Internet infrastructures and health care systems: a qualitative comparative analysis on networks and markets in the British National Health Service and Kaiser Permanente.

PubMed

Séror, Ann C

2002-12-01

The Internet and emergent telecommunications infrastructures are transforming the future of health care management. The costs of health care delivery systems, products, and services continue to rise everywhere, but performance of health care delivery is associated with institutional and ideological considerations as well as availability of financial and technological resources. to identify the effects of ideological differences on health care market infrastructures including the Internet and telecommunications technologies by a comparative case analysis of two large health care organizations: the British National Health Service and the California-based Kaiser Permanente health maintenance organization. A qualitative comparative analysis focusing on the British National Health Service and the Kaiser Permanente health maintenance organization to show how system infrastructures vary according to market dynamics dominated by health care institutions ("push") or by consumer demand ("pull"). System control mechanisms may be technologically embedded, institutional, or behavioral. The analysis suggests that telecommunications technologies and the Internet may contribute significantly to health care system performance in a context of ideological diversity. The study offers evidence to validate alternative models of health care governance: the national constitution model, and the enterprise business contract model. This evidence also suggests important questions for health care policy makers as well as researchers in telecommunications, organizational theory, and health care management.

Kaiser captures spirit of games.

PubMed

Herreria, J

1998-01-01

With a multi-media campaign, Kaiser Permanente blitzed its market area by becoming a sponsor of the Nike World Masters Games. The advertising campaign promoted Kaiser as the exclusive health care sponsor. Company officials are counting on this campaign to leverage the health care institution's commitment to the community. In addition to the advertising, Kaiser searched for local athletes to represent its "play the sports for life" theme. As part of a promotion to award 200 athlete sponsorships to the Games, Kaiser's own master athletes were invited to tell their stories. Some of the members shared stories about such topics as experiencing an accident, receiving assistance from a Kaiser physician and incorporating a lifestyle of sport for rehabilitation. From the hundreds of letters received, two members and one employee were selected for the television spots. The sporting event reinforces Kaiser's philosophy of fitness-oriented lifestyles among its members. The Nike World Masters Games are the largest participatory multi-sport competition in the world, gathering together more than 25,000 men and women from more than 100 countries.

The Kaiser Permanente Clinician Cultural and Linguistic Assessment Initiative: Research and Development in Patient–Provider Language Concordance

PubMed Central

MSN, Gayle Tang; Lanza, Oscar; Rodriguez, Fátima Marinely; Chang, Annie

2011-01-01

Patient–clinician language concordance is a critical component of the language access equation and is considered the gold standard for communication. As a result of lack of validated testing standards, measures, and tools, Kaiser Permanente developed the Clinician Cultural and Linguistic Assessment Initiative to ensure verifiable linguistic proficiency in clinical encounters and has established a standard level whereby the clinician is deemed to have a qualifying level of proficiency in communicating directly with patients independent of an interpreter. Our benchmarking efforts in language concordance have been rooted with the key aim to identify talented bilingual and bicultural clinician workforce and to establish the systems foundation to coordinate appropriate language services. We share accomplishments, lessons learned, and promising practices to inform future efforts in language concordance. PMID:21228282

Kaiser Permanente implant registries benefit patient safety, quality improvement, cost-effectiveness.

PubMed

Paxton, Elizabeth W; Kiley, Mary-Lou; Love, Rebecca; Barber, Thomas C; Funahashi, Tadashi T; Inacio, Maria C S

2013-06-01

In response to the increased volume, risk, and cost of medical devices, in 2001 Kaiser Permanente (KP) developed implant registries to enhance patient safety and quality, and to evaluate cost-effectiveness. Using an integrated electronic health record system, administrative databases, and other institutional databases, orthopedic, cardiology, and vascular implant registries were developed in 2001, 2006, and 2011, respectively. These registries monitor patients, implants, clinical practices, and surgical outcomes for KP's 9 million members. Critical to registry success is surgeon leadership and engagement; each geographical region has a surgeon champion who provides feedback on registry initiatives and disseminates registry findings. The registries enhance patient safety by providing a variety of clinical decision tools such as risk calculators, quality reports, risk-adjusted medical center reports, summaries of surgeon data, and infection control reports to registry stakeholders. The registries are used to immediately identify patients with recalled devices, evaluate new and established device technology, and identify outlier implants. The registries contribute to cost-effectiveness initiatives through collaboration with sourcing and contracting groups and confirming adherence to device formulary guidelines. Research studies based on registry data have directly influenced clinical best practices. Registries are important tools to evaluate longitudinal device performance and safety, study the clinical indications for and outcomes of device implantation, respond promptly to recalls and advisories, and contribute to the overall high quality of care of our patients.

Internet Infrastructures and Health Care Systems: a Qualitative Comparative Analysis on Networks and Markets in the British National Health Service and Kaiser Permanente

PubMed Central

2002-01-01

Background The Internet and emergent telecommunications infrastructures are transforming the future of health care management. The costs of health care delivery systems, products, and services continue to rise everywhere, but performance of health care delivery is associated with institutional and ideological considerations as well as availability of financial and technological resources. Objective To identify the effects of ideological differences on health care market infrastructures including the Internet and telecommunications technologies by a comparative case analysis of two large health care organizations: the British National Health Service and the California-based Kaiser Permanente health maintenance organization. Methods A qualitative comparative analysis focusing on the British National Health Service and the Kaiser Permanente health maintenance organization to show how system infrastructures vary according to market dynamics dominated by health care institutions ("push") or by consumer demand ("pull"). System control mechanisms may be technologically embedded, institutional, or behavioral. Results The analysis suggests that telecommunications technologies and the Internet may contribute significantly to health care system performance in a context of ideological diversity. Conclusions The study offers evidence to validate alternative models of health care governance: the national constitution model, and the enterprise business contract model. This evidence also suggests important questions for health care policy makers as well as researchers in telecommunications, organizational theory, and health care management. PMID:12554552

TPMG Northern California appointments and advice call center.

PubMed

Conolly, Patricia; Levine, Leslie; Amaral, Debra J; Fireman, Bruce H; Driscoll, Tom

2005-08-01

Kaiser Permanente (KP) has been developing its use of call centers as a way to provide an expansive set of healthcare services to KP members efficiently and cost effectively. Since 1995, when The Permanente Medical Group (TPMG) began to consolidate primary care phone services into three physical call centers, the TPMG Appointments and Advice Call Center (AACC) has become the "front office" for primary care services across approximately 89% of Northern California. The AACC provides primary care phone service for approximately 3 million Kaiser Foundation Health Plan members in Northern California and responds to approximately 1 million calls per month across the three AACC sites. A database records each caller's identity as well as the day, time, and duration of each call; reason for calling; services provided to callers as a result of calls; and clinical outcomes of calls. We here summarize this information for the period 2000 through 2003.

Questioning the claims from Kaiser

PubMed Central

Talbot-Smith, Alison; Gnani, Shamini; Pollock, Allyson M; Gray, Denis Pereira

2004-01-01

Background: The article by Feachem et al, published in the BMJ in 2002, claimed to show that, compared with the United Kingdom (UK) National Health Service (NHS), the Kaiser Permanente healthcare system in the United States (US) has similar healthcare costs per capita, and performance that is considerably better in certain respects. Aim: To assess the accuracy of Feachem et al's comparison and conclusions. Method: Detailed re-examination of the data and methods used and consideration of the 82 letters responding to the article. Results: Analyses revealed four main areas in which Feachem et al's methodology was flawed. Firstly, the populations of patients served by Kaiser Permanente and by the NHS are fundamentally different. Kaiser's patients are mainly employed, significantly younger, and significantly less socially deprived and so are healthier. Feachem et al fail to adjust adequately for these factors. Secondly, Feachem et al have wrongly inflated NHS costs by omitting substantial user charges payable by Kaiser members for care, excluding the costs of marketing and administration, and deducting the surplus from Kaiser's costs while underestimating the capital charge element of the NHS budget and other costs. They also used two methods of converting currency, the currency rate and a health purchasing power parity conversion. This is double counting. Feachem et al reported that NHS costs were 10% less per head than Kaiser. Correcting for the double currency conversion gives the NHS a 40% cost advantage such that per capita costs are $1161 and $1951 for the NHS and Kaiser, respectively. Thirdly, Feachem et al use non-standardised data for NHS bed days from the Organisation for Economic Cooperation and Development, rather than official Department of Health bed availability and activity statistics for England. Leaving aside the non-comparability of the population and lack of standardisation of the data, the result is to inflate NHS acute bed use and underestimate the

The organizational dynamics enabling patient portal impacts upon organizational performance and patient health: a qualitative study of Kaiser Permanente.

PubMed

Otte-Trojel, Terese; Rundall, Thomas G; de Bont, Antoinette; van de Klundert, Joris; Reed, Mary E

2015-12-16

Patient portals may lead to enhanced disease management, health plan retention, changes in channel utilization, and lower environmental waste. However, despite growing research on patient portals and their effects, our understanding of the organizational dynamics that explain how effects come about is limited. This paper uses qualitative methods to advance our understanding of the organizational dynamics that influence the impact of a patient portal on organizational performance and patient health. The study setting is Kaiser Permanente, the world's largest not-for-profit integrated delivery system, which has been using a portal for over ten years. We interviewed eighteen physician leaders and executives particularly knowledgeable about the portal to learn about how they believe the patient portal works and what organizational factors affect its workings. Our analytical framework centered on two research questions. (1) How does the patient portal impact care delivery to produce the documented effects?; and (2) What are the important organizational factors that influence the patient portal's development? We identify five ways in which the patient portal may impact care delivery to produce reported effects. First, the portal's ability to ease access to services improves some patients' satisfaction as well as changes the way patients seek care. Second, the transparency and activation of information enable some patients to better manage their care. Third, care management may also be improved through augmented patient-physician interaction. This augmented interaction may also increase the 'stickiness' of some patients to their providers. Forth, a similar effect may be triggered by a closer connection between Kaiser Permanente and patients, which may reduce the likelihood that patients will switch health plans. Finally, the portal may induce efficiencies in physician workflow and administrative tasks, stimulating certain operational savings and deeper involvement of

Vincristine-associated Neuropathy With Antifungal Usage: A Kaiser Northern California Experience.

PubMed

Nikanjam, Mina; Sun, Aida; Albers, Mark; Mangalindin, Kristine; Song, Eyun; Vempaty, Hyma; Sam, Danny; Capparelli, Edmund V

2018-05-16

The dose-limiting toxicity for vincristine is peripheral neuropathy which can be potentiated with concurrent usage of azole antifungals. The current retrospective study assessed the incidence of concurrent vincristine and azole antifungal usage to determine if it led to increased neurotoxicity for the Kaiser Northern California pediatric acute lymphoblastic leukemia (ALL) and Hodgkin lymphoma patient population. Data were obtained from the electronic medical record (2007 to 2014). In total, 130 subjects received at least one dose of vincristine for ALL or Hodgkin lymphoma (median age 9, 88% ALL, 58% male, 47% Caucasian). Thirty one percent of patients received concurrent antifungal usage (fluconazole, 78%; voriconazole, 10%; fluconazole/voriconazole, 12%); however, concurrent antifungal usage accounted for <15% of vincristine doses. Grade 2 or greater neuropathy occurred in 51% of patients; grade 3 neuropathy was present in 8% of patients. No difference in the incidence of grade 2 or greater neuropathy was observed with the concurrent use of antifungal therapy (P=0.35), sex (P=0.59), type of cancer (P=0.41), ethnicity (P=0.29), or age (P=0.39), but was higher with increasing amount of vincristine doses (P=0.004). These results suggest that concurrent azole antifungal usage with vincristine for patients with ALL and Hodgkin lymphoma was low in the Kaiser Northern California population and limited usage as needed may be reasonable and safe.

The Kaiser Permanente implant registries: effect on patient safety, quality improvement, cost effectiveness, and research opportunities.

PubMed

Paxton, Elizabeth W; Inacio, Maria Cs; Kiley, Mary-Lou

2012-01-01

Considering the high cost, volume, and patient safety issues associated with medical devices, monitoring of medical device performance is critical to ensure patient safety and quality of care. The purpose of this article is to describe the Kaiser Permanente (KP) implant registries and to highlight the benefits of these implant registries on patient safety, quality, cost effectiveness, and research. Eight KP implant registries leverage the integrated health care system's administrative databases and electronic health records system. Registry data collected undergo quality control and validation as well as statistical analysis. Patient safety has been enhanced through identification of affected patients during major recalls, identification of risk factors associated with outcomes of interest, development of risk calculators, and surveillance programs for infections and adverse events. Effective quality improvement activities included medical center- and surgeon-specific profiles for use in benchmarking reports, and changes in practice related to registry information output. Among the cost-effectiveness strategies employed were collaborations with sourcing and contracting groups, and assistance in adherence to formulary device guidelines. Research studies using registry data included postoperative complications, resource utilization, infection risk factors, thromboembolic prophylaxis, effects of surgical delay on concurrent injuries, and sports injury patterns. The unique KP implant registries provide important information and affect several areas of our organization, including patient safety, quality improvement, cost-effectiveness, and research.

Surveillance lessons from first-wave pandemic (H1N1) 2009, Northern California, USA.

PubMed

Baxter, Roger

2010-03-01

After the appearance of pandemic (H1N1) 2009 in April 2009, influenza activity was monitored within the Kaiser Permanente Northern California division by using laboratory, pharmacy, telephone calls, and utilization (services patients received) data. A combination of testing and utilization data showed a pattern of disease activity, but this pattern may have been affected by public perception of the epidemic.

The Department of Veterans Affairs, Department of Defense, and Kaiser Permanente Nationwide Health Information Network exchange in San Diego: patient selection, consent, and identity matching.

PubMed

Bouhaddou, Omar; Bennett, Jamie; Cromwell, Tim; Nixon, Graham; Teal, Jennifer; Davis, Mike; Smith, Robert; Fischetti, Linda; Parker, David; Gillen, Zachary; Mattison, John

2011-01-01

The Nationwide Health Information Network allow for the secure exchange of Electronic Health Records over the Internet. The Department of Veterans Affairs, Department of Defense, and Kaiser Permanente, participated in an implementation of the NwHIN specifications in San Diego, California. This paper focuses primarily on patient involvement. Specifically, it describes how the shared patients were identified, were invited to participate and to provide consent for disclosing parts of their medical record, and were matched across organizations. A total 1,144 were identified as shared patients. Invitation letters containing consent forms were mailed and resulted in 42% participation. Invalid consent forms were a significant issue (25%). Initially, the identity matching algorithms yielded low success rate (5%). However, elimination of certain traits and abbreviations and probabilistic algorithms have significantly increased matching rate. Access to information from external sources better informs providers, improves decisions and efficiency, and helps meet the meaningful use criteria.

Comparative health systems research among Kaiser Permanente and other integrated delivery systems: a systematic literature review.

PubMed

Maeda, Jared Lane K; Lee, Karen M; Horberg, Michael

2014-01-01

Because of rising health care costs, wide variations in quality, and increased patient complexity, the US health care system is undergoing rapid changes that include payment reform and movement toward integrated delivery systems. Well-established integrated delivery systems, such as Kaiser Permanente (KP), should work to identify the specific system-level factors that result in superior patient outcomes in response to policymakers' concerns. Comparative health systems research can provide insights into which particular aspects of the integrated delivery system result in improved care delivery. To provide a baseline understanding of comparative health systems research related to integrated delivery systems and KP. Systematic literature review. We conducted a literature search on PubMed and the KP Publications Library. Studies that compared KP as a system or organization with other health care systems or across KP facilities internally were included. The literature search identified 1605 articles, of which 65 met the study inclusion criteria and were examined by 3 reviewers. Most comparative health systems studies focused on intra-KP comparisons (n = 42). Fewer studies compared KP with other US (n = 15) or international (n = 12) health care systems. Several themes emerged from the literature as possible factors that may contribute to improved care delivery in integrated delivery systems. Of all studies published by or about KP, only a small proportion of articles (4%) was identified as being comparative health systems research. Additional empirical studies that compare the specific factors of the integrated delivery system model with other systems of care are needed to better understand the "system-level" factors that result in improved and/or diminished care delivery.

The Department of Veterans Affairs, Department of Defense, and Kaiser Permanente Nationwide Health Information Network Exchange in San Diego: Patient Selection, Consent, and Identity Matching

PubMed Central

Bouhaddou, Omar; Bennett, Jamie; Cromwell, Tim; Nixon, Graham; Teal, Jennifer; Davis, Mike; Smith, Robert; Fischetti, Linda; Parker, David; Gillen, Zachary; Mattison, John

2011-01-01

The Nationwide Health Information Network allow for the secure exchange of Electronic Health Records over the Internet. The Department of Veterans Affairs, Department of Defense, and Kaiser Permanente, participated in an implementation of the NwHIN specifications in San Diego, California. This paper focuses primarily on patient involvement. Specifically, it describes how the shared patients were identified, were invited to participate and to provide consent for disclosing parts of their medical record, and were matched across organizations. A total 1,144 were identified as shared patients. Invitation letters containing consent forms were mailed and resulted in 42% participation. Invalid consent forms were a significant issue (25%). Initially, the identity matching algorithms yielded low success rate (5%). However, elimination of certain traits and abbreviations and probabilistic algorithms have significantly increased matching rate. Access to information from external sources better informs providers, improves decisions and efficiency, and helps meet the meaningful use criteria. PMID:22195064

Kaiser Permanente Georgia's Experience with Operation Zero: A Group Medical Appointment to Address Pediatric Overweight

PubMed Central

Hinchman, Josephine; Beno, Luke; Mims, Adrienne

2006-01-01

Context: The rate of overweight (OW) in children in the United States has more than tripled since 1980. The health consequences of pediatric OW include type 2 diabetes and significant illness later in life. Treating pediatric OW is a necessity; however, health care clinicians have minimal access to successful and comprehensive treatment modalities for addressing it. Objective: Kaiser Permanente of Georgia (KPGA) offers a group medical appointment clinic, Operation Zero (O.Z.), as a referral program for preadolescent and adolescent patients who are in the 85th or higher percentile for body mass index (BMI) for their age. The eight-session clinic uses a family-oriented approach and provides a supportive group environment with interactive learning, games, physical activity, and creative problem solving. The goal of the program is to improve lifestyle behaviors for nutrition and physical activity. Clinically, meeting these goals can manifest as reductions in body fat (BF), waist size, and BMI-for-age percentile. Two implementation models help improve dissemination of the program within KPGA. Design: Baseline and eight-week postclinical outcomes for O.Z. participants were analyzed to determine program effectiveness. A retrospective analysis with a control group looked at long-term clinical outcomes to determine weight maintenance. Main outcome measures were weight, BMI-for-age percentile, waist size, and percentage of body fat (%BF). Results: At eight weeks after program completion compared with baseline, there were significant reductions in %BF and waist size for the total sample and specifically for adolescents, preteens, and participants who attended six or more sessions. Among O.Z. participants, there were insignificant increases in weight at six months after program participation and BMI-for-age percentile at one year after participation. At six months, the mean change in weight and BMI in the O.Z. group was statistically less than the mean change in the control

The fetal heart rate collaborative practice project: situational awareness in electronic fetal monitoring-a Kaiser Permanente Perinatal Patient Safety Program Initiative.

PubMed

MacEachin, S Rachel; Lopez, Connie M; Powell, Kimberly J; Corbett, Nancy L

2009-01-01

Electronic fetal monitoring has historically been interpreted with wide variation between and within disciplines on the obstetric healthcare team. This leads to inconsistent decision making in response to tracing interpretation. To implement a multidisciplinary electronic fetal monitoring training program, utilizing the best evidence available, enabling standardization of fetal heart rate interpretation to promote patient safety. Local multidisciplinary expertise along with an outside consultant collaborated over a series of meetings to create a multimedia instructional electronic fetal monitoring training program. After production was complete, a series of conferences attended by nurses, certified nurse midwives, and physician champions, from each hospital, attended to learn how to facilitate training at their own perinatal units. All healthcare personnel across the Kaiser Permanente perinatal program were trained in NICHD nomenclature, emergency response, interpretation guidelines, and how to create local collaborative practice agreements. Metrics for program effectiveness were measured through program evaluations from attendees, the Safety Attitudes Questionnaire. Program evaluations rendered very positive scores from both physicians and clinicians. Comparing baseline to 4 years later, the perception of safety from the staff has increased over 10% in 5 out of the 6 factors analyzed. Active participation from all disciplines in this training series has highlighted the importance of teamwork and communication. The Fetal Heart Rate Collaborative Practice Project continues to evolve utilizing other educational modalities, such as online EFM education and unit-based interdisciplinary tracing reviews.

C-A1-02: Evaluating Kaiser Permanente Georgia’s Worksite Wellness Programs in the Atlanta Area

PubMed Central

Roblin, Douglas; Robinson, Brandi; Benjamin-Stone, Staycee

2010-01-01

Background/Aims: There are few prospective evaluations of the effectiveness of worksite wellness programs in achieving improved lifestyle and health. Our study has two objectives: to assess the cross-sectional associations of biometric status, lifestyle, and health obtained at a wellness program’s enrollment session, and to assess changes in biometric status, lifestyle, and health between the enrollment and 6-month disenrollment sessions. Methods: For this prospective cohort study, participants were recruited from Kaiser Permanente Georgia (KPG) subscribers who were employed at a mid-sized private employer group. Participants completed a biometric assessment and written survey. The biometric measures included height, weight, blood pressure, hip/waist ratio, and total cholesterol. The written survey included measures of: health (SF-12), patient activation (PAM-13), leisure physical activity (BRFSS), food screeners (Block), and work presenteeism (SPS-6) and absenteeism. Over the next 6 months, participants will attend seminars on exercise, weight loss, and healthy cooking and eating. The biometric assessment and survey be repeated in February 2010. Results: Of the 63 eligible KPG subscribers, 60 (41 females and 19 males) consented to participate. Participant ages ranged from 28–77 years. Overall, physical and emotional health, activation, leisure physical activity, dietary intake, and BMI were comparable to results obtained among relatively healthy, low risk working age adults in a 2005 survey of KPG subscribers in large group employers. Total cholesterol was significantly (p<0.05), positively associated with percent fat in diet; and, percent fat in diet was significantly, inversely associated with activation. Participants with 1 or more days absent from work in the most recent 4-week period reported significantly higher total cholesterol and percent fat in diet and significantly lower activation. Participants with high levels of presenteeism were significantly

The Northern California Perinatal Research Unit: A Hybrid Model Bridging Research, Quality Improvement and Clinical Practice

PubMed Central

Garrido, Terhilda; Barbeau, Rosemarie

2010-01-01

Kaiser Permanente (KP) has a long-standing commitment to conduct research and report publicly. Simultaneously, it faces a different imperative: harnessing information systems to leverage internal improvements in outcomes, efficiency, and costs. Now that KP HealthConnect, the KP electronic health record, is fully implemented, research challenges at KP are moving away from issues of data access and toward the mechanisms through which raw data create meaningful clinical knowledge that is based on rigorous research. In this report we describe a model for research—the Northern California Division of Research Perinatal Research Unit—that leverages internal and external resources to fulfill these twin missions. PMID:20844705

A Markov model of the cost-effectiveness of pharmacist care for diabetes in prevention of cardiovascular diseases: evidence from Kaiser Permanente Northern California.

PubMed

Yu, Junhua; Shah, Bijal M; Ip, Eric J; Chan, James

2013-03-01

It has been demonstrated in previous studies that pharmacist management of patients with type 2 diabetes mellitus (T2DM) in the outpatient setting not only improves diabetes-related clinical outcomes such as hemoglobin A1c but also blood pressure (BP), total cholesterol (TC), and quality of life. Improved control of BP and TC has been shown to reduce the risks of cardiovascular disease (CVD), which has placed a heavy economic burden on the health care system. However, no study has evaluated the cost-effectiveness of pharmacist intervention programs with respect to the long-term preventive effects on CVD outcomes among T2DM patients. To (a) quantify the long-term preventive effects of pharmacist intervention on CVD outcomes among T2DM patients using evidence from a matched cohort study in the outpatient primary care setting and (b) assess the relative cost-effectiveness of adding a clinical pharmacist to the primary care team for the management of patients with T2DM based on improvement in CVD risks with the aid of an economic model. Clinical data between the periods of June 2007 to February 2010 were collected from electronic medical records at 2 separate clinics at Kaiser Permanente (KP) Northern California, 1 with primary care physicians only (control group) and the other with the addition of a pharmacist (enhanced care group). Patients in the enhanced care group were matched 1:1 with patients in the control group according to baseline characteristics that included age, gender, A1c, and Charlson comorbidity score. The estimated 10-year CVD risk for both groups was calculated by the United Kingdom Prospective Diabetes Study (UKPDS) Risk Engine (version 2) based on age, sex, race, smoking status, atrial fibrillation, duration of diabetes, levels of A1c, systolic BP (SBP) and TC, and high-density lipoprotein cholesterol (HDL-C) observed at 12 months. There was no statistical difference in the baseline clinical inputs to the Risk Engine (A1c [P=0.115], SBP [P=0

End-Stage Renal Disease Outcomes among the Kaiser Permanente Southern California Creatinine Safety Program (Creatinine SureNet): Opportunities to Reflect and Improve

PubMed Central

Sim, John J; Batech, Michael; Danforth, Kim N; Rutkowski, Mark P; Jacobsen, Steven J; Kanter, Michael H

2017-01-01

Objectives: The Kaiser Permanente Southern California (KPSC) creatinine safety program (Creatinine SureNet) identifies and outreaches to thousands of people annually who may have had a missed diagnosis for chronic kidney disease (CKD). We sought to determine the value of this outpatient program and evaluate opportunities for improvement. Methods: Longitudinal cohort study (February 2010 through December 2015) of KPSC members captured into the creatinine safety program who were characterized using demographics, laboratory results, and different estimations of glomerular filtration rate. Age- and sex-adjusted rates of end-stage renal disease (ESRD) were compared with those in the overall KPSC population. Results: Among 12,394 individuals, 83 (0.7%) reached ESRD. The age- and sex-adjusted relative risk of ESRD was 2.7 times higher compared with the KPSC general population during the same period (94.7 vs 35.4 per 100,000 person-years; p < 0.001). Screening with the Chronic Kidney Disease Epidemiology Collaboration (vs Modification Diet in Renal Diseases) equation would capture 44% fewer individuals and have a higher predictive value for CKD. Of those who had repeated creatinine measurements, only 13% had a urine study performed (32% among patients with confirmed CKD). Conclusion: Our study found a higher incidence of ESRD among individuals captured into the KPSC creatinine safety program. If the Chronic Kidney Disease Epidemiology Collaboration equation were used, fewer people would have been captured while improving the accuracy for diagnosing CKD. Urine testing was low even among patients with confirmed CKD. Our findings demonstrate the importance of a creatinine safety net program in an integrated health system but also suggest opportunities to improve CKD care and screening. PMID:28241912

End-Stage Renal Disease Outcomes among the Kaiser Permanente Southern California Creatinine Safety Program (Creatinine SureNet): Opportunities to Reflect and Improve.

PubMed

Sim, John J; Batech, Michael; Danforth, Kim N; Rutkowski, Mark P; Jacobsen, Steven J; Kanter, Michael H

2017-01-01

The Kaiser Permanente Southern California (KPSC) creatinine safety program (Creatinine SureNet) identifies and outreaches to thousands of people annually who may have had a missed diagnosis for chronic kidney disease (CKD). We sought to determine the value of this outpatient program and evaluate opportunities for improvement. Longitudinal cohort study (February 2010 through December 2015) of KPSC members captured into the creatinine safety program who were characterized using demographics, laboratory results, and different estimations of glomerular filtration rate. Age- and sex-adjusted rates of end-stage renal disease (ESRD) were compared with those in the overall KPSC population. Among 12,394 individuals, 83 (0.7%) reached ESRD. The age- and sex-adjusted relative risk of ESRD was 2.7 times higher compared with the KPSC general population during the same period (94.7 vs 35.4 per 100,000 person-years; p < 0.001). Screening with the Chronic Kidney Disease Epidemiology Collaboration (vs Modification Diet in Renal Diseases) equation would capture 44% fewer individuals and have a higher predictive value for CKD. Of those who had repeated creatinine measurements, only 13% had a urine study performed (32% among patients with confirmed CKD). Our study found a higher incidence of ESRD among individuals captured into the KPSC creatinine safety program. If the Chronic Kidney Disease Epidemiology Collaboration equation were used, fewer people would have been captured while improving the accuracy for diagnosing CKD. Urine testing was low even among patients with confirmed CKD. Our findings demonstrate the importance of a creatinine safety net program in an integrated health system but also suggest opportunities to improve CKD care and screening.

Incidence of Norovirus and Other Viral Pathogens That Cause Acute Gastroenteritis (AGE) among Kaiser Permanente Member Populations in the United States, 2012-2013.

PubMed

Grytdal, Scott P; DeBess, Emilio; Lee, Lore E; Blythe, David; Ryan, Patricia; Biggs, Christianne; Cameron, Miriam; Schmidt, Mark; Parashar, Umesh D; Hall, Aron J

2016-01-01

Noroviruses and other viral pathogens are increasingly recognized as frequent causes of acute gastroenteritis (AGE). However, few laboratory-based data are available on the incidence of AGE caused by viral pathogens in the U.S. This study examined stool specimens submitted for routine clinical diagnostics from patients enrolled in Kaiser Permanente (KP) health plans in metro Portland, OR, and the Maryland, District of Columbia, and northern Virginia geographic areas to estimate the incidence of viral enteropathogens in these populations. Over a one-year study period, participating laboratories randomly selected stools submitted for routine clinical diagnostics for inclusion in the study along with accompanying demographic and clinical data. Selected stools were tested for norovirus, rotavirus, sapovirus, and astrovirus using standardized real-time RT-PCR protocols. Each KP site provided administrative data which were used in conjunction with previously published data on healthcare utilization to extrapolate pathogen detection rates into population-based incidence rates. A total of 1,099 specimens collected during August 2012 to September 2013 were included. Mean age of patients providing stool specimens was 46 years (range: 0-98 years). Noroviruses were the most common viral pathogen identified among patients with AGE (n = 63 specimens, 6% of specimens tested). In addition, 22 (2%) of specimens were positive for rotavirus; 19 (2%) were positive for sapovirus; and 7 (1%) were positive for astrovirus. Incidence of norovirus-associated outpatient visits was 5.6 per 1,000 person-years; incidence of norovirus disease in the community was estimated to be 69.5 per 1,000 person-years. Norovirus incidence was highest among children <5 years of age (outpatient incidence = 25.6 per 1,000 person-years; community incidence = 152.2 per 1,000 person-years), followed by older adults aged >65 years (outpatient incidence = 7.8 per 1,000 person-years; community incidence = 75.8 per 1

Maternal Infection during Pregnancy and Autism Spectrum Disorders

ERIC Educational Resources Information Center

Zerbo, Ousseny; Qian, Yinge; Yoshida, Cathleen; Grether, Judith K.; Van de Water, Judy; Croen, Lisa A.

2015-01-01

We conducted a nested case-control study including 407 cases and 2,075 frequency matched controls to investigate the association between maternal infections during pregnancy and risk of autism spectrum disorders (ASD). Cases, controls, and maternal infections were ascertained from Kaiser Permanente Northern California clinical databases. No…

Measuring integrated care.

PubMed

Strandberg-Larsen, Martin

2011-02-01

The positive outcomes of coordination of healthcare services are to an increasing extent becoming clear. However the complexity of the field is an inhibiting factor for vigorously designed trial studies. Conceptual clarity and a consistent theoretical frame-work are thus needed. While researchers respond to these needs, patients and providers face the multiple challenges of today's healthcare environment. Decision makers, planners and managers need evidence based policy options and information on the scope of the integrated care challenges they are facing. The US managed care organization Kaiser Permanente has been put forward as an example for European healthcare systems to follow, although the evidence base is far from conclusive. The thesis has five objectives: 1) To contribute to the understanding of the concept of integration in healthcare systems and to identify measurement methods to capture the multi-dimensional aspects of integrated healthcare delivery. 2) To assess the level of integration of the Danish healthcare system. 3) To assess the use of joint health plans as a tool for coordination between the regional and local level in the Danish healthcare system. 4) To compare the inputs and performance of the Danish healthcare system and the managed care organization Kaiser Permanente, California, US. 5) To compare primary care clinicians' perception of clinical integration in two healthcare systems: Kaiser Permanente, Northern California and the Danish healthcare system. Further to examine the associations between specific organizational factors and clinical integration within each system. The literature was systematically searched to identify methods for measurement of integrated healthcare delivery. A national cross-sectional survey was conducted among major professional stake-holders at five different levels of the Danish healthcare system. The survey data were used to allow for analysis of the level of integration achieved. Data from the survey were

Incidence of Norovirus and Other Viral Pathogens That Cause Acute Gastroenteritis (AGE) among Kaiser Permanente Member Populations in the United States, 2012–2013

PubMed Central

Grytdal, Scott P.; Biggs, Christianne; Cameron, Miriam; Schmidt, Mark; Parashar, Umesh D.; Hall, Aron J.

2016-01-01

Noroviruses and other viral pathogens are increasingly recognized as frequent causes of acute gastroenteritis (AGE). However, few laboratory-based data are available on the incidence of AGE caused by viral pathogens in the U.S. This study examined stool specimens submitted for routine clinical diagnostics from patients enrolled in Kaiser Permanente (KP) health plans in metro Portland, OR, and the Maryland, District of Columbia, and northern Virginia geographic areas to estimate the incidence of viral enteropathogens in these populations. Over a one-year study period, participating laboratories randomly selected stools submitted for routine clinical diagnostics for inclusion in the study along with accompanying demographic and clinical data. Selected stools were tested for norovirus, rotavirus, sapovirus, and astrovirus using standardized real-time RT-PCR protocols. Each KP site provided administrative data which were used in conjunction with previously published data on healthcare utilization to extrapolate pathogen detection rates into population-based incidence rates. A total of 1,099 specimens collected during August 2012 to September 2013 were included. Mean age of patients providing stool specimens was 46 years (range: 0–98 years). Noroviruses were the most common viral pathogen identified among patients with AGE (n = 63 specimens, 6% of specimens tested). In addition, 22 (2%) of specimens were positive for rotavirus; 19 (2%) were positive for sapovirus; and 7 (1%) were positive for astrovirus. Incidence of norovirus-associated outpatient visits was 5.6 per 1,000 person-years; incidence of norovirus disease in the community was estimated to be 69.5 per 1,000 person-years. Norovirus incidence was highest among children <5 years of age (outpatient incidence = 25.6 per 1,000 person-years; community incidence = 152.2 per 1,000 person-years), followed by older adults aged >65 years (outpatient incidence = 7.8 per 1,000 person-years; community incidence = 75.8 per

Age and correlation of the Calera Limestone in the Permanente terrane of northern California

USGS Publications Warehouse

Sliter, William V.; McGann, Mary

1992-01-01

Planktonic foraminifers indicate that outcrops of Calera Limestone from the Permanente terrane in the Franciscan Complex of northern California range in age from possibly as old as Barremian to late Turonian. Underlying black limestone, which is devoid of planktonic foraminifers, presumably is Barremian in age or older. The top of the sequence exposed in major quarries is always faulted. Improved biostratigraphic resolution shows two patterns of missing time intervals. The primary pattern, which is found at all localities and involves missing planktonic foraminiferal zones in the late Aptian to early Albian and the late Albian, is linked to paleoceanographic changes in the Cretaceous Pacific Ocean. The secondary pattern, which is found at the scattered outcrops outside the major quarries and involves missing zones in the Albian and Cenomanian, suggests the results of a common tectonic history related to the accretion of a large seamount.

75 FR 21041 - Notice of Determinations Terminating Investigations of Petitions Regarding Eligibility To Apply...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-04-22

... Slingsby Systems, Inc., Jupiter, Florida. TA-W-72,372: Kaiser Permanente, Corona, California, covered by TA-W- 71,894: Kaiser Permanente, Corona, California. TA-W-72,432: Matthew Bender and Company, Inc...

Malignant melanoma slide review project: Patients from non-Kaiser hospitals in the San Francisco Bay Area. Final report

DOE Office of Scientific and Technical Information (OSTI.GOV)

Reynolds, P.

This project was initiated, in response to concerns that the observed excess of malignant melanoma among employees of Lawrence Livermore National Laboratory (LLNL) might reflect the incidence of disease diagnostically different than that observed in the general population. LLNL sponsored a slide review project, inviting leading dermatopathology experts to independently evaluate pathology slides from LLNL employees diagnosed with melanoma and those from a matched sample of Bay Area melanoma patients who did not work at the LLNL. The study objectives were to: Identify all 1969--1984 newly diagnosed cases of malignant melanoma among LLNL employees resident in the San Francisco-Oakland Metropolitanmore » Statistical Area, and diagnosed at facilities other than Kaiser Permanente; identify a comparison series of melanoma cases also diagnosed between 1969--1984 in non-Kaiser facilities, and matched as closely as possible to the LLNL case series by gender, race, age at diagnosis, year of diagnosis, and hospital of diagnosis; obtain pathology slides for the identified (LLNL) case and (non-LLNL) comparison patients for review by the LLNL-invited panel of dermatopathology experts; and to compare the pathologic characteristics of the case and comparison melanoma patients, as recorded by the dermatopathology panel.« less

Novel Telestroke Program Improves Thrombolysis for Acute Stroke Across 21 Hospitals of an Integrated Healthcare System.

PubMed

Nguyen-Huynh, Mai N; Klingman, Jeffrey G; Avins, Andrew L; Rao, Vivek A; Eaton, Abigail; Bhopale, Sunil; Kim, Anne C; Morehouse, John W; Flint, Alexander C

2018-01-01

Faster treatment with intravenous alteplase in acute ischemic stroke is associated with better outcomes. Starting in 2015, Kaiser Permanente Northern California redesigned its acute stroke workflow across all 21 Kaiser Permanente Northern California stroke centers to (1) follow a single standardized version of a modified Helsinki model and (2) have all emergency stroke cases managed by a dedicated telestroke neurologist. We examined the effect of Kaiser Permanente Northern California's Stroke EXpediting the PRrocess of Evaluating and Stopping Stroke program on door-to-needle (DTN) time, alteplase use, and symptomatic intracranial hemorrhage rates. The program was introduced in a staggered fashion from September 2015 to January 2016. We compared DTN times for a seasonally adjusted 9-month period at each center before implementation to the corresponding 9-month calendar period from the start of implementation. The primary outcome was the DTN time for alteplase administration. Secondary outcomes included rate of alteplase administrations per month, symptomatic intracranial hemorrhage, and disposition at time of discharge. This study included 310 patients treated with alteplase in the pre-EXpediting the PRrocess of Evaluating and Stopping Stroke period and 557 patients treated with alteplase in the EXpediting the PRrocess of Evaluating and Stopping Stroke period. After implementation, alteplase administrations increased to 62/mo from 34/mo at baseline ( P <0.001). Median DTN time decreased to 34 minutes after implementation from 53.5 minutes prior ( P <0.001), and DTN time of <60 minutes was achieved in 87.1% versus 61.0% ( P <0.001) of patients. DTN times <30 minutes were much more common in the Stroke EXpediting the PRrocess of Evaluating and Stopping Stroke period (40.8% versus 4.2% before implementation). There was no significant difference in symptomatic intracranial hemorrhage rates in the 2 periods (3.8% versus 2.2% before implementation; P =0.29). Introduction

Disparities in outpatient and home health service utilization following stroke: results of a 9-year cohort study in Northern California.

PubMed

Chan, Leighton; Wang, Hua; Terdiman, Joe; Hoffman, Jeanne; Ciol, Marcia A; Lattimore, Bernadette Ford; Sidney, Steven; Quesenberry, Charles; Lu, Qi; Sandel, M Elizabeth

2009-11-01

To examine whether there are disparities in utilization of outpatient and home care services after stroke. Retrospective cohort study. The Kaiser Permanente of Northern California health care system, which provides health care for approximately 3.3 million members. A total of 11,119 patients hospitalized for a stroke between 1996 and 2003 and followed for 1 year. Receipt of outpatient rehabilitation (physical therapy, occupational therapy, speech pathology, or physical medicine and rehabilitation/physiatry visits), and/or home health care. There were significant differences in outpatient rehabilitation visits and home health enrollment during the year after acute care discharge for all the parameters under study. Older age and female gender were associated with less outpatient rehabilitation treatment, but these subpopulations were more likely to be enrolled in home health care. Non-whites, patients from urban areas, those with ischemic strokes, and those with longer acute care hospital stays had relatively more outpatient rehabilitation and were also more likely to be enrolled in the home health program. In addition, patients living in geographic areas with a median household income of $80,000 or more had significantly more outpatient rehabilitation visits than did patients living in lower income areas. Variations in outpatient rehabilitation visits and in home health care exist in this large integrated health system in terms of age, gender, race/ethnicity, residence area, type of stroke, and length of stay in an acute care hospital. The Kaiser Permanente integrated health care system seems to have outpatient stroke rehabilitation and home health programs that are providing care without disparities in relation to non-white populations, but other disparities appear to exist that may be related to socioeconomic factors, referral patterns, family support systems, or other cultural factors that have not been identified.

Investigating Mars: Kaiser Crater Dunes

NASA Image and Video Library

2018-02-02

This is a false color image of Kaiser Crater. In this combination of filters "blue" typically means basaltic sand. This VIS image crosses 3/4 of the crater and demonstrates how extensive the dunes are on the floor of Kaiser Crater. Kaiser Crater is located in the southern hemisphere in the Noachis region west of Hellas Planitia. Kaiser Crater is just one of several large craters with extensive dune fields on the crater floor. Other nearby dune filled craters are Proctor, Russell, and Rabe. Kaiser Crater is 207 km (129 miles) in diameter. The dunes are located in the southern part of the crater floor. The THEMIS VIS camera contains 5 filters. The data from different filters can be combined in multiple ways to create a false color image. These false color images may reveal subtle variations of the surface not easily identified in a single band image. The Odyssey spacecraft has spent over 15 years in orbit around Mars, circling the planet more than 71,000 times. It holds the record for longest working spacecraft at Mars. THEMIS, the IR/VIS camera system, has collected data for the entire mission and provides images covering all seasons and lighting conditions. Over the years many features of interest have received repeated imaging, building up a suite of images covering the entire feature. From the deepest chasma to the tallest volcano, individual dunes inside craters and dune fields that encircle the north pole, channels carved by water and lava, and a variety of other feature, THEMIS has imaged them all. For the next several months the image of the day will focus on the Tharsis volcanoes, the various chasmata of Valles Marineris, and the major dunes fields. We hope you enjoy these images! Orbit Number: 66602 Latitude: -47.0551 Longitude: 19.446 Instrument: VIS Captured: 2016-12-18 21:42 https://photojournal.jpl.nasa.gov/catalog/PIA22265

Investigating Mars: Kaiser Crater Dunes

NASA Image and Video Library

2018-02-01

This VIS image of the floor of Kaiser Crater contains several sand dune shapes and sizes. The "whiter" material is the hard crater floor surface. Kaiser Crater is located in the southern hemisphere in the Noachis region west of Hellas Planitia. Kaiser Crater is just one of several large craters with extensive dune fields on the crater floor. Other nearby dune filled craters are Proctor, Russell, and Rabe. Kaiser Crater is 207 km (129 miles) in diameter. The dunes are located in the southern part of the crater floor. The Odyssey spacecraft has spent over 15 years in orbit around Mars, circling the planet more than 71,000 times. It holds the record for longest working spacecraft at Mars. THEMIS, the IR/VIS camera system, has collected data for the entire mission and provides images covering all seasons and lighting conditions. Over the years many features of interest have received repeated imaging, building up a suite of images covering the entire feature. From the deepest chasma to the tallest volcano, individual dunes inside craters and dune fields that encircle the north pole, channels carved by water and lava, and a variety of other feature, THEMIS has imaged them all. For the next several months the image of the day will focus on the Tharsis volcanoes, the various chasmata of Valles Marineris, and the major dunes fields. We hope you enjoy these images! Orbit Number: 39910 Latitude: -46.9063 Longitude: 19.8112 Instrument: VIS Captured: 2010-12-13 11:17 https://photojournal.jpl.nasa.gov/catalog/PIA22264

Investigating Mars: Kaiser Crater Dunes

NASA Image and Video Library

2018-01-31

This VIS image of the floor of Kaiser Crater contains a large variety of sand dune shapes and sizes. The "whiter" material is the hard crater floor surface. Kaiser Crater is located in the southern hemisphere in the Noachis region west of Hellas Planitia. Kaiser Crater is just one of several large craters with extensive dune fields on the crater floor. Other nearby dune filled craters are Proctor, Russell, and Rabe. Kaiser Crater is 207 km (129 miles) in diameter. The dunes are located in the southern part of the crater floor. The Odyssey spacecraft has spent over 15 years in orbit around Mars, circling the planet more than 71,000 times. It holds the record for longest working spacecraft at Mars. THEMIS, the IR/VIS camera system, has collected data for the entire mission and provides images covering all seasons and lighting conditions. Over the years many features of interest have received repeated imaging, building up a suite of images covering the entire feature. From the deepest chasma to the tallest volcano, individual dunes inside craters and dune fields that encircle the north pole, channels carved by water and lava, and a variety of other feature, THEMIS has imaged them all. For the next several months the image of the day will focus on the Tharsis volcanoes, the various chasmata of Valles Marineris, and the major dunes fields. We hope you enjoy these images! Orbit Number: 35430 Latitude: -46.8699 Longitude: 19.4731 Instrument: VIS Captured: 2009-12-09 14:09 https://photojournal.jpl.nasa.gov/catalog/PIA22263

Frederik Kaiser (1808-1872) and the Modernisation of Dutch Astronomy

NASA Astrophysics Data System (ADS)

van der Heijden, Petra

Frederik Kaiser was the director of Leiden Observatory from 1837 until his death in 1872. Educated by his German-born uncle Johan Frederik Keyser (1766-1823), who was a proficient amateur astronomer, Kaiser proved to be a real observational talent. Despite the poor conditions in which he worked, his observations soon rivalled with the best in the world. Kaiser's contributions to astronomical practice include the foundation of a new, completely up-to-date observatory building in Leiden, and the introduction of statistics and precision measurements in daily practice at the observatory. Moreover he was the author of several bestselling books on popular astronomy. Kaiser had an extensive correspondence with colleagues all over Europe, mostly in Germany. Correpondents include Airy, Argelander, Von Auwers, Bessel, Encke, John Herschel, LeVerrier, Von Littrow, Schumacher, Otto W. Struve, as well as several geodesists and instrument makers. Preliminary research indicates that Frederik Kaiser played a crucial role in the revival of Dutch astronomy in the second half of the 19th century. This project aims at analysing and explaining Kaiser's activities in science, institutionalisation and popularisation, in the context of national and international developments in 19th-century astronomy and scientific culture.

