

PRECIS: At 1-year postoperative follow-up, concurrent placement of a dexamethasone intravitreal implant and glaucoma drainage device effectively controlled intraocular pressure (IOP) and inflammation in eyes with uveitic glaucoma with no changes in systemic immunomodulatory therapy. PURPOSE: The purpose of this study was to assess 1-year postoperative outcomes in eyes with uncontrolled uveitic glaucoma following concurrent placement of a dexamethasone intravitreal implant and glaucoma drainage device. MATERIALS AND METHODS: This is a retrospective, observational case series of patients with chronic, noninfectious uveitis and uveitic glaucoma uncontrolled on maximal tolerated medical therapy with at least 1-year postoperative follow-up. The main outcomes were visual acuity, IOP, number of glaucoma medications, recurrent inflammation, frequency of topical steroids, systemic immunomodulatory therapy, and adverse events. Success was defined as IOP <21 mm Hg and IOP reduced by >20% from baseline on at least 2 consecutive visits after 3 months either with or without glaucoma medications (ie, partial or complete success, respectively). RESULTS: Eight eyes in 6 patients met the inclusion criteria. The average age was 44.1±19.7 years (range: 10 to 68 y) and 50% were female. At 1-year, there was no significant change in visual acuity. No eyes lost ≥3 lines of vision. The majority of eyes (87.5%) achieved complete (n=2) or partial success (n=5) with a decrease in average IOP from 36.5 to 11.8 mm Hg (P=0.002). Glaucoma medication use decreased from 3.0 to 1.3 medications (P=0.04). There was a significant decrease in the number of episodes of recurrent inflammation in the 6 months following surgery compared with the 6 months before surgery (P=0.004). CONCLUSION: In this small case series, dexamethasone intravitreal implant combined with Ahmed glaucoma drainage device appears to be an effective approach for the management of uncontrolled uveitic glaucoma.

The practice of neurology is a stressful occupation, at least if you do it right, but the chance to change someone’s life for the better is a reward that is hard to top. Fortunately, the tides of stress ebb long enough for us to think a little about our patients, and our daydreams can be rewarding too. I was privileged to see a patient whose story reminded me of a poetic tale of reward, metamorphosis and literary immortality. A 31-year-old man attended my neurology clinic, accompanied by his wife and his bubbling 3-year-old son. The man had caused a minor traffic accident when he fell asleep at the wheel. An emergency physician diagnosed epilepsy, reported him to the traffic authorities, and advised him not to drive until he had consulted a neurologist. My patient had no trouble falling asleep at night, and did not wake up once asleep. He awoke feeling refreshed, and did not fall asleep while working at his job as a construction foreman. However, he frequently felt drowsy while driving home from work and often found himself falling asleep momentarily. On closer questioning, my patient said that he lived in Modesto, a small agricultural city in the central valley of California, and worked 90 miles away in San Jose. He had moved to Modesto because, as a construction worker, he could not afford to buy a house in the San Francisco Bay area. Many other middle-class Californians face the same problem, resulting in severe traffic congestion on the only major highway between the two cities. The commuter’s day is a long one in many parts …

Herodotus' account of the mad acts of the Persian king Cambyses II contains one of the two extant pre-Hippocratic Greek references to epilepsy. This reference helps to illuminate Greek thinking about epilepsy, and disease more generally, in the time immediately preceding the publication of the Hippocratic treatise on epilepsy, On the Sacred Disease. Herodotus attributed Cambyses' erratic behavior as ruler of Egypt to either the retribution of an aggrieved god or to the fact that he had the sacred disease. Herodotus considered the possibility that the sacred disease was a somatic illness, agreeing with later Hippocratic authors that epilepsy has a natural rather than a divine cause. Archaeological evidence suggests Herodotus slanders Cambyses, and there is no corroboration that the Persian king had epilepsy or any other disease. However, the view of epilepsy as a somatic disease and uncertainty about the cause of madness shows Herodotus as a transitional figure between supernatural and naturalistic medical theories.