Investigating Mars: Kaiser Crater Dunes

NASA Image and Video Library

2018-01-23

Kaiser Crater is located in the southern hemisphere in the Noachis region west of Hellas Planitia. Kaiser Crater is just one of several large craters with extensive dune fields on the crater floor. Other nearby dune filled craters are Proctor, Russell, and Rabe. Kaiser Crater is 207 km (129 miles) in diameter. The dunes are located in the southeastern part of the crater floor. Most of the individual dunes in Kaiser Crater are barchan dunes. Barchan dunes are crescent shaped with the points of the crescent pointing downwind. The sand is blown up the low angle side of the dune and then tumbles down the steep slip face. This dune type forms on hard surfaces where there is limited amounts of sand. Barchan dunes can merge together over time with increased sand in the local area. The Odyssey spacecraft has spent over 15 years in orbit around Mars, circling the planet more than 69000 times. It holds the record for longest working spacecraft at Mars. THEMIS, the IR/VIS camera system, has collected data for the entire mission and provides images covering all seasons and lighting conditions. Over the years many features of interest have received repeated imaging, building up a suite of images covering the entire feature. From the deepest chasma to the tallest volcano, individual dunes inside craters and dune fields that encircle the north pole, channels carved by water and lava, and a variety of other feature, THEMIS has imaged them all. For the next several months the image of the day will focus on the Tharsis volcanoes, the various chasmata of Valles Marineris, and the major dunes fields. We hope you enjoy these images! Orbit Number: 1036 Latitude: -46.7795 Longitude: 20.2075 Instrument: VIS Captured: 2002-03-09 20:07 https://photojournal.jpl.nasa.gov/catalog/PIA22172

Investigating Mars: Kaiser Crater Dunes

NASA Image and Video Library

2018-01-29

This VIS image of Kaiser Crater shows a region of the dunes with varied appearances. The different dune forms developed due to different amounts of available sand, different wind directions, and the texture of the crater floor. The dune forms change from the bottom to the top of the image - large long connected dunes, to large individual dunes, to the very small individual dunes at the top of the image. Kaiser Crater is located in the southern hemisphere in the Noachis region west of Hellas Planitia. Kaiser Crater is just one of several large craters with extensive dune fields on the crater floor. Other nearby dune filled craters are Proctor, Russell, and Rabe. Kaiser Crater is 207 km (129 miles) in diameter. The dunes are located in the southern part of the crater floor. The Odyssey spacecraft has spent over 15 years in orbit around Mars, circling the planet more than 71,000 times. It holds the record for longest working spacecraft at Mars. THEMIS, the IR/VIS camera system, has collected data for the entire mission and provides images covering all seasons and lighting conditions. Over the years many features of interest have received repeated imaging, building up a suite of images covering the entire feature. From the deepest chasma to the tallest volcano, individual dunes inside craters and dune fields that encircle the north pole, channels carved by water and lava, and a variety of other feature, THEMIS has imaged them all. For the next several months the image of the day will focus on the Tharsis volcanoes, the various chasmata of Valles Marineris, and the major dunes fields. We hope you enjoy these images! Orbit Number: 17686 Latitude: -46.6956 Longitude: 19.8394 Instrument: VIS Captured: 2005-12-09 13:25 https://photojournal.jpl.nasa.gov/catalog/PIA22261

Investigating Mars: Kaiser Crater Dunes

NASA Image and Video Library

2018-01-24

This VIS image of Kaiser Crater shows individual dunes and where the dunes have coalesced into longer dune forms. The addition of sand makes the dunes larger and the intra-dune areas go from sand-free to complete coverage of the hard surface of the crater floor. With a continued influx of sand the region will transition from individual dunes to a sand sheet with surface dune forms. Kaiser Crater is located in the southern hemisphere in the Noachis region west of Hellas Planitia. Kaiser Crater is just one of several large craters with extensive dune fields on the crater floor. Other nearby dune filled craters are Proctor, Russell, and Rabe. Kaiser Crater is 207 km (129 miles) in diameter. The dunes are located in the southern part of the crater floor. The Odyssey spacecraft has spent over 15 years in orbit around Mars, circling the planet more than 69000 times. It holds the record for longest working spacecraft at Mars. THEMIS, the IR/VIS camera system, has collected data for the entire mission and provides images covering all seasons and lighting conditions. Over the years many features of interest have received repeated imaging, building up a suite of images covering the entire feature. From the deepest chasma to the tallest volcano, individual dunes inside craters and dune fields that encircle the north pole, channels carved by water and lava, and a variety of other feature, THEMIS has imaged them all. For the next several months the image of the day will focus on the Tharsis volcanoes, the various chasmata of Valles Marineris, and the major dunes fields. We hope you enjoy these images! Orbit Number: 1423 Latitude: -46.9573 Longitude: 18.6192 Instrument: VIS Captured: 2002-04-10 16:44 https://photojournal.jpl.nasa.gov/catalog/PIA22173

Similar Risk Patterns After Cervical Screening in Two Large U.S. Populations: Implications for Clinical Guidelines.

PubMed

Gage, Julia C; Hunt, William C; Schiffman, Mark; Katki, Hormuzd A; Cheung, Li A; Myers, Orrin; Cuzick, Jack; Wentzensen, Nicolas; Kinney, Walter; Castle, Philip E; Wheeler, Cosette M

2016-12-01

To compare the risks of histologic high-grade cervical intraepithelial neoplasia (CIN) or worse after different cervical cancer screening test results between two of the largest U.S. clinical practice research data sets. The New Mexico Human Papillomavirus (HPV) Pap Registry is a statewide registry representing a diverse population experiencing varied clinical practice delivery. Kaiser Permanente Northern California is a large integrated health care delivery system practicing routine HPV cotesting since 2003. In this retrospective cohort study, a logistic-Weibull survival model was used to estimate and compare the cumulative 3- and 5-year risks of histologic CIN 3 or worse among women aged 21-64 years screened in 2007-2011 in the New Mexico HPV Pap Registry and 2003-2013 in Kaiser Permanente Northern California. Results were stratified by age and baseline screening result: negative cytology, atypical squamous cells of undetermined significance (ASC-US) (with or without HPV triage), low-grade squamous intraepithelial lesion, and high-grade squamous intraepithelial lesion. There were 453,618 women in the New Mexico HPV Pap Registry and 1,307,528 women at Kaiser Permanente Northern California. The 5-year CIN 3 or worse risks were similar within screening results across populations: cytology negative (0.52% and 0.30%, respectively, P<.001), HPV-negative and ASC-US (0.72% and 0.49%, respectively, P=.5), ASC-US (3.4% and 3.4%, respectively, P=.8), HPV-positive and ASC-US (7.7% and 7.1%, respectively, P=.3), low-grade squamous intraepithelial lesion (6.5% and 5.4%, respectively, P=.009), and high-grade squamous intraepithelial lesion (53.1% and 50.4%, respectively, P=.2). Cervical intraepithelial neoplasia grade 2 or worse risks and 3-year risks had similar trends across populations. Age-stratified analyses showed more variability, especially among women aged younger than 30 years, but patterns of risk stratification were comparable. Current U.S. cervical screening and

75 FR 70689 - Kaiser Aluminum Fabricated Products, LLC; Kaiser Aluminum-Greenwood Forge Division; Currently...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-11-18

... Fabricated Products, LLC; Kaiser Aluminum- Greenwood Forge Division; Currently Known As Contech Forgings, LLC..., South Carolina; Amended Certification Regarding Eligibility To Apply or Worker Adjustment Assistance In... Labor issued a Certification of Eligibility to Apply for Worker Adjustment Assistance on October 2, 2009...

Observation of the Kaiser Effect Using Noble Gas Release Signals

DOE Office of Scientific and Technical Information (OSTI.GOV)

Bauer, Stephen J.

The Kaiser effect was defined in the early 1950s (Kaiser 1953) and was extensively reviewed and evaluated by Lavrov (2002) with a view toward understanding stress estimations. The Kaiser effect is a stress memory phenomenon which has most often been demonstrated in rock using acoustic emissions. During cyclic loading–unloading–reloading, the acoustic emissions are near zero until the load exceeds the level of the previous load cycle. Here, we sought to explore the Kaiser effect in rock using real-time noble gas release. Laboratory studies using real-time mass spectrometry measurements during deformation have quantified, to a degree, the types of gases releasedmore » (Bauer et al. 2016a, b), their release rates and amounts during deformation, estimates of permeability created from pore structure modifications during deformation (Gardner et al. 2017) and the impact of mineral plasticity upon gas release. We found that noble gases contained in brittle crystalline rock are readily released during deformation.« less

Observation of the Kaiser Effect Using Noble Gas Release Signals

DOE PAGES

Bauer, Stephen J.

2017-10-24

The Kaiser effect was defined in the early 1950s (Kaiser 1953) and was extensively reviewed and evaluated by Lavrov (2002) with a view toward understanding stress estimations. The Kaiser effect is a stress memory phenomenon which has most often been demonstrated in rock using acoustic emissions. During cyclic loading–unloading–reloading, the acoustic emissions are near zero until the load exceeds the level of the previous load cycle. Here, we sought to explore the Kaiser effect in rock using real-time noble gas release. Laboratory studies using real-time mass spectrometry measurements during deformation have quantified, to a degree, the types of gases releasedmore » (Bauer et al. 2016a, b), their release rates and amounts during deformation, estimates of permeability created from pore structure modifications during deformation (Gardner et al. 2017) and the impact of mineral plasticity upon gas release. We found that noble gases contained in brittle crystalline rock are readily released during deformation.« less

75 FR 43885 - Proposed Amendment of Class E Airspace; Kaiser/Lake Ozark, MO

Federal Register 2010, 2011, 2012, 2013, 2014

2010-07-27

...-0604; Airspace Docket No. 10-ACE-5] Proposed Amendment of Class E Airspace; Kaiser/Lake Ozark, MO...: This action proposes to amend Class E airspace for the Kaiser/ Lake Ozark, MO, area. Additional... for the Kaiser/Lake Ozark, MO area, to accommodate SIAPs at Camdenton Memorial Airport, Camdenton, MO...

Energy Assessment Helps Kaiser Aluminum Save Energy and Improve Productivity

DOE Office of Scientific and Technical Information (OSTI.GOV)

None

2008-07-01

The Kaiser Aluminum plant in Sherman, Texas, adjusted controls and made repairs to a furnace for a simple payback of 1 month. Kaiser adopted DOE's Process Heating Assessment and Survey Tool (PHAST) software as the corporate diagnostic tool and has used it to evaluate process heating systems at five other aluminum plants.

Investigating Mars: Kaiser Crater Dunes

NASA Image and Video Library

2018-01-30

At the top of this VIS image crescent shaped dunes are visible. As the dunes approach a break in elevation the forms change to connect the crescents together forming long aligned dune forms. Kaiser Crater is located in the southern hemisphere in the Noachis region west of Hellas Planitia. Kaiser Crater is just one of several large craters with extensive dune fields on the crater floor. Other nearby dune filled craters are Proctor, Russell, and Rabe. Kaiser Crater is 207 km (129 miles) in diameter. The dunes are located in the southern part of the crater floor. The Odyssey spacecraft has spent over 15 years in orbit around Mars, circling the planet more than 71,000 times. It holds the record for longest working spacecraft at Mars. THEMIS, the IR/VIS camera system, has collected data for the entire mission and provides images covering all seasons and lighting conditions. Over the years many features of interest have received repeated imaging, building up a suite of images covering the entire feature. From the deepest chasma to the tallest volcano, individual dunes inside craters and dune fields that encircle the north pole, channels carved by water and lava, and a variety of other feature, THEMIS has imaged them all. For the next several months the image of the day will focus on the Tharsis volcanoes, the various chasmata of Valles Marineris, and the major dunes fields. We hope you enjoy these images! Orbit Number: 34157 Latitude: -46.9336 Longitude: 18.9272 Instrument: VIS Captured: 2009-08-26 18:49 https://photojournal.jpl.nasa.gov/catalog/PIA22262

Geographic Clusters of Basal Cell Carcinoma in a Northern California Health Plan Population.

PubMed

Ray, G Thomas; Kulldorff, Martin; Asgari, Maryam M

2016-11-01

Rates of skin cancer, including basal cell carcinoma (BCC), the most common cancer, have been increasing over the past 3 decades. A better understanding of geographic clustering of BCCs can help target screening and prevention efforts. Present a methodology to identify spatial clusters of BCC and identify such clusters in a northern California population. This retrospective study used a BCC registry to determine rates of BCC by census block group, and used spatial scan statistics to identify statistically significant geographic clusters of BCCs, adjusting for age, sex, and socioeconomic status. The study population consisted of white, non-Hispanic members of Kaiser Permanente Northern California during years 2011 and 2012. Statistically significant geographic clusters of BCC as determined by spatial scan statistics. Spatial analysis of 28 408 individuals who received a diagnosis of at least 1 BCC in 2011 or 2012 revealed distinct geographic areas with elevated BCC rates. Among the 14 counties studied, BCC incidence ranged from 661 to 1598 per 100 000 person-years. After adjustment for age, sex, and neighborhood socioeconomic status, a pattern of 5 discrete geographic clusters emerged, with a relative risk ranging from 1.12 (95% CI, 1.03-1.21; P = .006) for a cluster in eastern Sonoma and northern Napa Counties to 1.40 (95% CI, 1.15-1.71; P < .001) for a cluster in east Contra Costa and west San Joaquin Counties, compared with persons residing outside that cluster. In this study of a northern California population, we identified several geographic clusters with modestly elevated incidence of BCC. Knowledge of geographic clusters can help inform future research on the underlying etiology of the clustering including factors related to the environment, health care access, or other characteristics of the resident population, and can help target screening efforts to areas of highest yield.

Police-Recorded Crime and Perceived Stress among Patients with Type 2 Diabetes: the Diabetes Study of Northern California (DISTANCE).

PubMed

Tamayo, Aracely; Mujahid, Mahasin S; Laraia, Barbara; Warton, E Margaret; Blanchard, Samuel D; Kelly, Maggi; Moffet, Howard H; Adler, Nancy; Schillinger, Dean; Karter, Andrew J

2016-10-01

While stress has been linked to poor health outcomes, little is known about the impact of objective measures of neighborhood crime on stress in patients with chronic disease. Using the Kaiser Permanente Diabetes Study of Northern California (DISTANCE), we examined associations between police-recorded crime (2005-2007) and stress (Perceived Stress Scale-4) in four large Northern California cities (Oakland, Sacramento, San Francisco, and San Jose). We performed stratified analysis by gender and race/ethnicity using generalized linear regression models. In our study sample (n = 3188, mean age 59, range 30-77), 10 % reported high stress. In adjusted analyses, higher neighborhood all crimes rate was associated with modest increase in high stress for African-American (OR = 1.10; 95 % CI 1.02-1.22) and Latina women (OR = 1.36; 95 % CI 1.10-1.67) and property crime showed similar associations with stress for these groups of women. Visible crime was associated with stress only for Latina women (OR = 1.43; 95 % CI 1.14-1.78). We found no association between crime and stress among men or other racial/ethnic groups of women. High crime levels may disproportionately impact health among certain subpopulations. Studies using additional measures of stress are necessary to differentiate the health impact of crime-related stress from other forms of stressors among individuals living with diabetes.

A new class of weight and WA systems of the Kravchenko-Kaiser functions

NASA Astrophysics Data System (ADS)

Kravchenko, V. F.; Pustovoit, V. I.; Churikov, D. V.

2014-05-01

A new class of weight and WA-systems of the Kravchenko-Kaiser functions which showed its efficiency in various physical applications is proposed and substantiated. This publication consists of three parts. In the first the Kravchenko-Kaiser weight functions are constructed on basis of the theory of atomic functions (AFs) and the Kaiser windows for the first time. In the second part new constructions of analytic WA-systems of the Kravchenko-Kaiser functions are costructed. In the third part their applications to problems of weight averaging of the difference frequency signals are considered. The numerical experiment and the physical analysis of the results for concrete physical models confirmed their efficiency. This class of functions can find wide physical applications in problems of digital signal processing, restoration of images, radar, radiometry, radio astronomy, remote sensing, etc.

Caregiver involvement in a large clinical systems project.

PubMed Central

Sales, S.; Mathews, P.; Gamblin, D.; Gee, S.

1994-01-01

The Kaiser Permanente Northern California Region (KPNCR) CareGiver Workstation (CGW) Project's mission is to develop and implement a clinical workstation system that will enhance each caregiver-member interaction and aid in the decision-making processes of direct patient care in the inpatient and outpatient settings. The requirements analysis approach for CareGiver Workstation (CGW) is based on the belief that extensive caregiver involvement will provide a better understanding of the diverse needs of Kaiser Permanente Northern California Region (KPNCR). In order to involve as many caregivers as reasonably possible, CGW included a 16 member caregiver core team and 6 different Medical Centers in the requirements definition process. The Medical Centers are referred to as "focus facilities". A "focus group" (caregiver team) at each selected focus facility consisted of a site coordinator and a 24-30 person multidisciplinary team involving physicians, nurses, therapists and other caregivers. The Medical Center selection process identified facilities that provided the best cross-sectional representation of KPNCR. The Lead Focus Facility participated in the initial round of requirements definition activities. These sessions assisted in the design of a simulation that was used at five additional Medical Centers to validate requirements. The five additional Focus Facilities participated in simulation review sessions. Feedback from these sessions was used to revise the simulation and update the requirements document. Caregivers from all six focus facilities and other identified groups participated in a requirements survey to assist CGW with identification of high priority features. Caregiver commitment and continuing involvement are essential for the success of CGW.(ABSTRACT TRUNCATED AT 250 WORDS) PMID:7949953

Association Between Influenza Infection and Vaccination During Pregnancy and Risk of Autism Spectrum Disorder.

PubMed

Zerbo, Ousseny; Qian, Yinge; Yoshida, Cathleen; Fireman, Bruce H; Klein, Nicola P; Croen, Lisa A

2017-01-02

Maternal infections and fever during pregnancy are associated with increased risk for autism spectrum disorders (ASDs). To our knowledge, no study has investigated the association between influenza vaccination during pregnancy and ASD. To investigate the association between influenza infection and vaccination during pregnancy and ASD risk. This cohort study included 196 929 children born at Kaiser Permanente Northern California from January 1, 2000 to December 31, 2010, at a gestational age of at least 24 weeks. Data on maternal influenza infection and vaccination from conception date to delivery date, obtained from Kaiser Permanente Northern California inpatient and outpatient databases. Influenza infection was defined by the International Classification of Diseases, Ninth Revision, Clinical Modification codes or positive influenza laboratory test results. Clinical diagnoses of ASDs identified by International Classification of Diseases, Ninth Revision, Clinical Modification codes 299.0, 299.8, or 299.9 recorded in Kaiser Permanente Northern California electronic medical records on at least 2 occasions any time from birth through June 2015. Within this cohort of 196 929 children, influenza was diagnosed in 1400 (0.7%) mothers and 45 231 (23%) received an influenza vaccination during pregnancy. The mean (SD) ages of vaccinated and unvaccinated women were 31.6 (5.2) and 30.4 (5.6) years, respectively. A total number of 3101 (1.6%) children were diagnosed with ASD. After adjusting for covariates, we found that maternal influenza infection (adjusted hazard ratio, 1.04; 95% CI, 0.68-1.58) or influenza vaccination (adjusted hazard ratio, 1.10; 95% CI, 1.00-1.21) anytime during pregnancy was not associated with increased ASD risk. In trimester-specific analyses, first-trimester influenza vaccination was the only period associated with increased ASD risk (adjusted hazard ratio, 1.20; 95% CI, 1.04-1.39). However, this association could be due to chance (P = 0.1) if

Prepaid group practice staffing and U.S. physician supply: lessons for workforce policy.

PubMed

Weiner, Jonathan P

2004-01-01

This paper describes staffing at eight large prepaid group practices (PGPs) serving more than eight million enrollees at Kaiser Permanente and two other health maintenance organizations (HMOs). Even after characteristics of the patient populations and outside referrals are accounted for, these PGPs have a physician-to-population ratio that is 22-37 percent below the national rate. Two decades of historical data at Kaiser Permanente indicate that its rate of specialist growth was far higher than that of primary care. The study suggests that efficient systems of care can readily meet the demands of patient populations with workforce staffing ratios below current U.S. levels.

Psychiatric and Medical Conditions in Transition-Aged Individuals With ASD.

PubMed

Davignon, Meghan N; Qian, Yinge; Massolo, Maria; Croen, Lisa A

2018-04-01

Children with autism spectrum disorder (ASD) have a variety of medical and psychiatric conditions and an increased use of health care services. There is limited information about the prevalence of psychiatric and medical conditions in adolescents and young adults with ASD. Our objective was to describe the frequency of medical and psychiatric conditions in a large population of diverse, insured transition-aged individuals with ASD. Participants included Kaiser Permanente Northern California members who were enrolled from 2013 to 2015 and who were 14 to 25 years old. Individuals with ASD ( n = 4123) were compared with peers with attention-deficit/hyperactivity disorder ( n = 20 615), diabetes mellitus ( n = 2156), and typical controls with neither condition ( n = 20 615). Over one-third (34%) of individuals with ASD had a co-occurring psychiatric condition; the most commonly reported medical conditions included infections (42%), obesity (25%), neurologic conditions (18%), allergy and/or immunologic conditions (16%), musculoskeletal conditions (15%), and gastrointestinal (11%) conditions. After controlling for sex, age, race, and duration of Kaiser Permanente Northern California membership, most psychiatric conditions were significantly more common in the ASD group than in each comparison group, and most medical conditions were significantly more common in the ASD group than in the attention-deficit/hyperactivity disorder and typical control groups but were similar to or significantly less common than the diabetes mellitus group. Although more research is needed to identify factors contributing to this excess burden of disease, there is a pressing need for all clinicians to approach ASD as a chronic health condition requiring regular follow-up and routine screening and treatment of medical and psychiatric issues. Copyright © 2018 by the American Academy of Pediatrics.

Code-based Diagnostic Algorithms for Idiopathic Pulmonary Fibrosis. Case Validation and Improvement.

PubMed

Ley, Brett; Urbania, Thomas; Husson, Gail; Vittinghoff, Eric; Brush, David R; Eisner, Mark D; Iribarren, Carlos; Collard, Harold R

2017-06-01

Population-based studies of idiopathic pulmonary fibrosis (IPF) in the United States have been limited by reliance on diagnostic code-based algorithms that lack clinical validation. To validate a well-accepted International Classification of Diseases, Ninth Revision, code-based algorithm for IPF using patient-level information and to develop a modified algorithm for IPF with enhanced predictive value. The traditional IPF algorithm was used to identify potential cases of IPF in the Kaiser Permanente Northern California adult population from 2000 to 2014. Incidence and prevalence were determined overall and by age, sex, and race/ethnicity. A validation subset of cases (n = 150) underwent expert medical record and chest computed tomography review. A modified IPF algorithm was then derived and validated to optimize positive predictive value. From 2000 to 2014, the traditional IPF algorithm identified 2,608 cases among 5,389,627 at-risk adults in the Kaiser Permanente Northern California population. Annual incidence was 6.8/100,000 person-years (95% confidence interval [CI], 6.1-7.7) and was higher in patients with older age, male sex, and white race. The positive predictive value of the IPF algorithm was only 42.2% (95% CI, 30.6 to 54.6%); sensitivity was 55.6% (95% CI, 21.2 to 86.3%). The corrected incidence was estimated at 5.6/100,000 person-years (95% CI, 2.6-10.3). A modified IPF algorithm had improved positive predictive value but reduced sensitivity compared with the traditional algorithm. A well-accepted International Classification of Diseases, Ninth Revision, code-based IPF algorithm performs poorly, falsely classifying many non-IPF cases as IPF and missing a substantial proportion of IPF cases. A modification of the IPF algorithm may be useful for future population-based studies of IPF.

Birth outcomes following immunization of pregnant women with pandemic H1N1 influenza vaccine 2009-2010.

PubMed

Eaton, Abigail; Lewis, Ned; Fireman, Bruce; Hansen, John; Baxter, Roger; Gee, Julianne; Klein, Nicola P

2018-05-03

Following the H1N1 influenza pandemic in 2009, pregnant women were recommended to receive both seasonal (TIV) and H1N1 influenza vaccines. This study presents incidence of adverse birth and pregnancy outcomes among a population of pregnant women immunized with TIV and H1N1 vaccines at Kaiser Permanente Northern California during 2009-2010. We telephone surveyed pregnant Kaiser Permanente Northern California members to assess non-medically-attended reactions following H1N1, TIV or both vaccines during 2009-2010 (n=5365) in a separate study. Here we assessed preterm birth (<37weeks), very preterm birth (<32weeks), low birth weight (<2500 g, LBW), very low birth weight (<1500g), small for gestational age, spontaneous abortions, stillbirths and congenital anomalies among this cohort by comparing incidence and 95% confidence intervals between the following immunization groups: TIV only, H1N1 only, H1N1 prior to TIV immunization, TIV prior to H1N1 and both immunizations given at the same time. Results did not vary significantly between groups. Comparing H1N1 with TIV, incidence were similar for preterm births (6.37vs 6.28/100 births), very preterm births (5.30vs 8.29/1000 births), LBW (4.19vs 2.90/100 births), very LBW (4.54vs 5.52/1000 births), small for gestational age (9.99vs 9.24/1000 births), spontaneous abortion (7.10vs 6.83/1000 pregnancies), stillbirths (7.10vs 4.57/1000 pregnancies), and congenital anomalies (2.66vs 2.43/100 births). Although constrained by small sample size, complex vaccine groups, and differential vaccine availability during 2009-2010, this study found no difference in adverse birth outcomes between H1N1 vaccine and TIV. Copyright © 2017 Elsevier Ltd. All rights reserved.

Protocol: changes in rates of opioid overdose and poisoning events in an integrated health system following the introduction of a formulation of OxyContin® with abuse-deterrent properties.

PubMed

Janoff, Shannon L; Perrin, Nancy A; Coplan, Paul M; Chilcoat, Howard D; Campbell, Cynthia I; Green, Carla A

2016-05-14

Addiction, overdoses and deaths resulting from prescription opioids have increased dramatically over the last decade. In response, several manufacturers have developed formulations of opioids with abuse-deterrent properties. For many of these products, the Food and Drug Administration (FDA) recognized the formulation with labeling claims and mandated post-marketing studies to assess the abuse-deterrent effects. In response, we assess differences in rates of opioid-related overdoses and poisonings prior to and following the introduction of a formulation of OxyContin® with abuse-deterrent properties. To assess effects of this formulation, electronic medical record (EMR) data from Kaiser Permanente Northwest (KPNW) and Kaiser Permanente Northern California (KPNC) are linked to state death data and compared to chart audits. Overdose and poisoning events will be categorized by intentionality and number of agents involved, including illicit drugs and alcohol. Using 6-month intervals over a 10-year period, trends will be compared in rates of opioid-related overdoses and poisoning events associated with OxyContin® to rates of events associated with other oxycodone and opioid formulations. Qualitative interviews with patients and relatives of deceased patients will be conducted to capture circumstances surrounding events. This study assesses and tracks changes in opioid-related overdoses and poisoning events prior to and following the introduction of OxyContin® with abuse-deterrent properties. Public health significance is high because these medications are designed to reduce abuse-related behaviors that lead to important adverse outcomes, including overdoses and deaths.

Timely detection of localized excess influenza activity in Northern California across patient care, prescription, and laboratory data.

PubMed

Greene, Sharon K; Kulldorff, Martin; Huang, Jie; Brand, Richard J; Kleinman, Kenneth P; Hsu, John; Platt, Richard

2011-02-28

Timely detection of clusters of localized influenza activity in excess of background seasonal levels could improve situational awareness for public health officials and health systems. However, no single data type may capture influenza activity with optimal sensitivity, specificity, and timeliness, and it is unknown which data types could be most useful for surveillance. We compared the performance of 10 types of electronic clinical data for timely detection of influenza clusters throughout the 2007/08 influenza season in northern California. Kaiser Permanente Northern California generated zip code-specific daily episode counts for: influenza-like illness (ILI) diagnoses in ambulatory care (AC) and emergency departments (ED), both with and without regard to fever; hospital admissions and discharges for pneumonia and influenza; antiviral drugs dispensed (Rx); influenza laboratory tests ordered (Tests); and tests positive for influenza type A (FluA) and type B (FluB). Four credible events of localized excess illness were identified. Prospective surveillance was mimicked within each data stream using a space-time permutation scan statistic, analyzing only data available as of each day, to evaluate the ability and timeliness to detect the credible events. AC without fever and Tests signaled during all four events and, along with Rx, had the most timely signals. FluA had less timely signals. ED, hospitalizations, and FluB did not signal reliably. When fever was included in the ILI definition, signals were either delayed or missed. Although limited to one health plan, location, and year, these results can inform the choice of data streams for public health surveillance of influenza. Copyright © 2010 John Wiley & Sons, Ltd.

20. Photocopy of drawing (1961 mechanical drawing by Kaiser Engineers) ...

Library of Congress Historic Buildings Survey, Historic Engineering Record, Historic Landscapes Survey

20. Photocopy of drawing (1961 mechanical drawing by Kaiser Engineers) ELECTRICAL LAYOUTS FOR VEHICLE SUPPORT BUILDING, SHEET E-2 - Vandenberg Air Force Base, Space Launch Complex 3, Vehicle Support Building, Napa & Alden Roads, Lompoc, Santa Barbara County, CA

18. Photocopy of drawing (1961 architectural drawing by Kaiser Engineers) ...

Library of Congress Historic Buildings Survey, Historic Engineering Record, Historic Landscapes Survey

18. Photocopy of drawing (1961 architectural drawing by Kaiser Engineers) FLOOR PLAN, ELEVATIONS, AND SCHEDULE FOR VEHICLE SUPPORT BUILDING, SHEET A-1 - Vandenberg Air Force Base, Space Launch Complex 3, Vehicle Support Building, Napa & Alden Roads, Lompoc, Santa Barbara County, CA

19. Photocopy of drawing (1961 piping drawing by Kaiser Engineers) ...

Library of Congress Historic Buildings Survey, Historic Engineering Record, Historic Landscapes Survey

19. Photocopy of drawing (1961 piping drawing by Kaiser Engineers) PIPING PLANS AND DETAILS FOR VEHICLE SUPPORT BUILDING, SHEET P-1 - Vandenberg Air Force Base, Space Launch Complex 3, Vehicle Support Building, Napa & Alden Roads, Lompoc, Santa Barbara County, CA

17. Photocopy of drawing (1961 civil engineering drawing by Kaiser ...

Library of Congress Historic Buildings Survey, Historic Engineering Record, Historic Landscapes Survey

17. Photocopy of drawing (1961 civil engineering drawing by Kaiser Engineers) SITE PLAN, PLOT PLAN, AND LOCATION MAP FOR VEHICLE SUPPORT BUILDING, SHEET C-1 - Vandenberg Air Force Base, Space Launch Complex 3, Vehicle Support Building, Napa & Alden Roads, Lompoc, Santa Barbara County, CA

The Dilemma of Campus Upkeep: An Interview with Harvey Kaiser.

ERIC Educational Resources Information Center

Christian, Roslyn Stewart

1984-01-01

Deferred maintenance is reaching crisis proportion on many campuses. An overview of this priority for governing boards and a look at how trustees should be involved is presented in an interview of Harvey Kaiser, vice president for facilities administration at Syracuse University. (Author/MLW)

Bedrock Outcrops in Kaiser Crater

NASA Image and Video Library

2017-03-13

This enhanced-color image from NASA Mars Reconnaissance Orbiter shows a patch of well-exposed bedrock on the floor of Kaiser Crater. The wind has stripped off the overlying soil, and created grooves and scallops in the bedrock. The narrow linear ridges are fractures that have been indurated, probably by precipitation of cementing minerals from groundwater flow. The rippled dark blue patches consist of sand. The map is projected here at a scale of 25 centimeters (9.8 inches) per pixel. [The original image scale is 25.3 centimeters (9.9 inches) per pixel (with 1 x 1 binning); objects on the order of 76 centimeters (29.9 inches) across are resolved.] North is up. http://photojournal.jpl.nasa.gov/catalog/PIA21559

Incidence of Parkinson's disease: variation by age, gender, and race/ethnicity.

PubMed

Van Den Eeden, Stephen K; Tanner, Caroline M; Bernstein, Allan L; Fross, Robin D; Leimpeter, Amethyst; Bloch, Daniel A; Nelson, Lorene M

2003-06-01

The goal of this study was to estimate the incidence of Parkinson's disease by age, gender, and ethnicity. Newly diagnosed Parkinson's disease cases in 1994-1995 were identified among members of the Kaiser Permanente Medical Care Program of Northern California, a large health maintenance organization. Each case met modified standardized criteria/Hughes diagnostic criteria as applied by a movement disorder specialist. Incidence rates per 100,000 person-years were calculated using the Kaiser Permanente membership information as the denominator and adjusted for age and/or gender using the direct method of standardization. A total of 588 newly diagnosed (incident) cases of Parkinson's disease were identified, which gave an overall annualized age- and gender-adjusted incidence rate of 13.4 per 100,000 (95% confidence interval (CI): 11.4, 15.5). The incidence rapidly increased over the age of 60 years, with only 4% of the cases being under the age of 50 years. The rate for men (19.0 per 100,000, 95% CI: 16.1, 21.8) was 91% higher than that for women (9.9 per 100,000, 95% CI: 7.6, 12.2). The age- and gender-adjusted rate per 100,000 was highest among Hispanics (16.6, 95% CI: 12.0, 21.3), followed by non-Hispanic Whites (13.6, 95% CI: 11.5, 15.7), Asians (11.3, 95% CI: 7.2, 15.3), and Blacks (10.2, 95% CI: 6.4, 14.0). These data suggest that the incidence of Parkinson's disease varies by race/ethnicity.

Information Placement and Retrieval Through NHIN (InfoPRN)

DTIC Science & Technology

2011-05-01

and FISMA.  Dr. Steffensen will contact NMDS (Captain Bensic), JTF CapMed , and perhaps Kaiser Permanente to ascertain their interest in...activities, project stakeholders, critical project deliverables and milestones were defined and agreed upon. Therefore, the Integrated Master

Observations of the Kaiser effect under multiaxial stress states: Implications for its use in determining in situ stress

DOE Office of Scientific and Technical Information (OSTI.GOV)

Holcomb, D.J.

1993-10-08

Experimental tests of the Kaiser effect, the stress-history dependence of acoustic emission production, show that interactions between principal stresses cannot be ignored as is commonly done when trying to use the Kaiser effect to determine in situ stress. Experimental results obtained under multiaxial stress states are explained in terms of a qualitative model. The results show that the commonly-used technique of loading uniaxially along various directions to determine stress history must be reevaluated as it cannot be justified in terms of the laboratory experiments. One possible resolution of the conflict between laboratory and field results is that the Kaiser effectmore » phenomenon observed in cores retrieved from the earth is not the same phenomenon as is observed in rock loaded under laboratory conditions.« less

Does the diagnosis of breast or ovarian cancer trigger referral to genetic counseling?

PubMed

Powell, C Bethan; Littell, Ramey; Hoodfar, Elizabeth; Sinclair, Fiona; Pressman, Alice

2013-03-01

Kaiser Permanente Northern California is a large integrated health care delivery system in the United States that has guidelines for referring women with newly diagnosed BRCA1-and BRCA2-associated cancers for genetic counseling. This study assesses adherence to genetic counseling referral guidelines within this health system. Chart review was performed to identify patients with cancer who met the following pathology-based Kaiser Permanente Northern California guidelines for referral for genetic counseling: invasive breast cancer, younger than age 40; nonmucinous epithelial ovarian, fallopian tube, or peritoneal cancer, younger than age 60; women with synchronous or metachronous primary cancers of the breast and ovaries; and male breast cancer. We assessed compliance with referral guidelines. An electronic notice was sent to the managing physician of patients with newly diagnosed cancer to assess the feasibility of this intervention. A total of 340 patients were identified with breast cancer at younger than age 40 or with ovarian, peritoneal, or tubal cancer between January and June, 2008. Upon chart review, 105 of these patients met pathology-based criteria for referral to genetic counseling, of whom 47 (45%) were referred within the 2-year study period. Of the 67 subjects with breast cancer, 40 subjects (60%) were referred. In contrast, only 7 (21%) of 33 patients with ovarian cancer were referred (P < 0.001). A pilot study was performed to test the feasibility of notifying managing oncologists with an electronic letter alerting them of eligibility for genetic referral of patients with new diagnosis (n = 21). In the 3 to 6 months after this notification, 12 of these 21 patients were referred for counseling including 5 of 7 patients with a diagnosis of ovarian cancer. There is a missed opportunity for referring patients to genetic counseling, especially among patients with ovarian cancer. A pilot study suggests that alerting treating physicians is a feasible

Meet your senior's online needs to compete in Medicare marketplace.

PubMed

1997-12-01

As more seniors turn to the Internet for health care information and services, is your organization prepared to meet their needs? Kaiser Permanente is reaching the cyber-senior market on the World Wide Web with interactive online services, including discussion groups with providers.

Physician involvement in disease management as part of the CCM.

PubMed

Wallace, Paul J

2005-01-01

Phase I of the voluntary chronic care improvement (CCI-I) under traditional fee-for-service Medicare initiative seeks to extend the benefits of disease management to an elderly population with comorbid chronic medical conditions. Active, sustained involvement of treating physicians, a historical deficit of disease management programs, is a CCI-I program goal. During the last decade, Kaiser Permanente, an integrated health care delivery system with more than 60 years of experience in managing the care of individuals and populations, has applied the chronic care model (CCM) to develop care management strategies for populations of patients with chronic medical conditions. Physician leadership and involvement have been key to successfully incorporating these practices into care. The scope of physician involvement in leading, developing, and delivering chronic illness care management at Kaiser Permanente is described as a basis for identifying opportunities to involve practicing physicians in the CCI-I.

Physician Involvement in Disease Management as Part of the CCM

PubMed Central

Wallace, Paul J.

2005-01-01

Phase I of the voluntary chronic care improvement (CCI-I) under traditional fee-for-service Medicare initiative seeks to extend the benefits of disease management to an elderly population with comorbid chronic medical conditions. Active, sustained involvement of treating physicians, a historical deficit of disease management programs, is a CCI-I program goal. During the last decade, Kaiser Permanente, an integrated health care delivery system with more than 60 years of experience in managing the care of individuals and populations, has applied the chronic care model (CCM) to develop care management strategies for populations of patients with chronic medical conditions. Physician leadership and involvement have been key to successfully incorporating these practices into care. The scope of physician involvement in leading, developing, and delivering chronic illness care management at Kaiser Permanente is described as a basis for identifying opportunities to involve practicing physicians in the CCI-I. PMID:17288075

Maternal Infection during Pregnancy and Autism Spectrum Disorders

PubMed Central

Zerbo, Ousseny; Qian, Yinge; Yoshida, Cathleen; Grether, Judith K.; Van de Water, Judy; Croen, Lisa A.

2014-01-01

We conducted a nested case-control study including 407 cases and 2075 frequency matched controls to investigate the association between maternal infections during pregnancy and risk of autism spectrum disorders (ASD). Cases, controls, and maternal infections were ascertained from Kaiser Permanente Northern California clinical databases. No overall association between diagnoses of any maternal infection during pregnancy and ASD (adjusted odds ratio [ORadj] = 1.15, 95% confidence interval [CI] 0.92 – 1.43). However, women with infections diagnosed during a hospital admission (ORadj= 1.48, 95% CI1.07 – 2.04), particularly bacterial infections (ORadj = 1.58, 95% CI 1.06 – 2.37), were at increased risk of delivering a child with ASD. Multiple infections during pregnancy were associated with ASD (ORadj = 1.36, 95% CI 1.05 – 1.78). PMID:24366406

Clinical pharmacy travel medicine services: a new frontier.

PubMed

Jackson, Adam B; Humphries, Tammy L; Nelson, Kent M; Helling, Dennis K

2004-12-01

Travel to remote destinations has increased dramatically in recent years. The Clinical Pharmacy International Travel Clinic (CPITC) was established in 1991 in the Kaiser Permanente Colorado Region to provide pre-travel advice to members to decrease their risk of travel-related diseases. The CPITC is unique from other travel medicine clinics because it is a pharmacist-run telepharmacy service. The team includes an infectious diseases physician, an infectious diseases clinical pharmacy specialist, 4 clinical pharmacists, and a pharmacy technician. The clinical pharmacists provide consultations via telephone. Both patient- and trip-related information are gathered to assess the traveler's health risks. Recommendations are provided regarding food- and water-borne diseases, insect-borne diseases, sexually transmitted diseases, and diseases related to animal bites. Additionally, detailed information is provided on vaccines that may be needed to protect travelers against various diseases. The travel consult is documented electronically. A copy of the consult, along with a booklet that provides travel information, is mailed to the patient. Success of the CPITC is demonstrated in several ways. The clinic initially served Kaiser Permanente members in the Colorado Region. The service has expanded and now also provides travel consults to Kaiser Permanente members in the Northwest and Ohio Regions. Patient satisfaction is high, and significant cost-savings have been realized secondary to avoiding the use of unnecessary vaccinations and medications. The CPITC allows resources to be leveraged and provides one center where individuals trained in travel medicine provide information to members, thus improving efficiency and decreasing cost.

75 FR 66302 - Establishment of Class E Airspace; Kaiser/Lake Ozark, MO

Federal Register 2010, 2011, 2012, 2013, 2014

2010-10-28

... Class E airspace for the Kaiser/Lake Ozark, MO, area to accommodate Area Navigation (RNAV) Standard Instrument Approach Procedures (SIAP) at Camdenton Memorial Airport, Camdenton, MO. The FAA is taking this action to enhance the safety and management of Instrument Flight Rule (IFR) operations at the airport...

External Validation of Early Weight Loss Nomograms for Exclusively Breastfed Newborns.

PubMed

Schaefer, Eric W; Flaherman, Valerie J; Kuzniewicz, Michael W; Li, Sherian X; Walsh, Eileen M; Paul, Ian M

2015-12-01

Nomograms that show hour-by-hour percentiles of weight loss during the birth hospitalization were recently developed to aid clinical care of breastfeeding newborns. The nomograms for breastfed neonates were based on a sample of 108,907 newborns delivered at 14 Kaiser Permanente medical centers in Northern California (United States). The objective of this study was to externally validate the published nomograms for newborn weight loss using data from a geographically distinct population. Data were compiled from the Penn State Milton S. Hershey Medical Center located in Hershey, PA. For singleton neonates delivered at ≥36 weeks of gestation between January 2013 and September 2014, weights were obtained between 6 hours and 48 hours (vaginal delivery) or 60 hours (cesarean delivery) for neonates who were exclusively breastfeeding. Quantile regression methods appropriate for repeated measures were used to estimate 50th, 75th, 90th, and 95th percentiles of weight loss as a function of time after birth. These percentile estimates were compared with the published nomograms. Of the 1,587 newborns who met inclusion criteria, 1,148 were delivered vaginally, and 439 were delivered via cesarean section. These newborns contributed 1,815 weights for vaginal deliveries (1.6 per newborn) and 893 weights for cesarean deliveries (2.0 per newborn). Percentile estimates from this Penn State sample were similar to the published nomograms. Deviations in percentile estimates for the Penn State sample were similar to deviations observed after fitting the same model separately to each medical center that made up the Kaiser Permanente sample. The published newborn weight loss nomograms for breastfed neonates were externally validated in a geographically distinct population.

Neonatal hyperbilirubinemia and risk of autism spectrum disorders.

PubMed

Croen, Lisa A; Yoshida, Cathleen K; Odouli, Roxana; Newman, Thomas B

2005-02-01

To investigate the association between neonatal hyperbilirubinemia and autism spectrum disorders (ASD). We conducted a large case-control study nested within the cohort of singleton term infants born between 1995 and 1998 at a northern California Kaiser Permanente hospital. Case subjects (n = 338) were children with an ASD diagnosis recorded in Kaiser Permanente outpatient databases; control subjects (n = 1817) were children without an ASD diagnosis, who were randomly sampled and frequency-matched to case subjects according to gender, birth year, and birth hospital. Approximately 28% of case and control subjects received > or =1 bilirubin test in the first 30 days of life. No case-control differences were observed for maximal bilirubin levels of > or =15 mg/dL (10.1% vs 12.1%), > or =20 mg/dL (2.1% vs 2.5%), or > or =25 mg/dL (0.3% vs 0.2%). Compared with children whose maximal neonatal bilirubin levels were <15 mg/dL or not measured, children with any degree of bilirubin level elevation were not at increased risk of ASD, after adjustment for gender, birth facility, maternal age, maternal race/ethnicity, maternal education, and gestational age (for bilirubin levels of 15-19.9 mg/dL: odds ratio: 0.7; 95% confidence interval: 0.5-1.2; for bilirubin levels of 20-24.9 mg/dL: odds ratio: 0.7; 95% confidence interval: 0.3-1.6; for bilirubin levels of > or =25 mg/dL: odds ratio: 1.1; 95% confidence interval: 0.1-11.2). These data suggest that neonatal hyperbilirubinemia is not a risk factor for ASD.

Differences in the clinical recognition of depression in diabetes patients: the Diabetes Study of Northern California (DISTANCE).

PubMed

Hudson, Darrell L; Karter, Andrew J; Fernandez, Alicia; Parker, Melissa; Adams, Alyce S; Schillinger, Dean; Moffet, Howard H; Zhou, Jufen; Adler, Nancy E

2013-05-01

It is unknown to what extent the gap between need and care for depression among patients with diabetes differs across racial/ethnic groups. We compared, by race/ethnicity, the likelihood of clinical recognition of depression (diagnosis or treatment) of patients who reported depressive symptoms in a well-characterized community-based population with diabetes. We used a survey follow-up study of 20,188 patients with diabetes from Kaiser Permanente Northern California. Analyses were limited to 910 patients who scored 10 or higher on the Patient Health Questionnaire (PHQ-8) which was included in the survey and who had no clinical recognition of depression in the 12 months prior to survey. Clinical recognition of depression was defined by a depression diagnosis, referral to mental health services, or antidepressant medication prescription. Among the 910 patients reporting moderate to severe depressive symptoms on the survey and who had no clinical recognition in the prior year, 12%, 8%, 8%, 14%, and 15% of African American, Asian, Filipino, Latino, and white patients, respectively, were clinically recognized for depression in the subsequent 12 months. After adjusting for sociodemographics, limited English proficiency, and depressive symptom severity, racial/ethnic minorities were less likely to be clinically recognized for depression compared with whites (relative risk: Filipino: 0.30, African American: 0.62). More work is needed to understand the modifiable patient and provider factors that influence clinical recognition of depression among diabetes patients from different racial/ethnic groups, and the potential impact of low rates of clinical recognition on quality of care.

Pathways: improving outcomes, not just 'cookbook medicine'.

PubMed

O'Malley, S

1997-04-01

A Kaiser Permanente medical director cites four benefits to be derived from using clinical guidelines: better outcomes, faster patient recovery, reduced costs, and increased physician accountability. And, he notes, physicians are free to deviate from the guidelines--so long as they can justify their actions.

Site support program plan for ICF Kaiser Hanford Company, Revision 1

DOE Office of Scientific and Technical Information (OSTI.GOV)

NONE

1995-10-01

This document is the general administrative plan implemented by the Hanford Site contractor, ICF Kaiser Hanford Company. It describes the mission, administrative structure, projected staffing, to be provided by the contractor. The report breaks out the work responsibilities within the different units of the company, a baseline schedule for the different groups, and a cost summary for the different operating units.

DM programs take different roads to CHF success.

PubMed

2001-02-01

Improving CHF outcomes: There's no single right way. But there are some elements in common, as suggested by the experience of Duke, Kaiser Permanente, and First Priority Health. The challenge is to identify high-risk patients and provide as comprehensive an array of services as possible.

Developing a data infrastructure for a learning health system: the PORTAL network

PubMed Central

McGlynn, Elizabeth A; Lieu, Tracy A; Durham, Mary L; Bauck, Alan; Laws, Reesa; Go, Alan S; Chen, Jersey; Feigelson, Heather Spencer; Corley, Douglas A; Young, Deborah Rohm; Nelson, Andrew F; Davidson, Arthur J; Morales, Leo S; Kahn, Michael G

2014-01-01

The Kaiser Permanente & Strategic Partners Patient Outcomes Research To Advance Learning (PORTAL) network engages four healthcare delivery systems (Kaiser Permanente, Group Health Cooperative, HealthPartners, and Denver Health) and their affiliated research centers to create a new national network infrastructure that builds on existing relationships among these institutions. PORTAL is enhancing its current capabilities by expanding the scope of the common data model, paying particular attention to incorporating patient-reported data more systematically, implementing new multi-site data governance procedures, and integrating the PCORnet PopMedNet platform across our research centers. PORTAL is partnering with clinical research and patient experts to create cohorts of patients with a common diagnosis (colorectal cancer), a rare diagnosis (adolescents and adults with severe congenital heart disease), and adults who are overweight or obese, including those with pre-diabetes or diabetes, to conduct large-scale observational comparative effectiveness research and pragmatic clinical trials across diverse clinical care settings. PMID:24821738

Leveraging Geographic Information Systems in an Integrated Health Care Delivery Organization

PubMed Central

Clift, Kathryn; Scott, Luther; Johnson, Michael; Gonzalez, Carlos

2014-01-01

A handful of the many changes resulting from the Affordable Care Act underscore the need for a geographic understanding of existing and prospective member communities. Health exchanges require that health provider networks are geographically accessible to underserved populations, and nonprofit hospitals nationwide are required to conduct community health needs assessments every three years. Beyond these requirements, health care providers are using maps and spatial analysis to better address health outcomes that are related in complex ways to social and economic factors. Kaiser Permanente is applying geographic information systems, with spatial analytics and map-based visualizations, to data sourced from its electronic medical records and from publicly and commercially available datasets. The results are helping to shape an understanding of the health needs of Kaiser Permanente members in the context of their communities. This understanding is part of a strategy to inform partnerships and interventions in and beyond traditional care delivery settings. PMID:24694317

Joint Venture Arrangement for RN to BSN: A Model of Synergy between Academia and Service.

ERIC Educational Resources Information Center

Bargagliotti, L. Antoinette; And Others

1991-01-01

Joint venture among educational and practice institutions is well on its way toward becoming the norm in nursing education and practice. Kaiser Permanente and the University of San Francisco School of Nursing offer a venture that allows registered nurses to pursue a bachelor of science in nursing degree. (JOW)

Community Resources for Promoting Youth Nutrition and Physical Activity

ERIC Educational Resources Information Center

Moore, Kelly R.; McGowan, Melissa K.; Donato, Karen A.; Kollipara, Sobha; Roubideaux, Yvette

2009-01-01

Childhood obesity is a national public health crisis. The National Diabetes Education Program (NDEP), the National Institutes of Health and Kaiser Permanente have developed community tools and resources for children and families to lower their risk for obesity through healthier, active lifestyles. The authors describe innovative practices and…

Quality of Care for Work-associated Carpal Tunnel Syndrome

PubMed Central

Nuckols, Teryl; Conlon, Craig; Robbins, Michael; Dworsky, Michael; Lai, Julie; Roth, Carol P.; Levitan, Barbara; Seabury, Seth; Seelam, Rachana; Asch, Steven M.

2017-01-01

Objective To evaluate the quality of care provided to individuals with workers’ compensation claims related to CTS and identify patient characteristics associated with receiving better care. Methods We recruited subjects with new claims for CTS from 30 occupational clinics affiliated with Kaiser Permanente Northern California. We applied 45 process-oriented quality measures to 477 subjects’ medical records, and performed multivariate logistic regression to identify patient characteristics associated with quality. Results Overall, 81.6% of care adhered to recommended standards. Certain tasks related to assessing and managing activity were underused. Patients with classic/probable Katz diagrams, positive electrodiagnostic tests, and higher incomes received better care. However, age, gender, and race/ethnicity were not associated with quality. Conclusions Care processes for work-associated CTS frequently adhered to quality measures. Clinical factors were more strongly associated with quality than demographic and socioeconomic ones. PMID:28045797

Crack Identification in CFRP Laminated Beams Using Multi-Resolution Modal Teager–Kaiser Energy under Noisy Environments

PubMed Central

Xu, Wei; Cao, Maosen; Ding, Keqin; Radzieński, Maciej; Ostachowicz, Wiesław

2017-01-01

Carbon fiber reinforced polymer laminates are increasingly used in the aerospace and civil engineering fields. Identifying cracks in carbon fiber reinforced polymer laminated beam components is of considerable significance for ensuring the integrity and safety of the whole structures. With the development of high-resolution measurement technologies, mode-shape-based crack identification in such laminated beam components has become an active research focus. Despite its sensitivity to cracks, however, this method is susceptible to noise. To address this deficiency, this study proposes a new concept of multi-resolution modal Teager–Kaiser energy, which is the Teager–Kaiser energy of a mode shape represented in multi-resolution, for identifying cracks in carbon fiber reinforced polymer laminated beams. The efficacy of this concept is analytically demonstrated by identifying cracks in Timoshenko beams with general boundary conditions; and its applicability is validated by diagnosing cracks in a carbon fiber reinforced polymer laminated beam, whose mode shapes are precisely acquired via non-contact measurement using a scanning laser vibrometer. The analytical and experimental results show that multi-resolution modal Teager–Kaiser energy is capable of designating the presence and location of cracks in these beams under noisy environments. This proposed method holds promise for developing crack identification systems for carbon fiber reinforced polymer laminates. PMID:28773016

Mineralogical control on thermal damage and the presence of a thermal Kaiser effect during temperature-cycling experiments

NASA Astrophysics Data System (ADS)

Browning, J.; Daoud, A.; Meredith, P. G.; Mitchell, T. M.

2017-12-01

Volcanic and geothermal systems are in part controlled by the mechanical and thermal stresses acting on them and so it is important to understand the response of volcanic rocks to thermo-mechanical loading. One such response is the well-known `Kaiser stress-memory' effect observed under cyclic mechanical loading. By contrast, the presence of an analogous `Kaiser temperature-memory effect' during cyclic thermal loading has received little attention. We have therefore explored the possibility of a Kaiser temperature-memory effect using three igneous rocks of different composition, grain size and origin; Slaufrudalur Granophyre (SGP), Nea Kameni Andesite (NKA) and Seljadalur Basalt (SB). We present results from a series of thermal stressing experiments in which acoustic emissions (AE) were recorded contemporaneously with changing temperature. Samples of each rock were subjected to both a single heating and cooling cycle to a maximum temperature of 900 °C and multiple heating/cooling cycles to peak temperatures of 350°C, 500°C, 700°C and 900 °C (all at a constant rate of 1°C/min on heating and a natural cooling rate of <1°C/min). Porosity, permeability and P-wave velocity measurements were made on each sample both before and after thermal treatment. We use the onset of AEs as a proxy for the onset of thermal cracking. This clearly demonstrates the presence of a Kaiser temperature-memory effect in SGP, but not in either NKA and SB. We further find that the vast majority of thermal crack damage is generated upon cooling in the finer grained materials (NKA and SB), but that substantial thermal crack damage is generated during heating in the coarser grained SGP. The total amount of crack damage generated due to heating or cooling is dependent on the mineral composition and, most importantly, the grain size and arrangement, as well as the maximum temperature to which the rock is exposed. Knowledge of thermal stress history and the presence of a Kaiser temperature

Restorative Integral Support (RIS) for Older Adults Experiencing Co-Occurring Disorders

ERIC Educational Resources Information Center

Larkin, Heather; MacFarland, Nicole S.

2012-01-01

The Restorative Integral Support (RIS) model is a whole person response that assists people to overcome adversity. The Adverse Childhood Experiences (ACE) Study conducted by Kaiser Permanente and the Centers for Disease Control and Prevention shows the association between stressors in childhood and multiple later-life health and social problems.…

A Single Subject Evaluation of the K-P Diet for Hyperkinesis.

ERIC Educational Resources Information Center

Burlton-Bennet, Jocelyn A.; Robinson, Viviane M. J.

1987-01-01

A single subject ABAB design was employed to determine the effectiveness of the Feingold Kaiser Permanente (K-P) diet in the treatment of a six-year-old hyperkinetic male. Results indicated the K-P diet was effective in controlling the subject's hyperkinesis, nutritionally adequate, and moderately difficult to implement. (Author/DB)

The Risk of Dupuytren Diagnosis in Obese Individuals.

PubMed

Hacquebord, Jacques H; Chiu, Vicki Y; Harness, Neil G

2017-03-01

Dupuytren disease is a common benign fibroproliferative disorder causing thickening and shortening of the palmar fascia of the hand. The exact etiology of the disease is unclear but known risk factors such as increased age, male sex, and northern European ethnicity have been established. A link between body mass index (BMI) and Dupuytren disease has not been established previously. The purpose of this study was to test the hypothesis that lower BMI is associated with increased risk for Dupuytren disease diagnosis. After we obtained institutional review board approval, we performed a retrospective review using an electronic medical record and an administrative database from Kaiser Permanente Southern California to identify all enrolled patients there between 2007 and 2014 who were diagnosed with Dupuytren disease. Basic demographic data including age, sex, ethnicity, and BMI were collected. Bivariate and multivariable logistical regression analyses were performed to evaluate for associations between Dupuytren disease and BMI. A total of 2,049,803 patients aged 18 years and older were enrolled in Kaiser Permanente Southern California from 2007 to 2014. During that period, 14,844 patients were identified as having Dupuytren disease. The data were consistent with well-defined demographic trends in Dupuytren disease, with increased rates seen in males, Caucasians, and patients aged 50 years and older. In the multivariable analysis, when controlling for age, race, and sex, the risk of Dupuytren disease was inversely proportional to BMI. The current study showed that higher BMI is associated with decreased odds of having Dupuytren disease. Further work will be required to determine the cause for the apparent relationship between Dupuytren disease and BMI and whether physiologic factors related to obesity may be protective against the development of Dupuytren disease. Prognostic II. Copyright © 2017 American Society for Surgery of the Hand. Published by Elsevier Inc. All

Incidence and Prevalence of Juvenile Idiopathic Arthritis Among Children in a Managed Care Population, 1996–2009

PubMed Central

Harrold, Leslie R.; Salman, Craig; Shoor, Stanford; Curtis, Jeffrey R.; Asgari, Maryam M.; Gelfand, Joel M.; Wu, Jashin J.; Herrinton, Lisa J.

2017-01-01

Objective Few studies based in well-defined North American populations have examined the occurrence of juvenile idiopathic arthritis (JIA), and none has been based in an ethnically diverse population. We used computerized healthcare information from the Kaiser Permanente Northern California membership to validate JIA diagnoses and estimate the incidence and prevalence of the disease in this well-characterized population. Methods We identified children aged ≤ 15 years with ≥ 1 relevant International Classification of Diseases, 9th edition, diagnosis code of 696.0, 714, or 720 in computerized clinical encounter data during 1996–2009. In a random sample, we then reviewed the medical records to confirm the diagnosis and diagnosis date and to identify the best-performing case-finding algorithms. Finally, we used the case-finding algorithms to estimate the incidence rate and point prevalence of JIA. Results A diagnosis of JIA was confirmed in 69% of individuals with at least 1 relevant code. Forty-five percent were newly diagnosed during the study period. The age- and sex-standardized incidence rate of JIA per 100,000 person-years was 11.9 (95% CI 10.9–12.9). It was 16.4 (95% CI 14.6–18.1) in girls and 7.7 (95% CI 6.5–8.9) in boys. The peak incidence rate occurred in children aged 11–15 years. The prevalence of JIA per 100,000 persons was 44.7 (95% CI 39.1–50.2) on December 31, 2009. Conclusion The incidence rate of JIA observed in the Kaiser Permanente population, 1996–2009, was similar to that reported in Rochester, Minnesota, USA, but 2 to 3 times higher than Canadian estimates. PMID:23588938

75 FR 61246 - Kaiser Federal Financial Group, Inc., Covina, CA; Approval of Conversion Application

Federal Register 2010, 2011, 2012, 2013, 2014

2010-10-04

... DEPARTMENT OF THE TREASURY Office of Thrift Supervision [AC-51: OTS No. H-4729] Kaiser Federal Financial Group, Inc., Covina, CA; Approval of Conversion Application Notice is hereby given that on September 28, 2010, the Office of Thrift Supervision approved the application of K-Fed Mutual Holding...

The Impact of Telephonic Wellness Coaching on Weight Loss: A “Natural Experiments for Translation in Diabetes (NEXT-D)” Study

PubMed Central

Schmittdiel, Julie A.; Adams, Sara R.; Goler, Nancy; Sanna, Rashel S.; Boccio, Mindy; Bellamy, David J.; Brown, Susan D.; Neugebauer, Romain S.; Ferrara, Assiamira

2016-01-01

Objective To evaluate the impact of a population-based telephonic wellness coaching program on weight loss. Methods Individual-level segmented regression analysis of interrupted time series data comparing the BMI trajectories in the 12 months before vs. the 12 months after initiating coaching among a cohort of Kaiser Permanente Northern California (KPNC) members (n=954) participating in The Permanente Medical Group (TPMG) Wellness Coaching program in 2011. The control group was a 20:1 propensity-score matched control group (n=19,080) matched with coaching participants based on baseline demographic and clinical characteristics. Results Wellness coaching participants had a significant upward trend in BMI in the 12 months before their first Wellness coaching session, and a significant downward trend in BMI in the 12 months after their first session equivalent to a clinically significant reduction of greater than one unit of baseline BMI (p<.01 for both). The control group did not have statistically significant decreases in BMI during the post-period. Conclusions Wellness coaching has a positive impact on BMI reduction that is both statistically and clinically significant. Future research and quality improvement efforts should focus on disseminating Wellness coaching for weight loss in diabetes patients and those at risk for developing the disease. PMID:28124501

Diagnosing the Kaiser: Psychiatry, Wilhelm II and the Question of German War Guilt The William Bynum Prize Essay 2016.

PubMed

Freis, David

2018-07-01

After his abdication in November 1918, the German emperor Wilhelm II continued to haunt the minds of his people. With the abolition of the lese-majesty laws in the new republic, many topics that were only discussed privately or obliquely before could now be broached openly. One of these topics was the mental state of the exiled Kaiser. Numerous psychiatrists, physicians and laypeople published their diagnoses of Wilhelm in high-circulation newspaper articles, pamphlets, and books shortly after the end of the war. Whether these diagnoses were accurate and whether the Kaiser really was mentally ill became the issue of a heated debate.This article situates these diagnoses of Wilhelm II in their political context. The authors of these diagnoses - none of whom had met or examined Wilhelm II in person - came from all political camps and they wrote with very different motives in mind. Diagnosing the exiled Kaiser as mentally ill was a kind of exorcism of the Hohenzollern rule, opening the way for either a socialist republic or the hoped-for rule of a new leader. But more importantly, it was a way to discuss and allocate political responsibility and culpability. Psychiatric diagnoses were used to exonerate both the Emperor (for whom the treaty of Versailles provided a tribunal as war criminal) and the German nation. They were also used to blame the Kaiser's entourage and groups that had allegedly manipulated the weak-willed monarch. Medical concepts became a vehicle for a debate on the key political questions in interwar Germany.

Antenatal Ultrasound and Risk of Autism Spectrum Disorders

ERIC Educational Resources Information Center

Grether, Judith K.; Li, Sherian Xu; Yoshida, Cathleen K.; Croen, Lisa A.

2010-01-01

We evaluated antenatal ultrasound (U/S) exposure as a risk factor for autism spectrum disorders (ASD), comparing affected singleton children and control children born 1995-1999 and enrolled in the Kaiser Permanente health care system. Among children with ASD (n = 362) and controls (n = 393), 13% had no antenatal exposure to U/S examinations;…

Developing a data infrastructure for a learning health system: the PORTAL network.

PubMed

McGlynn, Elizabeth A; Lieu, Tracy A; Durham, Mary L; Bauck, Alan; Laws, Reesa; Go, Alan S; Chen, Jersey; Feigelson, Heather Spencer; Corley, Douglas A; Young, Deborah Rohm; Nelson, Andrew F; Davidson, Arthur J; Morales, Leo S; Kahn, Michael G

2014-01-01

The Kaiser Permanente & Strategic Partners Patient Outcomes Research To Advance Learning (PORTAL) network engages four healthcare delivery systems (Kaiser Permanente, Group Health Cooperative, HealthPartners, and Denver Health) and their affiliated research centers to create a new national network infrastructure that builds on existing relationships among these institutions. PORTAL is enhancing its current capabilities by expanding the scope of the common data model, paying particular attention to incorporating patient-reported data more systematically, implementing new multi-site data governance procedures, and integrating the PCORnet PopMedNet platform across our research centers. PORTAL is partnering with clinical research and patient experts to create cohorts of patients with a common diagnosis (colorectal cancer), a rare diagnosis (adolescents and adults with severe congenital heart disease), and adults who are overweight or obese, including those with pre-diabetes or diabetes, to conduct large-scale observational comparative effectiveness research and pragmatic clinical trials across diverse clinical care settings. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Data That Drive: Closing the Loop in the Learning Hospital System

PubMed Central

Liu, Vincent X.; Morehouse, John W.; Baker, Jennifer M.; Greene, John D.; Kipnis, Patricia; Escobar, Gabriel J.

2017-01-01

The learning healthcare system describes a vision of US healthcare that capitalizes on science, information technology, incentives, and care culture to drive improvements in the quality of health care. The inpatient setting, one of the most costly and impactful domains of healthcare, is an ideal setting in which to use data and information technology to foster continuous learning and quality improvement. The rapid digitization of inpatient medicine offers incredible new opportunities to use data from routine care to generate new discovery and thus close the virtuous cycle of learning. We use an object lesson—sepsis care within the 21 hospitals of the Kaiser Permanente Northern California integrated healthcare delivery system—to offer insight into the critical elements necessary for developing a learning hospital system. We then describe how a hospital-wide data-driven approach to inpatient care can facilitate improvements in the quality of hospital care. PMID:27805797

Consider outsourcing IT projects when cutting-edge technology, specialized focus are needed.

PubMed

1999-05-01

Looking outside to meet information technology needs proves a smart way to avert extra staffing costs. Kaiser Permanente saves thousands each year by contracting out cutting-edge IT projects instead of hiring more full-time staff it doesn't need. Learn how the organization incorporates outsourcing and other temporary work methods into its IT staffing strategy.

Patient-reported racial/ethnic healthcare provider discrimination and medication intensification in the Diabetes Study of Northern California (DISTANCE).

PubMed

Lyles, Courtney R; Karter, Andrew J; Young, Bessie A; Spigner, Clarence; Grembowski, David; Schillinger, Dean; Adler, Nancy

2011-10-01

Racial/ethnic minority patients are more likely to report experiences with discrimination in the healthcare setting, potentially leading to reduced access to appropriate care; however, few studies evaluate reports of discrimination with objectively measured quality of care indicators. To evaluate whether patient-reported racial/ethnic discrimination by healthcare providers was associated with evidence of poorer quality care measured by medication intensification. Baseline data from the Diabetes Study of Northern California (DISTANCE), a random, race-stratified sample from the Kaiser Permanente Diabetes Registry from 2005-2006, including both survey and medical record data. Self-reported healthcare provider discrimination (from survey data) and medication intensification (from electronic prescription records) for poorly controlled diabetes patients (A1c ≥9.0%; systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg; low-density lipoprotein (LDL) ≥130 mg/dl). Of 10,409 eligible patients, 21% had hyperglycemia, 14% had hyperlipidemia, and 32% had hypertension. Of those with hyperglycemia, 59% had their medications intensified, along with 40% with hyperlipidemia, 33% with hypertension, and 47% in poor control of any risk factor. In adjusted log-binomial GEE models, discrimination was not associated with medication intensification [RR = 0.96 (95% CI: 0.74, 1.24) for hyperglycemia, RR = 1.23 (95% CI: 0.93, 1.63) for hyperlipidemia, RR = 1.06 (95% CI: 0.69, 1.61) for hypertension, and RR = 1.08 (95% CI: 0.88, 1.33) for the composite cohort]. We found no evidence that patient-reported healthcare discrimination was associated with less medication intensification. While not associated with this technical aspect of care, discrimination could still be associated with other aspects of care (e.g., patient-centeredness, communication).

Evaluation of a surveillance case definition for anogenital warts, Kaiser Permanente northwest.

PubMed

Naleway, Allison L; Weinmann, Sheila; Crane, Brad; Gee, Julianne; Markowitz, Lauri E; Dunne, Eileen F

2014-08-01

Most studies of anogenital wart (AGW) epidemiology have used large clinical or administrative databases and unconfirmed case definitions based on combinations of diagnosis and procedure codes. We developed and validated an AGW case definition using a combination of diagnosis codes and other information available in the electronic medical record (provider type, laboratory testing). We calculated the positive predictive value (PPV) of this case definition compared with manual medical record review in a random sample of 250 cases. Using this case definition, we calculated the annual age- and sex-stratified prevalence of AGW among individuals 11 through 30 years of age from 2000 through 2005. We identified 2730 individuals who met the case definition. The PPV of the case definition was 82%, and the average annual prevalence was 4.16 per 1000. Prevalence of AGW was higher in females compared with males in every age group, with the exception of the 27- to 30-year-olds. Among females, prevalence peaked in the 19- to 22-year-olds, and among males, the peak was observed in 23- to 26-year-olds. The case definition developed in this study is the first to be validated with medical record review and has a good PPV for the detection of AGW. The prevalence rates observed in this study were higher than other published rates, but the age- and sex-specific patterns observed were consistent with previous reports.

Health and loyalty promotion visits for new enrollees: results of a randomized controlled trial.

PubMed

Thompson, M; Gee, S; Larson, P; Kotz, K; Northrop, L

2001-01-01

Managed care needs effective and efficient ways to orient new members, enhance trust and loyalty, and offer prevention and self-care education and services. Recent adult enrollees of Kaiser Permanente (Northern California) were randomly assigned to one of three intervention conditions (n = 286) (individual visit with a physician, physician visit plus a visit with a health educator, a group visit of eight new members led by a physician and health educator) or a random control group (n = 278). Outcomes were gauged via pre- and post-visit questionnaires and a 20-min telephone survey at baseline and at a 6-month follow-up. Compared to controls, attendees of the three interventions had higher satisfaction, self-rated prevention knowledge, acceptance of health plan guidelines, and were more likely to plan to remain in the health plan. Group visit attendees stood out as experiencing the greatest benefits and were especially likely to report saving a telephone call or visit to their doctor by using a self-care handbook.

Interdisciplinary Guidelines for Care of Women Presenting to the Emergency Department With Pregnancy Loss.

PubMed

Catlin, Anita

In April 2016, the National Perinatal Association and Kaiser Permanente Northern California Nursing Research Community Benefits Grant sponsored an interdisciplinary summit to explore the needs of women who present with actual or potential pregnancy loss to the emergency department (ED). Thirty-two experts in the field of pregnancy loss, 17 of whom represented their professional organizations, participated. These experts, which included nurses, physicians, social workers, counselors, authors, and parents, worked together to create guidelines for care of women with a pregnancy loss in the ED. Recommendations for ED healthcare providers are included. Emergency department personnel agreed that improvements in care could be offered and were willing to endorse education for their staff. The guidelines delineate how to better provide physical, emotional, and bereavement support at any stage of gestational loss. Administrative support for policies in the ED is essential to ensure the delivery of family-centered, culturally sensitive practices when a pregnancy ends.

Air Pollution and Pulmonary Tuberculosis: A Nested Case-Control Study among Members of a Northern California Health Plan.

PubMed

Smith, Geneé S; Van Den Eeden, Stephen K; Garcia, Cynthia; Shan, Jun; Baxter, Roger; Herring, Amy H; Richardson, David B; Van Rie, Annelies; Emch, Michael; Gammon, Marilie D

2016-06-01

Ecologic analyses, case-case comparisons, and animal experiments suggest positive associations between air pollution and tuberculosis. We evaluated this hypothesis in a large sample, which yielded results that are applicable to the general population. We conducted a case-control study nested within a cohort of Kaiser Permanente of Northern California members. All active pulmonary tuberculosis (TB) cases newly diagnosed between 1996 and 2010 (n = 2,309) were matched to two controls (n = 4,604) by age, sex, and race/ethnicity on the index date corresponding with the case diagnosis date. Average individual-level concentrations of carbon monoxide (CO), nitrogen dioxide (NO2), sulfur dioxide (SO2), ozone (O3), and particulate matter with aerodynamic diameter ≤ 2.5 μm (PM2.5) and 10 μm (PM10) for 2 years before diagnosis/entry into the study were estimated using measurements from the California Air Resources Board monitor closest to the participant's residence. In single-pollutant adjusted conditional logistic regression models, the pulmonary TB odds ratios (95% confidence intervals) for the highest quintile (vs. lowest) were 1.50 (95% CI: 1.15, 1.95) for CO and 1.42 (95% CI: 1.10, 1.84) for NO2. Corresponding estimates were higher among never [1.68 (95% CI: 1.26, 2.24)] than ever [1.19 (95% CI: 0.74, 1.92)] smokers for CO. In contrast, for NO2, estimates were higher among ever [1.81 (95% CI: 1.13, 2.91)] than never [1.29 (95% CI: 0.97, 1.71)] smokers. O3 was inversely associated for smokers [0.66 (95% CI: 0.43, 1.02)] and never smokers [0.65 (95% CI: 0.52, 0.81)]. No other consistent patterns were observed. In this first, to our knowledge, U.S. nested case-control study on air pollution and pulmonary TB, we observed positive associations with ambient CO and NO2, which require confirmation. Smith GS, Van Den Eeden SK, Garcia C, Shan J, Baxter R, Herring AH, Richardson DB, Van Rie A, Emch M, Gammon MD. 2016. Air pollution and pulmonary tuberculosis: a nested case

The impact of telephonic wellness coaching on weight loss: A "Natural Experiments for Translation in Diabetes (NEXT-D)" study.

PubMed

Schmittdiel, Julie A; Adams, Sara R; Goler, Nancy; Sanna, Rashel S; Boccio, Mindy; Bellamy, David J; Brown, Susan D; Neugebauer, Romain S; Ferrara, Assiamira

2017-02-01

To evaluate the impact of a population-based telephonic wellness coaching program on weight loss. Individual-level segmented regression analysis of interrupted time series data comparing the BMI trajectories in the 12 months before versus the 12 months after initiating coaching among a cohort of Kaiser Permanente Northern California members (n = 954) participating in The Permanente Medical Group Wellness Coaching program in 2011. The control group was a 20:1 propensity-score matched control group (n = 19,080) matched with coaching participants based on baseline demographic and clinical characteristics. Wellness coaching participants had a significant upward trend in BMI in the 12 months before their first wellness coaching session and a significant downward trend in BMI in the 12 months after their first session equivalent to a clinically significant reduction of greater than one unit of baseline BMI (P < 0.01 for both). The control group did not have statistically significant decreases in BMI during the post-period. Wellness coaching has a positive impact on BMI reduction that is both statistically and clinically significant. Future research and quality improvement efforts should focus on disseminating wellness coaching for weight loss in patients with diabetes and those at risk for developing the disease. © 2017 The Authors. Obesity published by Wiley Periodicals, Inc. on behalf of The Obesity Society (TOS).

Using a High-Performance Planning Model to Increase Levels of Functional Effectiveness Within Professional Development.

PubMed

Winter, Peggi

2016-01-01

Nursing professional practice models continue to shape how we practice nursing by putting families and members at the heart of everything we do. Faced with enormous challenges around healthcare reform, models create frameworks for practice by unifying, uniting, and guiding our nurses. The Kaiser Permanente Practice model was developed to ensure consistency for nursing practice across the continuum. Four key pillars support this practice model and the work of nursing: quality and safety, leadership, professional development, and research/evidence-based practice. These four pillars form the foundation that makes transformational practice possible and aligns nursing with Kaiser Permanente's mission. The purpose of this article is to discuss the pillar of professional development and the components of the Nursing Professional Development: Scope and Standards of Practice model (American Nurses Association & National Nursing Staff Development Organization, 2010) and place them in a five-level development framework. This process allowed us to identify the current organizational level of practice, prioritize each nursing professional development component, and design an operational strategy to move nursing professional development toward a level of high performance. This process is suggested for nursing professional development specialists.

Physician-Owned Surgical Hospitals Outperform Other Hospitals in Medicare Value-Based Purchasing Program.

PubMed

Ramirez, Adriana G; Tracci, Margaret C; Stukenborg, George J; Turrentine, Florence E; Kozower, Benjamin D; Jones, R Scott

2016-10-01

The Hospital Value-Based Purchasing Program measures value of care provided by participating Medicare hospitals and creates financial incentives for quality improvement and fosters increased transparency. Limited information is available comparing hospital performance across health care business models. The 2015 Hospital Value-Based Purchasing Program results were used to examine hospital performance by business model. General linear modeling assessed differences in mean total performance score, hospital case mix index, and differences after adjustment for differences in hospital case mix index. Of 3,089 hospitals with total performance scores, categories of representative health care business models included 104 physician-owned surgical hospitals, 111 University HealthSystem Consortium, 14 US News & World Report Honor Roll hospitals, 33 Kaiser Permanente, and 124 Pioneer accountable care organization affiliated hospitals. Estimated mean total performance scores for physician-owned surgical hospitals (64.4; 95% CI, 61.83-66.38) and Kaiser Permanente (60.79; 95% CI, 56.56-65.03) were significantly higher compared with all remaining hospitals, and University HealthSystem Consortium members (36.8; 95% CI, 34.51-39.17) performed below the mean (p < 0.0001). Significant differences in mean hospital case mix index included physician-owned surgical hospitals (mean 2.32; p < 0.0001), US News & World Report honorees (mean 2.24; p = 0.0140), and University HealthSystem Consortium members (mean 1.99; p < 0.0001), and Kaiser Permanente hospitals had lower case mix value (mean 1.54; p < 0.0001). Re-estimation of total performance scores did not change the original results after adjustment for differences in hospital case mix index. The Hospital Value-Based Purchasing Program revealed superior hospital performance associated with business model. Closer inspection of high-value hospitals can guide value improvement and policy-making decisions for all Medicare Value

Prevention of Vertical Transmission of Hepatitis B: An Observation Study

PubMed Central

Kubo, Ai; Shlager, Lyle; Marks, Amy R.; Lakritz, Dena; Beaumont, Colette; Gabellini, Kim; Corley, Douglas A.

2014-01-01

Background For mothers with chronic hepatitis B virus (HBV) infection, the US Centers for Disease Control recommend immunoprophylaxis to decrease perinatal transmission; however, its effectiveness and risk factors for failure have not been well studied in community practice. Objective To investigate the effectiveness of a contemporary immunoprophylaxis protocol. Design Observational study. Setting HBV perinatal immunoprophylaxis program within Kaiser Permanente Northern California, an integrated health services delivery organization. Patients 4,446 infants born to 3,253 HBV positive mothers, between 1997-2010. Measurements Compliance with immunoprophylaxis, follow-up testing rates, maternal risk factors for HBV transmission and transmission rates. Results The infant infection rate was 0.75 per 100 births for 1997-2010 (Poisson 95% confidence interval (CI): 0.48-1.10)]. Rates were 3.37 per 100 (95% CI 2.08-5.14) for e-antigen positive mothers; and 0.04 (95% CI 0.001-0.24) for e-antigen negative mothers. Among mothers with viral load testing, the lowest level associated with transmission was 63,200,000 IU/ml. Infection rates per 100 were 3.61 (95% CI 0.75-10.56) among the 83 births to mothers with viral loads ≥50,000,000 IU/mL and 0.00 among the 831 births to mothers with viral loads <50,000,000 IU/mL, regardless of e-antigen status. Limitations Testing for HBV immunity and infection was somewhat less complete in earlier years. Viral load testing was only consistently available starting in 2007. Conclusion Pre-natal HBV screening followed by post-natal prophylaxis is highly effective in preventing vertical transmission of HBV. A negative e-antigen status or a viral load of <50,000,000 IU/mL (90.9% of women tested) identifies women at extremely low risk of transmission after immunoprophylaxis who are unlikely to benefit from further interventions. Primary Funding Source Kaiser Permanente Community Benefit Grant (CN-09LShla-01-H); National Institute of Health (K07CA

Cohort profile: Study of Transition, Outcomes and Gender (STRONG) to assess health status of transgender people.

PubMed

Quinn, Virginia P; Nash, Rebecca; Hunkeler, Enid; Contreras, Richard; Cromwell, Lee; Becerra-Culqui, Tracy A; Getahun, Darios; Giammattei, Shawn; Lash, Timothy L; Millman, Andrea; Robinson, Brandi; Roblin, Douglas; Silverberg, Michael J; Slovis, Jennifer; Tangpricha, Vin; Tolsma, Dennis; Valentine, Cadence; Ward, Kevin; Winter, Savannah; Goodman, Michael

2017-12-27

The Study of Transition, Outcomes and Gender (STRONG) was initiated to assess the health status of transgender people in general and following gender-affirming treatments at Kaiser Permanente health plans in Georgia, Northern California and Southern California. The objectives of this communication are to describe methods of cohort ascertainment and data collection and to characterise the study population. A stepwise methodology involving computerised searches of electronic medical records and free-text validation of eligibility and gender identity was used to identify a cohort of 6456 members with first evidence of transgender status (index date) between 2006 and 2014. The cohort included 3475 (54%) transfeminine (TF), 2892 (45%) transmasculine (TM) and 89 (1%) members whose natal sex and gender identity remained undetermined from the records. The cohort was matched to 127 608 enrollees with no transgender evidence (63 825 women and 63 783 men) on year of birth, race/ethnicity, study site and membership year of the index date. Cohort follow-up extends through the end of 2016. About 58% of TF and 52% of TM cohort members received hormonal therapy at Kaiser Permanente. Chest surgery was more common among TM participants (12% vs 0.3%). The proportions of transgender participants who underwent genital reconstruction surgeries were similar (4%-5%) in the two transgender groups. Results indicate that there are sufficient numbers of events in the TF and TM cohorts to further examine mental health status, cardiovascular events, diabetes, HIV and most common cancers. STRONG is well positioned to fill existing knowledge gaps through comparisons of transgender and reference populations and through analyses of health status before and after gender affirmation treatment. Analyses will include incidence of cardiovascular disease, mental health, HIV and diabetes, as well as changes in laboratory-based endpoints (eg, polycythemia and bone density), overall and in relation to

Cohort profile: Study of Transition, Outcomes and Gender (STRONG) to assess health status of transgender people

PubMed Central

Quinn, Virginia P; Nash, Rebecca; Hunkeler, Enid; Contreras, Richard; Cromwell, Lee; Becerra-Culqui, Tracy A; Getahun, Darios; Giammattei, Shawn; Lash, Timothy L; Millman, Andrea; Robinson, Brandi; Roblin, Douglas; Silverberg, Michael J; Slovis, Jennifer; Tangpricha, Vin; Tolsma, Dennis; Valentine, Cadence; Ward, Kevin; Winter, Savannah; Goodman, Michael

2017-01-01

Purpose The Study of Transition, Outcomes and Gender (STRONG) was initiated to assess the health status of transgender people in general and following gender-affirming treatments at Kaiser Permanente health plans in Georgia, Northern California and Southern California. The objectives of this communication are to describe methods of cohort ascertainment and data collection and to characterise the study population. Participants A stepwise methodology involving computerised searches of electronic medical records and free-text validation of eligibility and gender identity was used to identify a cohort of 6456 members with first evidence of transgender status (index date) between 2006 and 2014. The cohort included 3475 (54%) transfeminine (TF), 2892 (45%) transmasculine (TM) and 89 (1%) members whose natal sex and gender identity remained undetermined from the records. The cohort was matched to 127 608 enrollees with no transgender evidence (63 825 women and 63 783 men) on year of birth, race/ethnicity, study site and membership year of the index date. Cohort follow-up extends through the end of 2016. Findings to date About 58% of TF and 52% of TM cohort members received hormonal therapy at Kaiser Permanente. Chest surgery was more common among TM participants (12% vs 0.3%). The proportions of transgender participants who underwent genital reconstruction surgeries were similar (4%–5%) in the two transgender groups. Results indicate that there are sufficient numbers of events in the TF and TM cohorts to further examine mental health status, cardiovascular events, diabetes, HIV and most common cancers. Future plans STRONG is well positioned to fill existing knowledge gaps through comparisons of transgender and reference populations and through analyses of health status before and after gender affirmation treatment. Analyses will include incidence of cardiovascular disease, mental health, HIV and diabetes, as well as changes in laboratory-based endpoints (eg

The Kaiser Permanente shoulder arthroplasty registry: results from 6,336 primary shoulder arthroplasties.

PubMed

Dillon, Mark T; Ake, Christopher F; Burke, Mary F; Singh, Anshuman; Yian, Edward H; Paxton, Elizabeth W; Navarro, Ronald A

2015-06-01

Shoulder arthroplasty is being performed in the United States with increasing frequency. We describe the medium-term findings from a large integrated healthcare system shoulder arthroplasty registry. Shoulder arthroplasty cases registered between January 2005 and June 2013 were included for analysis. The registry included patient characteristics, surgical information, implant data, attrition, and patient outcomes such as surgical site infections, venous thromboembolism, and revision procedures. During the study period, 6,336 primary cases were registered. Median follow-up time for all primaries was 3.3 years; 461 cases were lost to follow-up by ending of health plan membership. Primary cases were predominantly female (56%) and white (81%), with an average age of 70 years. The most common reason for surgery was osteoarthritis in 60% of cases, followed by acute fracture (17%) and rotator cuff tear arthropathy (15%). In elective shoulder arthroplasty procedures, 200 all-cause revisions (4%) were reported, with glenoid wear being the most common reason. Most arthroplasties were elective procedures: over half performed for osteoarthritis. Glenoid wear was the most common reason for revision of primary shoulder arthroplasty in elective cases.

Marijuana use and mortality.

PubMed Central

Sidney, S; Beck, J E; Tekawa, I S; Quesenberry, C P; Friedman, G D

1997-01-01

OBJECTIVES: The purpose of this study was to examine the relationship of marijuana use to mortality. METHODS: The study population comprised 65171 Kaiser Permanente Medical Care Program enrollees, aged 15 through 49 years, who completed questionnaires about smoking habits, including marijuana use, between 1979 and 1985. Mortality follow-up was conducted through 1991. RESULTS: Compared with nonuse or experimentation (lifetime use six or fewer times), current marijuana use was not associated with a significantly increased risk of non-acquired immunodeficiency syndrome (AIDS) mortality in men (relative risk [RR] = 1.12, 95% confidence interval [CI] = 0.89, 1.39) or of total mortality in women (RR = 1.09, 95% CI = 0.80, 1.48). Current marijuana use was associated with increased risk of AIDS mortality in men (RR = 1.90, 95% CI = 1.33, 2.73), an association that probably was not causal but most likely represented uncontrolled confounding by male homosexual behavior. This interpretation was supported by the lack of association of marijuana use with AIDS mortality in men from a Kaiser Permanente AIDS database. Relative risks for ever use of marijuana were similar. CONCLUSIONS: Marijuana use in a prepaid health care-based study cohort had little effect on non-AIDS mortality in men and on total mortality in women. PMID:9146436

Air Pollution and Pulmonary Tuberculosis: A Nested Case–Control Study among Members of a Northern California Health Plan

PubMed Central

Smith, Geneé S.; Van Den Eeden, Stephen K.; Garcia, Cynthia; Shan, Jun; Baxter, Roger; Herring, Amy H.; Richardson, David B.; Van Rie, Annelies; Emch, Michael; Gammon, Marilie D.

2016-01-01

Background: Ecologic analyses, case–case comparisons, and animal experiments suggest positive associations between air pollution and tuberculosis. Objectives: We evaluated this hypothesis in a large sample, which yielded results that are applicable to the general population. Methods: We conducted a case–control study nested within a cohort of Kaiser Permanente of Northern California members. All active pulmonary tuberculosis (TB) cases newly diagnosed between 1996 and 2010 (n = 2,309) were matched to two controls (n = 4,604) by age, sex, and race/ethnicity on the index date corresponding with the case diagnosis date. Average individual-level concentrations of carbon monoxide (CO), nitrogen dioxide (NO2), sulfur dioxide (SO2), ozone (O3), and particulate matter with aerodynamic diameter ≤ 2.5 μm (PM2.5) and 10 μm (PM10) for 2 years before diagnosis/entry into the study were estimated using measurements from the California Air Resources Board monitor closest to the participant’s residence. Results: In single-pollutant adjusted conditional logistic regression models, the pulmonary TB odds ratios (95% confidence intervals) for the highest quintile (vs. lowest) were 1.50 (95% CI: 1.15, 1.95) for CO and 1.42 (95% CI: 1.10, 1.84) for NO2. Corresponding estimates were higher among never [1.68 (95% CI: 1.26, 2.24)] than ever [1.19 (95% CI: 0.74, 1.92)] smokers for CO. In contrast, for NO2, estimates were higher among ever [1.81 (95% CI: 1.13, 2.91)] than never [1.29 (95% CI: 0.97, 1.71)] smokers. O3 was inversely associated for smokers [0.66 (95% CI: 0.43, 1.02)] and never smokers [0.65 (95% CI: 0.52, 0.81)]. No other consistent patterns were observed. Conclusions: In this first, to our knowledge, U.S. nested case–control study on air pollution and pulmonary TB, we observed positive associations with ambient CO and NO2, which require confirmation. Citation: Smith GS, Van Den Eeden SK, Garcia C, Shan J, Baxter R, Herring AH, Richardson DB, Van Rie A, Emch M

Is a reduction in distance to nearest supermarket associated with BMI change among type 2 diabetes patients?

PubMed Central

Zhang, Y. Tara; Laraia, Barbara A.; Mujahid, Mahasin S.; Blanchard, Samuel D.; Warton, E. Margaret; Moffet, Howard H.; Karter, Andrew J.

2016-01-01

We examined whether residing within 2 miles of a new supermarket opening was longitudinally associated with a change in body mass index (BMI). We identified 12 new supermarkets that opened between 2009–2010 in 8 neighborhoods. Using the Kaiser Permanente Northern California Diabetes Registry, we identified members with type 2 diabetes residing continuously in any of these neighborhoods 12 months prior to the first supermarket opening until 10 months following the opening of the last supermarket. Exposure was defined as a reduction (yes/no) in travel distance to the nearest supermarket as a result of a new supermarket opening. First difference regression models were used to estimate the impact of reduced supermarket distance on BMI, adjusting for longitudinal changes in patient and neighborhood characteristics. Among patients in the exposed group, new supermarket openings reduced travel distance to the nearest supermarket by 0.7 miles on average. However, reduced distance to nearest supermarket was not associated with BMI changes. Overall, we found no evidence that reduced supermarket distance was associated with reduced levels of obesity for residents with type 2 diabetes. PMID:27160530

Data that drive: Closing the loop in the learning hospital system.

PubMed

Liu, Vincent X; Morehouse, John W; Baker, Jennifer M; Greene, John D; Kipnis, Patricia; Escobar, Gabriel J

2016-11-01

The learning healthcare system describes a vision of US healthcare that capitalizes on science, information technology, incentives, and care culture to drive improvements in the quality of health care. The inpatient setting, one of the most costly and impactful domains of healthcare, is an ideal setting in which to use data and information technology to foster continuous learning and quality improvement. The rapid digitization of inpatient medicine offers incredible new opportunities to use data from routine care to generate new discovery and thus close the virtuous cycle of learning. We use an object lesson-sepsis care within the 21 hospitals of the Kaiser Permanente Northern California integrated healthcare delivery system-to offer insight into the critical elements necessary for developing a learning hospital system. We then describe how a hospital-wide data-driven approach to inpatient care can facilitate improvements in the quality of hospital care. Journal of Hospital Medicine 2016;11:S11-S17. © 2016 Society of Hospital Medicine. © 2016 Society of Hospital Medicine.

Social organization of self-management support of persons with diabetes: a health systems comparison.

PubMed

Schiøtz, Michaela; Frølich, Anne; Krasnik, Allan; Taylor, Warren; Hsu, John

2012-09-01

Identify important organizational elements for providing self-management support (SMS). Semi-structured qualitative interviews conducted in two healthcare systems. Kaiser Permanente Northern California and the Danish Health Care System. 36 managers and healthcare professionals in the two healthcare systems. Elements important to providing self-management support to persons with diabetes. Healthcare professionals' provision of SMS was influenced by healthcare system organization and their perceptions of SMS, the capability and responsibility of healthcare systems, and their roles in the healthcare organization. Enabling factors for providing SMS included: strong leadership; aligned incentives; use of an integrated health information technology (HIT) system; multidisciplinary healthcare provider teams; ongoing training for healthcare professionals; outreach; and quality goals. Barriers to providing SMS included lack of collaboration between providers and skeptical attitudes towards prevention and outreach. Implementation of SMS can be improved by an understanding of the elements that enhance its provision: (1) initiatives seeking to improve collaboration and integration between providers; (2) implementation of an integrated HIT system; and (3) ongoing training of healthcare professionals.

Application of the Teager-Kaiser energy operator in bearing fault diagnosis.

PubMed

Henríquez Rodríguez, Patricia; Alonso, Jesús B; Ferrer, Miguel A; Travieso, Carlos M

2013-03-01

Condition monitoring of rotating machines is important in the prevention of failures. As most machine malfunctions are related to bearing failures, several bearing diagnosis techniques have been developed. Some of them feature the bearing vibration signal with statistical measures and others extract the bearing fault characteristic frequency from the AM component of the vibration signal. In this paper, we propose to transform the vibration signal to the Teager-Kaiser domain and feature it with statistical and energy-based measures. A bearing database with normal and faulty bearings is used. The diagnosis is performed with two classifiers: a neural network classifier and a LS-SVM classifier. Experiments show that the Teager domain features outperform those based on the temporal or AM signal. Copyright © 2012 ISA. Published by Elsevier Ltd. All rights reserved.

Genetics as a modernization program: biological research at the Kaiser Wilhelm Institutes and the political economy of the Nazi State.

PubMed

Gausemeier, Bernd

2010-01-01

During the Third Reich, the biological institutes of the Kaiser Wilhelm Society (KWG, Kaiser-Wilhelm-Gesellschaft) underwent a substantial reorganization and modernization. This paper discusses the development of projects in the fields of biochemical genetics, virus research, radiation genetics, and plant genetics that were initiated in those years. These cases exemplify, on the one hand, the political conditions for biological research in the Nazi state. They highlight how leading scientists advanced their projects by building close ties with politicians and science-funding organizations and companies. On the other hand, the study examines how the contents of research were shaped by, and how they contributed to, the aims and needs of the political economy of the Nazi system. This paper therefore aims not only to highlight basic aspects of scientific development under Nazism, but also to provide general insights into the structure of the Third Reich and the dynamics of its war economy.

Association between personal health record enrollment and patient loyalty.

PubMed

Turley, Marianne; Garrido, Terhilda; Lowenthal, Alex; Zhou, Yi Yvonne

2012-07-01

To examine the association between patient loyalty, as measured by member retention in the health plan, and access to My Health Manager (MHM), Kaiser Permanente's PHR, which is linked to its electronic health record, KP HealthConnect. We conducted a retrospective cohort observational quality improvement project from the third quarter of 2005 to the fourth quarter of 2008 for approximately 394,000 Kaiser Permanente Northwest members. To control for self-selection bias, we used propensity scores to perform exact 1-to-1 matching without replacement between MHM users and nonusers. We estimated retention rates of the matched data and assessed the association between MHM use and retention versus voluntary termination. We also estimated odds ratios of significant variables impacting member retention. The probability of remaining a member or being involuntarily terminated versus voluntary termination was 96.7% for users (95% confidence interval [CI], 96.6%-96.7%) and 92.2% for nonusers (95% CI, 92.1%-92.4%; P <.001). In the logistic model, MHM use was a significant predictor; only tenure and illness burden were stronger predictors. Users were 2.578 (95% CI, 2.487%-2.671%) times more likely to choose to remain members than were nonusers. The impact was more substantial among newer members. MHM use was significantly associated with voluntary membership retention. An indicator of patient loyalty, retention is critical to healthcare organizations.

Specialty pharmaceuticals care management in an integrated health care delivery system with electronic health records.

PubMed

Monroe, C Douglas; Chin, Karen Y

2013-05-01

The specialty pharmaceuticals market is expanding more rapidly than the traditional pharmaceuticals market. Specialty pharmacy operations have evolved to deliver selected medications and associated clinical services. The growing role of specialty drugs requires new approaches to managing the use of these drugs. The focus, expectations, and emphasis in specialty drug management in an integrated health care delivery system such as Kaiser Permanente (KP) can vary as compared with more conventional health care systems. The KP Specialty Pharmacy (KP-SP) serves KP members across the United States. This descriptive account addresses the impetus for specialty drug management within KP, the use of tools such as an electronic health record (EHR) system and process management software, the KP-SP approach for specialty pharmacy services, and the emphasis on quality measurement of services provided. Kaiser Permanente's integrated system enables KP-SP pharmacists to coordinate the provision of specialty drugs while monitoring laboratory values, physician visits, and most other relevant elements of the patient's therapy. Process management software facilitates the counseling of patients, promotion of adherence, and interventions to resolve clinical, logistic, or pharmacy benefit issues. The integrated EHR affords KP-SP pharmacists advantages for care management that should become available to more health care systems with broadened adoption of EHRs. The KP-SP experience may help to establish models for clinical pharmacy services as health care systems and information systems become more integrated.

Comparison of paper and electronic surveys for measuring patient-reported outcomes after anterior cruciate ligament reconstruction.