BACKGROUND: Haemarthrosis of the knee after trauma is a common problem often seen in accident and emergency departments. OBJECTIVE: : To evaluate the injuries sustained after haemarthrosis of the knee in a relatively young population, and to assess the need for performing cultures on aspirated blood. PATIENTS AND METHODS: The notes of 510 patients who were seen at the accident and emergency department of the Alexandra Hospital, Redditch, between 1990 and 1999 were retrospectively studied. The age, sex, mechanism of injury, final diagnosis and management were recorded. The exact diagnosis was confirmed by a magnetic resonance imaging scan or arthroscopy findings. All the patients had their knee aspirate cultured, and the reports on the culture of aspirated blood were obtained from the department of pathology. RESULTS: A fall was the major cause of haemarthrosis in 52%, followed by sports injury in 38%. The medical records of all 510 patients were reviewed. All patients' follow-up records were seen, most patients were followed up in the orthopaedic outpatient clinic and some in the accident and emergency follow-up clinic, all attended at least three or more clinics before discharge. CONCLUSION: Culture of the aspirate of all patients was felt to be a waste of time and money. Nearly 40% of cases were thought to be idiopathic and settled conservatively without intervention.

Tacrolimus, widely known as Prograf, has become the preferred immunosuppressant for preventing graft rejection in solid organ transplant recipients, particularly in steroid-sparing regimens. Its efficacy and reduced risk of acute and chronic rejection compared to cyclosporine have made it the preferred treatment option for transplant patients. However, tacrolimus has drawbacks as it is associated with adverse effects, such as renal tubular necrosis, kidney failure, hypertension, metabolic acidosis, and new-onset diabetes mellitus. Among the less common but potentially severe complications is thrombotic microangiopathy linked to tacrolimus usage. Identifying and addressing this condition early on is crucial given its severity and potential complications. Manifestations of this microangiopathy can vary, encompassing renal, neurological, cardiac, and respiratory symptoms, and, in some cases, presenting as pancreatitis, intestinal ischemia, or skin abnormalities. Although conventional management often involves plasma exchange as the primary therapeutic option, recent insights into the pathophysiology have led to newer drugs, such as eculizumab and belatacept, offering promising outcomes. In this narrative review, we delve deeper into the underlying pathophysiological mechanisms of tacrolimus-induced thrombotic microangiopathy and aim to provide clinicians with valuable recommendations for efficient and timely treatment strategies. By understanding the complexities of this condition and staying abreast of the latest advancements in therapeutic options, healthcare providers can optimize patient outcomes and ensure safer tacrolimus administration in solid organ transplant recipients.

Hospital libraries need ways to demonstrate their value to the parent organization or risk shrinking budgets, loss of physical space, reduced staff, and even closing. The hospital librarians at Kaiser Permanente developed a post-query patron survey to assess how the librarians’ work directly supported the organization’s mission and goals. Through this survey, the librarians gathered quantitative and qualitative evidence of the librarians’ role in helping clinicians and leaders make important decisions. This article discusses the survey process and implementation, highlights survey results, and examines some of the positive impact the project has generated.

Systematic testing of muscle tone, bulk, and strength and analysis of the distribution of abnormal findings is a key element of bedside cerebral localization. A codified neurological examination was developed in the 20th century, but physicians have commented on weakness since antiquity. The ancient Egyptians, Greeks, and Romans described weakness in patients with head injuries and strokes, explaining it in terms of the pathophysiology of their times. Diagnostic principles of lateralization and localization developed in the Enlightenment, alongside an understanding of the anatomy of the motor system. In the 19th century, the work of Romberg, Todd, Charcot, and Gowers popularized the use of motor localization by demonstrating the power of scientific reasoning at the bedside. The concept of the upper motor neuron, as elaborated by Gowers, has enduring clinical utility.

Contemporary historiographical ideas have the potential to enrich the history written by practicing neurologists. Neurology is a science, and historians of neurology might profit from considering the experiences of historians of other sciences. An explicit consideration of the range of possible objectives, justifications, sources and methods of historical research may open new and exciting avenues of inquiry. Any plausible answer to the question, "What does a historian do when he or she sits down to write history" helps an historian to develop the structure of his or her project. The selection of sources for a historical study is improved, if also expanded, by understanding its aims.