PubMed

Bojcic, Jamie L; Sue, Valerie M; Huon, Tomy S; Maletis, Gregory B; Inacio, Maria C S

2014-01-01

This study compared response rates of paper and electronic versions of the Knee injury Osteoarthritis and Outcome Score questionnaire and examined the characteristics of patients who responded to each survey method. A total of 1486 patients registered by the Kaiser Permanente Anterior Cruciate Ligament Reconstruction Registry between 2005 and 2010 were included in this study. Response rates by survey modality for the overall cohort, by the specific time periods, and by age and sex at time of anterior cruciate ligament reconstruction were compared using χ(2) tests or the Fisher exact test when appropriate. Independent Student t tests were used to compare the Knee injury Osteoarthritis and Outcome Scores of survey respondents. The overall survey response rate was 42%. The 36% response rate in the electronic-survey group was significantly higher than the 22% response rate in the paper-survey group (p < 0.001). The electronic response rate was also significantly higher than the paper response rate at all follow-up times (35% vs 25% at 1 year, p = 0.004, 38% vs 20% at 2 years, p < 0.001, and 35% vs 21% at 3 years; p < 0.001) and among all age groups 19 years and older. Although the electronic survey produced higher response rates, it is not sufficient alone to replace the traditional paper version among this Kaiser Permanente population.

Using Population Dose to Evaluate Community-level Health Initiatives.

PubMed

Harner, Lisa T; Kuo, Elena S; Cheadle, Allen; Rauzon, Suzanne; Schwartz, Pamela M; Parnell, Barbara; Kelly, Cheryl; Solomon, Loel

2018-05-01

Successful community-level health initiatives require implementing an effective portfolio of strategies and understanding their impact on population health. These factors are complicated by the heterogeneity of overlapping multicomponent strategies and availability of population-level data that align with the initiatives. To address these complexities, the population dose methodology was developed for planning and evaluating multicomponent community initiatives. Building on the population dose methodology previously developed, this paper operationalizes dose estimates of one initiative targeting youth physical activity as part of the Kaiser Permanente Community Health Initiative, a multicomponent community-level obesity prevention initiative. The technical details needed to operationalize the population dose method are explained, and the use of population dose as an interim proxy for population-level survey data is introduced. The alignment of the estimated impact from strategy-level data analysis using the dose methodology and the data from the population-level survey suggest that dose is useful for conducting real-time evaluation of multiple heterogeneous strategies, and as a viable proxy for existing population-level surveys when robust strategy-level evaluation data are collected. This article is part of a supplement entitled Building Thriving Communities Through Comprehensive Community Health Initiatives, which is sponsored by Kaiser Permanente, Community Health. Copyright © 2018 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.

Physician-owned Surgical Hospitals Outperform Other Hospitals in the Medicare Value-based Purchasing Program

PubMed Central

Ramirez, Adriana G; Tracci, Margaret C; Stukenborg, George J; Turrentine, Florence E; Kozower, Benjamin D; Jones, R Scott

2016-01-01

Background The Hospital Value-Based Purchasing Program measures value of care provided by participating Medicare hospitals while creating financial incentives for quality improvement and fostering increased transparency. Limited information is available comparing hospital performance across healthcare business models. Study Design 2015 hospital Value-Based Purchasing Program results were used to examine hospital performance by business model. General linear modeling assessed differences in mean total performance score, hospital case mix index, and differences after adjustment for differences in hospital case mix index. Results Of 3089 hospitals with Total Performance Scores (TPS), categories of representative healthcare business models included 104 Physician-owned Surgical Hospitals (POSH), 111 University HealthSystem Consortium (UHC), 14 US News & World Report Honor Roll (USNWR) Hospitals, 33 Kaiser Permanente, and 124 Pioneer Accountable Care Organization affiliated hospitals. Estimated mean TPS for POSH (64.4, 95% CI 61.83, 66.38) and Kaiser (60.79, 95% CI 56.56, 65.03) were significantly higher compared to all remaining hospitals while UHC members (36.8, 95% CI 34.51, 39.17) performed below the mean (p < 0.0001). Significant differences in mean hospital case mix index included POSH (mean 2.32, p<0.0001), USNWR honorees (mean 2.24, p 0.0140) and UHC members (mean =1.99, p<0.0001) while Kaiser Permanente hospitals had lower case mix value (mean =1.54, p<0.0001). Re-estimation of TPS did not change the original results after adjustment for differences in hospital case mix index. Conclusions The Hospital Value-Based Purchasing Program revealed superior hospital performance associated with business model. Closer inspection of high-value hospitals may guide value improvement and policy-making decisions for all Medicare Value-Based Purchasing Program Hospitals. PMID:27502368

[The Internet and shared decision-making between patients and healthcare providers].

PubMed

Silber, Denise

2009-10-01

Insurance companies like Kaiser Permanente in the United States remunerate physicians for their email correspondence with patients, increasing the efficiency of office visits. A survey by the French National Board of Physicians regarding the computerization of medical practices in April 2009, confirms that both physicians and patients in France are very favorable to the development of these tools. When patients can manage and/or access their medical files and determine which providers can access them, they become a true partner.

Caring Science: Transforming the Ethic of Caring-Healing Practice, Environment, and Culture within an Integrated Care Delivery System.

PubMed

Foss Durant, Anne; McDermott, Shawna; Kinney, Gwendolyn; Triner, Trudy

2015-01-01

In early 2010, leaders within Kaiser Permanente (KP) Northern California's Patient Care Services division embarked on a journey to embrace and embed core tenets of Caring Science into the practice, environment, and culture of the organization. Caring Science is based on the philosophy of Human Caring, a theory articulated by Jean Watson, PhD, RN, AHN-BC, FAAN, as a foundational covenant to guide nursing as a discipline and a profession. Since 2010, Caring Science has enabled KP Northern California to demonstrate its commitment to being an authentic person- and family-centric organization that promotes and advocates for total health. This commitment empowers KP caregivers to balance the art and science of clinical judgment by considering the needs of the whole person, honoring the unique perception of health and healing that each member or patient holds, and engaging with them to make decisions that nurture their well-being. The intent of this article is two-fold: 1) to provide context and background on how a professional practice framework was used to transform the ethic of caring-healing practice, environment, and culture across multiple hospitals within an integrated delivery system; and 2) to provide evidence on how integration of Caring Science across administrative, operational, and clinical areas appears to contribute to meaningful patient quality and health outcomes.

Caring Science: Transforming the Ethic of Caring-Healing Practice, Environment, and Culture within an Integrated Care Delivery System

PubMed Central

Durant, Anne Foss; McDermott, Shawna; Kinney, Gwendolyn; Triner, Trudy

2015-01-01

In early 2010, leaders within Kaiser Permanente (KP) Northern California’s Patient Care Services division embarked on a journey to embrace and embed core tenets of Caring Science into the practice, environment, and culture of the organization. Caring Science is based on the philosophy of Human Caring, a theory articulated by Jean Watson, PhD, RN, AHN-BC, FAAN, as a foundational covenant to guide nursing as a discipline and a profession. Since 2010, Caring Science has enabled KP Northern California to demonstrate its commitment to being an authentic person- and family-centric organization that promotes and advocates for total health. This commitment empowers KP caregivers to balance the art and science of clinical judgment by considering the needs of the whole person, honoring the unique perception of health and healing that each member or patient holds, and engaging with them to make decisions that nurture their well-being. The intent of this article is two-fold: 1) to provide context and background on how a professional practice framework was used to transform the ethic of caring-healing practice, environment, and culture across multiple hospitals within an integrated delivery system; and 2) to provide evidence on how integration of Caring Science across administrative, operational, and clinical areas appears to contribute to meaningful patient quality and health outcomes. PMID:26828076

Provider Factors and Patient-Reported Healthcare Discrimination in the Diabetes Study of California (DISTANCE)

PubMed Central

Lyles, Courtney R.; Karter, Andrew J.; Young, Bessie A.; Spigner, Clarence; Grembowski, David; Schillinger, Dean; Adler, Nancy

2011-01-01

Objective We examined provider-level factors and reported discrimination in the healthcare setting. Methods With data from the Diabetes Study of Northern California (DISTANCE)—a race-stratified survey of diabetes patients in Kaiser Permanente Northern California—we analyzed patient-reported racial/ethnic discrimination from providers. Primary exposures were characteristics of the primary care provider (PCP, who coordinates care in this system), including specialty/type, and patient-provider relationship variables including racial concordance. Results Subjects (n=12,151) included 20% black, 20% Latino, 23% Asian, 30% white, and 6% other patients, with 2% to 8% reporting discrimination by racial/ethnic group. Patients seeing nurse practitioners as their PCP (OR=0.09; 95% CI: 0.01–0.67), those rating their provider higher on communication (OR=0.70; 95% CI: 0.66–0.74) were less likely to report discrimination, while those with more visits (OR=1.10; 95% CI: 1.03–1.18) were more likely to report discrimination. Racial concordance was not significant once adjusting for patient race/ethnicity. Conclusions Among diverse diabetes patients in managed care, provider type and communication were significantly related to patient-reported discrimination. Practice Implications Given potential negative impacts on patient satisfaction and treatment decisions, future studies should investigate which interpersonal aspects of the provider-patient relationship reduce patient perceptions of unfair treatment. PMID:21605956

Resistance Tests of a 1/16 Size Model of the Hughes-kaiser Flying Boat, NACA Model 183

NASA Technical Reports Server (NTRS)

Posner, Jack; Woodward, David R.; Olson, Roland E.

1944-01-01

Tank tests were made of a hull model of the Hughes-Kaiser cargo airplane for estimates of take-off performance and maximum gross load for take-off. At hump speeds, with the model free to trim, the trim and resistance were high, which resulted in a load-resistance ratio of approximately 4.0 for a gross load coefficient of 0.75. With a 4000,000-lb load, the full size craft may take off in 69 sec over a distance of 5600 ft.

Type C investigation of electrical fabrication projects in ICF Kaiser shops

DOE Office of Scientific and Technical Information (OSTI.GOV)

Huckfeldt, R.A.

1995-06-01

A Type C Investigation Board was convened to investigate an electrical miswiring problem found during the operation of the electrical distribution trailer for the TWRS Rotary Mode Core Sampling Truck {number_sign}2. The trailer was designed by WHC and fabricated ICF KH on site for use in the Characterization Program. This problem resulted in a serious safety hazard since the support truck frame/chassis became electrically energized. This final report provides results of the ``Type C Investigation, Electrical Fabrication Projects in ICF KH Shops, June, 1995.`` It contains the investigation scope, executive summary, relevant facts, analysis, conclusions and corrective actions. DOE Ordermore » 5484.1, ``Environmental Protection, Safety and Health Protection Information Reporting Requirements,`` was followed in preparation of this report. Because the incident was electrical in nature and involved both Westinghouse Hanford Company and ICF Kaiser Hanford organizations, the board included members from both contractors and members with considerable electrical expertise.« less

Kaiser and Felicity effects and their application for evaluation of concrete by acoustic emission method

DOE Office of Scientific and Technical Information (OSTI.GOV)

Nesvijski, E.; Nesvijski, T.

1996-12-31

Concrete as one of the main construction materials, which is used for building of industrial and civil structures, highways, bridges, etc. requires periodical evaluation of its properties by different nondestructive methods. Application of acoustic emission (AE) for these purposes occupies a modest place among other nondestructive methods. But the AE methods proved to be very effective for testing of concrete and reinforced concrete elements and structures under load. This work is devoted to an important, from methodological point of view, problem connected with two opposite effects: of Kaiser and of Felicity, and their application for evaluation of concrete by themore » AE method.« less

Rapid spread of complex change: a case study in inpatient palliative care.

PubMed

Della Penna, Richard; Martel, Helene; Neuwirth, Esther B; Rice, Jennifer; Filipski, Marta I; Green, Jennifer; Bellows, Jim

2009-12-29

Based on positive findings from a randomized controlled trial, Kaiser Permanente's national executive leadership group set an expectation that all Kaiser Permanente and partner hospitals would implement a consultative model of interdisciplinary, inpatient-based palliative care (IPC). Within one year, the number of IPC consultations program-wide increased almost tenfold from baseline, and the number of teams nearly doubled. We report here results from a qualitative evaluation of the IPC initiative after a year of implementation; our purpose was to understand factors supporting or impeding the rapid and consistent spread of a complex program. Quality improvement study using a case study design and qualitative analysis of in-depth semi-structured interviews with 36 national, regional, and local leaders. Compelling evidence of impacts on patient satisfaction and quality of care generated 'pull' among adopters, expressed as a remarkably high degree of conviction about the value of the model. Broad leadership agreement gave rise to sponsorship and support that permeated the organization. A robust social network promoted knowledge exchange and built on an existing network with a strong interest in palliative care. Resource constraints, pre-existing programs of a different model, and ambiguous accountability for implementation impeded spread. A complex, hospital-based, interdisciplinary intervention in a large health care organization spread rapidly due to a synergy between organizational 'push' strategies and grassroots-level pull. The combination of push and pull may be especially important when the organizational context or the practice to be spread is complex.

Effect of direct physician involvement on tobacco abstinence rates and other variables affecting participants of a freedom from tobacco class.

PubMed

Ismail, Mohamed H; Ho, Ngoc J; Lara, Nancy Irazu

2013-01-01

Kaiser Permanente measures how often tobacco users are offered strategies to quit but not the success of such strategies. To compare tobacco abstinence rates for participants of the Kaiser Permanente Riverside (California) Medical Center's Freedom from Tobacco Class in 2008, before direct physician involvement, and in 2009, after direct physician involvement, and to compare other variables affecting these rates. In a retrospective study, participants were divided into two groups based on year of participation. Data were collected using electronic medical records and phone interviews. Tobacco use status between both groups at 1, 3, 6, and 12 months after the classes started and within groups by sex, number of classes attended, medication received, and class teacher. The 12-month abstinence rates were 27% in 2008 and 33% in 2009 (p = 0.3). The abstinence rate for men improved from 23% to 38% (2008 vs 2009; p = 0.05), whereas for women it was 30% vs 27% (p = 0.7). Abstinence rates decreased over time for the group as a whole (p < 0.001). Attendance of 6 or more classes was associated with higher abstinence rates. There was no significant impact on abstinence rates due to age, body mass index, class teacher, or medications used. Direct physician involvement improved men's but not women's abstinence rates among class participants. The relapse rate was significant over the first year after the class. Further research is needed to study the difference between sexes and the factors affecting relapse.

Is a reduction in distance to nearest supermarket associated with BMI change among type 2 diabetes patients?

PubMed

Zhang, Y Tara; Laraia, Barbara A; Mujahid, Mahasin S; Blanchard, Samuel D; Warton, E Margaret; Moffet, Howard H; Karter, Andrew J

2016-07-01

We examined whether residing within 2 miles of a new supermarket opening was longitudinally associated with a change in body mass index (BMI). We identified 12 new supermarkets that opened between 2009 and 2010 in 8 neighborhoods. Using the Kaiser Permanente Northern California Diabetes Registry, we identified members with type 2 diabetes residing continuously in any of these neighborhoods 12 months prior to the first supermarket opening until 10 months following the opening of the last supermarket. Exposure was defined as a reduction (yes/no) in travel distance to the nearest supermarket as a result of a new supermarket opening. First difference regression models were used to estimate the impact of reduced supermarket distance on BMI, adjusting for longitudinal changes in patient and neighborhood characteristics. Among patients in the exposed group, new supermarket openings reduced travel distance to the nearest supermarket by 0.7 miles on average. However, reduced distance to nearest supermarket was not associated with BMI changes. Overall, we found no evidence that reduced supermarket distance was associated with reduced levels of obesity for residents with type 2 diabetes. Published by Elsevier Ltd.

PS3-21: Extracting Utilization Data from Clarity into VDW Using Oracle and SAS

PubMed Central

Chimmula, Srivardhan

2013-01-01

Background/Aims The purpose of the presentation is to demonstrate how we use SAS and Oracle to load VDW_Utilization, VDW_DX, and VDW_PX tables from Clarity at the Kaiser Permanente Northern California (KPNC) Division of Research (DOR) site. Methods DOR uses the best of Oracle PL/ SQL and SAS capabilities in building Extract Transform and Load (ETL) processes. These processes extract patient encounter, diagnosis, and procedure data from Teradata-based Clarity. The data is then transformed to fit HMORN’s VDW definitions of the table. This data is then loaded into the Oracle-based VDW table on DOR’s research database and then finally a copy of the table is also created as a SAS dataset. Results DOR builds robust and efficient ETL processes that refresh VDW Utilization table on a monthly basis processing millions of records/observations. The ETL processes have the capability to identify daily changes in Clarity and update the VDW tables on a daily basis. Conclusions KPNC DOR combines the best of both Oracle and SAS worlds to build ETL processes that load the data into VDW Utilization tables efficiently.

Vision and creation of the American Heart Association pharmaceutical roundtable outcomes research centers.

PubMed

Peterson, Eric D; Spertus, John A; Cohen, David J; Hlatky, Mark A; Go, Alan S; Vickrey, Barbara G; Saver, Jeffrey L; Hinton, Patricia C

2009-11-01

The field of outcomes research seeks to define optimal treatment in practice and to promote the rapid full adoption of efficacious therapies into routine clinical care. The American Heart Association (AHA) formed the AHA Pharmaceutical Roundtable (PRT) Outcomes Research Centers Network to accelerate attainment of these goals. Participating centers were intended to carry out state-of-the-art outcomes research in cardiovascular disease and stroke, to train the next generation of investigators, and to support the formation of a collaborative research network. After a competitive application process, 4 AHA PRT Outcomes Research Centers were selected: Duke Clinical Research Institute; Saint Luke's Mid America Heart Institute; Stanford University-Kaiser Permanente of Northern California; and University of California, Los Angeles. Each center proposed between 1 and 3 projects organized around a single theme in cardiovascular disease or stroke. Additionally, each center will select and train up to 6 postdoctoral fellows over the next 4 years, and will participate in cross-collaborative activities among the centers. The AHA PRT Outcomes Research Centers Network is designed to further strengthen the field of cardiovascular disease and stroke outcomes research by fostering innovative research, supporting high quality training, and encouraging center-to-center collaborations.

The greatest challenges reported by long-term colorectal cancer survivors with stomas.

PubMed

McMullen, Carmit K; Hornbrook, Mark C; Grant, Marcia; Baldwin, Carol M; Wendel, Christopher S; Mohler, M Jane; Altschuler, Andrea; Ramirez, Michelle; Krouse, Robert S

2008-04-01

This paper presents a qualitative analysis of the greatest challenges reported by long-term colorectal cancer survivors with ostomies. Surveys that included an open-ended question about challenges of living with an ostomy were administered at three Kaiser Permanente regions: Northern California, Northwest, and Hawaii. The study was coordinated at the Southern Arizona Veterans Affairs Health Care System in Tucson. The City of Hope Quality of Life Model for Ostomy Patients provided a framework for the study's design, measures, data collection, and data analysis. The study's findings may be generalized broadly to community settings across the United States. Results replicate those of previous research among veterans, California members of the United Ostomy Association, Koreans with ostomies, and colorectal cancer survivors with ostomies residing in the United Kingdom. The greatest challenges reported by 178 colorectal cancer survivors with ostomies confirmed the Institute of Medicine's findings that survivorship is a distinct, chronic phase of cancer care and that cancer's effects are broad and pervasive. The challenges reported by study participants should inform the design, testing and integration of targeted education, early interventions, and ongoing support services for colorectal cancer patients with ostomies.

Reassurance Against Future Risk of Precancer and Cancer Conferred by a Negative Human Papillomavirus Test

PubMed Central

Schiffman, Mark; Katki, Hormuzd A.; Castle, Philip E.; Fetterman, Barbara; Wentzensen, Nicolas; Poitras, Nancy E.; Lorey, Thomas; Cheung, Li C.; Kinney, Walter K.

2014-01-01

Primary human papillomavirus (HPV) testing (without concurrent Pap tests) every 3 years is under consideration in the United States as an alternative to the two recommended cervical cancer screening strategies: primary Pap testing every 3 years, or concurrent Pap and HPV testing (“cotesting”) every 5 years. Using logistic regression and Weibull survival models, we estimated and compared risks of cancer and cervical intraepithelial neoplasia grade 3 or worse (CIN3+) for the three strategies among 1011092 women aged 30 to 64 years testing HPV-negative and/or Pap-negative in routine screening at Kaiser Permanente Northern California since 2003. All statistical tests were two sided. Three-year risks following an HPV-negative result were lower than 3-year risks following a Pap-negative result (CIN3+ = 0.069% vs 0.19%, P < .0001; Cancer = 0.011% vs 0.020%, P < .0001) and 5-year risks following an HPV-negative/Pap-negative cotest (CIN3+ = 0.069% vs 0.11%, P < .0001; Cancer = 0.011% vs 0.014%, P = .21). These findings suggest that primary HPV testing merits consideration as another alternative for cervical screening. PMID:25038467

Reassurance against future risk of precancer and cancer conferred by a negative human papillomavirus test.

PubMed

Gage, Julia C; Schiffman, Mark; Katki, Hormuzd A; Castle, Philip E; Fetterman, Barbara; Wentzensen, Nicolas; Poitras, Nancy E; Lorey, Thomas; Cheung, Li C; Kinney, Walter K

2014-08-01

Primary human papillomavirus (HPV) testing (without concurrent Pap tests) every 3 years is under consideration in the United States as an alternative to the two recommended cervical cancer screening strategies: primary Pap testing every 3 years, or concurrent Pap and HPV testing ("cotesting") every 5 years. Using logistic regression and Weibull survival models, we estimated and compared risks of cancer and cervical intraepithelial neoplasia grade 3 or worse (CIN3+) for the three strategies among 1011092 women aged 30 to 64 years testing HPV-negative and/or Pap-negative in routine screening at Kaiser Permanente Northern California since 2003. All statistical tests were two sided. Three-year risks following an HPV-negative result were lower than 3-year risks following a Pap-negative result (CIN3+ = 0.069% vs 0.19%, P < .0001; Cancer = 0.011% vs 0.020%, P < .0001) and 5-year risks following an HPV-negative/Pap-negative cotest (CIN3+ = 0.069% vs 0.11%, P < .0001; Cancer = 0.011% vs 0.014%, P = .21). These findings suggest that primary HPV testing merits consideration as another alternative for cervical screening. © Published by Oxford University Press 2014.

Achieving performance breakthroughs in an HMO business process through quality planning.

PubMed

Hanan, K B

1993-01-01

Kaiser Permanente's Georgia Region commissioned a quality planning team to design a new process to improve payments to its suppliers and vendors. The result of the team's effort was a 73 percent reduction in cycle time. This team's experiences point to the advantages of process redesign as a quality planning model, as well as some general guidelines for its most effective use in teams. If quality planning project teams are carefully configured, sufficiently expert in the existing process, and properly supported by management, organizations can achieve potentially dramatic improvements in process performance using this approach.

Does Consuming Sugar and Artificial Sweeteners Change Taste Preferences?

PubMed

Bartolotto, Carole

2015-01-01

Americans consume 22.3 teaspoons of added caloric sweeteners a day. Sweeteners range from 180 to 13,000 times sweeter than sugar. In summer 2014, 20 people from Kaiser Permanente California facilities cut out all added sugars and artificial sweeteners for 2 weeks: 95% of participants found that sweet foods and drinks tasted sweeter or too sweet, 75% found that other foods tasted sweeter, and 95% said moving forward they would use less or even no sugar. Additionally, 86.6% of participants stopped craving sugar after 6 days.

Energy Assessment Helps Kaiser Aluminum Save Energy and Improve Productivity; DOE Software Adopted as Standard for Analyzing Plant Process Heating Systems Company-Wide

DOE Office of Scientific and Technical Information (OSTI.GOV)

Not Available

2008-07-01

This case study describes how the Kaiser Aluminum plant in Sherman, Texas, achieved annual savings of $360,000 and 45,000 MMBtu, and improved furnace energy intensity by 11.1% after receiving a DOE Save Energy Now energy assessment and implementing recommendations to improve the efficiency of its process heating system.

Infection and antibiotic use in infancy and risk of childhood obesity: a longitudinal birth cohort study.

PubMed

Li, De-Kun; Chen, Hong; Ferber, Jeannette; Odouli, Roxana

2017-01-01

Data from previous studies have suggested a possible association between antibiotic use in infancy and risk of childhood obesity, with implications for health-care delivery and obesity prevention strategies. However, whether the observed association was due to antibiotic use or underlying infection, or both, is unclear. We aimed to disentangle the effect of antibiotic use in infancy from that of underlying infection on the risk of childhood obesity. In this longitudinal birth cohort study, we included infants in the Kaiser Permanente Northern California population born between Jan 1, 1997, and March 31, 2013. We used electronic medical records to ascertain data for antibiotic use, infection diagnosis, and anthropometric measurements (and thus BMI and obesity status) from birth up to age 18 years. We used standard mixed-effects logistic regression for repeated measurements to analyse multiple BMI measurements per child (median five measurements) and to obtain odds ratios (ORs) and 95% CIs for obesity risk. We also did a substudy in 547 same-sex twin pairs with discordant exposure status to substantiate our findings. 260 556 individuals were included in our analysis. After controlling for maternal age, race or ethnic origin, pre-pregnancy BMI, preterm delivery, low birthweight, maternal antibiotic use, and infection during pregnancy, infection without antibiotic use in infancy was associated with an increased risk of childhood obesity compared with controls without infection (OR 1·25, 95% CI 1·20-1·29). A clear dose-response relation was seen between infection episodes and risk of childhood obesity (p trend <0·0001). By contrast, compared with infants with untreated infection, antibiotic use during infancy was not associated with risk of childhood obesity (1·01, 0·98-1·04). Neither broad-spectrum nor narrow-spectrum antibiotics were associated with risk of childhood obesity. These findings were supported by the results of the twin set analysis. Infection

Improved Blood Pressure Control Associated With a Large-Scale Hypertension Program

PubMed Central

Jaffe, Marc G.; Lee, Grace A.; Young, Joseph D.; Sidney, Stephen; Go, Alan S.

2014-01-01

Importance Hypertension control for large populations remains a major challenge. Objective To describe a large-scale hypertension program in northern California and to compare rates of hypertension control of the program to statewide and national estimates. Design, Setting, and Patients The Kaiser Permanente Northern California (KPNC) Hypertension program included a multi-faceted approach to blood pressure control. Patients identified with hypertension within an integrated health care delivery system in northern California from 2001–2009 were included. The comparison group included insured patients in California between 2006–2009 who were included in the Healthcare Effectiveness Data and Information Set (HEDIS) commercial measurement by California health insurance plans participating in the National Committee for Quality Assurance (NQCA) quality measure reporting process. A secondary comparison group was the reported national mean NCQA HEDIS commercial rates of hypertension control from 2001–2009 from health plans that participated in the NQCA HEDIS quality measure reporting process. Main Outcome Measure Hypertension control as defined by NCQA HEDIS. Results The KPNC hypertension registry established in 2001 included 349,937 patients and grew to 652,763 by 2009. The NCQA HEDIS commercial measurement for hypertension control increased from 44% to 80% during the study period. In contrast, the national mean NCQA HEDIS commercial measurement increased modestly from 55.4% to 64.1%. California mean NCQA HEDIS commercial rates of hypertension were similar to those reported nationally from 2006–2009. (63.4% to 69.4%). Conclusion and Relevance Among adults diagnosed with hypertension, implementation of a large-scale hypertension program was associated with a significant increase in hypertension control compared with state and national control rates. PMID:23989679

Epidemiology and healthcare costs of incident Clostridium difficile infections identified in the outpatient healthcare setting.

PubMed

Kuntz, Jennifer L; Johnson, Eric S; Raebel, Marsha A; Petrik, Amanda F; Yang, Xiuhai; Thorp, Micah L; Spindel, Steven J; Neil, Nancy; Smith, David H

2012-10-01

To describe the epidemiology and healthcare costs of Clostridium difficile infection (CDI) identified in the outpatient setting. Population-based, retrospective cohort study. Kaiser Permanente Colorado and Kaiser Permanente Northwest members between June 1, 2005, and September 30, 2008. We identified persons with incident CDI and classified CDI by whether it was identified in the outpatient or inpatient healthcare setting. We collected information about baseline variables and follow-up healthcare utilization, costs, and outcomes among patients with CDI. We compared characteristics of patients with CDI identified in the outpatient versus inpatient setting. We identified 3,067 incident CDIs; 56% were identified in the outpatient setting. Few strong, independent predictors of diagnostic setting were identified, although a previous stay in a nonacute healthcare institution (odds ratio [OR], 1.45 [95% confidence interval (CI), 1.13-1.86]) was statistically associated with outpatient-identified CDI, as was age from 50 to 59 years (OR, 1.64 [95% CI, 1.18-2.29]), 60 to 69 years (OR, 1.37 [95% CI, 1.03-1.82]), and 70 to 79 years (OR, 1.36 [95% CI, 1.06-1.74]), when compared with persons aged 80-89 years. We found that more than one-half of incident CDIs in this population were identified in the outpatient setting. Patients with outpatient-identified CDI were younger with fewer comorbidities, although they frequently had previous exposure to healthcare. These data suggest that practitioners should be aware of CDI and obtain appropriate diagnostic testing on outpatients with CDI symptoms.

Effect of Direct Physician Involvement on Tobacco Abstinence Rates and Other Variables Affecting Participants of a Freedom from Tobacco Class

PubMed Central

Ismail, Mohamed H; Ho, Ngoc J; Lara, Nancy Irazu

2013-01-01

Context Kaiser Permanente measures how often tobacco users are offered strategies to quit but not the success of such strategies. Objective: To compare tobacco abstinence rates for participants of the Kaiser Permanente Riverside (California) Medical Center’s Freedom from Tobacco Class in 2008, before direct physician involvement, and in 2009, after direct physician involvement, and to compare other variables affecting these rates. Design: In a retrospective study, participants were divided into two groups based on year of participation. Data were collected using electronic medical records and phone interviews. Main Outcome Measures: Tobacco use status between both groups at 1, 3, 6, and 12 months after the classes started and within groups by sex, number of classes attended, medication received, and class teacher. Results: The 12-month abstinence rates were 27% in 2008 and 33% in 2009 (p = 0.3). The abstinence rate for men improved from 23% to 38% (2008 vs 2009; p = 0.05), whereas for women it was 30% vs 27% (p = 0.7). Abstinence rates decreased over time for the group as a whole (p < 0.001). Attendance of 6 or more classes was associated with higher abstinence rates. There was no significant impact on abstinence rates due to age, body mass index, class teacher, or medications used. Conclusion: Direct physician involvement improved men’s but not women’s abstinence rates among class participants. The relapse rate was significant over the first year after the class. Further research is needed to study the difference between sexes and the factors affecting relapse. PMID:23704836

e-Measures: insight into the challenges and opportunities of automating publicly reported quality measures

PubMed Central

Garrido, Terhilda; Kumar, Sudheen; Lekas, John; Lindberg, Mark; Kadiyala, Dhanyaja; Whippy, Alan; Crawford, Barbara; Weissberg, Jed

2014-01-01

Using electronic health records (EHR) to automate publicly reported quality measures is receiving increasing attention and is one of the promises of EHR implementation. Kaiser Permanente has fully or partly automated six of 13 the joint commission measure sets. We describe our experience with automation and the resulting time savings: a reduction by approximately 50% of abstractor time required for one measure set alone (surgical care improvement project). However, our experience illustrates the gap between the current and desired states of automated public quality reporting, which has important implications for measure developers, accrediting entities, EHR vendors, public/private payers, and government. PMID:23831833

Prevalence of migraine in a diverse community--electronic methods for migraine ascertainment in a large integrated health plan.

PubMed

Pressman, Alice; Jacobson, Alice; Eguilos, Roderick; Gelfand, Amy; Huynh, Cynthia; Hamilton, Luisa; Avins, Andrew; Bakshi, Nandini; Merikangas, Kathleen

2016-04-01

The growing availability of electronic health data provides an opportunity to ascertain diagnosis-specific cases via systematic methods for sample recruitment for clinical research and health services evaluation. We developed and implemented a migraine probability algorithm (MPA) to identify migraine from electronic health records (EHR) in an integrated health plan. We identified all migraine outpatient diagnoses and all migraine-specific prescriptions for a five-year period (April 2008-March 2013) from the Kaiser Permanente, Northern California (KPNC) EHR. We developed and evaluated the MPA in two independent samples, and derived prevalence estimates of medically-ascertained migraine in KPNC by age, sex, and race. The period prevalence of medically-ascertained migraine among KPNC adults during April 2008-March 2013 was 10.3% (women: 15.5%, men: 4.5%). Estimates peaked with age in women but remained flat for men. Prevalence among Asians was half that of whites. We demonstrate the feasibility of an EHR-based algorithm to identify cases of diagnosed migraine and determine that prevalence patterns by our methods yield results comparable to aggregate estimates of treated migraine based on direct interviews in population-based samples. This inexpensive, easily applied EHR-based algorithm provides a new opportunity for monitoring changes in migraine prevalence and identifying potential participants for research studies. © International Headache Society 2015.

Bendectin and human congenital malformations.

PubMed

Shiono, P H; Klebanoff, M A

1989-08-01

The relationship between Bendectin exposure during the first trimester of pregnancy and the occurrence of congenital malformations was prospectively studied in 31,564 newborns registered in the Northern California Kaiser Permanente Birth Defects Study. The odds ratio for any major malformation and Bendectin use was 1.0 (95% confidence interval 0.8-1.4). There were 58 categories of congenital malformations; three of them were statistically associated with Bendectin exposure (microcephaly--odds ratio = 5.3, 95% confidence interval = 1.8-15.6; congenital cataract--odds ratio = 5.3, 95% confidence interval = 1.2-24.3; lung malformations (ICD-8 codes 484.4-484.8)--odds ratio = 4.6, 95% confidence interval = 1.9-10.9). This is exactly the number of associations that would be expected by chance. An independent study (the Collaborative Perinatal Project) was used to determine whether vomiting during pregnancy in the absence of Bendectin use was associated with these three malformations. Two of the three (microcephaly and cataract) had strong positive associations with vomiting in the absence of Bendectin use. We conclude that there is no increase in the overall rate of major malformations after exposure to Bendectin and that the three associations found between Bendectin and individual malformations are unlikely to be causal.

Time to Send the Preemie Home? Additional Maturity at Discharge and Subsequent Health Care Costs and Outcomes

PubMed Central

Silber, Jeffrey H; Lorch, Scott A; Rosenbaum, Paul R; Medoff-Cooper, Barbara; Bakewell-Sachs, Susan; Millman, Andrea; Mi, Lanyu; Even-Shoshan, Orit; Escobar, Gabriel J

2009-01-01

Objective To determine whether longer stays of premature infants allowing for increased physical maturity result in subsequent postdischarge cost savings that help counterbalance increased inpatient costs. Data Sources One thousand four hundred and two premature infants born in the Northern California Kaiser Permanente Medical Care Program between 1998 and 2002. Study Design/Methods Using multivariate matching with a time-dependent propensity score we matched 701 “Early” babies to 701 “Late” babies (developmentally similar at the time the earlier baby was sent home but who were discharged on average 3 days later) and assessed subsequent costs and clinical outcomes. Principal Findings Late babies accrued inpatient costs after the Early baby was already home, yet costs after discharge through 6 months were virtually identical across groups, as were clinical outcomes. Overall, after the Early baby went home, the Late–Early cost difference was $5,016 (p<.0001). A sensitivity analysis suggests our conclusions would not easily be altered by failure to match on some unmeasured covariate. Conclusions In a large integrated health care system, if a baby is ready for discharge (as defined by the typical criteria), staying longer increased inpatient costs but did not reduce postdischarge costs nor improve postdischarge clinical outcomes. PMID:19207592

Racial/ethnic and socioeconomic differences in short-term breast cancer survival among women in an integrated health system.

PubMed

Keegan, Theresa H M; Kurian, Allison W; Gali, Kathleen; Tao, Li; Lichtensztajn, Daphne Y; Hershman, Dawn L; Habel, Laurel A; Caan, Bette J; Gomez, Scarlett L

2015-05-01

We examined the combined influence of race/ethnicity and neighborhood socioeconomic status (SES) on short-term survival among women with uniform access to health care and treatment. Using electronic medical records data from Kaiser Permanente Northern California linked to data from the California Cancer Registry, we included 6262 women newly diagnosed with invasive breast cancer. We analyzed survival using multivariable Cox proportional hazards regression with follow-up through 2010. After consideration of tumor stage, subtype, comorbidity, and type of treatment received, non-Hispanic White women living in low-SES neighborhoods (hazard ratio [HR] = 1.28; 95% confidence interval [CI] = 1.07, 1.52) and African Americans regardless of neighborhood SES (high SES: HR = 1.44; 95% CI = 1.01, 2.07; low SES: HR = 1.88; 95% CI = 1.42, 2.50) had worse overall survival than did non-Hispanic White women living in high-SES neighborhoods. Results were similar for breast cancer-specific survival, except that African Americans and non-Hispanic Whites living in high-SES neighborhoods had similar survival. Strategies to address the underlying factors that may influence treatment intensity and adherence, such as comorbidities and logistical barriers, should be targeted at low-SES non-Hispanic White and all African American patients.

Risk factors for anal HPV infection and anal precancer in HIV-infected men who have sex with men.

PubMed

Schwartz, Lauren M; Castle, Philip E; Follansbee, Stephen; Borgonovo, Sylvia; Fetterman, Barbara; Tokugawa, Diane; Lorey, Thomas S; Sahasrabuddhe, Vikrant V; Luhn, Patricia; Gage, Julia C; Darragh, Teresa M; Wentzensen, Nicolas

2013-12-01

Carcinogenic human papillomaviruses (HPVs) cause a large proportion of anal cancers. Human immunodeficiency virus (HIV)-infected men who have sex with men (MSM) are at increased risk of HPV infection and anal cancer compared with HIV-negative men. We evaluated risk factors for HPV infection and anal precancer in a population of HIV-infected MSM. Our study included 305 MSM at an HIV/AIDS clinic in the Kaiser Permanente Northern California Health Maintenance Organization. Logistic regression was used to estimate associations of risk factors comparing men without anal HPV infection; men with anal HPV infection, but no precancer; and men with anal precancer. Low CD4 count (<350 cells/mm(3)) and previous chlamydia infection were associated with an increased risk of carcinogenic HPV infection (odds ratio [OR], 3.65; 95% confidence interval [CI], 1.28-10.40 and OR, 4.24; 95% CI, 1.16-15.51, respectively). History of smoking (OR, 2.71 95% CI, 1.43-5.14), duration, recency, and dose of smoking increased the risk of anal precancer among carcinogenic HPV-positive men but had no association with HPV infection. We found distinct risk factors for anal HPV infection and anal precancer. Risk factors for HPV infection and anal precancer are similar to established risk factors for cervical cancer progression.

Socioeconomic differences in adolescent substance abuse treatment participation and long-term outcomes.

PubMed

Lui, Camillia K; Sterling, Stacy A; Chi, Felicia W; Lu, Yun; Campbell, Cynthia I

2017-05-01

Socioeconomic status (SES) has been consistently linked to poorer access, utilization and outcomes of health care services, but this relationship has been understudied in adolescent substance abuse treatment research. This study examined SES differences in adolescent's treatment participation and long-term outcomes of abstinence and 12-step attendance over five years after treatment. Data are from 358 adolescents (ages 13-18) who were recruited at intake to substance abuse treatment between 2000 and 2002 at four Kaiser Permanente Northern California outpatient treatment programs. Follow-up interviews of adolescents and their parents were conducted at 1, 3, and 5years, with over 80% response rates across time points. Using parent SES as a proxy for adolescent SES, no socioeconomic differences were found in treatment initiation, treatment retention, or long-term abstinence from alcohol or drugs. Parent education, but not parent income, was significantly associated with 12-step attendance post-treatment such that adolescents with higher parent education were more likely to attend than those with lower parent education. Findings suggest a lack of socioeconomic disparities in substance abuse treatment participation in adolescence, but potential disparities in post-treatment 12-step attendance during the transition from adolescence to young adulthood. Copyright © 2017 Elsevier Ltd. All rights reserved.

A novel power harmonic analysis method based on Nuttall-Kaiser combination window double spectrum interpolated FFT algorithm

NASA Astrophysics Data System (ADS)

Jin, Tao; Chen, Yiyang; Flesch, Rodolfo C. C.

2017-11-01

Harmonics pose a great threat to safe and economical operation of power grids. Therefore, it is critical to detect harmonic parameters accurately to design harmonic compensation equipment. The fast Fourier transform (FFT) is widely used for electrical popular power harmonics analysis. However, the barrier effect produced by the algorithm itself and spectrum leakage caused by asynchronous sampling often affects the harmonic analysis accuracy. This paper examines a new approach for harmonic analysis based on deducing the modifier formulas of frequency, phase angle, and amplitude, utilizing the Nuttall-Kaiser window double spectrum line interpolation method, which overcomes the shortcomings in traditional FFT harmonic calculations. The proposed approach is verified numerically and experimentally to be accurate and reliable.

Case studies of orthopedic surgery in California: the virtues of care coordination versus specialization.

PubMed

Robinson, James C

2013-05-01

Two overarching frameworks compete to address the organizational ills of the health care system. One framework diagnoses lack of coordination and prescribes integration and global payment. The other diagnoses loss of focus and prescribes specialization and episode payment. This article, based on research and interviews, assesses how the two frameworks manifest themselves at two high-volume orthopedic hospitals in Irvine, California. The Kaiser Permanente Irvine Medical Center is part of a large and diversified health system. The Hoag Orthopedic Institute is a single-specialty facility jointly owned by the physicians and the hospital. Market outcomes, such as the merger of the Hoag specialty hospital into a larger diversified health system, suggest that Kaiser's focus on coordination of patient care from preadmission to postdischarge is a key factor in its success. But Hoag's specialization also leads to improved efficiencies. The integrated approach appears to be prevailing. At the same time, large diversified organizations might obtain further efficiencies by pursuing service-line strategies as described in this article--for instance, by providing incentives for efficiency and quality for each specialty and type of care.

An HMO-based prospective pilot study of energy medicine for chronic headaches: whole-person outcomes point to the need for new instrumentation.

PubMed

Sutherland, Elizabeth G; Ritenbaugh, Cheryl; Kiley, Susan J; Vuckovic, Nancy; Elder, Charles

2009-08-01

The purpose of this study was to evaluate an energy healing treatment for possible inclusion as a Kaiser Permanente Northwest (KPNW) Pain Clinic provided therapy, and to identify the appropriate number of treatment sessions for a Pain Clinic protocol, should the intervention prove successful. In addition, our intent was to document the full range of outcomes experienced by patients undergoing energy healing, including whole-person and transformative outcomes should they occur. The setting for this study was Kaiser Permanente Northwest Pain Clinic. Thirteen (13) patients with chronic headache who were members of the KPNW Health Plan were recruited through flyers or mailings. Thirteen (13) participants received at least three energy healing sessions at approximately weekly intervals. Assessments were based on pre- and post-treatment qualitative interviews. The treatment consisted of three Healing Touch sessions provided by a Certified Healing Touch Practitioner. Treatments contained elements common to all sessions, and elements that were tailored to the individual subject. Twelve (12) of 13 participants experienced improvement in frequency, intensity, or duration of pain after three treatments. In addition, 11 of 13 participants experienced profound shifts in their view of themselves, their lives, and their potential for healing and transformation. These changes lasted from 24 hours to more than 6 months at follow-up. Energy healing can be an important addition to pain management services. More in-depth qualitative research is needed to explore the diversity of outcomes facilitated by energy healing treatments. Furthermore, the development of new instrumentation is warranted to capture outcomes that reflect transformative change and changes at the level of the whole person.

Prevalence of prostatitis-like symptoms in a managed care population.

PubMed

Clemens, J Quentin; Meenan, Richard T; O'Keeffe-Rosetti, Maureen C; Gao, Sara Y; Brown, Sheila O; Calhoun, Elizabeth A

2006-08-01

We calculated the prevalence of symptoms typically associated with chronic prostatitis/chronic pelvic pain syndrome in men in a managed care population in the Pacific Northwest. A questionnaire mailing to 5,000 male enrollees 25 to 80 years old in the Kaiser Permanente Northwest (Portland, Oregon) health plan was performed. The questionnaires included screening questions about the presence, duration and severity of pelvic pain, and the National Institutes of Health Chronic Prostatitis Symptom Index. Chronic prostatitis/chronic pelvic pain syndrome symptoms were defined in 2 ways: 1) presence of any of the following for a duration of 3 or more months: pain in the perineum, testicles, tip of penis, pubic or bladder area, dysuria, ejaculatory pain; and 2) perineal and/or ejaculatory pain, and a National Institutes of Health Chronic Prostatitis Symptom Index total pain score of 4 or more. Prevalence estimates were age adjusted to the total Kaiser Permanente Northwest male population. A total of 1,550 questionnaires were returned. The prevalence of chronic prostatitis/chronic pelvic pain syndrome symptoms was 7.5% for definition 1 and 5.9% for definition 2. Mean National Institutes of Health Chronic Prostatitis Symptom Index scores were 17 for definitions 1 and 2. Of those with prostatitis-like symptoms, 30% met criteria for having both definitions present. The prevalence of prostatitis-like symptoms using either of the 2 diagnoses was 11.2%. This population based study indicates that approximately 1 in 9 men have prostatitis-like symptoms. Application of 2 different definitions for prostatitis-like symptoms identified unique groups of men, with limited overlap in the groups.

An HMO-Based Prospective Pilot Study of Energy Medicine for Chronic Headaches: Whole-Person Outcomes Point to the Need for New Instrumentation

PubMed Central

Ritenbaugh, Cheryl; Kiley, Susan J.; Vuckovic, Nancy; Elder, Charles

2009-01-01

Abstract Objectives The purpose of this study was to evaluate an energy healing treatment for possible inclusion as a Kaiser Permanente Northwest (KPNW) Pain Clinic provided therapy, and to identify the appropriate number of treatment sessions for a Pain Clinic protocol, should the intervention prove successful. In addition, our intent was to document the full range of outcomes experienced by patients undergoing energy healing, including whole-person and transformative outcomes should they occur. Setting The setting for this study was Kaiser Permanente Northwest Pain Clinic. Participants Thirteen (13) patients with chronic headache who were members of the KPNW Health Plan were recruited through flyers or mailings. Methods Thirteen (13) participants received at least three energy healing sessions at approximately weekly intervals. Assessments were based on pre- and post-treatment qualitative interviews. Intervention The treatment consisted of three Healing Touch sessions provided by a Certified Healing Touch Practitioner. Treatments contained elements common to all sessions, and elements that were tailored to the individual subject. Results Twelve (12) of 13 participants experienced improvement in frequency, intensity, or duration of pain after three treatments. In addition, 11 of 13 participants experienced profound shifts in their view of themselves, their lives, and their potential for healing and transformation. These changes lasted from 24 hours to more than 6 months at follow-up. Conclusions Energy healing can be an important addition to pain management services. More in-depth qualitative research is needed to explore the diversity of outcomes facilitated by energy healing treatments. Furthermore, the development of new instrumentation is warranted to capture outcomes that reflect transformative change and changes at the level of the whole person. PMID:19678772

Food Environment and Weight Change: Does Residential Mobility Matter?: The Diabetes Study of Northern California (DISTANCE).

PubMed

Laraia, Barbara A; Downing, Janelle M; Zhang, Y Tara; Dow, William H; Kelly, Maggi; Blanchard, Samuel D; Adler, Nancy; Schillinger, Dean; Moffet, Howard; Warton, E Margaret; Karter, Andrew J

2017-05-01

Associations between neighborhood food environment and adult body mass index (BMI; weight (kg)/height (m)2) derived using cross-sectional or longitudinal random-effects models may be biased due to unmeasured confounding and measurement and methodological limitations. In this study, we assessed the within-individual association between change in food environment from 2006 to 2011 and change in BMI among adults with type 2 diabetes using clinical data from the Kaiser Permanente Diabetes Registry collected from 2007 to 2011. Healthy food environment was measured using the kernel density of healthful food venues. Fixed-effects models with a 1-year-lagged BMI were estimated. Separate models were fitted for persons who moved and those who did not. Sensitivity analysis using different lag times and kernel density bandwidths were tested to establish the consistency of findings. On average, patients lost 1 pound (0.45 kg) for each standard-deviation improvement in their food environment. This relationship held for persons who remained in the same location throughout the 5-year study period but not among persons who moved. Proximity to food venues that promote nutritious foods alone may not translate into clinically meaningful diet-related health changes. Community-level policies for improving the food environment need multifaceted strategies to invoke clinically meaningful change in BMI among adult patients with diabetes. © The Author 2017. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Systematic review of economic evaluation studies and budget impact on ambulatory monitoring of capillary glucose in type 2 diabetics.

PubMed

Olry de Labry Lima, Antonio; Moya Garrido, María Natividad; Espín Balbino, Jaime

2014-04-01

Realise a review of studies of economic evaluation about the ambulatory monitoring of capillary glucose (AMGC) in diabetic type II persons. A review of the literature was conducted, in MedLine, various websites, referenced paper and provided by expert's persons. Five studies concluded that the AMGC was a cost-effective strategic, of this papers use Kaiser Permanente data base, its make that these studies could be considered a solely one study. The rest of the papers did not find difference in the AMGC use. The use of AMGC has an uncertainty efficiency. More studies are needed. Copyright © 2013 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.

Secure e-mailing between physicians and patients: transformational change in ambulatory care.

PubMed

Garrido, Terhilda; Meng, Di; Wang, Jian J; Palen, Ted E; Kanter, Michael H

2014-01-01

Secure e-mailing between Kaiser Permanente physicians and patients is widespread; primary care providers receive an average of 5 e-mails from patients each workday. However, on average, secure e-mailing with patients has not substantially impacted primary care provider workloads. Secure e-mail has been associated with increased member retention and improved quality of care. Separate studies associated patient portal and secure e-mail use with both decreased and increased use of other health care services, such as office visits, telephone encounters, emergency department visits, and hospitalizations. Directions for future research include more granular analysis of associations between patient-physician secure e-mail and health care utilization.

Transforming care delivery through health information technology.

PubMed

Wheatley, Benjamin

2013-01-01

The slow but progressive adoption of health information technology (IT) nationwide promises to usher in a new era in health care. Electronic health record systems provide a complete patient record at the point of care and can help to alleviate some of the challenges of a fragmented delivery system, such as drug-drug interactions. Moreover, health IT promotes evidence-based practice by identifying gaps in recommended treatment and providing clinical decision-support tools. In addition, the data collected through digital records can be used to monitor patient outcomes and identify potential improvements in care protocols. Kaiser Permanente continues to advance its capability in each of these areas.

Secure E-mailing Between Physicians and Patients

PubMed Central

Garrido, Terhilda; Meng, Di; Wang, Jian J.; Palen, Ted E.; Kanter, Michael H.

2014-01-01

Secure e-mailing between Kaiser Permanente physicians and patients is widespread; primary care providers receive an average of 5 e-mails from patients each workday. However, on average, secure e-mailing with patients has not substantially impacted primary care provider workloads. Secure e-mail has been associated with increased member retention and improved quality of care. Separate studies associated patient portal and secure e-mail use with both decreased and increased use of other health care services, such as office visits, telephone encounters, emergency department visits, and hospitalizations. Directions for future research include more granular analysis of associations between patient-physician secure e-mail and health care utilization. PMID:24887522

Successful practices in the use of secure e-mail.

PubMed

Johnson, Laura W; Garrido, Terhilda; Christensen, Kate; Handley, Matt

2014-01-01

Physician use of secure e-mail with patients is anticipated to increase under Stage 2 Meaningful Use requirements, but little is known about how physicians can successfully incorporate it into daily work. We interviewed 27 "super user" physicians at Kaiser Permanente and Group Health who were identified by leaders as being technologically, operationally, and clinically adept and as having high levels of secure e-mail use with patients. They highly valued the use of secure e-mail with patients, despite concerns about a lack of adequate time to respond, and provided tips for using it successfully. They identified benefits that included better care and improved relationships with their patients.

It pays to be Herr Kaiser: Germans with noble-sounding surnames more often work as managers than as employees.

PubMed

Silberzahn, Raphael; Uhlmann, Eric Luis

2013-12-01

In the field study reported here (N = 222,924), we found that Germans with noble-sounding surnames, such as Kaiser ("emperor"), König ("king"), and Fürst ("prince"), more frequently hold managerial positions than Germans with last names that either refer to common everyday occupations, such as Koch ("cook"), Bauer ("farmer"), and Becker/Bäcker ("baker"), or do not refer to any social role. This phenomenon occurs despite the fact that noble-sounding surnames never indicated that the person actually held a noble title. Because of basic properties of associative cognition, the status linked to a name may spill over to its bearer and influence his or her occupational outcomes.

Health assessment for Kaiser Steel Corporation Fontana, San Nernadino County, California, Region 9. CERCLIS No. CAD008274938. Preliminary report

DOE Office of Scientific and Technical Information (OSTI.GOV)

Not Available

1989-10-25

The Kaiser Steel Corporation (KSC) site was included in the Update 7, proposed National Priorities List (NPL). The site was subsequently dropped from the proposed NPL on October 4, 1989. The site is located near Fontana, California, in San Bernardino County, approximately 45 miles east of Los Angeles. The on-site environmental contamination in groundwater and soil consisted of volatile organic compounds, organic acids, aluminum, barium, iron, lead, manganese, cadmium, and chromium compounds. The site is of potential health concern because of the risk to human health resulting from possible exposure to hazardous substances at concentrations that may result in adversemore » health effects.« less

What Does Professionalism Mean to the Physician?

PubMed Central

Kanter, Michael H; Nguyen, Miki; Klau, Marc H; Spiegel, Nancy H; Ambrosini, Virginia L

2013-01-01

Professionalism, which is a core competency for physicians, can be described as a spectrum of behaviors and may have a significant impact on the problems in today’s changing health care climate. In this article, we discuss the meaning of professionalism and its role in the Southern California Permanente Medical Group (SCPMG) and consider how it may be applied to integrated care delivery systems such as Kaiser Permanente. To understand professionalism, one must consider Stern’s definition, which consists of four principles: excellence, humanism, accountability, and altruism. SCPMG has taken three of these principles—excellence, accountability, and altruism—and divided the fourth, humanism, into another three principles similar to those identified by the University of California Los Angeles Task Force on Professionalism: humanitarianism, respect for others, and honor and integrity. SCPMG has a rich history and culture of promoting clinical excellence and professionalism, as evidenced by the programs and initiatives described throughout this article. Indeed, the SCPMG experience validates professionalism as a core physician competency comprising a set of behaviors that are continually refined. PMID:24355895

Parents and the V-Chip: A Kaiser Family Foundation Survey. How Parents Feel (and What They Know) about TV, the V-Chip, and the TV Ratings System. Toplines.

ERIC Educational Resources Information Center

1999

This report presents the data from a national, random sample survey designed by the Kaiser Family Foundation and Princeton Survey Research Associates (PSRA) and conducted by PSRA by telephone between April 6-26, 1999, when 1001 parents of children ages 2-17 were interviewed about their opinions of television, the V-Chip, and the TV ratings system.…

The Effect of Guided Care Teams on the Use of Health Services

PubMed Central

Boult, Chad; Reider, Lisa; Leff, Bruce; Frick, Kevin D.; Boyd, Cynthia M.; Wolff, Jennifer L.; Frey, Katherine; Karm, Lya; Wegener, Stephen T.; Mroz, Tracy; Scharfstein, Daniel O.

2015-01-01

Background The effect of interdisciplinary primary care teams on the use of health services by patients with multiple chronic conditions is uncertain. This study aimed to measure the effect of guided care teams on multimorbid older patients’ use of health services. Methods Eligible patients from 3 health care systems in the Baltimore, Maryland–Washington, DC, area were cluster-randomized to receive guided care or usual care for 20 months between November 1, 2006, and June 30, 2008. Eight services of a guided care nurse working in partnership with patients’ primary care physicians were provided: comprehensive assessment, evidence-based care planning, monthly monitoring of symptoms and adherence, transitional care, coordination of health care professionals, support for self-management, support for family caregivers, and enhanced access to community services. Outcome measures were frequency of use of emergency departments, hospitals, skilled nursing facilities, home health agencies, primary care physician services, and specialty physician services. Results The study included 850 older patients at high risk for using health care heavily in the future. The only statistically significant overall effect of guided care in the whole sample was a reduction in episodes of home health care (odds ratio, 0.70; 95% confidence interval, 0.53–0.93). In a preplanned analysis, guided care also reduced skilled nursing facility admissions (odds ratio, 0.53; 95% confidence interval,0.31–0.89) and days (0.48; 0.28–0.84) among Kaiser-Permanente patients. Conclusions Guided care reduces the use of home health care but has little effect on the use of other health services in the short run. Its positive effect on Kaiser-Permanente patients’ use of skilled nursing facilities and other health services is intriguing. Trial Registration clinicaltrials.gov Identifier: NCT00121940 PMID:21403043

A comparison of revision and rerupture rates of ACL reconstruction between autografts and allografts in the skeletally immature.

PubMed

Nelson, Ian R; Chen, Jason; Love, Rebecca; Davis, Brent R; Maletis, Gregory B; Funahashi, Tadashi T

2016-03-01

Anterior cruciate ligament reconstructions (ACLRs) in skeletally immature patients are increasing. The purpose of this study is to describe the demographics, graft usage, revision, and re-operation rates in skeletally immature ACLRs in the Kaiser Permanente healthcare system. Skeletally immature patients (<17.0 years old with open physes) were identified using the Kaiser Permanente ACLR registry. Multi-ligament reconstructions and physeal-sparing ACLRs were excluded. Aseptic revision and same-knee re-operation were the outcomes of interest. Exposure of interest was graft type; bone-patellar-tendon-bone (BPTB) autograft, hamstring autograft, and any type of allograft. Age, gender, body mass index (BMI), and race were evaluated as confounders. Cox proportional hazard models stratified by surgeon were used to analyse the risk of revision and re-operation. A total of 534 primary ACLR cases were evaluated with a mean follow-up of 2.9 years. The majority were hamstring autografts (n = 388, 72.7%), male (n = 339, 63.9%), and White (n = 232, 43.4%). Median age was 14.9 years, and median BMI was 21.9 kg/m(2). There were 44 (8.2%) aseptic revisions and 48 (9.0%) same-knee re-operations. The incidence rate for revision was BPTB autograft 5.5%, hamstring autograft 7.5%, and allograft 13.2%. After adjusting for confounders and surgeon clustering effect, the risk of aseptic revision and revision between allograft and hamstring autograft did not reach statistical significance. Graft selection differs in skeletally immature patients with a preponderance of surgeries being performed with hamstring tendon autografts. High revision rates were identified for all graft types used, though differences in revision rates across different graft types did not reach statistical significance. Surgeons should be aware of high rates of revision in this skeletally immature young population, although type of graft used did not appear to make a difference. III.

Multi-Center, Community-Based Cardiac Implantable Electronic Devices Registry: Population, Device Utilization, and Outcomes.

PubMed

Gupta, Nigel; Kiley, Mary Lou; Anthony, Faith; Young, Charlie; Brar, Somjot; Kwaku, Kevin

2016-03-09

The purpose of this study is to describe key elements, clinical outcomes, and potential uses of the Kaiser Permanente-Cardiac Device Registry. This is a cohort study of implantable cardioverter defibrillators (ICD), pacemakers (PM), and cardiac resynchronization therapy (CRT) devices implanted between January 1, 2007 and December 31, 2013 by ≈400 physicians in 6 US geographical regions. Registry data variables, including patient characteristics, comorbidities, indication for procedures, complications, and revisions, were captured using the healthcare system's electronic medical record. Outcomes were identified using electronic screening algorithms and adjudicated via chart review. There were 11 924 ICDs, 33 519 PMs, 4472 CRTs, and 66 067 leads registered. A higher proportion of devices were implanted in males: 75.1% (ICD), 55.0% (PM), and 66.7% (CRT), with mean patient age 63.2 years (ICD), 75.2 (PM), and 67.2 (CRT). The 30-day postoperative incidence of tamponade, hematoma, and pneumothorax were ≤0.3% (ICD), ≤0.6% (PM), and ≤0.4% (CRT). Device failures requiring revision occurred at a rate of 2.17% for ICDs, 0.85% for PMs, and 4.93% for CRTs, per 100 patient observation years. Superficial infection rates were <0.03% for all devices; deep infection rates were 0.6% (ICD), 0.5% (PM), and 1.0% (CRT). Results were used to monitor vendor-specific variations and were systematically shared with individual regions to address potential variations in outcomes, utilization, and to assist with the management of device recalls. The Kaiser Permanente-Cardiac Device Registry is a robust tool to monitor postprocedural patient outcomes and postmarket surveillance of implants and potentially change practice patterns. © 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

Nurse Knowledge Exchange Plus: Human-Centered Implementation for Spread and Sustainability.

PubMed

Lin, Mike; Heisler, Scott; Fahey, Linda; McGinnis, Juli; Whiffen, Teri L

2015-07-01

Kaiser Permanente implemented a new model of nursing communication at shift change-in the bedside nursing report known as the Nurse Knowledge Exchange (NKE) in 2004-but noted variations in its spread and sustainability across medical centers five years later. The six core elements of NKEplus were as follows: team rounding in the last hour before shift changes, pre-shift patient assignments that limit the number of departing nurses at shift change, unit support for uninterrupted bedside reporting, standardization for report and safety check formats, and collaboration with patients to update in-room care boards. In January 2011 Kaiser Permanente Southern California (KPSC; Pasadena) began implementing NKEplus in 125 nursing units across 14 hospitals, with the use of human-centered design principles: creating shared understanding of the need for change, minimum specifications, and customization by frontline staff. Champion teams on each nursing unit designed and pilot tested unit-specific versions of NKEplus for four to eight weeks. Implementation occurred in waves and proceeded from medical/surgical units to specialty units. Traditional performance improvement strategies of accountability, measurement, and management were also applied. By the end of 2012, 100% of the 64 medical/surgical units and 47 (77.0%) of the 61 specialty units in KPSC medical centers implemented NKEplus-as had all but 1 of the specialty units by May 2013. The mean KPSC score on the NKEplus nursing behavior bundle improved from 65.9% in 2010 to 71.3% in the first quarter of 2014. The mean KPSC Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score for nurse communication improved from 73.1% in 2010 to 76.4% in the first quarter of 2014 (p < . 001). Human-centered implementation appeared to help spread a new model of nursing handoffs and change the culture of professional nursing practice related to shift change.

Prevalence of migraine in a diverse community—electronic methods for migraine ascertainment in a large integrated health plan

PubMed Central

Pressman, Alice; Jacobson, Alice; Eguilos, Roderick; Gelfand, Amy; Huynh, Cynthia; Hamilton, Luisa; Avins, Andrew; Bakshi, Nandini; Merikangas, Kathleen

2016-01-01

Introduction The growing availability of electronic health data provides an opportunity to ascertain diagnosis-specific cases via systematic methods for sample recruitment for clinical research and health services evaluation. We developed and implemented a migraine probability algorithm (MPA) to identify migraine from electronic health records (EHR) in an integrated health plan. Methods We identified all migraine outpatient diagnoses and all migraine-specific prescriptions for a five-year period (April 2008–March 2013) from the Kaiser Permanente, Northern California (KPNC) EHR. We developed and evaluated the MPA in two independent samples, and derived prevalence estimates of medically-ascertained migraine in KPNC by age, sex, and race. Results The period prevalence of medically-ascertained migraine among KPNC adults during April 2008–March 2013 was 10.3% (women: 15.5%, men: 4.5%). Estimates peaked with age in women but remained flat for men. Prevalence among Asians was half that of whites. Conclusions We demonstrate the feasibility of an EHR-based algorithm to identify cases of diagnosed migraine and determine that prevalence patterns by our methods yield results comparable to aggregate estimates of treated migraine based on direct interviews in population-based samples. This inexpensive, easily applied EHR-based algorithm provides a new opportunity for monitoring changes in migraine prevalence and identifying potential participants for research studies. PMID:26069243

Antidepressant Medication Use, Depression and the Risk of Preeclampsia

PubMed Central

Avalos, Lyndsay Ammon; Chen, Hong Y.; Li, De-Kun

2018-01-01

Objective To assess the effects of depression and antidepressant medication use during pregnancy on the risk of preeclampsia. Methods We conducted a retrospective, population-based cohort study linking automated clinical and pharmacy databases including comprehensive electronic medical records of 21,589 pregnant Kaiser Permanente Northern California members between 2010 and 2012. Results The overall risk of preeclampsia was 4.5%. The timing of antidepressant medication exposure was an important factor. A significant increase in the risk of preeclampsia emerged for women with a depression diagnosis who took antidepressant medications during the second trimester compared to women with untreated depression (adjusted Relative Risk (aRR): 1.6, 95% CI: 1.06, 2.39), and to women without depression (aRR: 1.70, 95% CI: 1.30, 2.23). Similar associations existed for women who took antidepressant medications, but without depression. In contrast, depressed women with psychotherapy showed no increased risk of preeclampsia compared to women with untreated depression or no depression. There was also a statistically significant relationship between the duration of antidepressant medication use and preeclampsia. The observed association appeared stronger for SSRI use, although a non-significant trend was also noted for use of NDRIs and SNRIs. Conclusion Study findings suggest that the antidepressant use during pregnancy may increase the risk of preeclampsia, especially the use during the second trimester. PMID:25778691

Cigarette Smoking and the Risk of Barrett's Esophagus

PubMed Central

Kubo, Ai; Levin, T.R.; Block, Gladys; Rumore, Gregory; Quesenberry, Charles P.; Buffler, Patricia; Corley, Douglas A.

2008-01-01

Introduction We examined the association between smoking and the risk of Barrett's esophagus (BE), a metaplastic precursor to esophageal adenocarcinoma. Methods We conducted a case-control study within the Kaiser Permanente Northern California population. Patients with a new diagnosis of BE (n=320) were matched to persons with gastroesophageal reflux disease (GERD) (n=316) and to population controls (n=317). Information was collected using validated questionnaires from direct in-person interviews and electronic databases. Analyses used multivariate unconditional logistic regression that controlled for age, gender, race and education. Results Ever smoking status, smoking intensity (pack-years), and smoking cessation were not associated with the risk of BE. Stratified analyses suggested that ever smoking may be associated with an increased risk of BE among some groups (compared to population controls): persons with long-segment Barrett's esophagus (odds ratio [OR]=1.72, 95% confidence interval [CI] 1.12-2.63); subjects without GERD symptoms (OR=3.98, 95% CI 1.58-10.0); obese subjects (OR=3.38, 95%CI 1.46-7.82); and persons with a large abdominal circumference (OR=3.02, 95%CI (1.18-2.75)). Conclusion Smoking was not a strong or consistent risk factor for BE in a large community-based study, although associations may be present in some population subgroups. PMID:18853262

Racial/Ethnic and Socioeconomic Differences in Short-Term Breast Cancer Survival Among Women in an Integrated Health System

PubMed Central

Kurian, Allison W.; Gali, Kathleen; Tao, Li; Lichtensztajn, Daphne Y.; Hershman, Dawn L.; Habel, Laurel A.; Caan, Bette J.; Gomez, Scarlett L.

2015-01-01

Objectives. We examined the combined influence of race/ethnicity and neighborhood socioeconomic status (SES) on short-term survival among women with uniform access to health care and treatment. Methods. Using electronic medical records data from Kaiser Permanente Northern California linked to data from the California Cancer Registry, we included 6262 women newly diagnosed with invasive breast cancer. We analyzed survival using multivariable Cox proportional hazards regression with follow-up through 2010. Results. After consideration of tumor stage, subtype, comorbidity, and type of treatment received, non-Hispanic White women living in low-SES neighborhoods (hazard ratio [HR] = 1.28; 95% confidence interval [CI] = 1.07, 1.52) and African Americans regardless of neighborhood SES (high SES: HR = 1.44; 95% CI = 1.01, 2.07; low SES: HR = 1.88; 95% CI = 1.42, 2.50) had worse overall survival than did non-Hispanic White women living in high-SES neighborhoods. Results were similar for breast cancer–specific survival, except that African Americans and non-Hispanic Whites living in high-SES neighborhoods had similar survival. Conclusions. Strategies to address the underlying factors that may influence treatment intensity and adherence, such as comorbidities and logistical barriers, should be targeted at low-SES non-Hispanic White and all African American patients. PMID:25790426

Human Papillomavirus Genotyping After Denaturation of Specimens for Hybrid Capture 2 Testing: Feasibility Study for the HPV Persistence and Progression Cohort†

PubMed Central

LaMere, Brandon J.; Kornegay, Janet; Fetterman, Barbara; Sadorra, Mark; Shieh, Jen; Castle, Philip E.

2009-01-01

Human papillomavirus (HPV) genotyping could be clinically useful, depending on the results of large, prospective studies like the HPV Persistence and Progression cohort. The cohort is based on genotyping and follow-up of Hybrid Capture-positive women at Kaiser Permanente, Northern California. HPV DNA testing by Hybrid Capture 2 requires denaturation with alkali, possibly damaging the DNA for optimal PCR-based genotyping. A feasibility study was conducted on paired aliquots of anonymized specimens from 100 women with low-grade intraepithelial lesion cytology. Test aliquots were left in denaturant for 10 or 18 hours at 4°C and then neutralized; comparison aliquots were not denatured but diluted to match the timing, temperature, concentration and salt conditions of the treated specimens. The masked aliquots were tested using a commercialized PCR-based assay that detects of 37 HPV genotypes. There was no overall effect of treatment on test positivity or number of types. HPV16 was marginally more likely to be detected in untreated versus treated aliquots (P = 0.09) but HPV45 was marginally more likely to be detected in treated than untreated aliquots (P = 0.07), suggesting that these differences represented chance (intra-test variability). It can be concluded that residual Hybrid Capture-positive specimens can be accurately genotyped by PCR after Hybrid Capture 2 processing. PMID:17673302

Effect of influenza vaccination on hospitalizations in persons aged 50 years and older.

PubMed

Baxter, Roger; Ray, G Thomas; Fireman, Bruce H

2010-10-21

To estimate influenza vaccine effectiveness (VE) in preventing hospitalizations in persons over 50 years of age. We performed a retrospective, population based study, using a "difference-in-differences" approach to determine the association between hospitalization and prior vaccination. We examined this association when influenza was not circulating and compared it to the association found when influenza was circulating. VE was estimated from the difference in the association between hospitalization and prior vaccination, inside vs. outside influenza seasons. Kaiser Permanente in Northern California. Health plan members aged 50 years and older during the September 1997 to August 2008 study period, when there were about 68,000 pneumonia hospitalizations in 10 million person-years. Vaccination was associated with lower risk of hospitalization for pneumonia and influenza, even before flu season, presumably due to unmeasured confounders. When influenza arrived the hospitalization-vaccination association strengthened, yielding an adjusted VE estimate of 12.4% (95% CI: 1.6-22.0) in persons aged 50-64, and 8.5% (95% CI: 3.3-13.5) in those aged 65 years and older. There was no significant effect on hospitalizations for ischemic heart disease (IHD), congestive heart failure (CHF), cerebrovascular disease (CVD), or trauma. Influenza vaccination has a modest but significant effect on prevention of hospitalization for pneumonia and influenza in persons 50 years of age and older. Copyright © 2010 Elsevier Ltd. All rights reserved.

Demographic, Insurance, and Health Characteristics of Newly Enrolled HIV-Positive Patients After Implementation of the Affordable Care Act in California

PubMed Central

Parthasarathy, Sujaya; Altschuler, Andrea; Silverberg, Michael J.; Storholm, Erik; Campbell, Cynthia I.

2016-01-01

Objectives. To examine changes in HIV-positive patient enrollment in a large health care delivery system before and after key Affordable Care Act (ACA) provisions went into effect in 2014. Methods. Analyses compared HIV-positive patients newly enrolled in Kaiser Permanente Northern California between January and June 2012 (n = 339) to those newly enrolled between January and June 2014 through the California insurance exchange or via other mechanisms (n = 549). Results. After the ACA, the HIV-positive patient enrollment increased. These new enrollees were more likely to be male (93.6% vs 89.1%; P = .01), to be enrolled in high-deductible benefit plans (≥ $1000; 18.8% vs 5.5%; P = .01), and to have better HIV viral control (HIV RNA levels below limits of quantification 79.5% vs 73.6%; P = .05) compared with pre-ACA new enrollees. Among post-ACA new enrollees, there were more patients in the lowest and highest age groups. Post-ACA exchange enrollees (22%) were more likely to be male and to have high-deductible plans than those enrolled through other mechanisms. Conclusions. More men, higher deductibles, and better HIV viral control characterize newly enrolled HIV-positive patients after the ACA in California. Public health implications. Evolving characteristics of HIV-positive enrollees may affect HIV policy, patient care needs, and service utilization. PMID:27077361

Maintenance of Certification Part IV Quality-Improvement Project for Hypertension Control: A Preliminary Retrospective Analysis

PubMed Central

Kolasinski, Vallerie A; Price, David W

2015-01-01

Context: A Maintenance of Certification Part IV project was created on the basis of an existing, multifaceted hypertension improvement program. Objective: To evaluate the impact of the Maintenance of Certification project, the effects of the improvement options on blood pressure control in hypertensive patients, and the participants’ perception of the workload related to participation in the project. Design: Nonexperimental retrospective analysis. Setting: Kaiser Permanente hospitals and medical office buildings in Northern California. Intervention: Participants used one or more options from a defined menu of strategies to attempt to increase the percentage of hypertensive patients on their patient panels who had controlled blood pressure. Main Outcome Measure: Proportion of hypertensive patients with blood pressure ≤ 139/89 mm Hg. Results: Fifty-two American Board of Family Medicine and 19 American Board of Internal Medicine certified physicians completed projects. Mean panel blood pressure control improved from 79.49% (standard deviation [SD] = 11.32) to 84.64% (SD = 7.80). The choice of improvement option was not associated with the level of improvement or with the participants’ perception of the workload related to completing the project. Conclusion: Project participants improved the care of their patients without an increased perceived burden to their practice. We found no association between the choice of improvement option and either the level of improvement or the perception of workload. PMID:25785642

Medication Exposure in Pregnancy Risk Evaluation Program

PubMed Central

Andrade, Susan E.; Davis, Robert L.; Cheetham, T. Craig; Cooper, William O.; Li, De-Kun; Amini, Thushi; Beaton, Sarah J.; Dublin, Sascha; Hammad, Tarek A.; Pawloski, Pamala A.; Raebel, Marsha A.; Smith, David H.; Staffa, Judy A.; Toh, Sengwee; Dashevsky, Inna; Haffenreffer, Katherine; Lane, Kimberly; Platt, Richard; Scott, Pamela E.

2011-01-01

To describe a program to study medication safety in pregnancy, the Medication Exposure in Pregnancy Risk Evaluation Program (MEPREP). MEPREP is a multi-site collaborative research program developed to enable the conduct of studies of medication use and outcomes in pregnancy. Collaborators include the U.S. Food and Drug Administration and researchers at the HMO Research Network, Kaiser Permanente Northern and Southern California, and Vanderbilt University. Datasets have been created at each site linking healthcare data for women delivering an infant between January 1, 2001 and December 31, 2008 and infants born to these women. Standardized data files include maternal and infant characteristics, medication use, and medical care at 11 health plans within 9 states; birth certificate data were obtained from the state departments of public health. MEPREP currently involves more than 20 medication safety researchers and includes data for 1,221,156 children delivered to 933,917 mothers. Current studies include evaluations of the prevalence and patterns of use of specific medications and a validation study of data elements in the administrative and birth certificate data files. MEPREP can support multiple studies by providing information on a large, ethnically and geographically diverse population. This partnership combines clinical and research expertise and data resources to enable the evaluation of outcomes associated with medication use during pregnancy. PMID:22002179

Medication Exposure in Pregnancy Risk Evaluation Program.

PubMed

Andrade, Susan E; Davis, Robert L; Cheetham, T Craig; Cooper, William O; Li, De-Kun; Amini, Thushi; Beaton, Sarah J; Dublin, Sascha; Hammad, Tarek A; Pawloski, Pamala A; Raebel, Marsha A; Smith, David H; Staffa, Judy A; Toh, Sengwee; Dashevsky, Inna; Haffenreffer, Katherine; Lane, Kimberly; Platt, Richard; Scott, Pamela E

2012-10-01

To describe a program to study medication safety in pregnancy, the Medication Exposure in Pregnancy Risk Evaluation Program (MEPREP). MEPREP is a multi-site collaborative research program developed to enable the conduct of studies of medication use and outcomes in pregnancy. Collaborators include the U.S. Food and Drug Administration and researchers at the HMO Research Network, Kaiser Permanente Northern and Southern California, and Vanderbilt University. Datasets have been created at each site linking healthcare data for women delivering an infant between January 1, 2001 and December 31, 2008 and infants born to these women. Standardized data files include maternal and infant characteristics, medication use, and medical care at 11 health plans within 9 states; birth certificate data were obtained from the state departments of public health. MEPREP currently involves more than 20 medication safety researchers and includes data for 1,221,156 children delivered to 933,917 mothers. Current studies include evaluations of the prevalence and patterns of use of specific medications and a validation study of data elements in the administrative and birth certificate data files. MEPREP can support multiple studies by providing information on a large, ethnically and geographically diverse population. This partnership combines clinical and research expertise and data resources to enable the evaluation of outcomes associated with medication use during pregnancy.

Successful Practices in the Use of Secure E-mail

PubMed Central

Johnson, Laura W; Garrido, Terhilda; Christensen, Kate; Handley, Matt

2014-01-01

Physician use of secure e-mail with patients is anticipated to increase under Stage 2 Meaningful Use requirements, but little is known about how physicians can successfully incorporate it into daily work. We interviewed 27 “super user” physicians at Kaiser Permanente and Group Health who were identified by leaders as being technologically, operationally, and clinically adept and as having high levels of secure e-mail use with patients. They highly valued the use of secure e-mail with patients, despite concerns about a lack of adequate time to respond, and provided tips for using it successfully. They identified benefits that included better care and improved relationships with their patients. PMID:24937149

Career ladder program for registered nurses in ambulatory care.

PubMed

Nelson, Joan; Sassaman, Becky; Phillips, Alison

2008-01-01

RN ladder programs are designed to inspire and reward clinical excellence. Kaiser Permanente Colorado's (KPCO) career ladder program emerged as a result of a labor-management partnership. Career ladder point assignments are reflective of the organization's priorities and values. KPCO's career ladder point tool awards RNs for formal and continuing education, professional presentations, organizational experience and experience as an RN, certifications and active professional memberships, leadership activities, research and publications, and nursing-related volunteer work. Participation in the RN career ladder requires that the nurse achieve a self-determined, manager-approved, measurable goal that will improve patient care. Career ladder nurses at KPCO were significantly more involved in leadership and interdisciplinary activities, quality improvement projects, and preceptorship.

Heart rate calculation from ensemble brain wave using wavelet and Teager-Kaiser energy operator.

PubMed

Srinivasan, Jayaraman; Adithya, V

2015-01-01

Electroencephalogram (EEG) signal artifacts are caused by various factors, such as, Electro-oculogram (EOG), Electromyogram (EMG), Electrocardiogram (ECG), movement artifact and line interference. The relatively high electrical energy cardiac activity causes EEG artifacts. In EEG signal processing the general approach is to remove the ECG signal. In this paper, we introduce an automated method to extract the ECG signal from EEG using wavelet and Teager-Kaiser energy operator for R-peak enhancement and detection. From the detected R-peaks the heart rate (HR) is calculated for clinical diagnosis. To check the efficiency of our method, we compare the HR calculated from ECG signal recorded in synchronous with EEG. The proposed method yields a mean error of 1.4% for the heart rate and 1.7% for mean R-R interval. The result illustrates that, proposed method can be used for ECG extraction from single channel EEG and used in clinical diagnosis like estimation for stress analysis, fatigue, and sleep stages classification studies as a multi-model system. In addition, this method eliminates the dependence of additional synchronous ECG in extraction of ECG from EEG signal process.

Correlates of patient-reported racial/ethnic health care discrimination in the Diabetes Study of Northern California (DISTANCE).

PubMed

Lyles, Courtney R; Karter, Andrew J; Young, Bessie A; Spigner, Clarence; Grembowski, David; Schillinger, Dean; Adler, Nancy E

2011-02-01

We examined possible determinants of self-reported health care discrimination. We examined survey data from the Diabetes Study of Northern California (DISTANCE), a race-stratified sample of Kaiser diabetes patients. Respondents reported perceived discrimination, and regression models examined socioeconomic, acculturative, and psychosocial correlates. Subjects (n=17,795) included 20% Blacks, 23% Latinos, 13% East Asians, 11% Filipinos, and 27% Whites. Three percent and 20% reported health care and general discrimination. Health care discrimination was more frequently reported by minorities (ORs ranging from 2.0 to 2.9 compared with Whites) and those with poorer health literacy (OR=1.10, 95% CI: 1.04-1.16), limited English proficiency (OR=1.91, 95% CI: 1.32-2.78), and depression (OR=1.53, 95% CI: 1.10-2.13). In addition to race/ethnicity, health literacy and English proficiency may be bases of discrimination. Evaluation is needed to determine whether patients are treated differently or more apt to perceive discrimination, and whether depression fosters and/or follows perceived discrimination.

Searching for the optimal renal prescription. Fresenius, Kaiser Permanente team up to offer new options in dialysis care.

PubMed

Neumann, M E

1999-01-01

The goals are simple: Improve well-being of the dialysis patient and reduce hospitalizations. The tools are diverse: Ultrapure dialysate. On-line blood monitoring. Biocompatible membranes. No reuse. Daily, in-center dialysis and possibly nocturnal dialysis at home. Reimbursement: Full-risk capitation, With Medicare and commercial payor rates varying on a patient-by-patient basis. Create an incubator with approximately 1,000 end-stage renal disease patients, treated at both capitated payment-exclusive dialysis units and mingled in at traditional fee-for-service clinics. Establish a team of nurses and renal care staff to direct the care plan, and put the program in place. After the first year, analyze the data and see if the end--hopefully, improved outcomes and resulting reduced hospitalizations--justifies the means--the higher cost for "optimal technologies."

Collaboration in health services research: on developing relationships between VA researchers and those in other institutions.

PubMed Central

Greenlick, M R; Freeborn, D K

1986-01-01

This article explores the potential for collaboration between investigators in institutions outside of the VA and those engaged in research within the VA. The focus is on the potential for collaborative work in health services research; our perspective is that of researchers in a freestanding HMO research center affiliated with the Veterans Administration's Northwest Health Services Research and Development Field Program. The paper begins with a review of the reasons that make collaboration between VA researchers and other health services researchers so appropriate at this time. An example of collaboration is presented, drawing on the experience of the Northwest Field Program and the Kaiser Permanente Center for Health Research. Finally, some difficulties inherent in collaboration between VA and other health services researchers are discussed. PMID:3512485

Use of electronic health records can improve the health care industry's environmental footprint.

PubMed

Turley, Marianne; Porter, Catherine; Garrido, Terhilda; Gerwig, Kathy; Young, Scott; Radler, Linda; Shaber, Ruth

2011-05-01

Electronic health records have the potential to improve the environmental footprint of the health care industry. We estimate that Kaiser Permanente's electronic health record system, which covers 8.7 million beneficiaries, eliminated 1,000 tons of paper records and 68 tons of x-ray film, and that it has lowered gasoline consumption among patients who otherwise would have made trips to the doctor by at least three million gallons per year. However, the use of personal computers resulted in higher energy consumption and generated an additional 250 tons of waste. We conclude that electronic health records have a positive net effect on the environment, and that our model for evaluating their impact can be used to determine whether their use can improve communities' health.

Health assessment for Kaiser Aluminum and Chemical Corporation, Mead, Spokane County, Washington, Region 10. CERCLIS No. WAD000065508. Preliminary report

DOE Office of Scientific and Technical Information (OSTI.GOV)

Not Available

1989-04-12

The 240-acre Kaiser Aluminum Site is on the National Priorities List. The plant was built in 1942 as an aluminum-reduction facility. Concentrations of cyanide (total) in the river range from 0.011 to 1.7 parts per million (ppm) and free cyanide concentrations ranged from non-detected (ND) to 0.58 ppm. Soils on-site are contaminated with cyanide and fluoride; total cyanide levels range from ND to 985 ppm. The site is considered to be of potential public health concern because of the risk to human health caused by the possibility of exposure to hazardous substances via ingestion of contaminated ground water, dermal absorptionmore » of contaminants found in the surface soils on-site, and inhalation of and dermal contact with reentrained contaminated dust.« less

[The history of the Kaiser Wilhelm Society during the Third Reich. Interim reports of the president's commission of the Max Planck Society].

PubMed

Weber, M M

2002-11-01

In 1997 the Max Planck Society set up a presidential commission to do research on the historical development of its precursor organization, the Kaiser Wilhelm Society (KWG), during the Third Reich. This paper presents some of the important results given in the interim reports of this commission that are relevant to psychiatry. It focuses on brain research, anthropology, psychiatric genetics, and the role of the well-known biochemist Adolf Butenandt. In general, the interim reports reflect the numerous links between the biomedical research of the KWG and the institutions of the National Socialist (Nazi) state. However, they do not yet allow a final historical assessment as to the complex situation of this field of research during National Socialism.

Use of the Teager-Kaiser Energy Operator for Muscle Activity Detection in Children

PubMed Central

Lauer, Richard T.; Prosser, Laura A.

2009-01-01

The purpose of this study was to demonstrate the usefulness of the Teager-Kaiser Energy (TKE) operator to assess surface electromyographic (sEMG) activity from the hip and trunk muscles during pediatric gait in children with and without cerebral palsy (CP). Muscle activity was recorded from the trapezius, erector spinae, rectus abdominus, external oblique, gluteus maximus and medius, rectus femoris, and semitendinosus bilaterally in ten children with typical development (TD) and five children with CP ages 44.4 ± 18.6 months. Duration of muscle activity was calculated as a percentage of the gait cycle, and compared to two common onset detection methods, a standard deviation (SD) amplitude threshold method, and the visual inspection from two raters (R1, R2). Relative and absolute agreement was determined using intraclass correlation coefficients (ICCs) and Bland-Altman plots. Of the two automated methods, the TKE method demonstrated better agreement with visual inspection (0.45–0.89) than the SD (0.11–0.76) method. The Bland-Altman plots indicated a smaller bias and 95% confidence interval for the TKE method in comparison to the raters (TKE to R1: −5, 113%; TKE to R2: 4, 95%; SD to R1: −24, 170%; SD to R2: −15, 151%). The use of the TKE operator may better detect sEMG activity in children than the standard amplitude method. PMID:19484385

Rectal Cancer Survivors' Participation in Productive Activities.

PubMed

Hornbrook, Mark C; Grant, Marcia; Wendel, Christopher; Bulkley, Joanna E; Mcmullen, Carmit K; Altschuler, Andrea; Temple, Larissa Kf; Herrinton, Lisa J; Krouse, Robert S

2017-01-01

Rectal cancer and its treatment impair survivors' productivity. To assess determinants of market and nonmarket employment, job search, volunteering, and homemaking among survivors five years or longer after diagnosis. We mailed questionnaires to 1063 survivors who were members of Kaiser Permanente (Northern California, Northwest) during 2010 and 2011. Productive activities, functional health status, and bowel management at the time of the survey. Response rate was 60.5% (577/953). Higher comorbidity burdens were associated with lower productivity for men and women rectal cancer survivors. Productive survivors were younger and had lower disease stage and age at diagnosis, higher household income and educational attainment, and fewer comorbidity burdens and workplace adjustments than did nonproductive survivors (p < 0.05 each; 2-sided). Productive rectal cancer survivors were evenly split by sex. Staying productive is associated with better mental health for rectal cancer survivors. Rectal cancer survivors with multiple chronic conditions, higher disease stage, lower productive activities, and older age need better access to medical care and closer monitoring of the quality of their care, including self-care. To capture the full extent of the involvement of survivors in all types of productive activities, research should routinely include measures of employment, searching for employment, homemaking, and volunteering. Counting market and nonmarket productive activities is innovative and recognizes the continuum of contributions survivors make to families and society. Health care systems should routinely monitor rectal cancer survivors' medical care access, comorbidities, health-related quality of life, and productive activities.

Fecal Immunochemical Test (FIT) for Colon Cancer Screening: Variable Performance with Ambient Temperature

PubMed Central

Doubeni, Chyke A.; Jensen, Christopher D.; Fedewa, Stacey A.; Quinn, Virginia P.; Zauber, Ann G.; Schottinger, Joanne E.; Corley, Douglas A.; Levin, Theodore R.

2017-01-01

Introduction Fecal immunochemical tests (FITs) are widely used in colorectal cancer (CRC) screening, but hemoglobin degradation, due to exposure of the collected sample to high temperatures, could reduce test sensitivity. We examined the relation of ambient temperature exposure with FIT positivity rate and sensitivity. Methods This was a retrospective cohort study of patients 50 to 75 years in Kaiser Permanente Northern California’s CRC screening program, which began mailing FIT kits annually to screen-eligible members in 2007. Primary outcomes were FIT positivity rate and sensitivity to detect CRC. Predictors were month, season, and daily ambient temperatures of test result dates based on US National Oceanic and Atmospheric Administration data. Results Patients (n =472,542) completed 1,141,162 FITs. Weekly test positivity rate ranged from 2.6% to 8.0% (median, 4.4%) and varied significantly by month (June/July vs December/January rate ratio [RR] =0.79, 95% confidence interval [CI], 0.76 to 0.83) and season. FIT sensitivity was lower in June/July (74.5%; 95% CI, 72.5 to 76.6) than January/December (78.9%; 95% CI, 77.0 to 80.7). Conclusions FITs completed during high ambient temperatures had lower positivity rates and lower sensitivity. Changing kit design, specimen transportation practices, or avoiding periods of high ambient temperatures may help optimize FIT performance, but may also increase testing complexity and reduce patient adherence, requiring careful study. PMID:28076249

Effects of dietary fiber, fats, and meat intakes on the risk of Barrett’s Esophagus

PubMed Central

Kubo, Ai; Block, Gladys; Quesenberry, Charles P.; Buffler, Patricia; Corley, Douglas A.

2009-01-01

Animal and human models suggest associations between fat intake, fiber intake and the risk of esophageal adenocarcinoma. We evaluated whether these factors may act early in the carcinogenic pathway as a risk factor for Barrett’s esophagus, a potentially premalignant precursor to esophageal adenocarcinoma using a case-control design within the Kaiser Permanente, Northern California population. Incident Barrett’s esophagus cases (n=296) were matched to persons with gastroesophageal reflux disease (GERD) (n=308), and to population controls (n=309). Higher intakes of omega-3-fatty-acids (cases vs. population controls; OR=0.46, 95% CI 0.22–0.97, 4th vs. 1st quartiles of intake), polyunsaturated fat, total fiber (OR=0.34, 95% CI 0.15–0.76), and fiber from fruits and vegetables (OR=0.47 95% CI 0.25–0.88) were associated with a lower risk of Barrett’s esophagus. Higher meat intakes were associated with a lower risk of long-segment Barrett’s esophagus (OR=0.25, 95% CI 0.09–0.72). In contrast, higher trans-fat intakes were associated with increased risk (OR=1.11; 95% CI 1.03–1.21 per gram/day). Total fat intake, barbecued foods, and fiber intake from sources other than fruits and vegetables were not associated with Barrett’s esophagus. Future studies to evaluate whether dietary interventions might influence the risk of Barrett’s esophagus or esophageal adenocarcinoma in high risk persons are needed. PMID:19838934

Pneumococcal Conjugate Vaccines and Otitis Media: An Appraisal of the Clinical Trials

PubMed Central

Fletcher, Mark A.; Fritzell, Bernard

2012-01-01

Streptococcus pneumoniae is the predominant otitis media pathogen and its prevention through effective vaccination could diminish childhood illness and antibiotic use. This paper reviews 5 pneumococcal conjugate vaccine (PCV) trials that used otitis media as an endpoint: Northern California Kaiser Permanente (NCKP; vaccine, 7-valent PCV [PCV7]-CRM); Finnish Otitis Media (FinOM; vaccines, PCV7-CRM or PCV7-OMPC); Native American Trial (vaccine, PCV7-CRM); Pneumococcal Otitis Efficacy Trial (POET; vaccine, 11-valent PCV [PCV11]-PD). For the microbiological endpoint, vaccine efficacy against vaccine-serotype pneumococcal otitis media was about 60% across trials. Against the clinical endpoint of all episodes, vaccine efficacy was 7% (PCV7-CRM/NCKP), 6% (PCV7-CRM/FinOM), −1% (PCV7-OMPC/FinOM), and −0.4% (PCV7-CRM/Native American Trial); 34% against first episodes of ear, nose, and throat specialist-referral cases (PCV11-PD/POET). Both follow-up through 2 years of age, for the 5 trials, and long-term follow-up, for PCV7-CRM/NCKP and PCV7-CRM/FinOM, demonstrated greater vaccine efficacy against recurrent AOM and tympanostomy-tube placement, suggesting that vaccination against early episodes of AOM may prevent subsequent episodes of complicated otitis media. Although study designs varied by primary endpoint measured, age at follow-up, source of middle-ear fluid for culture, case ascertainment, and type of randomization, each clinical trial demonstrated vaccine efficacy against microbiological and/or clinical otitis media. PMID:22701486

Pioglitazone does not affect the risk of ovarian cancer: analysis of a nationwide reimbursement database in Taiwan.

PubMed

Tseng, Chin-Hsiao

2013-10-01

The association between pioglitazone and ovarian cancer has not been studied. The reimbursement databases of all Taiwanese patients with a diagnosis of diabetes and under oral anti-diabetic agents or insulin from 1996 to 2009 were retrieved from the National Health Insurance. An entry date was set at 1 January 2006 and a total of 546,632 female patients with type 2 diabetes were followed up for ovarian cancer incidence until the end of 2009. Incidences for ever-users, never-users and subgroups of pioglitazone exposure [using cutoffs of the Kaiser Permanente Northern California study and tertile cutoffs derived from the databases] were calculated and the hazard ratios were estimated by Cox regression in unadjusted, age-adjusted and fully adjusted models. There were 30,783 ever-users and 515,849 never-users, with respective numbers of incident ovarian cancer of 49 (0.16%) and 946 (0.18%), and respective incidence of 43.08 and 51.47 per 100,000 person-years. The overall hazard ratios (95% confidence intervals) in unadjusted, age-adjusted and fully adjusted models were 0.822 (0.616-1.095), 0.823 (0.617-1.097) and 0.968 (0.718-1.305), respectively. In the dose-response analyses, none of the categories showed a significant hazard ratio, and all P-trends were >0.05 without statistical significance. This study does not support a positive or negative association between pioglitazone use and ovarian cancer in female patients with type 2 diabetes. © 2013.

GENDER DIFFERENCES IN QUALITY OF LIFE AMONG LONG-TERM COLORECTAL CANCER SURVIVORS WITH OSTOMIES

PubMed Central

Grant, Marcia; McMullen, Carmit K.; Altschuler, Andrea; Mohler, M. Jane; Hornbrook, Mark C.; Herrinton, Lisa J.; Wendel, Christopher S.; Baldwin, Carol M.; Krouse, Robert S.

2011-01-01

Objective To describe how gender shapes the concerns and adaptations of long-term (> 5 years) colorectal cancer (CRC) survivors with ostomies. Design Qualitative study using content analysis of focus group content. Setting Member of Kaiser Permanente, residing in either Oregon, Southwest Washington State, or Northern California. Sample Four female and four male focus groups selected from quantitative survey participants with health-related quality of life (HRQOL) scores in the highest or lowest quartile. Methods Eight focus groups, discussed challenges of living with an ostomy. Content was recorded, transcribed, and analyzed using directive and summative content analysis. Main Research Variables HRQOL domains of physical, psychological, social and spiritual well being. Findings All groups reported avoiding foods that cause gas or rapid transit, and discussed how limiting the amount of food eaten controlled the output. All groups discussed physical activities, getting support from friends and family, and the importance of being resilient. Both genders identified challenges with sexuality/intimacy. Coping and adjustment difficulties were discussed by women with men only discussing these issues to a small extent. Difficulties with sleep were primarily identified by Low HRQOL women. Problems with body image and depression were discussed only by Low HRQOL women. Conclusions Common issues included diet management, physical activity, social support and sexuality. Women with low HRQOL discussed problems with depression, body image, and sleep. Implications for Nursing Application of these gender-based differences can inform educational interventions for CRC survivors with ostomies. PMID:21875846

Race-ethnicity on blood pressure control after ischemic stroke: a prospective cohort study.

PubMed

Nguyen-Huynh, Mai N; Hills, Nancy K; Sidney, Stephen; Klingman, Jeffrey G; Johnston, S Claiborne

2017-01-01

Disparities in health care access and socioeconomic status (SES) have been associated with racial-ethnic differences in blood pressure (BP) control. We examined post-ischemic stroke BP in a multiethnic cohort with good health care access. We included all hypertensive patients (n = 2972) from a randomized quality improvement trial on secondary stroke prevention, conducted in 14 Kaiser Permanente hospitals in Northern California from 2004-2006 (QUISP). Average age 73.2 ± 12.2 years; 52% female, 66% non-Hispanic white, 14% African-American, 11% Asian, 8% Hispanic, and 1% other. Demographics, diagnoses, health care utilization, BP measurements, and medications were obtained as part of routine care. We used random effects logistic regression models to examine race as a predictor of blood pressure control (<140/90 mm Hg) at 6 months post-discharge, adjusted for SES, age, gender, dementia, antihypertensive therapy, and attendance at follow-up visits. At 6 months, BP was controlled in 52.7% of blacks compared to 61.4% of whites (OR = 0.63, 95% CI, 0.48-0.82, P = .001). Black race remained independently associated with poorer BP control in adjusted analysis, although blacks were as likely to attend post-discharge visits, and more likely to be on any antihypertensive therapy than whites. Greater difficulty in controlling BP and lifestyle differences may account for this difference. Copyright © 2016 American Society of Hypertension. Published by Elsevier Inc. All rights reserved.

Immune mediated conditions in autism spectrum disorders.

PubMed

Zerbo, Ousseny; Leong, Albin; Barcellos, Lisa; Bernal, Pilar; Fireman, Bruce; Croen, Lisa A

2015-05-01

We conducted a case-control study among members of Kaiser Permanente Northern California (KPNC) born between 1980 and 2003 to determine the prevalence of immune-mediated conditions in individuals with autism, investigate whether these conditions occur more often than expected, and explore the timing of onset relative to autism diagnosis. Cases were children and young adults with at least two autism diagnoses recorded in outpatient records (n=5565). Controls were children without autism randomly sampled at a ratio of 5 to 1, matched to cases on birth year, sex, and length of KPNC membership (n=27,825). The main outcomes - asthma, allergies, and autoimmune diseases - were identified from KPNC inpatient and outpatient databases. Chi-square tests were used to evaluate case-control differences. Allergies and autoimmune diseases were diagnosed significantly more often among children with autism than among controls (allergy: 20.6% vs. 17.7%, Crude odds ratio (OR)=1.22, 95% confidence interval (CI) 1.13-1.31; autoimmune disease: 1% vs. 0.76%, OR=1.36, 95% CI 1.01-1.83), and asthma was diagnosed significantly less often (13.7% vs. 15.9%; OR=0.83, 95% CI 0.76-0.90). Psoriasis occurred more than twice as often in cases than in controls (0.34% vs. 0.15%; OR=2.35, 95% CI 1.36-4.08). Our results support previous observations that children with autism have elevated prevalence of specific immune-related comorbidities. Copyright © 2015 Elsevier Inc. All rights reserved.

Manual dexterity aptitude testing: a soap carving study.

PubMed

Tang, Christopher G; Hilsinger, Raymond L; Cruz, Raul M; Schloegel, Luke J; Byl, Fred M; Rasgon, Barry M

2014-03-01

Currently there are few validated metrics for predicting surgical skill among otolaryngology residency applicants. To determine whether manual dexterity aptitude testing in the form of soap carving during otolaryngology residency interviews at Kaiser Permanente Medical Center Oakland predicts surgical skill at the time of graduation from otolaryngology residency programs. This study was conducted to determine how applicants with the best and worst soap carvings compared at the time of graduation with respect to various metrics including visuospatial ability and manual dexterity. Over the last 25 years, applicants to the residency program at Kaiser Permanente Oakland were required to carve soap during their residency interview. The 3 best and 3 worst soap carvings from 1990 through 2006 were determined. Of the individuals who carved those soaps, 62 qualified for the study and matriculated into otolaryngology residency programs. Surveys were sent to the 62 individuals' residency programs to evaluate those individuals on a 5-point Likert scale in various categories as well as to rank those individuals as being in the top 50% or bottom 50% of their graduating class. All else being equal, we hypothesized that applicants who had the manual dexterity and visuospatial skills to accurately carve a bar of soap would more likely possess the skills necessary to become a good surgeon. There was no difference between individuals with the best soap carvings and those with the worst soap carvings in all categories: cognitive knowledge, visuospatial ability, manual dexterity, decision making, and overall score (P > .10 for all categories). There was a 95% response rate, with 35 of 37 residency programs responding and 59 of 62 surveys returned. Manual dexterity aptitude testing in the form of soap carving does not appear to correlate with surgical skill at the time of graduation. Further studies need to be conducted to determine the role of manual dexterity and visuospatial

The historical development of modern virus research in Germany, especially in the Kaiser-Wilhelm-/Max-Planck-Society, 1936--1954.

PubMed

Butenandt, A

1977-01-01

This is lecture on the historical development of modern virus research in Germany to introduce a symposium dedicated to Prof. Werner Schäfer, Tübingen, on the occasion of his 65th birthday. The author was set the task of relating from his memories the beginning of modern virus research in Germany. This research has, since 1936, essentially taken place in the Kaiser-Wilhelm/Max-Planck-Society and in 1954 led to the founding of the Max-Planck-Institute for Virus Research in Tübingen, an institute which to the present day owes its scientific reputation in considerable part to the activity of Werner Schäfer. Since the author personally experienced and participated in the Institute's development from 1936-1954, his remarks are predominantly influenced by personal recollections, which have been sharpended by a renewed study of old records in the 'Library and Archive of the History of the Max-Planck-Gesellschaft', Berlin-Dahlem.

2014 Hypertension Guideline: Recommendation for a Change in Goal Systolic Blood Pressure

PubMed Central

Handler, Joel

2015-01-01

The 2014 Kaiser Permanente Care Management Institute National Hypertension Guideline was developed to assist primary care physicians and other health care professionals in the outpatient treatment of uncomplicated hypertension in adult men and nonpregnant women aged 18 years and older. The new guideline reflects general acceptance, with minor modifications, of the “Evidence-Based Guideline” report by the panel members appointed to the National Heart, Lung, and Blood Institute 8th Joint National Committee. A major practice change is the recommendation for goal systolic blood pressure less than 150 mmHg in patients aged 60 years and older who are treated for hypertension in the absence of diabetes or chronic kidney disease. This article describes the reasons for, evidence for, and consequences of the change, and is followed by the National Guidelines handout. PMID:26057683

Declining Effectiveness of Herpes Zoster Vaccine in Adults Aged ≥60 Years.

PubMed

Tseng, Hung Fu; Harpaz, Rafael; Luo, Yi; Hales, Craig M; Sy, Lina S; Tartof, Sara Y; Bialek, Stephanie; Hechter, Rulin C; Jacobsen, Steven J

2016-06-15

Understanding long-term effectiveness of herpes zoster (HZ) vaccine is critical for determining vaccine policy. 176 078 members of Kaiser Permanente ≥60 years vaccinated with HZ vaccine and three matched unvaccinated members were included. Hazard ratios and 95% confidence intervals (CIs) associated with vaccination at each year following vaccination were estimated by Cox regression model. The effectiveness of HZ vaccine decreased from 68.7% (95% CI, 66.3%-70.9%) in the first year to 4.2% (95% CI, -24.0% to 25.9%) in the eighth year. This rapid decline in effectiveness of HZ vaccine suggests that a revaccination strategy may be needed, if feasible. © The Author 2016. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail journals.permissions@oup.com.

A three-dimensional `Kaiser damage-memory' effect through true-triaxial loading

NASA Astrophysics Data System (ADS)

Meredith, P. G.; Browning, J.; Harland, S. R.; Healy, D.; Stuart, C.; Mitchell, T. M.

2017-12-01

Microcrack damage leading to failure in rocks evolves in response to differential loading. The vast majority of experimental studies investigate damage evolution, the `Kaiser damage-memory' effect, and rock failure using conventional triaxial stress states (σ1 > σ2 = σ3). Such stress states develop a crack population that displays cylindrical transverse isotropy. However, in nature the stress state is in general truly triaxial (σ1 > σ2 > σ3) and experiments that utilise such loading conditions can generate crack populations that display planar transverse isotropy which in turn influences properties such as permeability and strength. We investigate the evolution of crack damage under both conventional and true triaxial stress conditions using results from measurements made on cubic samples of sandstone deformed in three orthogonal directions with independently controlled stress paths. We have measured, simultaneously with stress and strain, the changes in ultrasonic compressional and shear wave velocities in the three principal directions, together with the bulk acoustic emission (AE) output. Changes in acoustic wave velocities are associated with both elastic closure and opening of pre-existing cracks, and the inelastic formation of new cracks. By contrast, AE is only associated with the inelastic growth of new crack damage and as such, we use the onset of AE to determine the initiation of new crack damage. By mapping these damage onsets under both conventional triaxial and true triaxial sequential cyclic loading, we have shown that `damage envelopes' evolve dynamically and can be pushed closer to the failure envelope. Whether a stress state has been `visited' before is key to determining and understanding damage states. Crack damage populations can be generated with multiple orientations depending on the arrangement of loading directions and hence principal stress directions. The sequential cyclic loading tests show that further damage in any one population

Acute Uterine Bleeding Unrelated to Pregnancy: A Southern California Permanente Medical Group Practice Guideline

PubMed Central

Munro, Malcolm G

2013-01-01

Acute uterine bleeding unrelated to pregnancy has been defined as bleeding “sufficient in volume as to, in the opinion of the treating clinician, require urgent or emergent intervention.” The Southern California Permanente Medical Group updated its guidelines for the management of this condition on the basis of the best available evidence, as identified in a systematic review of the available literature. Given the paucity of studies evaluating this condition, the guidelines, by necessity, include recommendations largely based on opinion or other sources such as case series that are, in general, categorized as low-quality evidence. Medical interventions with single or combined gonadal steroidal agents administered parenterally or orally show promise, but more high-quality studies are needed to better define the appropriate drugs, dose, and administrative scheduling. There is also some evidence that intrauterine tamponade may be useful in at least selected cases. Special attention must be paid to both diagnosing and treating inherited disorders of hemostasis, such as von Willebrand disease, that may otherwise be underdiagnosed in both adolescent and adult women. PMID:24355890

Northern Studies at Northern Universities.

ERIC Educational Resources Information Center

Northern Review: A Multidisciplinary Journal of the Arts and Social Sciences of the North, 1994

1994-01-01

Describes college programs and research projects focused on the Arctic, northern studies, or northern concerns at Athabasca University (Alberta), the University of British Columbia, the University of Alaska Anchorage, the University of Alaska Fairbanks, the Scott Polar Institute at the University of Cambridge (England), and Kent State University…

Subjective assessment of usefulness and appropriate presentation mode of alerts and reminders in the outpatient setting.

PubMed Central

Krall, M. A.; Sittig, D. F.

2001-01-01

There is very little known about the limits of alerting in the setting of the outpatient Electronic Medical Record (EMR). We are interested in how users value and prefer such alerts. One hundred Kaiser Permanente primary care clinicians were sent a four-page questionnaire. It contained questions related to the usability and usefulness of different approaches to presenting reminder and alert information. The survey also contained questions about the desirability of six categories of alerts. Forty-three of 100 questionnaires were returned. Users generally preferred an active, more intrusive interaction model for "alerts" and a passive, less intrusive model for order messages and other types of reminders and notifications. Drug related alerts were more highly rated than health maintenance or disease state reminders. Users indicated that more alerts would make the system "more useful" but "less easy to use". PMID:11825206

Subjective assessment of usefulness and appropriate presentation mode of alerts and reminders in the outpatient setting.

PubMed

Krall, M A; Sittig, D F

2001-01-01

There is very little known about the limits of alerting in the setting of the outpatient Electronic Medical Record (EMR). We are interested in how users value and prefer such alerts. One hundred Kaiser Permanente primary care clinicians were sent a four-page questionnaire. It contained questions related to the usability and usefulness of different approaches to presenting reminder and alert information. The survey also contained questions about the desirability of six categories of alerts. Forty-three of 100 questionnaires were returned. Users generally preferred an active, more intrusive interaction model for "alerts" and a passive, less intrusive model for order messages and other types of reminders and notifications. Drug related alerts were more highly rated than health maintenance or disease state reminders. Users indicated that more alerts would make the system "more useful" but "less easy to use".

The reliability of diagnostic coding and laboratory data to identify tuberculosis and nontuberculous mycobacterial disease among rheumatoid arthritis patients using anti-tumor necrosis factor therapy.

PubMed

Winthrop, Kevin L; Baxter, Roger; Liu, Liyan; McFarland, Bentson; Austin, Donald; Varley, Cara; Radcliffe, LeAnn; Suhler, Eric; Choi, Dongsoek; Herrinton, Lisa J

2011-03-01

Anti-tumor necrosis factor-alpha (anti-TNF) therapies are associated with severe mycobacterial infections in rheumatoid arthritis patients. We developed and validated electronic record search algorithms for these serious infections. The study used electronic clinical, microbiologic, and pharmacy records from Kaiser Permanente Northern California (KPNC) and the Portland Veterans Affairs Medical Center (PVAMC). We identified suspect tuberculosis and nontuberculous mycobacteria (NTM) cases using inpatient and outpatient diagnostic codes, culture results, and anti-tuberculous medication dispensing. We manually reviewed records to validate our case-finding algorithms. We identified 64 tuberculosis and 367 NTM potential cases, respectively. For tuberculosis, diagnostic code positive predictive value (PPV) was 54% at KPNC and 9% at PVAMC. Adding medication dispensings improved these to 87% and 46%, respectively. Positive tuberculosis cultures had a PPV of 100% with sensitivities of 79% (KPNC) and 55% (PVAMC). For NTM, the PPV of diagnostic codes was 91% (KPNC) and 76% (PVAMC). At KPNC, ≥ 1 positive NTM culture was sensitive (100%) and specific (PPV, 74%) if non-pathogenic species were excluded; at PVAMC, ≥1 positive NTM culture identified 76% of cases with PPV of 41%. Application of the American Thoracic Society NTM microbiology criteria yielded the highest PPV (100% KPNC, 78% PVAMC). The sensitivity and predictive value of electronic microbiologic data for tuberculosis and NTM infections is generally high, but varies with different facilities or models of care. Unlike NTM, tuberculosis diagnostic codes have poor PPV, and in the absence of laboratory data, should be combined with anti-tuberculous therapy dispensings for pharmacoepidemiologic research. Copyright © 2010 John Wiley & Sons, Ltd.

CREATE Wellness: A multi-component behavioral intervention for patients not responding to traditional Cardiovascular disease management.

PubMed

Miller-Rosales, Chris; Sterling, Stacy A; Wood, Sabrina B; Ross, Thekla; Makki, Mojdeh; Zamudio, Cindy; Kane, Irene M; Richardson, Megan C; Samayoa, Claudia; Charvat-Aguilar, Nancy; Lu, Wendy Y; Vo, Michelle; Whelan, Kimberly; Uratsu, Connie S; Grant, Richard W

2017-12-01

Cardiovascular disease (CVD) is the leading cause of death in the US. Many patients do not benefit from traditional disease management approaches to CVD risk reduction. Here we describe the rationale, development, and implementation of a multi-component behavioral intervention targeting patients who have persistently not met goals of CVD risk factor control. Informed by published evidence, relevant theoretical frameworks, stakeholder advice, and patient input, we developed a group-based intervention (Changing Results: Engage and Activate to Enhance Wellness; "CREATE Wellness") to address the complex needs of patients with elevated or unmeasured CVD-related risk factors. We are testing this intervention in a randomized trial among patients with persistent (i.e > 2 years) sub-optimal risk factor control despite being enrolled in an advanced and highly successful CVD disease management program. The CREATE Wellness intervention is designed as a 3 session, group-based intervention combining proven elements of patient activation, health system engagement skills training, shared decision making, care planning, and identification of lifestyle change barriers. Our key learnings in designing the intervention included the value of multi-level stakeholder input and the importance of pragmatic skills training to address barriers to care. The CREATE Wellness intervention represents an evidence-based, patient-centered approach for patients not responding to traditional disease management. The trial is currently underway at three medical facilities within Kaiser Permanente Northern California and next steps include an evaluation of efficacy, adaptation for non-English speaking patient populations, and modification of the curriculum for web- or phone-based versions. NCT02302612.

Rectal Cancer Survivors’ Participation in Productive Activities

PubMed Central

Hornbrook, Mark C; Grant, Marcia; Wendel, Christopher; Bulkley, Joanna E; McMullen, Carmit K; Altschuler, Andrea; Temple, Larissa KF; Herrinton, Lisa J; Krouse, Robert S

2018-01-01

Context Rectal cancer and its treatment impair survivors’ productivity. Objective To assess determinants of market and nonmarket employment, job search, volunteering, and homemaking among survivors five years or longer after diagnosis. Design We mailed questionnaires to 1063 survivors who were members of Kaiser Permanente (Northern California, Northwest) during 2010 and 2011. Main Outcome Measures Productive activities, functional health status, and bowel management at the time of the survey. Results Response rate was 60.5% (577/953). Higher comorbidity burdens were associated with lower productivity for men and women rectal cancer survivors. Productive survivors were younger and had lower disease stage and age at diagnosis, higher household income and educational attainment, and fewer comorbidity burdens and workplace adjustments than did nonproductive survivors (p < 0.05 each; 2-sided). Productive rectal cancer survivors were evenly split by sex. Conclusion Staying productive is associated with better mental health for rectal cancer survivors. Rectal cancer survivors with multiple chronic conditions, higher disease stage, lower productive activities, and older age need better access to medical care and closer monitoring of the quality of their care, including self-care. To capture the full extent of the involvement of survivors in all types of productive activities, research should routinely include measures of employment, searching for employment, homemaking, and volunteering. Counting market and nonmarket productive activities is innovative and recognizes the continuum of contributions survivors make to families and society. Health care systems should routinely monitor rectal cancer survivors’ medical care access, comorbidities, health-related quality of life, and productive activities. PMID:29236653

Methods for assessing fracture risk prediction models: experience with FRAX in a large integrated health care delivery system.

PubMed

Pressman, Alice R; Lo, Joan C; Chandra, Malini; Ettinger, Bruce

2011-01-01

Area under the receiver operating characteristics (AUROC) curve is often used to evaluate risk models. However, reclassification tests provide an alternative assessment of model performance. We performed both evaluations on results from FRAX (World Health Organization Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, UK), a fracture risk tool, using Kaiser Permanente Northern California women older than 50yr with bone mineral density (BMD) measured during 1997-2003. We compared FRAX performance with and without BMD in the model. Among 94,489 women with mean follow-up of 6.6yr, 1579 (1.7%) sustained a hip fracture. Overall, AUROCs were 0.83 and 0.84 for FRAX without and with BMD, suggesting that BMD did not contribute to model performance. AUROC decreased with increasing age, and BMD contributed significantly to higher AUROC among those aged 70yr and older. Using an 81% sensitivity threshold (optimum level from receiver operating characteristic curve, corresponding to 1.2% cutoff), 35% of those categorized above were reassigned below when BMD was added. In contrast, only 10% of those categorized below were reassigned to the higher risk category when BMD was added. The net reclassification improvement was 5.5% (p<0.01). Two versions of this risk tool have similar AUROCs, but alternative assessments indicate that addition of BMD improves performance. Multiple methods should be used to evaluate risk tool performance with less reliance on AUROC alone. Copyright © 2011 The International Society for Clinical Densitometry. Published by Elsevier Inc. All rights reserved.

Associations Between Maternal Pregravid Obesity and Gestational Diabetes and the Timing of Pubarche in Daughters

PubMed Central

Kubo, Ai; Ferrara, Assiamira; Laurent, Cecile A.; Windham, Gayle C.; Greenspan, Louise C.; Deardorff, Julianna; Hiatt, Robert A.; Quesenberry, Charles P.; Kushi, Lawrence H.

2016-01-01

Abstract We investigated whether in utero exposure to maternal pregravid obesity and/or gestational diabetes mellitus (GDM) was associated with early puberty in girls. We used data from a longitudinal study of 421 mother-daughter pairs enrolled in an integrated health services organization, Kaiser Permanente Northern California (2005–2012). Girls aged 6–8 years were followed annually through ages 12–14 years. Onset of puberty was assessed using study clinic-based Tanner staging. We examined associations of self-reported pregravid obesity and maternal GDM with timing of the daughter's transition to pubertal maturation stage 2 or above for development of breasts and pubic hair, using accelerated failure time regression models with interval censoring to estimate time ratios and hazard ratios and corresponding 95% confidence intervals. Maternal obesity (pregravid body mass index (BMI; weight (kg)/height (m)2) ≥30) was associated with a daughter's earlier transition to breast and pubic hair stage 2+ in comparison with girls whose mothers had pregravid BMI <25. These associations were attenuated and not statistically significant after adjustment for covariates. Girls whose mothers had both pregravid BMI ≥25 and GDM were at higher risk of an earlier transition to pubic hair stage 2+ than those whose mothers had neither condition (adjusted time ratio = 0.89, 95% confidence interval: 0.83, 0.96; hazard ratio = 2.97, 95% confidence interval: 1.52, 5.83). These findings suggest that exposure to maternal obesity and hyperglycemia places girls at higher risk of earlier pubarche. PMID:27268032

Impact of social and built environment factors on body size among breast cancer survivors: the Pathways Study

PubMed Central

Shariff-Marco, Salma; Von Behren, Julie; Reynolds, Peggy; Keegan, Theresa H. M.; Hertz, Andrew; Kwan, Marilyn L.; Roh, Janise M.; Thomsen, Catherine; Kroenke, Candyce H.; Ambrosone, Christine; Kushi, Lawrence H.; Gomez, Scarlett Lin

2017-01-01

Background As social and built environment factors have been shown to be associated with physical activity, dietary patterns, and obesity in the general population, they likely also influence these health behaviors among cancer survivors, and thereby impact survivorship outcomes. Methods Enhancing the rich, individual-level survey and medical record data from 4,505 breast cancer survivors in the Pathways Study, a prospective cohort drawn from Kaiser Permanente Northern California, we geocoded baseline residential addresses and appended social and built environment data. With multinomial logistic models, we examined associations between neighborhood characteristics and body mass index and whether neighborhood factors explained racial/ethnic/nativity disparities in overweight/obesity. Results Low neighborhood socioeconomic status, high minority composition, high traffic density, high prevalence of commuting by car, and a higher number of fast food restaurants were independently associated with higher odds of overweight or obesity. The higher odds of overweight among African Americans, US-born Asian Americans/Pacific Islanders and foreign-born Hispanics and the higher odds of obesity among African Americans and US-born Hispanics, compared to non-Hispanic Whites, remained significant though somewhat attenuated when accounting for social and built environment features. Conclusions Addressing aspects of neighborhood environments may help breast cancer survivors maintain a healthy body weight. Impact Further research in this area, such as incorporating data on individuals’ perceptions and use of their neighborhood environments, is needed to ultimately inform multilevel interventions that would ameliorate such disparities and improve outcomes for breast cancer survivors, regardless of their social status (e.g., race/ethnicity, socioeconomic status, nativity). PMID:28154107

Comparing Hospital Processes and Outcomes in California Medicare Beneficiaries: Simulation Prompts Reconsideration

PubMed Central

Escobar, Gabriel J; Baker, Jennifer M; Turk, Benjamin J; Draper, David; Liu, Vincent; Kipnis, Patricia

2017-01-01

Introduction This article is not a traditional research report. It describes how conducting a specific set of benchmarking analyses led us to broader reflections on hospital benchmarking. We reexamined an issue that has received far less attention from researchers than in the past: How variations in the hospital admission threshold might affect hospital rankings. Considering this threshold made us reconsider what benchmarking is and what future benchmarking studies might be like. Although we recognize that some of our assertions are speculative, they are based on our reading of the literature and previous and ongoing data analyses being conducted in our research unit. We describe the benchmarking analyses that led to these reflections. Objectives The Centers for Medicare and Medicaid Services’ Hospital Compare Web site includes data on fee-for-service Medicare beneficiaries but does not control for severity of illness, which requires physiologic data now available in most electronic medical records. To address this limitation, we compared hospital processes and outcomes among Kaiser Permanente Northern California’s (KPNC) Medicare Advantage beneficiaries and non-KPNC California Medicare beneficiaries between 2009 and 2010. Methods We assigned a simulated severity of illness measure to each record and explored the effect of having the additional information on outcomes. Results We found that if the admission severity of illness in non-KPNC hospitals increased, KPNC hospitals’ mortality performance would appear worse; conversely, if admission severity at non-KPNC hospitals’ decreased, KPNC hospitals’ performance would appear better. Conclusion Future hospital benchmarking should consider the impact of variation in admission thresholds. PMID:29035176

Menopausal hormone therapy and breast cancer phenotype: does dose matter?

PubMed

Garwood, Elisabeth R; Kumar, Anjali S; Shim, Veronica

2008-09-01

Duration and type of menopausal hormone therapy (HT) has been associated with increased breast cancer risk and the development of estrogen receptor (ER)-positive tumors. The effect of HT dose on breast cancer tumor characteristics remains undefined. We sought to determine if HT dosing regimens influence breast cancer phenotype. We conducted a retrospective review of incident female breast cancers occurring in the year 2003 listed in the Kaiser Permanente Northern California Cancer Registry. Type of HT, dose, number of tablets dispensed, tumor phenotype, stage, grade, and histology were obtained from electronic records for women aged >/=50 years who had more than 1 year of uninterrupted pharmacy data (n = 1701). A dose index of HT exposure was created and odds ratios were used to determine if tumor phenotype varied between exposure groups. These results were compared with a previously published analysis of HT duration on tumor phenotype conducted with the same dataset. The cumulative effect of estrogen and progesterone hormone therapy as calculated by factoring both dose and duration of HT use prior to breast cancer diagnosis did not reveal any new associations that were not previously identified by analysis of HT duration of exposure alone. Low-dose-index combination-HT users were less likely to have tumors with an ER-positive phenotype. An overall trend developed in which low- and high-dose-index exposed women had the lowest rates of ER- and progesterone receptor (PR) -positive tumors. Duration of use is an adequate surrogate for determining overall exposure to HT when considering the effect of HT on breast cancer phenotype.

Tumor markers and rectal cancer: support for an inflammation-related pathway

PubMed Central

Slattery, Martha L.; Wolff, Roger K.; Herrick, Jennifer; Caan, Bette J.; Samowitz, Wade

2009-01-01

Inflammation may be a key element in the etiology of colorectal cancer (CRC). In this study we examine associations between factors related to inflammation and specific rectal cancer mutations. A population-based study of 750 rectal cancer cases with interview and tumor DNA were compared to 1205 population-based controls. Study participants were from Utah and the Northern California Kaiser Permanente Medical Care Program. Tumor DNA was analyzed for TP53 and KRAS2 mutations and CpG Island methylator phenotype (CIMP). We assessed how these tumor markers were associated with use of anti-inflammatory drugs, polymorphisms in the IL6 genes (rs1800795 and rs1800796), and dietary antioxidants. Ibuprofen-type drugs, IL6 polymorphisms (rs1800796), and dietary alpha tocopherol and lycopene significantly altered likelihood of having a TP53 mutation. This was especially true for TP53 transversion mutations and dietary antioxidants (OR for beta carotene 0.51 95% CI 0.27,0.97, p trend 0.03; alpha tocopherol 0.41 95% CI 0.20,0.84, p trend 0.02) Beta carotene and ibuprofen significantly altered risk of KRAS2 tumors. The associations between lutein and tocopherol and TP53 and KRAS2 mutations were modified by IL6 genotype. These results suggest that inflammation-related factors may have unique associations with various rectal tumor markers. Many factors involved in an inflammation related pathway were associated with TP53 mutations and some dietary factors appeared to be modified by IL6 genotype. PMID:19452524

Evaluation of Patient and Proxy Responses on the Activity Measure for Post Acute Care

PubMed Central

Jette, Alan M.; Ni, Pengsheng; Rasch, Elizabeth K.; Appelman, Jed; Sandel, M. Elizabeth; Terdiman, Joseph; Chan, Leighton

2012-01-01

Background and Purpose Our objective was to examine the agreement between adult patients with stroke and family member or clinician proxies in Activity Measure for Post Acute Care (AM-PAC) summary scores for daily activity, basic mobility, and applied cognitive function. Methods This study involved 67 patients with stroke admitted to a hospital within the Kaiser Permanente of Northern California system and were participants in a parent study on stroke outcomes. Each participant and proxy respondent completed the AM-PAC by personal or telephone interview at the point of hospital discharge and/or during one or more transitions to different post-acute care settings. Results The results suggest that for patients with a stroke proxy AM-PAC data are robust for family or clinician proxy assessment of basic mobility function, clinician proxy assessment of daily activity function, but less robust for family proxy assessment of daily activity function and for all proxy groups’ assessment of applied cognitive function. The pattern of disagreement between patient and proxy was, on average, relatively small and random. There was little evidence of systematic bias between proxy and patient reports of their functional status. The degree of concordance between patient and proxy was similar for those with moderate to severe strokes compared with mild strokes. Conclusions Patient and proxy ratings on the AM-PAC achieved adequate agreement for use in stroke research where using proxy respondents could reduce sample selection bias. The AM-PAC data can be implemented across institutional as well as community care settings while achieving precision and reducing respondent burden. PMID:22343646

Twelve-Step affiliation and 3-year substance use outcomes among adolescents: social support and religious service attendance as potential mediators.

PubMed

Chi, Felicia W; Kaskutas, Lee A; Sterling, Stacy; Campbell, Cynthia I; Weisner, Constance

2009-06-01

Twelve-Step affiliation among adolescents is little understood. We examined 12-Step affiliation and its association with substance use outcomes 3 years post-treatment intake among adolescents seeking chemical dependency (CD) treatment in a private, managed-care health plan. We also examined the effects of social support and religious service attendance on the relationship. We analyzed data for 357 adolescents, aged 13-18, who entered treatment at four Kaiser Permanente Northern California CD programs between March 2000 and May 2002 and completed both baseline and 3-year follow-up interviews. Measures at follow-up included alcohol and drug use, 12-Step affiliation, social support and frequency of religious service attendance. At 3 years, 68 adolescents (19%) reported attending any 12-Step meetings, and 49 (14%) reported involvement in at least one of seven 12-Step activities, in the previous 6 months. Multivariate logistic regression analyses indicated that after controlling individual and treatment factors, 12-Step attendance at 1 year was marginally significant, while 12-Step attendance at 3 years was associated with both alcohol and drug abstinence at 3 years [odds ratio (OR) 2.58, P < 0.05 and OR 2.53, P < 0.05, respectively]. Similarly, 12-Step activity involvement was associated significantly with 30-day alcohol and drug abstinence. There are possible mediating effects of social support and religious service attendance on the relationship between post-treatment 12-Step affiliation and 3-year outcomes. The findings suggest the importance of 12-Step affiliation in maintaining long-term recovery, and help to understand the mechanism through which it works among adolescents.

A comparison of lifestyle and behavioral cardiovascular disease risk factors between Asian Indian and White non-Hispanic men.

PubMed

Ghai, Nirupa R; Jacobsen, Steven J; Van Den Eeden, Stephen K; Ahmed, Ameena T; Haque, Reina; Rhoads, George G; Quinn, Virginia P

2012-01-01

We compared lifestyle CVD risk factors between Asian Indian and White non-Hispanic men within categories of BMI. Participants included 51,901 White non-Hispanic men and 602 Asian Indian men enrolled in the California Men's Health Study cohort. Men were aged 45-69 years and members of Kaiser Permanente Southern or Northern California at baseline (2001-2002). Lifestyle characteristics including diet, physical activity, alcohol intake and smoking were collected from a survey. Multivariable logistic regression, adjusting for demographics, was performed. Asian Indians more often reported a healthy BMI (18.5-24.9), and consumed < 30% calories from fat within each BMI category (healthy weight and overweight/obese). Among healthy weight men, Asian Indians were less likely to eat -5 fruit and vegetables a day. Overall, Asian Indians were more likely to have never smoked and to abstain from alcohol. Asian Indians were less likely to report moderate/vigorous physical activity > or = 3.5 hours/week. No differences were found in sedentary activity. We identified health behaviors that were protective (lower fat intake, lower levels of smoking and alcohol) and harmful (lower levels of physical activity and fruit and vegetable intake) for cardiovascular health among the Asian Indians in comparison to White non-Hispanics. Results stratified by BMI were similar to those overall. However, the likelihood of consuming a low fat diet was lower among healthy weight men, while fruit and vegetable consumption, physical activity and alcohol intake was greater. These results suggest risk factors other than lifestyle behaviors may be important contributors to CVD in the Asian Indian population.

The comparative effectiveness of mail order pharmacy use vs. local pharmacy use on LDL-C control in new statin users.

PubMed

Schmittdiel, Julie A; Karter, Andrew J; Dyer, Wendy; Parker, Melissa; Uratsu, Connie; Chan, James; Duru, O Kenrik

2011-12-01

Mail order pharmacies are commonly used to deliver CVD risk factor medications. Previous studies have shown that mail order pharmacy use is associated with greater medication adherence; however, no studies have examined whether mail order pharmacy use is related to improved CVD risk factor outcomes. To examine the comparative effectiveness of mail order pharmacy vs. local pharmacy use on LDL-C control in new statin users. Observational cohort study. 100,298 adult Kaiser Permanente Northern California (KPNC) members who were new users of statins between January 1, 2005 and December 31, 2007. The main outcome measure was LDL-C control in the 3-15 month period after statin therapy was initiated. After adjustment for patient, clinical, and census-block characteristics, and for potential unmeasured differences between mail order and local KPNC pharmacy users with instrumental variables analysis, 85.0% of patients who used the mail order pharmacy to deliver their statin at any time achieved target LDL-C levels compared with 74.2% of patients who only used the local KPNC pharmacy to dispense the statin (p < 0.001). Greater adjusted rates of LDL-C control in mail order pharmacy users were seen across all gender and race/ethnicity subgroups. Mail order pharmacy use was positively associated with LDL-C control in new statin users. Future research should continue to explore the relationship between mail order pharmacy use and outcomes, and address how to appropriately target mail order services to patients most likely to benefit without compromising patient choice, care, and safety.

The Multigroup Ethnic Identity Measure-Revised: Measurement invariance across racial and ethnic groups

PubMed Central

Brown, Susan D.; Unger Hu, Kirsten A.; Mevi, Ashley A.; Hedderson, Monique M.; Shan, Jun; Quesenberry, Charles P.; Ferrara, Assiamira

2014-01-01

The Multigroup Ethnic Identity Measure-Revised (MEIM-R), a brief instrument assessing affiliation with one’s ethnic group, is a promising advance in the ethnic identity literature. However, equivalency of its measurement properties across specific racial and ethnic groups should be confirmed before using it in diverse samples. We examined a) the psychometric properties of the MEIM-R including factor structure, measurement invariance, and internal consistency reliability, and b) levels of and differences in ethnic identity across multiple racial and ethnic groups and subgroups. Asian (n = 630), Black/African American (n = 58), Hispanic (n = 240), multiethnic (n = 160), and White (n = 375) women completed the MEIM-R as part of the “Gestational diabetes’ Effect on Moms” diabetes prevention trial in the Kaiser Permanente Northern California health care setting (N = 1,463; M age 32.5 years, SD = 4.9). Multiple-groups confirmatory factor analyses provided provisional evidence of measurement invariance, i.e., an equal, correlated two-factor structure, equal factor loadings, and equal item intercepts across racial and ethnic groups. Latent factor means for the two MEIM-R subscales, exploration and commitment, differed across groups; effect sizes ranging from small to large generally supported the notion of ethnic identity as more salient among people of color. Pending replication, good psychometric properties in this large and diverse sample of women support the future use of the MEIM-R. Preliminary evidence of measurement invariance suggests that the MEIM-R could be used to measure and compare ethnic identity across multiple racial and ethnic groups. PMID:24188656

Serious infections among a large cohort of subjects with systemically treated psoriasis.

PubMed

Dobry, Allison S; Quesenberry, Charles P; Ray, G Thomas; Geier, Jamie L; Asgari, Maryam M

2017-11-01

Biologic therapy is effective for treatment of moderate-to-severe psoriasis but may be associated with an increased risk for serious infection. To estimate the serious infection rate among patients with psoriasis treated with biologic as compared with nonbiologic systemic agents within a community-based health care delivery setting. We identified 5889 adult Kaiser Permanente Northern California health plan members with psoriasis who had ever been treated with systemic therapies and calculated the incidence rates and 95% confidence intervals (CIs) for serious infections over 29,717 person-years of follow-up. Adjusted hazard ratios (aHRs) were calculated using Cox regression. Adjusting for age, sex, race or ethnicity, and comorbidities revealed a significantly increased risk for overall serious infection among patients treated with biologics as compared with those treated with nonbiologics (aHR, 1.31; 95% CI, 1.02-1.68). More specifically, there was a significantly elevated risk for skin and soft tissue infection (aHR, 1.75; 95% CI, 1.19-2.56) and meningitis (aHR, 9.22; 95% CI, 1.77-48.10) during periods of active biologic use. Risk associated with individual drugs was not examined. We found an increased rate of skin and soft tissue infections among patients with psoriasis treated with biologic agents. There also was a signal suggesting increased risk for meningitis. Clinicians should be aware of these potential adverse events when prescribing biologic agents. Copyright © 2017 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.

12-Step participation reduces medical use costs among adolescents with a history of alcohol and other drug treatment.

PubMed

Mundt, Marlon P; Parthasarathy, Sujaya; Chi, Felicia W; Sterling, Stacy; Campbell, Cynthia I

2012-11-01

Adolescents who attend 12-step groups following alcohol and other drug (AOD) treatment are more likely to remain abstinent and to avoid relapse post-treatment. We examined whether 12-step attendance is also associated with a corresponding reduction in health care use and costs. We used difference-in-difference analysis to compare changes in seven-year follow-up health care use and costs by changes in 12-step participation. Four Kaiser Permanente Northern California AOD treatment programs enrolled 403 adolescents, 13-18-years old, into a longitudinal cohort study upon AOD treatment entry. Participants self-reported 12-step meeting attendance at six-month, one-year, three-year, and five-year follow-up. Outcomes included counts of hospital inpatient days, emergency room (ER) visits, primary care visits, psychiatric visits, AOD treatment costs and total medical care costs. Each additional 12-step meeting attended was associated with an incremental medical cost reduction of 4.7% during seven-year follow-up. The medical cost offset was largely due to reductions in hospital inpatient days, psychiatric visits, and AOD treatment costs. We estimate total medical use cost savings at $145 per year (in 2010 U.S. dollars) per additional 12-step meeting attended. The findings suggest that 12-step participation conveys medical cost offsets for youth who undergo AOD treatment. Reduced costs may be related to improved AOD outcomes due to 12-step participation, improved general health due to changes in social network following 12-step participation, or better compliance to both AOD treatment and 12-step meetings. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Long-term effectiveness of varicella vaccine: a 14-Year, prospective cohort study.

PubMed

Baxter, Roger; Ray, Paula; Tran, Trung N; Black, Steve; Shinefield, Henry R; Coplan, Paul M; Lewis, Edwin; Fireman, Bruce; Saddier, Patricia

2013-05-01

Varicella vaccine was licensed in the United States in 1995 for individuals ≥12 months of age. A second dose was recommended in the United States in June 2006. Varicella incidence and vaccine effectiveness were assessed in a 14-year prospective study conducted at Kaiser Permanente Northern California. A total of 7585 children vaccinated with varicella vaccine in their second year of life in 1995 were followed up prospectively for breakthrough varicella and herpes zoster (HZ) through 2009. A total of 2826 of these children received a second dose in 2006-2009. Incidences of varicella and HZ were estimated and compared with prevaccine era rates. In this cohort of vaccinated children, the average incidence of varicella was 15.9 per 1000 person-years, nine- to tenfold lower than in the prevaccine era. Vaccine effectiveness at the end of the study period was 90%, with no indication of waning over time. Most cases of varicella were mild and occurred early after vaccination. No child developed varicella after a second dose. HZ cases were mild, and rates were lower in the cohort of vaccinated children than in unvaccinated children during the prevaccine era (relative risk: 0.61 [95% confidence interval: 0.43-0.89]). This study confirmed that varicella vaccine is effective at preventing chicken pox, with no waning noted over a 14-year period. One dose provided excellent protection against moderate to severe disease, and most cases occurred shortly after the cohort was vaccinated. The study data also suggest that varicella vaccination may reduce the risks of HZ in vaccinated children.

Colon Cancer Survival With Herbal Medicine and Vitamins Combined With Standard Therapy in a Whole-Systems Approach: Ten-Year Follow-up Data Analyzed With Marginal Structural Models and Propensity Score Methods

PubMed Central

McCulloch, Michael; Broffman, Michael; van der Laan, Mark; Hubbard, Alan; Kushi, Lawrence; Abrams, Donald I.; Gao, Jin; Colford, John M.

2014-01-01

Although localized colon cancer is often successfully treated with surgery, advanced disease requires aggressive systemic therapy that has lower effectiveness. Approximately 30% to 75% of patients with colon cancer use complementary and alternative medicine (CAM), but there is limited formal evidence of survival efficacy. In a consecutive case series with 10-year follow-up of all colon cancer patients (n = 193) presenting at a San Francisco Bay-Area center for Chinese medicine (Pine Street Clinic, San Anselmo, CA), the authors compared survival in patients choosing short-term treatment lasting the duration of chemotherapy/radiotherapy with those continuing long-term. To put these data into the context of treatment responses seen in conventional medical practice, they also compared survival with Pan-Asian medicine + vitamins (PAM+V) with that of concurrent external controls from Kaiser Permanente Northern California and California Cancer Registries. Kaplan-Meier, traditional Cox regression, and more modern methods were used for causal inference—namely, propensity score and marginal structural models (MSMs), which have not been used before in studies of cancer survival and Chinese herbal medicine. PAM+V combined with conventional therapy, compared with conventional therapy alone, reduced the risk of death in stage I by 95%, stage II by 64%, stage III by 29%, and stage IV by 75%. There was no significant difference between short-term and long-term PAM+V. Combining PAM+V with conventional therapy improved survival, compared with conventional therapy alone, suggesting that prospective trials combining PAM+V with conventional therapy are justified. PMID:21964510

Benefits and harms of lung cancer screening in HIV-infected individuals with CD4+ ≥ 500: a simulation study.

PubMed

Kong, Chung Yin; Sigel, Keith; Criss, Steven D; Sheehan, Deirdre F; Triplette, Matthew; Silverberg, Michael J; Henschke, Claudia I; Justice, Amy; Braithwaite, R Scott; Wisnivesky, Juan; Crothers, Kristina

2018-04-19

Lung cancer is the leading cause of non-AIDS-defining cancer deaths among HIV-infected individuals. Although lung cancer screening with low-dose computed tomography (LDCT) is endorsed by multiple national organizations, whether HIV-infected individuals would have similar benefit as uninfected individuals from lung cancer screening is unknown. Our objective was to determine the benefits and harms of lung cancer screening among HIV-infected individuals. We modified an existing simulation model, the Lung Cancer Policy Model, for HIV-infected patients. Veterans Aging Cohort Study, Kaiser Permanente Northern California HIV Cohort, and medical literature. Target population: HIV-infected current and former smokers. Lifetime. Population. Annual LDCT screening from ages 45, 50, or 55 until ages 72 or 77 years. Benefits assessed included lung cancer mortality reduction and life-years gained; harms assessed included numbers of LDCT examinations, false-positive results, and overdiagnosed cases. For HIV-infected patients with CD4 at least 500 and 100% antiretroviral therapy adherence, screening using the Centers for Medicare & Medicaid Services criteria (age 55-77, 30 pack-years of smoking, current smoker or quit within 15 years of screening) would reduce lung cancer mortality by 18.9%, similar to the mortality reduction of uninfected individuals. Alternative screening strategies utilizing lower screening age and/or pack-years criteria increase mortality reduction, but require more LDCT examinations. Strategies assumed 100% screening adherence. Lung cancer screening reduces mortality in HIV-infected patients with CD4 at least l500, with a number of efficient strategies for eligibility, including the current Centers for Medicare & Medicaid Services criteria.

Comparing Hospital Processes and Outcomes in California Medicare Beneficiaries: Simulation Prompts Reconsideration.

PubMed

Escobar, Gabriel J; Baker, Jennifer M; Turk, Benjamin J; Draper, David; Liu, Vincent; Kipnis, Patricia

2017-01-01

This article is not a traditional research report. It describes how conducting a specific set of benchmarking analyses led us to broader reflections on hospital benchmarking. We reexamined an issue that has received far less attention from researchers than in the past: How variations in the hospital admission threshold might affect hospital rankings. Considering this threshold made us reconsider what benchmarking is and what future benchmarking studies might be like. Although we recognize that some of our assertions are speculative, they are based on our reading of the literature and previous and ongoing data analyses being conducted in our research unit. We describe the benchmarking analyses that led to these reflections. The Centers for Medicare and Medicaid Services' Hospital Compare Web site includes data on fee-for-service Medicare beneficiaries but does not control for severity of illness, which requires physiologic data now available in most electronic medical records.To address this limitation, we compared hospital processes and outcomes among Kaiser Permanente Northern California's (KPNC) Medicare Advantage beneficiaries and non-KPNC California Medicare beneficiaries between 2009 and 2010. We assigned a simulated severity of illness measure to each record and explored the effect of having the additional information on outcomes. We found that if the admission severity of illness in non-KPNC hospitals increased, KPNC hospitals' mortality performance would appear worse; conversely, if admission severity at non-KPNC hospitals' decreased, KPNC hospitals' performance would appear better. Future hospital benchmarking should consider the impact of variation in admission thresholds.

Cohort Study of ECG Left Ventricular Hypertrophy Trajectories: Ethnic Disparities, Associations With Cardiovascular Outcomes, and Clinical Utility.

PubMed

Iribarren, Carlos; Round, Alfred D; Lu, Meng; Okin, Peter M; McNulty, Edward J

2017-10-05

ECG left ventricular hypertrophy (LVH) is a well-known predictor of cardiovascular disease. However, no prior study has characterized patterns of presence/absence of ECG LVH ("ECG LVH trajectories") across the adult lifespan in both sexes and across ethnicities. We examined: (1) correlates of ECG LVH trajectories; (2) the association of ECG LVH trajectories with incident coronary heart disease, transient ischemic attack, ischemic stroke, hemorrhagic stroke, and heart failure; and (3) reclassification of cardiovascular disease risk using ECG LVH trajectories. We performed a cohort study among 75 412 men and 107 954 women in the Northern California Kaiser Permanente Medical Care Program who had available longitudinal exposures of ECG LVH and covariates, followed for a median of 4.8 (range <1-9.3) years. ECG LVH was measured by Cornell voltage-duration product. Adverse trajectories of ECG LVH (persistent, new development, or variable pattern) were more common among blacks and Native American men and were independently related to incident cardiovascular disease with hazard ratios ranging from 1.2 for ECG LVH variable pattern and transient ischemic attack in women to 2.8 for persistent ECG LVH and heart failure in men. ECG LVH trajectories reclassified 4% and 7% of men and women with intermediate coronary heart disease risk, respectively. ECG LVH trajectories were significant indicators of coronary heart disease, stroke, and heart failure risk, independently of level and change in cardiovascular disease risk factors, and may have clinical utility. © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

Effect of non-steroidal anti-inflammatory medications on the risk of amyotrophic lateral sclerosis.

PubMed

Popat, Rita A; Tanner, Caroline M; van den Eeden, Stephen K; Bernstein, Allan L; Bloch, Daniel A; Leimpeter, Amethyst; McGuire, Valerie; Nelson, Lorene M

2007-06-01

Inflammatory processes may be involved in the pathogenesis of amyotrophic lateral sclerosis (ALS). We examined the association of non-steroidal anti-inflammatory drugs (NSAIDs) with the risk of ALS in case-control study of incident cases (n = 111) conducted within the Kaiser Permanente Medical Care Program of Northern California during the years 1996-2000. Controls (n = 258) randomly selected from the same population were frequency matched by age and gender to the ALS cases. Information regarding use of NSAIDs (non-aspirin and aspirin) and three classes of 'control' medications was collected by in-person structured interview. Subjects who used medication at least twice a week for at least a month were classified as 'ever users'. Multivariable logistic regression models were adjusted for age, gender, history of osteoarthritis/rheumatoid arthritis and pain, and other medication use. Overall, there was no association between NSAID use and ALS; however, some sex differences were noted for non-aspirin NSAID use. Among men, non-aspirin NSAID use was associated with a two-fold increased risk of ALS (adjusted odds ratio (OR) 2.0, 95% confidence interval (CI) 1.0-3.9), whereas among women, non-aspirin NSAID use was not associated with increased ALS risk (adjusted OR 0.5, 95% CI 0.2-1.2). ALS risk was not associated with aspirin use or with 'control' medications. This study did not find any evidence to suggest that NSAID use reduces the risk of ALS. The observed sex differences with non-aspirin NSAID use could be due to chance or an unmeasured confounder.

Failure Modes and Effects Analysis of bilateral same-day cataract surgery

PubMed Central

Shorstein, Neal H.; Lucido, Carol; Carolan, James; Liu, Liyan; Slean, Geraldine; Herrinton, Lisa J.

2017-01-01

PURPOSE To systematically analyze potential process failures related to bilateral same-day cataract surgery toward the goal of improving patient safety. SETTING Twenty-one Kaiser Permanente surgery centers, Northern California, USA. DESIGN Retrospective cohort study. METHODS Quality experts performed a Failure Modes and Effects Analysis (FMEA) that included an evaluation of sterile processing, pharmaceuticals, perioperative clinic and surgical center visits, and biometry. Potential failures in human factors and communication (modes) were identified. Rates of endophthalmitis, toxic anterior segment syndrome (TASS), and unintended intraocular lens (IOL) implantation were assessed in eyes having bilateral same-day surgery from 2010 through 2014. RESULTS The study comprised 4754 eyes. The analysis identified 15 significant potential failure modes. These included lapses in instrument processing and compounding error of intracameral antibiotic that could lead to endophthalmitis or TASS and ambiguous documentation of IOL selection by surgeons, which could lead to unintended IOL implantation. Of the study sample, 1 eye developed endophthalmitis, 1 eye had unintended IOL implantation (rates, 2 per 10 000; 95% confidence intervals [CI] 0.1–12.0 per 10 000), and no eyes developed TASS (upper 95% CI, 8 per 10 000). Recommendations included improving oversight of cleaning and sterilization practices, separating lots of compounded drugs for each eye, and enhancing IOL verification procedures. CONCLUSIONS Potential failure modes and recommended actions in bilateral same-day cataract surgery were determined using a FMEA. These findings might help improve the reliability and safety of bilateral same-day cataract surgery based on current evidence and standards. PMID:28410711

Low Risk of Cervical Cancer/Precancer Among Most Women Under Surveillance Postcolposcopy.

PubMed

Demarco, Maria; Cheung, Li C; Kinney, Walter K; Wentzensen, Nicolas; Lorey, Thomas S; Fetterman, Barbara; Poitras, Nancy E; Befano, Brian; Castle, Philip E; Schiffman, Mark

2018-04-01

To inform impending postcolposcopy guidelines, this analysis examined the subsequent risk of CIN 3+ among women with a grade lower than CIN 2 (< CIN 2) colposcopy results, taking into account the referring results that brought them to colposcopy and cotest results postcolposcopy. We analyzed 107,005 women from 25 to 65 years old, recommended for colposcopy at Kaiser Permanente Northern California. We estimated absolute risks of CIN 3+ among women: (1) recommended for colposcopy (precolposcopy), (2) following colposcopy and with histology results < CIN 2 (postcolposcopy), and (3) with cotest results 12 months after a < CIN 2 colposcopy (return cotest). After colposcopy showing < CIN 2 (n = 69,790; 87% of the women at colposcopy), the 1-year risk of CIN 3+ was 1.2%, compared with 6.3% at the time of colposcopy recommendation. Negative cotest results 1 year after colposcopy identified a large group (37.1%) of women whose risk of CIN 3+ (i.e., <0.2% at 3 years after postcolposcopy cotest) was comparable with women with normal cytology in the screening population. These risks are consistent with current guidelines recommending repeat cotesting 12 months after colposcopy < CIN 2 and a 3-year return for women with a negative postcolposcopy cotest. Most women are at low risk of subsequent CIN 3+ after a colposcopy showing < CIN 2, especially those who are human papillomavirus-negative postcolposcopy, consistent with current management guidelines for repeat testing intervals. Before the finalizing the upcoming guidelines, we will consider additional rounds of postcolposcopy cotesting.

Low Risk of Cervical Cancer/Precancer Among Most Women Under Surveillance Postcolposcopy

PubMed Central

Demarco, Maria; Cheung, Li C.; Kinney, Walter K.; Wentzensen, Nicolas; Lorey, Thomas S.; Fetterman, Barbara; Poitras, Nancy E.; Befano, Brian; Castle, Philip E.; Schiffman, Mark

2018-01-01

Objective To inform impending postcolposcopy guidelines, this analysis examined the subsequent risk of CIN 3+ among women with a grade lower than CIN 2 (< CIN 2) colposcopy results, taking into account the referring results that brought them to colposcopy and cotest results postcolposcopy. Methods We analyzed 107,005 women from 25 to 65 years old, recommended for colposcopy at Kaiser Permanente Northern California. We estimated absolute risks of CIN 3+ among women: (1) recommended for colposcopy (precolposcopy), (2) following colposcopy and with histology results < CIN 2 (postcolposcopy), and (3) with cotest results 12 months after a < CIN 2 colposcopy (return cotest). Results After colposcopy showing < CIN 2 (n = 69,790; 87% of the women at colposcopy), the 1-year risk of CIN 3+ was 1.2%, compared with 6.3% at the time of colposcopy recommendation. Negative cotest results 1 year after colposcopy identified a large group (37.1%) of women whose risk of CIN 3+ (i.e., <0.2% at 3 years after postcolposcopy cotest) was comparable with women with normal cytology in the screening population. These risks are consistent with current guidelines recommending repeat cotesting 12 months after colposcopy < CIN 2 and a 3-year return for women with a negative postcolposcopy cotest. Conclusions Most women are at low risk of subsequent CIN 3+ after a colposcopy showing < CIN 2, especially those who are human papillomavirus–negative postcolposcopy, consistent with current management guidelines for repeat testing intervals. Before the finalizing the upcoming guidelines, we will consider additional rounds of postcolposcopy cotesting. PMID:29570564

Evaluation of a Therapeutic Interchange from Fluticasone/Salmeterol to Mometasone/Formoterol in Patients with Chronic Obstructive Pulmonary Disease.

PubMed

Yip, Elaine; Karimi, Sahar; Pien, Linda T

2016-04-01

Combination treatment with an inhaled corticosteroid and long-acting beta2-agonist is among the many treatment options for chronic obstructive pulmonary disease (COPD) that has been shown to improve clinical outcomes. While mometasone/formoterol does not currently have an FDA-approved indication for COPD, evidence from 2 phase 3 trials demonstrated that mometasone/formoterol can improve lung function and was well tolerated in patients with moderate-to-very severe COPD. Based on these data, a therapeutic interchange was implemented in the Kaiser Permanente Mid-Atlantic States region to convert patients with a COPD diagnosis from fluticasone/salmeterol to mometasone/formoterol. To evaluate the impact of a therapeutic interchange from fluticasone/salmeterol to mometasone/formoterol on health outcomes in patients with COPD in a large ambulatory and managed care setting. The investigators retrospectively reviewed the electronic medical records of patients with a COPD diagnosis who had a prescription for fluticasone/salmeterol converted to mometasone/formoterol between March 6, 2011, to March 6, 2013. Kaiser Permanente's Pharmacy and Therapeutics Committee provided recommended equivalent doses for conversion from fluticasone/salmeterol to mometasone/formoterol. Nonetheless, the final approval for the change in medication and selection of the dose was left to each physician's clinical judgment. Patients were excluded if they were (a) prescribed fluticasone/salmeterol 100/50 mcg, which has no equivalent mometasone/formoterol dose; (b) less than aged 18 years; or (c) prescribed fluticasone/salmeterol for a duration of less than 6 months preconversion to mometasone/formoterol. In addition, patients who left the Kaiser Permanente network or became deceased during the study period of interest were excluded. After the application of the inclusion and exclusion criteria, 521 patients were included in the data analysis. The primary endpoint was the determination of the difference

Changes in School Food Preparation Methods Result in Healthier Cafeteria Lunches in Elementary Schools.

PubMed

Behrens, Timothy K; Liebert, Mina L; Peterson, Hannah J; Howard Smith, Jennifer; Sutliffe, Jay T; Day, Aubrey; Mack, Jodi

2018-05-01

The purpose of this study is to examine the impact of a districtwide food best practices and preparation changes in elementary schools lunches, implemented as part of the LiveWell@School childhood obesity program, funded by LiveWell Colorado/Kaiser Permanente Community Health Initiative. Longitudinal study examining how school changes in best practices for food preparation impacted the types of side items offered from 2009 to 2015 in elementary school cafeterias in a high-need school district in southern Colorado. Specifically, this study examined changes in side items (fruits, vegetables, potatoes, breads, and desserts). In Phase 1 (2009-2010), baseline data were collected. During Phase 2 (2010-2011), breaded and processed foods (e.g., frozen nuggets, pre-packaged pizza) were removed and school chefs were trained on scratch cooking methods. Phase 3 (2011-2012) saw an increased use of fresh/frozen fruits and vegetables after a new commodity order. During Phase 4 (2013-2015), chef consulting and training took place. The frequency of side offerings was tracked across phases. Analyses were completed in Fall 2016. Because of limited sample sizes, data from Phases 2 to 4 (intervention phases) were combined for potatoes and desserts. Descriptive statistics were calculated. After adjusting for length of time for each phase, Pearson chi-square tests were conducted to examine changes in offerings of side items by phase. Fresh fruit offerings increased and canned fruit decreased in Phases 1-4 (p=0.001). A significant difference was observed for vegetables (p=0.001), with raw and steamed vegetables increasing and canned vegetables decreasing from Phase 1 to 4. Fresh potatoes (low in sodium) increased and fried potatoes (high in sodium) decreased from Phase 1 to Phases 2-4 (p=0.001). Breads were eliminated entirely in Phase 2, and dessert changes were not significant (p=0.927). This approach to promoting healthier lunch sides is a promising paradigm for improving elementary

Clinical, Epidemiologic, Histopathologic and Molecular Features of an Unexplained Dermopathy

PubMed Central

Pearson, Michele L.; Selby, Joseph V.; Katz, Kenneth A.; Cantrell, Virginia; Braden, Christopher R.; Parise, Monica E.; Paddock, Christopher D.; Lewin-Smith, Michael R.; Kalasinsky, Victor F.; Goldstein, Felicia C.; Hightower, Allen W.; Papier, Arthur; Lewis, Brian; Motipara, Sarita; Eberhard, Mark L.

2012-01-01

Background Morgellons is a poorly characterized constellation of symptoms, with the primary manifestations involving the skin. We conducted an investigation of this unexplained dermopathy to characterize the clinical and epidemiologic features and explore potential etiologies. Methods A descriptive study was conducted among persons at least 13 years of age and enrolled in Kaiser Permanente Northern California (KPNC) during 2006–2008. A case was defined as the self-reported emergence of fibers or materials from the skin accompanied by skin lesions and/or disturbing skin sensations. We collected detailed epidemiologic data, performed clinical evaluations and geospatial analyses and analyzed materials collected from participants' skin. Results We identified 115 case-patients. The prevalence was 3.65 (95% CI = 2.98, 4.40) cases per 100,000 enrollees. There was no clustering of cases within the 13-county KPNC catchment area (p = .113). Case-patients had a median age of 52 years (range: 17–93) and were primarily female (77%) and Caucasian (77%). Multi-system complaints were common; 70% reported chronic fatigue and 54% rated their overall health as fair or poor with mean Physical Component Scores and Mental Component Scores of 36.63 (SD = 12.9) and 35.45 (SD = 12.89), respectively. Cognitive deficits were detected in 59% of case-patients and 63% had evidence of clinically significant somatic complaints; 50% had drugs detected in hair samples and 78% reported exposure to solvents. Solar elastosis was the most common histopathologic abnormality (51% of biopsies); skin lesions were most consistent with arthropod bites or chronic excoriations. No parasites or mycobacteria were detected. Most materials collected from participants' skin were composed of cellulose, likely of cotton origin. Conclusions This unexplained dermopathy was rare among this population of Northern California residents, but associated with significantly reduced health-related quality of

Clinical, epidemiologic, histopathologic and molecular features of an unexplained dermopathy.

PubMed

Pearson, Michele L; Selby, Joseph V; Katz, Kenneth A; Cantrell, Virginia; Braden, Christopher R; Parise, Monica E; Paddock, Christopher D; Lewin-Smith, Michael R; Kalasinsky, Victor F; Goldstein, Felicia C; Hightower, Allen W; Papier, Arthur; Lewis, Brian; Motipara, Sarita; Eberhard, Mark L

2012-01-01

Morgellons is a poorly characterized constellation of symptoms, with the primary manifestations involving the skin. We conducted an investigation of this unexplained dermopathy to characterize the clinical and epidemiologic features and explore potential etiologies. A descriptive study was conducted among persons at least 13 years of age and enrolled in Kaiser Permanente Northern California (KPNC) during 2006-2008. A case was defined as the self-reported emergence of fibers or materials from the skin accompanied by skin lesions and/or disturbing skin sensations. We collected detailed epidemiologic data, performed clinical evaluations and geospatial analyses and analyzed materials collected from participants' skin. We identified 115 case-patients. The prevalence was 3.65 (95% CI = 2.98, 4.40) cases per 100,000 enrollees. There was no clustering of cases within the 13-county KPNC catchment area (p = .113). Case-patients had a median age of 52 years (range: 17-93) and were primarily female (77%) and Caucasian (77%). Multi-system complaints were common; 70% reported chronic fatigue and 54% rated their overall health as fair or poor with mean Physical Component Scores and Mental Component Scores of 36.63 (SD = 12.9) and 35.45 (SD = 12.89), respectively. Cognitive deficits were detected in 59% of case-patients and 63% had evidence of clinically significant somatic complaints; 50% had drugs detected in hair samples and 78% reported exposure to solvents. Solar elastosis was the most common histopathologic abnormality (51% of biopsies); skin lesions were most consistent with arthropod bites or chronic excoriations. No parasites or mycobacteria were detected. Most materials collected from participants' skin were composed of cellulose, likely of cotton origin. This unexplained dermopathy was rare among this population of Northern California residents, but associated with significantly reduced health-related quality of life. No common underlying medical

Where do teens go to get the 411 on sexual health? A teen intern in clinical research with teens.

PubMed

Reznik, Yana; Tebb, Kathleen

2008-01-01

Research Setting: The research for the study reported here was conducted in conjunction with the Biomedical and Health Sciences Internship for High School Students at the University of California, San Francisco, Department of Pediatrics. The eight-week intensive summer program promotes interest in science, medicine, and health among young people by introducing students to the professional world of science, broadly defined. Interns are expected to assist in a specific research project that addresses a scientific question. They participate in a variety of lectures and are exposed to faculty members, medical students, and college graduates working as research assistants in a rich academic and clinical research setting. This study was conducted within Kaiser Permanente (KP) of Northern California as part of a larger study aimed at increasing Chlamydia screening among sexually active adolescents. It was approved by Committee on Human Research, the institutional review board (IRB) for the University of California, San Francisco and the IRB for KP Northern California. There were two primary objectives of this study: first, we sought to identify where teenagers obtain information about sexual health; second, we examined whether aspects of a clinician's communication style with a teen during a health care visit were associated with the teen choosing that clinician as a primary source of sexual health information (as compared with parents, peers, teachers, the news media, and other sources). Teens who perceived that their clinician communicated with respect and explained information in ways that they could understand were more likely to cite their clinician as a source of sexual health information. Having time alone (confidentiality) with a physician was also associated with teens' selection of a clinician as a primary information source. Whether the clinician asked about sex during the health care visit was significantly associated with males selecting the clinician as a

Outcomes in Treatment for Intradural Spinal Cord Ependymomas

DOE Office of Scientific and Technical Information (OSTI.GOV)

Volpp, P. Brian; Han, Khanh; Kagan, A. Robert

2007-11-15

Purpose: Spinal cord ependymomas are rare tumors, accounting for <2% of all primary central nervous system tumors. This study assessed the treatment outcomes for patients diagnosed with spinal cord ependymomas within the Southern California Kaiser Permanente system. Methods and Materials: We studied 23 patients treated with surgery with or without external beam radiotherapy (EBRT). The local and distant control rates and overall survival rates were determined. Results: The overall local control, overall recurrence, and 9-year overall survival rate was 96%, 17.4%, and 63.9%, respectively. Conclusions: The results of our study indicate that en bloc gross total resection should be themore » initial treatment, with radiotherapy reserved primarily for postoperative cases with unfavorable characteristics such as residual tumor, anaplastic histologic features, or piecemeal resection. Excellent local control and overall survival rates can be achieved using modern microsurgical techniques, with or without local radiotherapy.« less

The mediating sex-specific effect of psychological distress on the relationship between adverse childhood experiences and current smoking among adults

PubMed Central

2012-01-01

Background Research suggests that ACEs have a long-term impact on the behavioral, emotional, and cognitive development of children. These disruptions can lead to adoption of unhealthy coping behaviors throughout the lifespan. The present study sought to examine psychological distress as a potential mediator of sex-specific associations between adverse childhood experiences (ACEs) and adult smoking. Method Data from 7,210 Kaiser-Permanente members in San Diego California collected between April and October 1997 were used. Results Among women, psychological distress mediated a significant portion of the association between ACEs and smoking (21% for emotional abuse, 16% for physical abuse, 15% for physical neglect, 10% for parental separation or divorce). Among men, the associations between ACEs and smoking were not significant. Conclusions These findings suggest that for women, current smoking cessation strategies may benefit from understanding the potential role of childhood trauma. PMID:22788356

Longitudinal Study of New and Prevalent Use of Self-Monitoring of Blood Glucose

PubMed Central

Karter, Andrew J.; Parker, Melissa M.; Moffet, Howard H.; Spence, Michele M.; Chan, James; Ettner, Susan L.; Selby, Joe V.

2008-01-01

OBJECTIVE We sought to assess longitudinal association between self-monitoring of blood glucose (SMBG) and glycemic control in diabetic patients from an integrated health plan (Kaiser Permanente Northern California). RESEARCH DESIGN AND METHODS Longitudinal analyses of glycemic control among 1) 16,091 patients initiating SMBG (new-user cohort) and 2) 15,347 ongoing users of SMBG (prevalent-user cohort). SMBG frequency was based on pharmacy use (number of blood glucose test strips dispensed), and glycemic control was based on HbA1c (A1C). In the new-user cohort, ANCOVA models (pre- and posttest design) were used to assess the effect of initiating SMBG. In the prevalent-user cohort, repeated-measure, mixed-effects models with random-intercept and time-dependent covariates were used to assess changes in SMBG and A1C. All models were stratified by therapy (no medications, oral agents only, or insulin) and adjusted for baseline A1C, sociodemographics, insulin injection frequency, comorbidity index, medication adherence, smoking status, health care use, and provider specialty. RESULTS Greater SMBG practice frequency among new users was associated with a graded decrease in A1C (relative to nonusers) regardless of diabetes therapy (P < 0.0001). Changes in SMBG frequency among prevalent users were associated with an inverse graded change in A1C only among pharmacologically treated patients (P < 0.0001). CONCLUSIONS These observational findings are consistent with short-term benefits of initiating SMBG practice for all patients but continuing benefits only for pharmacologically treated patients. Differences in effectiveness between new versus prevalent users of SMBG have implications for guideline development and interpretation of observational outcomes data. PMID:16873776

Correlates of Quality of Life in Older Adults With Diabetes

PubMed Central

Laiteerapong, Neda; Karter, Andrew J.; Liu, Jennifer Y.; Moffet, Howard H.; Sudore, Rebecca; Schillinger, Dean; John, Priya M.; Huang, Elbert S.

2011-01-01

OBJECTIVE To evaluate associations between health-related quality of life (HRQL) and geriatric syndromes, diabetes complications, and hypoglycemia in older adults with diabetes. RESEARCH DESIGN AND METHODS A race-stratified random sample of 6,317 adults with type 2 or type 1 diabetes, aged 60 to 75 years, enrolled in Kaiser Permanente Northern California, who completed a survey that included a HRQL instrument based on the Short Form 8-item health survey. Administrative records were used to ascertain diagnoses of geriatric syndromes, diabetes complications, and hypoglycemia. Associations were estimated between HRQL and exposures in exposure-specific and combined exposure models (any syndrome, any complication, or hypoglycemia). Conservatively, differences of ≥3 points were considered the minimally important difference in HRQL scores. RESULTS HRQL was lower with nearly all exposures of interest. The lowest physical HRQL was associated with amputation. In combined exposure models, geriatric syndromes (−5.3 [95% CI −5.8 to −4.8], P < 0.001) and diabetes complications (−3.5 [−4.0 to −2.9], P < 0.001) were associated with lower physical HRQL. The lowest mental HRQL was associated with depression, underweight (BMI <18 kg/m2), amputation, and hypoglycemia. In combined exposure models, only hypoglycemia was associated with lower mental HRQL (−4.0 [−7.0 to −1.1], P = 0.008). CONCLUSIONS Geriatric syndromes and hypoglycemia are associated with lower HRQL to a comparable degree as diabetes complications. Addressing geriatric syndromes and avoiding hypoglycemia should be given as high a priority as preventing diabetes complications in older adults with diabetes. PMID:21636795

Improvement of Sexually Transmitted Disease Screening Among HIV-Infected Men Who Have Sex With Men Through Implementation of a Standardized Sexual Risk Assessment Tool.

PubMed

Scarborough, Ashley P; Slome, Sally; Hurley, Leo B; Park, Ina U

2015-10-01

Screening for gonorrhea (GC) and chlamydia (CT) and syphilis among HIV-positive (HIV+) men who have sex with men (MSM) is recommended at least annually. However, significant gaps in screening coverage exist. We conducted a quality improvement intervention to determine whether informing providers of preintervention screening rates and routinizing sexual risk assessment would improve sexually transmitted disease (STD) screening in a large HIV care clinic. In partnership with Kaiser Permanente Northern California, we developed and implemented a 10-item assessment addressing sexual and other behavioral risk factors among HIV+ MSM. We analyzed the proportion of patients screened for GC/CT and syphilis in a preintervention period (June 25-September 26, 2012) and during the intervention period (June 25-September 26, 2013). Of 364 HIV+ MSM seen for care during the intervention period, 47.3% completed the sexual risk assessment. Improvements in GC/CT screening and syphilis screening were observed; when comparing the preintervention period with the intervention period, the proportion of HIV+ MSM receiving GC/CT screening increased by 26.8% (31.6%-40.1%, P = 0.01) at any anatomical site and by 45% (19.5%-28.3%, P = 0.003) at the pharyngeal site. Syphilis screening significantly increased by 18.8% (48.7%-58.0%, P = 0.009). Overall STD screening increases were observed after this intervention that included didactic training on the urgency of STD screening needs for HIV+ MSM, a presentation of preintervention clinic STD screening data, and the implementation of self-reported sexual risk assessment. Additional efforts are needed to determine feasible ways to accurately assess the appropriateness of STD screening and success of interventions to improve STD screening.

Dietary guideline adherence for gastroesophageal reflux disease

PubMed Central

2014-01-01

Background Gastroesophageal reflux disease (GERD) is the most common gastrointestinal disease, and the cost of health care and lost productivity due to GERD is extremely high. Recently described side effects of long-term acid suppression have increased the interest in nonpharmacologic methods for alleviating GERD symptoms. We aimed to examine whether GERD patients follow recommended dietary guidelines, and if adherence is associated with the severity and frequency of reflux symptoms. Methods We conducted a population-based cross-sectional study within the Kaiser Permanente Northern California population, comparing 317 GERD patients to 182 asymptomatic population controls. All analyses adjusted for smoking and education. Results GERD patients, even those with moderate to severe symptoms or frequent symptoms, were as likely to consume tomato products and large portion meals as GERD-free controls and were even more likely to consume soft drinks and tea [odds ratio (OR) = 2.01 95% confidence interval (CI) 1.12-3.61; OR = 2.63 95% CI 1.24-5.59, respectively] and eat fried foods and high fat diet. The only reflux-triggering foods GERD patients were less likely to consume were citrus and alcohol [OR = 0.59; 95% CI: 0.35-0.97 for citrus; OR = 0.41 95% CI 0.19-0.87 for 1 + drink/day of alcohol]. The associations were similar when we excluded users of proton pump inhibitors. Conclusions GERD patients consume many putative GERD causing foods as frequently or even more frequently than asymptomatic patients despite reporting symptoms. These findings suggest that, if dietary modification is effective in reducing GERD, substantial opportunities for nonpharmacologic interventions exist for many GERD patients. PMID:25125219

Association Between Neighborhood Supermarket Presence and Glycated Hemoglobin Levels Among Patients With Type 2 Diabetes Mellitus.

PubMed

Zhang, Y Tara; Mujahid, Mahasin S; Laraia, Barbara A; Warton, E Margaret; Blanchard, Samuel D; Moffet, Howard H; Downing, Janelle; Karter, Andrew J

2017-06-15

We estimated associations between neighborhood supermarket gain or loss and glycemic control (assessed by glycated hemoglobin (HbA1c) values) in patients from the Kaiser Permanente Northern California Diabetes Registry (n = 434,806 person-years; 2007-2010). Annual clinical measures were linked to metrics from a geographic information system for each patient's address of longest residence. We estimated the association between change in supermarket presence (gain, loss, or no change) and change in HbA1c value, adjusting for individual- and area-level attributes and according to baseline glycemic control (near normal, <6.5%; good, 6.5%-7.9%; moderate, 8.0%-8.9%; and poor, ≥9.0%). Supermarket loss was associated with worse HbA1c trajectories for those with good, moderate, and poor glycemic control at baseline, while supermarket gain was associated with marginally better HbA1c outcomes only among patients with near normal HbA1c values at baseline. Patients with the poorest baseline HbA1c values (≥9.0%) had the worst associated changes in glycemic control following either supermarket loss or gain. Differences were not clinically meaningful relative to no change in supermarket presence. For patients with type 2 diabetes mellitus, gaining neighborhood supermarket presence did not benefit glycemic control in a substantive way. The significance of supermarket changes on health depends on a complex interaction of resident, neighborhood, and store characteristics. © The Author 2017. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Geographic clusters in underimmunization and vaccine refusal.

PubMed

Lieu, Tracy A; Ray, G Thomas; Klein, Nicola P; Chung, Cindy; Kulldorff, Martin

2015-02-01

Parental refusal and delay of childhood vaccines has increased in recent years and is believed to cluster in some communities. Such clusters could pose public health risks and barriers to achieving immunization quality benchmarks. Our aims were to (1) describe geographic clusters of underimmunization and vaccine refusal, (2) compare clusters of underimmunization with different vaccines, and (3) evaluate whether vaccine refusal clusters may pose barriers to achieving high immunization rates. We analyzed electronic health records among children born between 2000 and 2011 with membership in Kaiser Permanente Northern California. The study population included 154,424 children in 13 counties with continuous membership from birth to 36 months of age. We used spatial scan statistics to identify clusters of underimmunization (having missed 1 or more vaccines by 36 months of age) and vaccine refusal (based on International Classification of Diseases, Ninth Revision, Clinical Modification codes). We identified 5 statistically significant clusters of underimmunization among children who turned 36 months old during 2010-2012. The underimmunization rate within clusters ranged from 18% to 23%, and the rate outside them was 11%. Children in the most statistically significant cluster had 1.58 (P < .001) times the rate of underimmunization as others. Underimmunization with measles, mumps, rubella vaccine and varicella vaccines clustered in similar geographic areas. Vaccine refusal also clustered, with rates of 5.5% to 13.5% within clusters, compared with 2.6% outside them. Underimmunization and vaccine refusal cluster geographically. Spatial scan statistics may be a useful tool to identify locations with challenges to achieving high immunization rates, which deserve focused intervention. Copyright © 2015 by the American Academy of Pediatrics.

Are Health Plan Design and Prior Use of Long-Acting Reversible Contraception Associated with Pregnancy Intention?

PubMed

Armstrong, Mary Anne; Postlethwaite, Debbie A; Darbinian, Jeanne A; McCoy, Mark; Law, Amy

2017-05-01

In 2007, high-deductible plans were added to the primarily nondeductible Kaiser Permanente Northern California (KPNC) integrated health plan, which had covered 100% of device and procedure costs of long-acting reversible contraception (LARC) for members regardless of prescription/visit copay amount. We hypothesized that nondeductible plans and prior LARC use decreased unintended pregnancy. The purpose of this study was to determine if health plan design (nondeductible vs. deductible) and LARC use before pregnancy were associated with pregnancy intention. In this retrospective cohort study, women aged 15-44 as of the index date of June 30, 2010 were followed from January 1, 2010 to December 31, 2012 for evidence of pregnancy (n = 65,989). Health plan design, copays, contraceptive method used most recently before the pregnancy, and self-reported pregnancy intention status (intended, mistimed, unwanted) were obtained from electronic medical records. Logistic regression models were developed to determine if various health plan designs, copays, or prior LARC use were associated with pregnancy intention, controlling for potential confounders such as age, race/ethnicity, marital status, education/income, parity, and comorbidities. In all models, LARC use before pregnancy versus non-LARC use was significantly related to intended pregnancies (all models: odds ratio [OR] = 2.26, 95% confidence interval [CI] 2.06-2.48). Women with deductible plans with healthcare spending accounts (HSA) were more likely to report intended pregnancies versus women with nondeductible plans (all models: OR = 1.2, 95% CI 1.04-1.30). In stratified analyses, high income/high education was a significant predictor of intended pregnancy regardless of race/ethnicity. LARC use before pregnancy and having an HSA were associated with intended pregnancy.

Risk of Serious Infection for Patients with Systemic Lupus Erythematosus Starting Glucocorticoids with or without Antimalarials.

PubMed

Herrinton, Lisa J; Liu, Liyan; Goldfien, Robert; Michaels, M Alex; Tran, Trung N

2016-08-01

To compare serious infection risk for systemic lupus erythematosus (SLE) patients starting glucocorticoids (GC), antimalarials (AM), or their combination. We conducted a new-user, historical cohort study, Kaiser Permanente Northern California, 1997-2013. Cox proportional hazards analysis was used to calculate adjusted HR and 95% CI. The study included 3030 patients with SLE followed an average of 4 years. Compared with patients starting AM without GC (9 infections/1461 patient-yrs), the HR for the risk of infection was 3.9 (95% CI 1.7-9.2) for those starting GC ≤ 15 mg/day without AM (14 infections/252 patient-yrs), while it was 0.0 (0 infections/128 patient-yrs) for those starting the combination. We split the 14 patients with a serious infection and with GC < 15 mg/day into 2 groups: < 7.5 and ≥ 7.5-15 mg/day. The HR for < 7.5 mg/day was 4.6 (95% CI 1.8-11.4) and for ≥ 7.5-15 mg/day, 3.1 (95% CI 1.0-9.7). For patients starting GC > 15 mg/day (reflecting more severe SLE), the risk of infection was nearly the same for the combination of GC and AM (9 infections/135 patient-yrs) and GC alone (41 infections/460 patient-yrs), but the combination users had evidence of more severe disease. Patients with SLE had a 6- to 7-fold greater risk of serious infection than the general population. Our findings suggest that the benefits of AM treatment for SLE may extend to preventing serious infections. Although the study included > 3000 patients, the statistical power to examine GC dosages < 15 mg/day was poor.

Dietary antioxidants, fruits and vegetables, and the risk of Barrett’s esophagus

PubMed Central

Kubo, Ai; Levin, T.R.; Block, Gladys; Rumore, Gregory J.; Quesenberry, Charles P.; Buffler, Patricia; Corley, Douglas A.

2009-01-01

OBJECTIVE The present study evaluated the associations between antioxidants, fruit and vegetable intakes and the risk of Barrett’s esophagus, a potential precursor to esophageal adenocarcinoma. METHODS We conducted a case-control study within the Kaiser Permanente Northern California population. Incident Barrett’s esophagus cases (n=296) were matched to persons with gastroesophageal reflux disease (GERD) (GERD controls, n=308) and to population controls (n=309). Nutrient intake was measured using a validated 110-item food frequency questionnaire. The antioxidant results were stratified by dietary vs. total intake of antioxidants. RESULTS Comparing cases to population controls, dietary intake of vitamin C and beta-carotene were inversely associated with the risk of Barrett’s esophagus [4th vs. 1st quartile, adjusted odds ratio [OR]=0.48 95% confidence interval [CI] (0.26–0.90); OR=0.56 95%CI(0.32–0.99), respectively], and the inverse association was strongest for vitamin E [OR=0.25 95%CI (0.11–0.59)]. The inverse trends for antioxidant index (total and dietary) and fruit and vegetable intake were statistically significant, while most total intakes were not associated with reduced risk. The use of antioxidant supplements did not influence the risk of Barrett’s esophagus, and antioxidants and fruits and vegetables were inversely associated with a GERD diagnosis. CONCLUSION Dietary antioxidants, fruit and vegetable are inversely associated with the risk of Barrett’s esophagus, while no association was observed for supplement intake. Our results suggest that fruits and vegetables themselves or associated undetected confounders may influence early events in the carcinogenesis of esophageal adenocarcinoma. PMID:18494834

Alcohol types and sociodemographic characteristics as risk factors for Barrett’s esophagus

PubMed Central

Kubo, Ai; Levin, T.R.; Block, Gladys; Rumore, Gregory; Quesenberry, Charles P.; Buffler, Patricia; Corley, Douglas A.

2009-01-01

Background & Aims Little is known about the effects of alcohol use and sociodemographics on the risk of Barrett’s esophagus, a precursor to esophageal adenocarcinoma. We evaluated the association between alcohol use, alcohol type, sociodemographic profiles, other lifestyle factors and the risk of Barrett’s esophagus. Methods Using a case-control study within the Kaiser Permanente Northern California membership, patients with a new diagnosis of Barrett’s esophagus (n=320) diagnosed between 2002–2005 were matched to persons with gastroesophageal reflux disease (GERD) (n=316) and to population controls (n=317). We collected information using validated questionnaires during direct in-person interviews. Analyses used multivariate unconditional logistic regression. Results Total alcohol use was not significantly associated with the risk of Barrett’s esophagus, although stratification by beverage type showed an inverse association for wine drinkers compared to nondrinkers (7+ drinks wine/week vs. none: OR=0.44, 95%CI (0.20–0.99); multivariate analysis). Among population controls, those who preferred wine were more likely to have college degrees and regularly take vitamin supplements than those who preferred beer or liquor, although adjustment for these factors or GERD symptoms did not eliminate the inverse association between wine consumption and Barrett’s esophagus. Education status was significantly inversely associated with the risk of Barrett’s esophagus. Conclusions There are associations between alcohol types, socioeconomic status and the risk of Barrett’s esophagus. Although choice of alcoholic beverages was associated with several factors, multiple adjustments (including for GERD) did not eliminate the association between alcohol and Barrett’s esophagus. Further research to evaluate the associations among socioeconomic status, GERD, and Barrett’s esophagus is warranted. PMID:19111726

Genital herpes and its treatment in relation to preterm delivery.

PubMed

Li, De-Kun; Raebel, Marsha A; Cheetham, T Craig; Hansen, Craig; Avalos, Lyndsay; Chen, Hong; Davis, Robert

2014-12-01

To examine the risks of genital herpes and antiherpes treatment during pregnancy in relation to preterm delivery (PTD), we conducted a multicenter, member-based cohort study within 4 Kaiser Permanente regions: northern and southern California, Colorado, and Georgia. The study included 662,913 mother-newborn pairs from 1997 to 2010. Pregnant women were classified into 3 groups based on genital herpes diagnosis and treatment: genital herpes without treatment, genital herpes with antiherpes treatment, and no herpes diagnosis or treatment (unexposed controls). After controlling for potential confounders, we found that compared with being unexposed, having untreated genital herpes during first or second trimester was associated with more than double the risk of PTD (odds ratio (OR) = 2.23, 95% confidence interval (CI): 1.80, 2.76). The association was stronger for PTD due to premature rupture of membrane (OR = 3.57, 95% CI: 2.53, 5.06) and for early PTD (≤35 weeks gestation) (OR = 2.87, 95% CI: 2.22, 3.71). In contrast, undergoing antiherpes treatment during pregnancy was associated with a lower risk of PTD compared with not being treated, and the PTD risk was similar to that observed in the unexposed controls (OR = 1.11, 95% CI: 0.89, 1.38). The present study revealed increased risk of PTD associated with genital herpes infection if left untreated and a potential benefit of antiherpes medications in mitigating the effect of genital herpes infection on the risk of PTD. © The Author 2014. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Asthma exacerbations among asthmatic children receiving live attenuated versus inactivated influenza vaccines.

PubMed

Ray, G Thomas; Lewis, Ned; Goddard, Kristin; Ross, Pat; Duffy, Jonathan; DeStefano, Frank; Baxter, Roger; Klein, Nicola P

2017-05-09

To investigate whether there is a difference in the risk of asthma exacerbations between children with pre-existing asthma who receive live attenuated influenza vaccine (LAIV) compared with inactivated influenza vaccine (IIV). We identified IIV and LAIV immunizations occurring between July 1, 2007 and March 31, 2014 among Kaiser Permanente Northern California members aged 2 to <18years with a history of asthma, and subsequent asthma exacerbations seen in the inpatient or Emergency Department (ED) setting. We calculated the ratio of the odds (OR) of an exacerbation being in the risk interval (1-14days) versus the comparison interval (29-42days) following immunization, separately for LAIV and IIV, and then examined whether the OR differed between children receiving LAIV and those receiving IIV ("difference-in-differences"). Among 387,633 immunizations, 85% were IIV and 15% were LAIV. Children getting LAIV vs. IIV were less likely to have "current or recent, persistent" asthma (25% vs. 47%), and more likely to have "remote history" of asthma (47% vs. 25%). Among IIV-vaccinated asthmatic children, the OR of an inpatient/ED asthma exacerbation was 0.97 (95% CI: 0.82-1.15). Among LAIV-vaccinated asthmatic children the OR was 0.38 (95% CI: 0.17-0.90). In the difference-in-differences analysis, the odds of asthma exacerbation following LAIV were less than IIV (Ratio of ORs: 0.40, CI: 0.17-0.95, p value: 0.04). Among children ≥2years old with asthma, we found no increased risk of asthma exacerbation following LAIV or IIV, and a decreased risk following LAIV compared to IIV. Copyright © 2017 Elsevier Ltd. All rights reserved.

Association between Lithium Use and Melanoma Risk and Mortality: A Population-Based Study.

PubMed

Asgari, Maryam M; Chien, Andy J; Tsai, Ai Lin; Fireman, Bruce; Quesenberry, Charles P

2017-10-01

Laboratory studies show that lithium, an activator of the Wnt/ß-catenin signaling pathway, slows melanoma progression, but to our knowledge no published epidemiologic studies have explored this association. We conducted a retrospective cohort study of adult white Kaiser Permanente Northern California members (n = 2,213,848) from 1997-2012 to examine the association between lithium use and melanoma risk. Lithium exposure (n = 11,317) was assessed from pharmacy databases, serum lithium levels were obtained from electronic laboratory databases, and incident cutaneous melanomas (n = 14,056) were identified from an established cancer registry. In addition to examining melanoma incidence, melanoma hazard ratios and 95% confidence intervals for lithium exposure were estimated using Cox proportional hazards models, adjusted for potential confounders. Melanoma incidence per 100,000 person-years among lithium-exposed individuals was 67.4, compared with 92.5 in unexposed individuals (P = 0.027). Lithium-exposed individuals had a 32% lower risk of melanoma (hazard ratio = 0.68, 95% confidence interval = 0.51-0.90) in unadjusted analysis, but the estimate was attenuated and nonsignificant in adjusted analysis (adjusted hazard ratio = 0.77, 95% confidence interval = 0.58-1.02). No lithium-exposed individuals presented with thick (>4 mm) or advanced-stage melanoma at diagnosis. Among melanoma patients, lithium-exposed individuals were less likely to suffer melanoma-associated mortality (rate = 4.68/1,000 person-years) compared with the unexposed (rate = 7.21/1,000 person-years). Our findings suggest that lithium may reduce melanoma risk and associated mortality. Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.

Patterns and Predictors of Severe Postpartum Anemia after Cesarean Section

PubMed Central

Butwick, Alexander. J.; Walsh, Eileen. M.; Kuzniewicz, Michael; Li, Sherian.X.; Escobar, Gabriel.J.

2016-01-01

Background Postpartum anemia is associated with maternal and perinatal morbidity. Population-level data may inform guideline development for postpartum anemia screening. Our objectives were to evaluate the associations between potential predictors (predelivery anemia and postpartum hemorrhage (PPH)) with severe postpartum anemia after cesarean section. Study Design and Methods Data were collected from 70,939 hospitalizations for cesarean section performed at Kaiser Permanente Northern California facilities between 2005 and 2013. Severe postpartum anemia was defined as a hemoglobin < 8 g/dl before hospital discharge. Using multivariable logistic regression, we assessed the associations between predelivery anemia and PPH with severe postpartum anemia. Distributions of these characteristics among women with severe postpartum anemia were evaluated. Results The overall rate of severe postpartum anemia was 7.3%; 95% confidence interval (CI) = 7.1 – 7.4. Severe postpartum anemia was strongly associated with a predelivery hemoglobin between 10 and 10.9 g/dl (adjusted odds ratio (aOR) 5.4; 95% CI = 4.89– 5.91), predelivery hemoglobin <10 g/dl (aOR 30.6; 95% CI = 27.21– 34.6, and PPH (aOR 8.45; 95% CI = 7.8–9.16). The proportions of women with severe postpartum anemia were highest for those experiencing PPH but no predelivery anemia (12.2%; 95% CI = 11.0 – 13.6), and those who did not incur PPH nor predelivery anemia (10.7%; 95% CI = 9.6 – 12.0). Conclusions Our findings suggest that PPH and predelivery anemia are strong independent risk factors for severe postpartum anemia. Optimization of patients’ hemoglobin prior to delivery may reduce the incidence of severe anemia after cesarean section. PMID:27618767

Heterogeneity in 14-year Dementia Incidence Between Asian American Subgroups.

PubMed

Mayeda, Elizabeth R; Glymour, M Maria; Quesenberry, Charles P; Whitmer, Rachel A

2017-01-01

Asian Americans are a rapidly growing and diverse population. Prior research on dementia among Asian Americans focused on Japanese Americans or Asian Americans overall, although marked differences in cardiometabolic conditions between subgroups have been documented. We compared dementia incidence among 4 Asian American subgroups (n=8384 Chinese; n=4478 Japanese; n=6210 Filipino; n=197 South Asian) and whites (n=206,490) who were Kaiser Permanente Northern California members aged 64 years and above with no dementia diagnoses as of January 1, 2000. Dementia diagnoses were collected from medical records January 1, 2000 to December 31, 2013. Baseline medical utilization and comorbidities (diabetes, depression, hypertension, stroke, cardiovascular disease) were abstracted from medical records January 1, 1996 to December 31, 1999. We calculated age-standardized dementia incidence rates and Cox models adjusted for age, sex, medical utilization, and comorbidities. Mean baseline age was 71.7 years; mean follow-up was 9.6 years. Age-standardized dementia incidence rates were higher among whites than "All Asian-Americans" or any subgroup. Compared with Chinese (13.7/1000 person-years), dementia incidence was slightly higher among Japanese [14.8/1000 person-years; covariate-adjusted hazard ratio (adjusted-HR)=1.08; 95% confidence interval (CI), 0.99-1.18] and Filipinos (17.3/1000 person-years; adjusted-HR=1.20; 95% CI, 1.11-1.31), and lower among South Asians (12.1/1000 person-years; adjusted-HR=0.81; 95% CI, 0.53-1.25). Future studies are needed to understand how immigration history, social, environmental, and genetic factors contribute to dementia risk in the growing and diverse Asian American population.

Obesity during childhood and adolescence increases susceptibility to multiple sclerosis after accounting for established genetic and environmental risk factors.

PubMed

Gianfrancesco, Milena A; Acuna, Brigid; Shen, Ling; Briggs, Farren B S; Quach, Hong; Bellesis, Kalliope H; Bernstein, Allan; Hedstrom, Anna K; Kockum, Ingrid; Alfredsson, Lars; Olsson, Tomas; Schaefer, Catherine; Barcellos, Lisa F

2014-01-01

To investigate the association between obesity and multiple sclerosis (MS) while accounting for established genetic and environmental risk factors. Participants included members of Kaiser Permanente Medical Care Plan, Northern California Region (KPNC) (1235 MS cases and 697 controls). Logistic regression models were used to estimate odds ratios (ORs) with 95% confidence intervals (95% CI). Body mass index (BMI) or body size was the primary predictor of each model. Both incident and prevalent MS cases were studied. In analyses stratified by gender, being overweight at ages 10 and 20 were associated with MS in females (p<0.01). Estimates trended in the same direction for males, but were not significant. BMI in 20s demonstrated a linear relationship with MS (p-trend=9.60×10(-4)), and a twofold risk of MS for females with a BMI≥30kg/m(2) was observed (OR=2.15, 95% CI 1.18, 3.92). Significant associations between BMI in 20s and MS in males were not observed. Multivariate modelling demonstrated that significant associations between BMI or body size with MS in females persisted after adjusting for history of infectious mononucleosis and genetic risk factors, including HLA-DRB1*15:01 and established non-HLA risk alleles. Results show that childhood and adolescence obesity confer increased risk of MS in females beyond established heritable and environmental risk factors. Strong evidence for a dose-effect of BMI in 20s and MS was observed. The magnitude of BMI association with MS is as large as other known MS risk factors. Copyright © 2014 Asian Oceanian Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved.

Telephone-Based Coaching: A Comparison of Tobacco Cessation Programs in an Integrated Health Care System

PubMed Central

Boccio, Mindy; Sanna, Rashel S.; Adams, Sara R.; Goler, Nancy C.; Brown, Susan D.; Neugebauer, Romain S.; Ferrara, Assiamira; Wiley, Deanne M.; Bellamy, David J.; Schmittdiel, Julie A.

2016-01-01

Purpose Many Americans continue to smoke, increasing their risk of disease and premature death. Both telephone-based counseling and in-person tobacco cessation classes may improve access for smokers seeking convenient support to quit. Little research has assessed whether such programs are effective in real-world clinical populations. Design Retrospective cohort study comparing wellness coaching participants with two groups of controls. Setting Kaiser Permanente, Northern California (KPNC), a large integrated health care delivery system. Subjects 241 patients who participated in telephonic tobacco cessation coaching from 1/1/2011–3/31/2012, and two control groups: propensity-score matched controls, and controls who participated in a tobacco cessation class during the same period. Wellness coaching participants received an average of two motivational interviewing based coaching sessions that engage the patient, evoke their reason to consider quitting and help them establish a quit plan. Measures Self-reported quitting of tobacco and fills of tobacco cessation medications within 12 months of follow-up. Analysis Logistic regressions adjusting for age, gender, race/ethnicity, and primary language. Results After adjusting for confounders, tobacco quit rates were higher among coaching participants vs. matched controls (31% vs. 23%, P<0.001) and comparable to class attendees (31% vs. 29%, P=0.28). Coaching participants and class attendees filled tobacco-cessation prescriptions at a higher rate (47% for both) than matched controls (6%, P<0.001). Conclusions Telephonic wellness coaching was as effective as in-person classes and was associated with higher rates of quitting compared to no treatment. The telephonic modality may increase convenience and scalability for health care systems looking to reduce tobacco use and improve health. PMID:26559720

Telephone-Based Coaching.

PubMed

Boccio, Mindy; Sanna, Rashel S; Adams, Sara R; Goler, Nancy C; Brown, Susan D; Neugebauer, Romain S; Ferrara, Assiamira; Wiley, Deanne M; Bellamy, David J; Schmittdiel, Julie A

2017-03-01

Many Americans continue to smoke, increasing their risk of disease and premature death. Both telephone-based counseling and in-person tobacco cessation classes may improve access for smokers seeking convenient support to quit. Little research has assessed whether such programs are effective in real-world clinical populations. Retrospective cohort study comparing wellness coaching participants with two groups of controls. Kaiser Permanente Northern California, a large integrated health care delivery system. Two hundred forty-one patients who participated in telephonic tobacco cessation coaching from January 1, 2011, to March 31, 2012, and two control groups: propensity-score-matched controls, and controls who participated in a tobacco cessation class during the same period. Wellness coaching participants received an average of two motivational interviewing-based coaching sessions that engaged the patient, evoked their reason to consider quitting, and helped them establish a quit plan. Self-reported quitting of tobacco and fills of tobacco cessation medications within 12 months of follow-up. Logistic regressions adjusting for age, gender, race/ethnicity, and primary language. After adjusting for confounders, tobacco quit rates were higher among coaching participants vs. matched controls (31% vs. 23%, p < .001) and comparable to those of class attendees (31% vs. 29%, p = .28). Coaching participants and class attendees filled tobacco-cessation prescriptions at a higher rate (47% for both) than matched controls (6%, p < .001). Telephonic wellness coaching was as effective as in-person classes and was associated with higher rates of quitting compared to no treatment. The telephonic modality may increase convenience and scalability for health care systems looking to reduce tobacco use and improve health.

Health Literacy and Awareness of Atrial Fibrillation.

PubMed

Reading, Stephanie R; Go, Alan S; Fang, Margaret C; Singer, Daniel E; Liu, In-Lu Amy; Black, Mary Helen; Udaltsova, Natalia; Reynolds, Kristi

2017-04-11

Atrial fibrillation (AF) is the most common clinically significant arrhythmia in adults and a major risk factor for ischemic stroke. Nonetheless, previous research suggests that many individuals diagnosed with AF lack awareness about their diagnosis and inadequate health literacy may be an important contributing factor to this finding. We examined the association between health literacy and awareness of an AF diagnosis in a large, ethnically diverse cohort of Kaiser Permanente Northern and Southern California adults diagnosed with AF between January 1, 2006 and June 30, 2009. Using self-reported questionnaire data completed between May 1, 2010 and September 30, 2010, awareness of an AF diagnosis was evaluated using the question "Have you ever been told by a doctor or other health professional that you have a heart rhythm problem called atrial fibrillation or atrial flutter?" and health literacy was assessed using a validated 3-item instrument examining problems because of reading, understanding, and filling out medical forms. Of the 12 517 patients diagnosed with AF, 14.5% were not aware of their AF diagnosis and 20.4% had inadequate health literacy. Patients with inadequate health literacy were less likely to be aware of their AF diagnosis compared with patients with adequate health literacy (prevalence ratio=0.96; 95% CI [0.94, 0.98]), adjusting for sociodemographics, health behaviors, and clinical characteristics. Lower health literacy is independently associated with less awareness of AF diagnosis. Strategies designed to increase patient awareness of AF and its complications are warranted among individuals with limited health literacy. © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

Long-Term Effectiveness of the Live Zoster Vaccine in Preventing Shingles: A Cohort Study.

PubMed

Baxter, Roger; Bartlett, Joan; Fireman, Bruce; Marks, Morgan; Hansen, John; Lewis, Edwin; Aukes, Laurie; Chen, Yong; Klein, Nicola P; Saddier, Patricia

2018-01-01

A live attenuated zoster vaccine was licensed in the United States in 2006 for prevention of shingles in persons aged 60 years or older; the indication was extended in 2011 to cover those aged 50-59 years. We assessed vaccine effectiveness (VE) against shingles for 8 years after immunization at Kaiser Permanente Northern California. VE was estimated by Cox regression with a calendar timeline that was stratified by birth year. We adjusted for demographics and time-varying covariates, including comorbidities and immune compromise. From 2007 to 2014, 1.4 million people entered the study when they became age eligible for vaccination; 392,677 (29%) received the zoster vaccine. During 5.8 million person-years of follow-up, 48,889 cases of shingles were observed, including 5,766 among vaccinees. VE was 49.1% (95% confidence interval (CI): 47.5, 50.6) across all follow-up. VE was 67.5% (95% CI: 65.4, 69.5) during the first year after vaccination, waned to 47.2% (95% CI: 44.1, 50.1) during the second year after vaccination, and then waned more gradually through year 8, when VE was 31.8% (95% CI: 15.1, 45.2). Unexpectedly, VE in persons vaccinated when they were aged 80 years or older was similar to VE in younger vaccinees, and VE in persons vaccinated when immune compromised was similar to VE in persons vaccinated when immune competent. © The Author(s) 2017. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Red wine consumption and risk of prostate cancer: the California men's health study.

PubMed

Chao, Chun; Haque, Reina; Van Den Eeden, Stephen K; Caan, Bette J; Poon, Kwun-Yee T; Quinn, Virginia P

2010-01-01

Red wine contains polyphenol antioxidants that inhibit prostate cancer development in animal studies. We investigated the effect of red wine intake on the risk of prostate cancer using data prospectively collected in the California Men's Health Study (CMHS). CMHS is a multiethnic cohort of 84,170 men aged 45-69 years who were members of the Kaiser Permanente Southern and Northern California Health Plans. Information on demographic and lifestyle factors was collected using mailed questionnaires between 2002 and 2003. We used Cox models to estimate the effect of red wine on prostate cancer risk, adjusting for potential confounders. A total of 1,340 incident prostate cancer cases identified from Surveillance, Epidemiology and End Result-affiliated cancer registries were included in the analyses. We did not find a clear association between red wine intake and risk of prostate cancer. Hazard ratio (HR) estimates for consuming <1 drink/week, > or =1 drink/week but <1 drink/day and > or =1 drink/day were 0.89, 95% confidence interval (0.74-1.07), 0.99 (0.83-1.17) and 0.88 (0.70-1.12), respectively. Further, we observed no linear dose response. The lack of association for red wine intake was consistently observed when we restricted the analyses to those with and without a history of PSA screening. In addition, we also did not observe any association with prostate cancer for beer, white wine, liquor or combined alcoholic beverage intake (HR for combined alcoholic beverage intake of > or =5 drinks/day = 1.16 (0.83-1.63). Neither red wine nor total alcohol consumption were associated with prostate cancer risk in this population of moderate drinkers.

Characterizing Race/Ethnicity and Genetic Ancestry for 100,000 Subjects in the Genetic Epidemiology Research on Adult Health and Aging (GERA) Cohort

PubMed Central

Banda, Yambazi; Kvale, Mark N.; Hoffmann, Thomas J.; Hesselson, Stephanie E.; Ranatunga, Dilrini; Tang, Hua; Sabatti, Chiara; Croen, Lisa A.; Dispensa, Brad P.; Henderson, Mary; Iribarren, Carlos; Jorgenson, Eric; Kushi, Lawrence H.; Ludwig, Dana; Olberg, Diane; Quesenberry, Charles P.; Rowell, Sarah; Sadler, Marianne; Sakoda, Lori C.; Sciortino, Stanley; Shen, Ling; Smethurst, David; Somkin, Carol P.; Van Den Eeden, Stephen K.; Walter, Lawrence; Whitmer, Rachel A.; Kwok, Pui-Yan; Schaefer, Catherine; Risch, Neil

2015-01-01

Using genome-wide genotypes, we characterized the genetic structure of 103,006 participants in the Kaiser Permanente Northern California multi-ethnic Genetic Epidemiology Research on Adult Health and Aging Cohort and analyzed the relationship to self-reported race/ethnicity. Participants endorsed any of 23 race/ethnicity/nationality categories, which were collapsed into seven major race/ethnicity groups. By self-report the cohort is 80.8% white and 19.2% minority; 93.8% endorsed a single race/ethnicity group, while 6.2% endorsed two or more. Principal component (PC) and admixture analyses were generally consistent with prior studies. Approximately 17% of subjects had genetic ancestry from more than one continent, and 12% were genetically admixed, considering only nonadjacent geographical origins. Self-reported whites were spread on a continuum along the first two PCs, indicating extensive mixing among European nationalities. Self-identified East Asian nationalities correlated with genetic clustering, consistent with extensive endogamy. Individuals of mixed East Asian–European genetic ancestry were easily identified; we also observed a modest amount of European genetic ancestry in individuals self-identified as Filipinos. Self-reported African Americans and Latinos showed extensive European and African genetic ancestry, and Native American genetic ancestry for the latter. Among 3741 genetically identified parent–child pairs, 93% were concordant for self-reported race/ethnicity; among 2018 genetically identified full-sib pairs, 96% were concordant; the lower rate for parent–child pairs was largely due to intermarriage. The parent–child pairs revealed a trend toward increasing exogamy over time; the presence in the cohort of individuals endorsing multiple race/ethnicity categories creates interesting challenges and future opportunities for genetic epidemiologic studies. PMID:26092716

Challenges in risk estimation using routinely collected clinical data: The example of estimating cervical cancer risks from electronic health-records.

PubMed

Landy, Rebecca; Cheung, Li C; Schiffman, Mark; Gage, Julia C; Hyun, Noorie; Wentzensen, Nicolas; Kinney, Walter K; Castle, Philip E; Fetterman, Barbara; Poitras, Nancy E; Lorey, Thomas; Sasieni, Peter D; Katki, Hormuzd A

2018-06-01

Electronic health-records (EHR) are increasingly used by epidemiologists studying disease following surveillance testing to provide evidence for screening intervals and referral guidelines. Although cost-effective, undiagnosed prevalent disease and interval censoring (in which asymptomatic disease is only observed at the time of testing) raise substantial analytic issues when estimating risk that cannot be addressed using Kaplan-Meier methods. Based on our experience analysing EHR from cervical cancer screening, we previously proposed the logistic-Weibull model to address these issues. Here we demonstrate how the choice of statistical method can impact risk estimates. We use observed data on 41,067 women in the cervical cancer screening program at Kaiser Permanente Northern California, 2003-2013, as well as simulations to evaluate the ability of different methods (Kaplan-Meier, Turnbull, Weibull and logistic-Weibull) to accurately estimate risk within a screening program. Cumulative risk estimates from the statistical methods varied considerably, with the largest differences occurring for prevalent disease risk when baseline disease ascertainment was random but incomplete. Kaplan-Meier underestimated risk at earlier times and overestimated risk at later times in the presence of interval censoring or undiagnosed prevalent disease. Turnbull performed well, though was inefficient and not smooth. The logistic-Weibull model performed well, except when event times didn't follow a Weibull distribution. We have demonstrated that methods for right-censored data, such as Kaplan-Meier, result in biased estimates of disease risks when applied to interval-censored data, such as screening programs using EHR data. The logistic-Weibull model is attractive, but the model fit must be checked against Turnbull non-parametric risk estimates. Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.

Study protocol: the Adherence and Intensification of Medications (AIM) study--a cluster randomized controlled effectiveness study.

PubMed

Heisler, Michele; Hofer, Timothy P; Klamerus, Mandi L; Schmittdiel, Julie; Selby, Joe; Hogan, Mary M; Bosworth, Hayden B; Tremblay, Adam; Kerr, Eve A

2010-10-12

Many patients with diabetes have poor blood pressure (BP) control. Pharmacological therapy is the cornerstone of effective BP treatment, yet there are high rates both of poor medication adherence and failure to intensify medications. Successful medication management requires an effective partnership between providers who initiate and increase doses of effective medications and patients who adhere to the regimen. In this cluster-randomized controlled effectiveness study, primary care teams within sites were randomized to a program led by a clinical pharmacist trained in motivational interviewing-based behavioral counseling approaches and authorized to make BP medication changes or to usual care. This study involved the collection of data during a 14-month intervention period in three Department of Veterans Affairs facilities and two Kaiser Permanente Northern California facilities. The clinical pharmacist was supported by clinical information systems that enabled proactive identification of, and outreach to, eligible patients identified on the basis of poor BP control and either medication refill gaps or lack of recent medication intensification. The primary outcome is the relative change in systolic blood pressure (SBP) measurements over time. Secondary outcomes are changes in Hemoglobin A1c, low-density lipoprotein cholesterol (LDL), medication adherence determined from pharmacy refill data, and medication intensification rates. Integration of the three intervention elements--proactive identification, adherence counseling and medication intensification--is essential to achieve optimal levels of control for high-risk patients. Testing the effectiveness of this intervention at the team level allows us to study the program as it would typically be implemented within a clinic setting, including how it integrates with other elements of care. The ClinicalTrials.gov registration number is NCT00495794.

Obesity during childhood and adolescence increases susceptibility to multiple sclerosis after accounting for established genetic and environmental risk factors

PubMed Central

Gianfrancesco, Milena A.; Acuna, Brigid; Shen, Ling; Briggs, Farren B.S.; Quach, Hong; Bellesis, Kalliope H.; Bernstein, Allan; Hedstrom, Anna K.; Kockum, Ingrid; Alfredsson, Lars; Olsson, Tomas; Schaefer, Catherine; Barcellos, Lisa F.

2014-01-01

Objective To investigate the association between obesity and multiple sclerosis (MS) while accounting for established genetic and environmental risk factors. Methods Participants included members of Kaiser Permanente Medical Care Plan, Northern California Region (KPNC) (1,235 MS cases and 697 controls). Logistic regression models were used to estimate odds ratios (ORs) with 95% confidence intervals (95% CI). Body mass index (BMI) or body size was the primary predictor of each model. Both incident and prevalent MS cases were studied. Results In analyses stratified by gender, being overweight at age 10 and 20 were associated with MS in females (p<0.01). Estimates trended in the same direction for males, but were not significant. BMI in 20’s demonstrated a linear relationship with MS (p-trend=9.60 × 10−4), and a twofold risk of MS for females with a BMI ≥ 30 kg/m2 was observed (OR = 2.15, 95% CI 1.18, 3.92). Significant associations between BMI in 20’s and MS in males were not observed. Multivariate modeling demonstrated that significant associations between BMI or body size with MS in females persisted after adjusting for history of infectious mononucleosis and genetic risk factors, including HLA-DRB1*15:01 and established non-HLA risk alleles. Interpretation Results show that childhood and adolescence obesity confer increased risk of MS in females beyond established heritable and environmental risk factors. Strong evidence for a dose-effect of BMI in 20’s and MS was observed. The magnitude of BMI association with MS is as large as other known MS risk factors. PMID:25263833

From diagnosis through survivorship: health-care experiences of colorectal cancer survivors with ostomies.

PubMed

Sun, Virginia; Grant, Marcia; McMullen, Carmit K; Altschuler, Andrea; Mohler, M Jane; Hornbrook, Mark C; Herrinton, Lisa J; Krouse, Robert S

2014-06-01

The journey from diagnosis through treatment to survivorship can be challenging for colorectal cancer (CRC) survivors with permanent ostomies. Memories of both the positive and negative health-care interactions can persist years after the initial diagnosis and treatment. The purpose of this paper is to describe the health-care experiences of long-term (>5 years) CRC survivors with ostomies. Thirty-three CRC survivors with ostomies who were members of Kaiser Permanente, an integrated care organization, in Oregon, southwestern Washington and northern California participated in eight focus groups. Discussions from the focus groups were recorded, transcribed, and analyzed for potential categories and themes. Health-care-related themes described CRC survivors' experiences with diagnosis, treatment decision-making, initial experiences with ostomy, and survivorship. Participants discussed both positive and negative health-care-related experiences, including the need for continued access to trained nurses for ostomy self-care, access to peer support, and resources related to managing persistent, debilitating symptoms. Long-term CRC survivors with ostomies have both positive and negative health-care experiences, regardless of health-related quality of life (HRQOL) and gender. Long-term support mechanisms and quality survivorship care that CRC survivors with ostomies can access are needed to promote positive adjustments and improved HRQOL. The current literature in CRC survivorship suggests that HRQOL concerns can persist years after treatment completion. The coordination of care to manage persistent late- and long-term effects are still lacking for CRC survivors living with an ostomy. Findings from this qualitative analysis will aid in the development of support strategies that foster more positive adjustments for CRC survivors living with an ostomy and support their ongoing ostomy-related needs.

Genetic Biomarker Prevalence Is Similar in Fecal Immunochemical Test Positive and Negative Colorectal Cancer Tissue.

PubMed

Levin, Theodore R; Corley, Douglas A; Jensen, Christopher D; Marks, Amy R; Zhao, Wei K; Zebrowski, Alexis M; Quinn, Virginia P; Browne, Lawrence W; Taylor, William R; Ahlquist, David A; Lidgard, Graham P; Berger, Barry M

2017-03-01

Fecal immunochemical test (FIT) screening detects most asymptomatic colorectal cancers. Combining FIT screening with stool-based genetic biomarkers increases sensitivity for cancer, but whether DNA biomarkers (biomarkers) differ for cancers detected versus missed by FIT screening has not been evaluated in a community-based population. To evaluate tissue biomarkers among Kaiser Permanente Northern California patients diagnosed with colorectal cancer within 2 years after FIT screening. FIT-negative and FIT-positive colorectal cancer patients 50-77 years of age were matched on age, sex, and cancer stage. Adequate DNA was isolated from paraffin-embedded specimens in 210 FIT-negative and 211 FIT-positive patients. Quantitative allele-specific real-time target and signal amplification assays were performed for 7 K-ras mutations and 10 aberrantly methylated DNA biomarkers (NDRG4, BMP3, SFMBT2_895, SFMBT2_896, SFMBT2_897, CHST2_7890, PDGFD, VAV3, DTX1, CHST2_7889). One or more biomarkers were found in 414 of 421 CRCs (98.3%). Biomarker expression was not associated with FIT status, with the exception of higher SFMBT2_897 expression in FIT-negative (194 of 210; 92.4%) than in FIT-positive cancers (180 of 211; 85.3%; p = 0.02). There were no consistent differences in biomarker expression by FIT status within age, sex, stage, and cancer location subgroups. The biomarkers of a currently in-use multi-target stool DNA test (K-ras, NDRG4, and BMP3) and eight newly characterized methylated biomarkers were commonly expressed in tumor tissue specimens, independent of FIT result. Additional study using stool-based testing with these new biomarkers will allow assessment of sensitivity, specificity, and clinical utility.

Incidence of genital warts in adolescents and young adults in an integrated health care delivery system in the United States before human papillomavirus vaccine recommendations.

PubMed

Camenga, Deepa R; Dunne, Eileen F; Desai, Mayur M; Gee, Julianne; Markowitz, Lauri E; Desiliva, Ajit; Klein, Nicola P

2013-07-01

Information on genital wart incidence in adolescents and young adults before human papillomavirus (HPV) vaccination is important for understanding the impact of the vaccine on the epidemiology of this early outcome of HPV infection. The study population included 11- to 29-year-old enrollees of Northern California Kaiser Permanente between July 1, 2000, and July 1, 2005, before the availability of the HPV vaccine. We identified genital warts with an algorithm combining genital wart-specific International Classification of Diseases, Ninth Revision, Clinical Modification codes (078.10, 078.11, and 078.19) with physician-recorded anatomic locations. We calculated sex- and age-specific incidence rates of genital warts and described the specific anatomic location of presentation, as well as recurrences of genital warts. We identified 1,682 cases of genital warts among 181,264 individuals. The incidence rate was highest among women (6.3/1000 person-years) and men (2.9/1000 person-years) aged 20 to 24 years old. Among women (n = 96,792), 63.4% of the 1240 incident genital wart cases occurred on the vulva and 21.1% on the cervix. Among men (n = 84,472), 91.6% of the 442 incident genital wart cases did not have a specific anatomic location recorded. Most people with an incident genital wart diagnosis (87.2%) did not have a recurrence during the observation period. Our study found that the incidence of genital warts was highest among persons aged 20 to 24 years using a unique method to identify the location of the wart. Information on incidence of genital warts before vaccine use provides baseline data that can be used to measure HPV vaccine impact.

Examining the Influence of Beta Blockers and ACE Inhibitors on the Risk for Breast Cancer Recurrence: Results from the LACE Cohort

PubMed Central

Ganz, Patricia A.; Habel, Laurel A.; Weltzien, Erin K.; Caan, Bette J.; Cole, Steven W.

2011-01-01

There is increasing interest in the relationship between host lifestyle factors and the outcomes of cancer treatment. Behavioral factors, comorbid conditions, and non-cancer related pharmaceutical exposures may affect breast cancer (BC) outcomes. We used observational data from the LACE Study cohort (women with early stage BC from the Kaiser Permanente Northern California Cancer Registry) to examine the association between beta-blockers (BB) and/or angiotensin converting enzyme inhibitors (ACEi) and BC recurrence, BC-specific mortality, and overall mortality. Among 1,779 women, there were 292 BC recurrences, 174 BC deaths, and 323 total deaths. 23% were exposed to either a BB and/or an ACEi. These drugs were associated with older age, postmenopausal status, tamoxifen therapy, greater pre-diagnosis BMI, hypertension, and diabetes. In Cox proportional hazards models, ACEi exposure was associated with BC recurrence (HR 1.56, 95% CI 1.02, 2.39, p=0.04), but not cause-specific mortality or overall mortality. Combined ACEi and BB was associated with overall mortality (HR 1.94, 95% CI 1.22, 3.10, p=0.01). BB exposure was associated with lower hazard of recurrence and cause-specific mortality. However, there was no evidence of a dose response with either medication. For recurrence and cause-specific mortality, BB combined with ACEi was associated with a lower HR for the outcome than when ACEi alone was used. These hypothesis generating findings suggest that BC recurrence and survival were associated with exposure to two commonly used classes of anti-hypertensive medications. These observations need to be confirmed and suggest that greater attention should focus on the potential role of these commonly used medications in BC outcomes. PMID:21479924

Characteristics and management of patients with chronic hepatitis B in an integrated care setting.

PubMed

Sarkar, Monika; Shvachko, Valentina A; Ready, Joanna B; Pauly, Mary Pat; Terrault, Norah A; Peters, Marion G; Manos, M Michele

2014-09-01

Few population-based studies have described characteristics and management of patients with chronic hepatitis B (CHB) in the USA. We retrospectively studied adults with CHB in the Northern California Kaiser Permanente Medical Care Program (KPNC) from July 2009 to December 2010 (n = 12,016). Laboratory tests, treatment patterns, and hepatocellular carcinoma (HCC) surveillance were ascertained during a "recent" 18-month study window (July 2009-December 2010), or as "ever" based on records dating to 1995. The mean age was 49 years; 51 % were men, 83 % Asian, and 87 % KPNC members >5 years. Overall, 51 % had ≥ 1 liver-related visit, 14 % with gastroenterology or infectious disease specialists, and 37 % with primary care providers (PCP) only. Less than 40 % of patients had both hepatitis B virus (HBV) DNA and ALT testing conducted recently, while 56 % of eligible patients had received HCC surveillance. Recent laboratory testing and HCC surveillance were more frequent in patients seen by a specialist versus PCP only (90 vs. 47 % and 92 vs. 73 %, respectively, p values <0.001). During the study period, 1,649 (14 %) received HBV treatment, while 5 % of untreated patients had evidence of treatment eligibility. Among 599 patients newly initiated on HBV therapy, 76 % had guideline-based indications for treatment. Most patients initiated on HBV treatment met eligibility, and very few patients with evidence of needing treatment were left untreated. However, monitoring of ALT and HBV DNA levels, as well as HCC surveillance, were not frequent, underestimating the proportion of patients that warranted HBV therapy. Viral monitoring and cancer surveillance are therefore important targets for improving the scope of CHB care in the community setting.

Implementation and Operational Research: Affordable Care Act Implementation in a California Health Care System Leads to Growth in HIV-Positive Patient Enrollment and Changes in Patient Characteristics.

PubMed

Satre, Derek D; Altschuler, Andrea; Parthasarathy, Sujaya; Silverberg, Michael J; Volberding, Paul; Campbell, Cynthia I

2016-12-15

This study examined implementation of the Affordable Care Act (ACA) in relation to HIV-positive patient enrollment in an integrated health care system; as well as changes in new enrollee characteristics, benefit structure, and health care utilization after key ACA provisions went into effect in 2014. This mixed-methods study was set in Kaiser Permanente Northern California (KPNC). Qualitative interviews with 29 KPNC leaders explored planning for ACA implementation. Quantitative analyses compared newly enrolled HIV-positive patients in KPNC between January and December 2012 ("pre-ACA," N = 661) with newly enrolled HIV-positive patients between January and December 2014 ("post-ACA," N = 880) on demographics; medical, psychiatric, and substance use disorder diagnoses; HIV clinical indicators; and type of health care utilization. Interviews found that ACA preparation focused on enrollment growth, staffing, competition among health plans, concern about cost sharing, and HIV pre-exposure prophylaxis (PrEP) services. Quantitative analyses found that post-ACA HIV-positive patient enrollment grew. New enrollees in 2014 were more likely than 2012 enrollees to be enrolled in high-deductible plans (P < 0.01) or through Medicaid (P < 0.01), and marginally more likely to have better HIV viral control (P < 0.10). They also were more likely to be diagnosed with asthma (P < 0.01) or substance use disorders (P < 0.05) and to have used primary care health services in the 6 months postenrollment (P < 0.05) than the pre-ACA cohort. As anticipated by KPNC interviewees, ACA implementation was followed by HIV-positive patient enrollment growth and changing benefit structures and patient characteristics. Although HIV viral control improved, comorbid diagnosis findings reinforced the importance of coordinated health care.

A joint model of persistent human papillomavirus infection and cervical cancer risk: Implications for cervical cancer screening

PubMed Central

Katki, Hormuzd A.; Cheung, Li C.; Fetterman, Barbara; Castle, Philip E.; Sundaram, Rajeshwari

2014-01-01

Summary New cervical cancer screening guidelines in the US and many European countries recommend that women get tested for human papillomavirus (HPV). To inform decisions about screening intervals, we calculate the increase in precancer/cancer risk per year of continued HPV infection. However, both time to onset of precancer/cancer and time to HPV clearance are interval-censored, and onset of precancer/cancer strongly informatively censors HPV clearance. We analyze this bivariate informatively interval-censored data by developing a novel joint model for time to clearance of HPV and time to precancer/cancer using shared random-effects, where the estimated mean duration of each woman’s HPV infection is a covariate in the submodel for time to precancer/cancer. The model was fit to data on 9,553 HPV-positive/Pap-negative women undergoing cervical cancer screening at Kaiser Permanente Northern California, data that were pivotal to the development of US screening guidelines. We compare the implications for screening intervals of this joint model to those from population-average marginal models of precancer/cancer risk. In particular, after 2 years the marginal population-average precancer/cancer risk was 5%, suggesting a 2-year interval to control population-average risk at 5%. In contrast, the joint model reveals that almost all women exceeding 5% individual risk in 2 years also exceeded 5% in 1 year, suggesting that a 1-year interval is better to control individual risk at 5%. The example suggests that sophisticated risk models capable of predicting individual risk may have different implications than population-average risk models that are currently used for informing medical guideline development. PMID:26556961

A joint model of persistent human papillomavirus infection and cervical cancer risk: Implications for cervical cancer screening.

PubMed

Katki, Hormuzd A; Cheung, Li C; Fetterman, Barbara; Castle, Philip E; Sundaram, Rajeshwari

2015-10-01

New cervical cancer screening guidelines in the US and many European countries recommend that women get tested for human papillomavirus (HPV). To inform decisions about screening intervals, we calculate the increase in precancer/cancer risk per year of continued HPV infection. However, both time to onset of precancer/cancer and time to HPV clearance are interval-censored, and onset of precancer/cancer strongly informatively censors HPV clearance. We analyze this bivariate informatively interval-censored data by developing a novel joint model for time to clearance of HPV and time to precancer/cancer using shared random-effects, where the estimated mean duration of each woman's HPV infection is a covariate in the submodel for time to precancer/cancer. The model was fit to data on 9,553 HPV-positive/Pap-negative women undergoing cervical cancer screening at Kaiser Permanente Northern California, data that were pivotal to the development of US screening guidelines. We compare the implications for screening intervals of this joint model to those from population-average marginal models of precancer/cancer risk. In particular, after 2 years the marginal population-average precancer/cancer risk was 5%, suggesting a 2-year interval to control population-average risk at 5%. In contrast, the joint model reveals that almost all women exceeding 5% individual risk in 2 years also exceeded 5% in 1 year, suggesting that a 1-year interval is better to control individual risk at 5%. The example suggests that sophisticated risk models capable of predicting individual risk may have different implications than population-average risk models that are currently used for informing medical guideline development.

Characterizing Race/Ethnicity and Genetic Ancestry for 100,000 Subjects in the Genetic Epidemiology Research on Adult Health and Aging (GERA) Cohort.

PubMed

Banda, Yambazi; Kvale, Mark N; Hoffmann, Thomas J; Hesselson, Stephanie E; Ranatunga, Dilrini; Tang, Hua; Sabatti, Chiara; Croen, Lisa A; Dispensa, Brad P; Henderson, Mary; Iribarren, Carlos; Jorgenson, Eric; Kushi, Lawrence H; Ludwig, Dana; Olberg, Diane; Quesenberry, Charles P; Rowell, Sarah; Sadler, Marianne; Sakoda, Lori C; Sciortino, Stanley; Shen, Ling; Smethurst, David; Somkin, Carol P; Van Den Eeden, Stephen K; Walter, Lawrence; Whitmer, Rachel A; Kwok, Pui-Yan; Schaefer, Catherine; Risch, Neil

2015-08-01

Using genome-wide genotypes, we characterized the genetic structure of 103,006 participants in the Kaiser Permanente Northern California multi-ethnic Genetic Epidemiology Research on Adult Health and Aging Cohort and analyzed the relationship to self-reported race/ethnicity. Participants endorsed any of 23 race/ethnicity/nationality categories, which were collapsed into seven major race/ethnicity groups. By self-report the cohort is 80.8% white and 19.2% minority; 93.8% endorsed a single race/ethnicity group, while 6.2% endorsed two or more. Principal component (PC) and admixture analyses were generally consistent with prior studies. Approximately 17% of subjects had genetic ancestry from more than one continent, and 12% were genetically admixed, considering only nonadjacent geographical origins. Self-reported whites were spread on a continuum along the first two PCs, indicating extensive mixing among European nationalities. Self-identified East Asian nationalities correlated with genetic clustering, consistent with extensive endogamy. Individuals of mixed East Asian-European genetic ancestry were easily identified; we also observed a modest amount of European genetic ancestry in individuals self-identified as Filipinos. Self-reported African Americans and Latinos showed extensive European and African genetic ancestry, and Native American genetic ancestry for the latter. Among 3741 genetically identified parent-child pairs, 93% were concordant for self-reported race/ethnicity; among 2018 genetically identified full-sib pairs, 96% were concordant; the lower rate for parent-child pairs was largely due to intermarriage. The parent-child pairs revealed a trend toward increasing exogamy over time; the presence in the cohort of individuals endorsing multiple race/ethnicity categories creates interesting challenges and future opportunities for genetic epidemiologic studies. Copyright © 2015 by the Genetics Society of America.

Risk of Autism Associated With Hyperbilirubinemia and Phototherapy.

PubMed

Wu, Yvonne W; Kuzniewicz, Michael W; Croen, Lisa; Walsh, Eileen M; McCulloch, Charles E; Newman, Thomas B

2016-10-01

Whether neonatal hyperbilirubinemia and/or phototherapy increase the risk of autism spectrum disorder (ASD) is unclear. We sought to quantify the risk of ASD associated with elevated total serum bilirubin (TSB) levels and with phototherapy. In a retrospective cohort study of 525 409 infants born at ≥35 weeks' gestation in 15 Kaiser Permanente Northern California (KPNC) hospitals, 1995-2011, we obtained all TSB levels and determined which infants received phototherapy. From the KPNC Autism Registry, we identified patients with ASD diagnosed at a KPNC Autism Center, by a clinical specialist, or by a pediatrician. We calculated Cox proportional hazard ratios (HRs) for time to diagnosis of ASD, adjusting for confounding factors. Among infants in the birth cohort, 2% had at least 1 TSB level ≥20 mg/dL, and 8% received phototherapy. The rate of ASD was 13 per 1000 births. Crude analyses revealed an association between TSB ≥20 and ASD (relative risk: 1.4; 95% confidence interval [CI]: 1.1-1.6), and between phototherapy and ASD (relative risk: 1.7; 95% CI: 1.5-1.8). After adjusting for confounders, TSB ≥20 (HR: 1.09; 95% CI: 0.89-1.35) and phototherapy (HR: 1.10; 95% CI: 0.98-1.24) were no longer significantly associated with ASD. Independent risk factors for ASD included maternal and paternal age; maternal and paternal higher education; male sex; birth weight <2500 g or ≥4200 g; and later year of birth. After adjustment for the effects of sociodemographic factors and birth weight, neither hyperbilirubinemia nor phototherapy was an independent risk factor for ASD. Copyright © 2016 by the American Academy of Pediatrics.

Incident Atrial Fibrillation and Risk of End-Stage Renal Disease in Adults with Chronic Kidney Disease

PubMed Central

Bansal, Nisha; Fan, Dongjie; Hsu, Chi-yuan; Ordonez, Juan D.; Marcus, Gregory M.; Go, Alan S.

2013-01-01

Background Atrial fibrillation (AF) frequently occurs in patients with chronic kidney disease (CKD). However, the long-term impact of development of AF on the risk of adverse renal outcomes in patients with CKD is unknown. In this study, we determined the association between incident AF and risk of end-stage renal disease (ESRD) among adults with CKD. Methods and Results We studied adults with CKD (defined as persistent glomerular filtration rate [eGFR] <60 ml/min/1.73 m2 by the CKD-EPI equation) enrolled in Kaiser Permanente Northern California who were identified between 2002–2010 and who did not have prior ESRD or previously documented AF. Incident AF was identified using primary hospital discharge diagnoses and/or two or more outpatient visits for AF. Incident ESRD was ascertained from a comprehensive health plan registry for dialysis and renal transplant. Among 206,229 adults with CKD, 16,463 developed incident AF. During a mean follow-up of 5.1± 2.5 years, there were 345 cases of ESRD that occurred after development of incident AF (74 per 1000 person-years) compared with 6505 cases of ESRD during periods without AF (64 per 1000 person-years, P<0.001). After adjustment for potential confounders, incident AF was associated with a 67% increase in rate of ESRD (hazard ratio 1.67, 95% confidence interval: 1.46–1.91). Conclusions Incident AF is independently associated with increased risk of developing ESRD in adults with CKD. Further study is needed to identify potentially modifiable pathways through which AF leads to a higher risk of progression to ESRD. PMID:23275377

Factors influencing variation in physician adenoma detection rates: a theory-based approach for performance improvement.

PubMed

Atkins, Louise; Hunkeler, Enid M; Jensen, Christopher D; Michie, Susan; Lee, Jeffrey K; Doubeni, Chyke A; Zauber, Ann G; Levin, Theodore R; Quinn, Virginia P; Corley, Douglas A

2016-03-01

Interventions to improve physician adenoma detection rates for colonoscopy have generally not been successful, and there are little data on the factors contributing to variation that may be appropriate targets for intervention. We sought to identify factors that may influence variation in detection rates by using theory-based tools for understanding behavior. We separately studied gastroenterologists and endoscopy nurses at 3 Kaiser Permanente Northern California medical centers to identify potentially modifiable factors relevant to physician adenoma detection rate variability by using structured group interviews (focus groups) and theory-based tools for understanding behavior and eliciting behavior change: the Capability, Opportunity, and Motivation behavior model; the Theoretical Domains Framework; and the Behavior Change Wheel. Nine factors potentially associated with adenoma detection rate variability were identified, including 6 related to capability (uncertainty about which types of polyps to remove, style of endoscopy team leadership, compromised ability to focus during an examination due to distractions, examination technique during withdrawal, difficulty detecting certain types of adenomas, and examiner fatigue and pain), 2 related to opportunity (perceived pressure due to the number of examinations expected per shift and social pressure to finish examinations before scheduled breaks or the end of a shift), and 1 related to motivation (valuing a meticulous examination as the top priority). Examples of potential intervention strategies are provided. By using theory-based tools, this study identified several novel and potentially modifiable factors relating to capability, opportunity, and motivation that may contribute to adenoma detection rate variability and be appropriate targets for future intervention trials. Copyright © 2016 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.

Alprazolam use and dependence. A retrospective analysis of 30 cases of withdrawal.

PubMed Central

Dickinson, B; Rush, P A; Radcliffe, A B

1990-01-01

From 1986 to 1989, the Chemical Dependency Recovery Program at Kaiser Permanente Hospital, Fontana, California, admitted an increasing number of patients for alprazolam dependence. Severe withdrawal reactions and adverse consequences with use were reported in the literature. In this review of 30 cases of alprazolam dependence and subsequent withdrawal, there was a statistically significant increase in the number of patient hospital days, the subjective symptoms, and staff time spent with patients compared with those in alcoholic controls. Most patients with diagnosed alprazolam dependence used doses in the range recommended by the package information at the time of admission. Patients with low preadmission doses of 1 mg or less per day showed notable withdrawal symptoms. The average duration of use was 29.9 months, considerably longer than suggested effective ranges. Most patients (28) had a chemical dependence history before being placed on alprazolam therapy; 24 had a positive family history of chemical dependence; and 24 had previous or current psychiatric care. PMID:2349800

Acceptance of direct physician access to a computer-based patient record in a managed care setting.

PubMed

Dewey, J B; Manning, P; Brandt, S

1993-01-01

Kaiser Permanente Mid-Atlantic States has developed a fully integrated outpatient information system which currently runs on an IBM ES9000 on a VM platform written in MUMPS. The applications include Lab, Radiology, Transcription, Appointments. Pharmacy, Encounter tracking, Hospitalizations, Referrals, Phone Advice, Pap tracking, Problem list, Immunization tracking, and Patient demographics. They are department specific and require input and output from a dumb terminal. We have developed a physician's work station to access this information using PC compatible computers running Microsoft Windows and a custom Microsoft Visual Basic 2.0 environment which draws from these 14 applications giving the physician a comprehensive view of all electronic medical records. Through rapid prototyping, voluntary participation, formal training and gradual implementation we have created an enthusiastic response. 95% of our physician PC users access the system each month. The use ranges from 0.2 to 3.0 screens of data viewed per patient visit. This response continues to drive the process toward still greater user acceptance and further practice enhancement.

Design and coverage of high throughput genotyping arrays optimized for individuals of East Asian, African American, and Latino race/ethnicity using imputation and a novel hybrid SNP selection algorithm.

PubMed

Hoffmann, Thomas J; Zhan, Yiping; Kvale, Mark N; Hesselson, Stephanie E; Gollub, Jeremy; Iribarren, Carlos; Lu, Yontao; Mei, Gangwu; Purdy, Matthew M; Quesenberry, Charles; Rowell, Sarah; Shapero, Michael H; Smethurst, David; Somkin, Carol P; Van den Eeden, Stephen K; Walter, Larry; Webster, Teresa; Whitmer, Rachel A; Finn, Andrea; Schaefer, Catherine; Kwok, Pui-Yan; Risch, Neil

2011-12-01

Four custom Axiom genotyping arrays were designed for a genome-wide association (GWA) study of 100,000 participants from the Kaiser Permanente Research Program on Genes, Environment and Health. The array optimized for individuals of European race/ethnicity was previously described. Here we detail the development of three additional microarrays optimized for individuals of East Asian, African American, and Latino race/ethnicity. For these arrays, we decreased redundancy of high-performing SNPs to increase SNP capacity. The East Asian array was designed using greedy pairwise SNP selection. However, removing SNPs from the target set based on imputation coverage is more efficient than pairwise tagging. Therefore, we developed a novel hybrid SNP selection method for the African American and Latino arrays utilizing rounds of greedy pairwise SNP selection, followed by removal from the target set of SNPs covered by imputation. The arrays provide excellent genome-wide coverage and are valuable additions for large-scale GWA studies. Copyright © 2011 Elsevier Inc. All rights reserved.

Companies commit to emergency contraception -- have you?

PubMed

1999-12-01

Despite the efforts of the medical community, as well as promotional efforts by pharmaceutical companies, relatively few women in the US have heard of emergency contraceptives (ECs). Gynetics, marketer of Preven, plans to file a new drug application for a levonorgestrel EC by the end of 1999, with an anticipated approval in the second half of 2000. Women's Capital Corp., marketer of Plan B, is also aiming for a national commercial launch of its product. According to a recently published acceptability study, women will use ECs when they are made available. A survey among 235 women at 13 Kaiser Permanente medical offices in San Diego, California, regarding their experiences with ECs showed that 91% were satisfied with ECs, and 97% said they would use ECs for emergencies only--dispelling fears that women would forego use of ongoing contraception. About 70% of the women who participated in the study were using a contraceptive method when they requested ECs.

Incidence and clinical characteristics of interstitial cystitis in the community.

PubMed

Patel, Ronak; Calhoun, Elizabeth A; Meenan, Richard T; O'Keeffe Rosetti, Maureen C; Kimes, Terry; Clemens, J Quentin

2008-08-01

We utilized physician-coded diagnoses and chart reviews to estimate the incidence of interstitial cystitis (IC) in women. A computer search of the Kaiser Permanente database was performed to identify newly coded diagnoses of IC (ICD-9 code 595.1) between May 2002 and May 2005. Chart reviews were performed and patient demographics, diagnosing physicians, and symptom characteristics were recorded. The IC incidence rate was 15 per 100,000 women per year. The mean age of the patients was 51 years (range 31-81 years). The most common presenting symptoms were frequency (70%), dysuria (52%), urgency (50%), suprapubic pain (50%), nocturia (35%), and dyspareunia (13%). Cases diagnosed by primary care physicians had a shorter median symptom duration (9 months) compared with those diagnosed by urologists (1 year) and gynecologists (3 years). IC is an uncommon diagnosis in the community setting, with an incidence rate of 15 per 100,000 women per year.

Experience using radio frequency laptops to access the electronic medical record in exam rooms.

PubMed Central

Dworkin, L. A.; Krall, M.; Chin, H.; Robertson, N.; Harris, J.; Hughes, J.

1999-01-01

Kaiser Permanente, Northwest, evaluated the use of laptop computers to access our existing comprehensive Electronic Medical Record in exam rooms via a wireless radiofrequency (RF) network. Eleven of 22 clinicians who were offered the laptops successfully adopted their use in the exam room. These clinicians were able to increase their exam room time with the patient by almost 4 minutes (25%), apparently without lengthening their overall work day. Patient response to exam room computing was overwhelmingly positive. The RF network response time was similar to the hardwired network. Problems cited by some laptop users and many of the eleven non-adopters included battery issues, different equipment layout and function, and inadequate training. IT support needs for the RF laptops were two to four times greater than for hardwired desktops. Addressing the reliability and training issues should increase clinician acceptance, making a successful general roll-out for exam room computing more likely. PMID:10566458

Ten strategies to lower costs, improve quality, and engage patients: the view from leading health system CEOs.

PubMed

Cosgrove, Delos M; Fisher, Michael; Gabow, Patricia; Gottlieb, Gary; Halvorson, George C; James, Brent C; Kaplan, Gary S; Perlin, Jonathan B; Petzel, Robert; Steele, Glenn D; Toussaint, John S

2013-02-01

Patient-centeredness--the idea that care should be designed around patients' needs, preferences, circumstances, and well-being--is a central tenet of health care delivery. For CEOs of health care organizations, patient-centered care is also quickly becoming a business imperative, with payments tied to performance on measures of patient satisfaction and engagement. In A CEO Checklist for High-Value Health Care, we, as executives of eleven leading health care delivery institutions, outlined ten key strategies for reducing costs and waste while improving outcomes. In this article we describe how implementation of these strategies benefits both health care organizations and patients. For example, Kaiser Permanente's Healthy Bones Program resulted in a 30 percent reduction in hip fracture rates for at-risk patients. And at Virginia Mason Health System in Seattle, nurses reorganized care patterns and increased the time they spent on direct patient care to 90 percent. Our experiences show that patient-engaged care can be delivered in ways that simultaneously improve quality and reduce costs.

The global diabetes model: user friendly version 3.0.

PubMed

Brown, J B; Russell, A; Chan, W; Pedula, K; Aickin, M

2000-11-01

The attributes of Release 3.0 of the user friendly version (UFV) of the global diabetes model (GDM) are described and documented in detail. The GDM is a continuous, stochastic microsimulation model of type 2 diabetes. Suitable for predicting the medical futures of both individuals with diabetes and representative diabetic populations, the GDM predicts medical events (complications of diabetes), survival, utilities, and medical care costs. Incidence rate functions for microvascular and macrovascular complications are based on a combination of published studies and analyses of data describing diabetic members of Kaiser Permanente Northwest Region, a non-profit group-model health maintenance organization. Active risk factors include average blood glucose (HbAlc), systolic blood pressure (SBP), low density lipoprotein cholesterol (LDL), high density lipoprotein cholesterol (HDL), triglycerides, smoking status, and use of prophylactic aspirin. Events predicted include diabetic eye disease, diabetic nephropathy, peripheral neuropathy amputation, myocardial infarction, stroke, peripheral artery disease, congestive heart failure, coronary artery surgery, coronary angioplasty, and death.

Adverse events associated with apremilast use and withdrawal for psoriasis in a real-world setting.

PubMed

Lee, Erica B; Amin, Mina; Egeberg, Alexander; Wu, Jashin J

2018-05-06

Apremilast, a phosphodiesterase-4 inhibitor, is an oral therapy for treatment of psoriasis. Its safety profile is favorable, with side effects including diarrhea, nausea, vomiting, depression, and weight decrease, primarily based on clinical trial data. However, limited research exists on the side effect frequency and subsequent adverse events (AEs) in real-world practice. This retrospective chart review included patients who presented to the dermatology clinic at Kaiser Permanente Los Angeles Medical Center and were treated with apremilast at any time between January 1, 2015 and January 11, 2018. Patients were not included if they did not have at least one follow-up by clinic visit, telephone, or email correspondence after being prescribed apremilast. A total of 77 patients were included. AEs and withdrawal due to AEs were assessed throughout the treatment period from each patient's respective medical record. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

The dissemination of clinical practice guidelines over an intranet: an evaluation.

PubMed Central

Stolte, J. J.; Ash, J.; Chin, H.

1999-01-01

This study compares two clinical practice guideline dissemination systems. It was hypothesized that placing guidelines on an intranet would make this information easier to retrieve. Retrieval time, retrieval accuracy, and ease of use were empirically evaluated. Sixteen clinicians from Kaiser Permanente volunteered to complete tasks that measured these variables. Time values were significantly longer for tasks completed with intranet guidelines (Intranet = 6.7 minutes, Paper = 5.7 minutes). Tasks completed with paper guidelines had a significantly higher percentage of perfect scores than those completed with the intranet (Paper = 85%, Intranet = 59%). There was no significant difference in reported ease of use. Simply placing clinical information on an electronic system does not guarantee that the information will be easier to retrieve. Such information needs to be fully integrated into the clinical decision making process. Computerizing guidelines may provide a necessary initial step toward this goal, but it does not represent the final solution. PMID:10566503

Unpacking the impact of adverse childhood experiences on adult mental health.

PubMed

Merrick, Melissa T; Ports, Katie A; Ford, Derek C; Afifi, Tracie O; Gershoff, Elizabeth T; Grogan-Kaylor, Andrew

2017-07-01

Exposure to childhood adversity has an impact on adult mental health, increasing the risk for depression and suicide. Associations between Adverse Childhood Experiences (ACEs) and several adult mental and behavioral health outcomes are well documented in the literature, establishing the need for prevention. The current study analyzes the relationship between an expanded ACE score that includes being spanked as a child and adult mental health outcomes by examining each ACE separately to determine the contribution of each ACE. Data were drawn from Wave II of the CDC-Kaiser ACE Study, consisting of 7465 adult members of Kaiser Permanente in southern California. Dichotomous variables corresponding to each of the 11 ACE categories were created, with ACE score ranging from 0 to 11 corresponding to the total number of ACEs experienced. Multiple logistic regression modeling was used to examine the relationship between ACEs and adult mental health outcomes adjusting for sociodemographic covariates. Results indicated a graded dose-response relationship between the expanded ACE score and the likelihood of moderate to heavy drinking, drug use, depressed affect, and suicide attempts in adulthood. In the adjusted models, being spanked as a child was significantly associated with all self-reported mental health outcomes. Over 80% of the sample reported exposure to at least one ACE, signifying the potential to capture experiences not previously considered by traditional ACE indices. The findings highlight the importance of examining both cumulative ACE scores and individual ACEs on adult health outcomes to better understand key risk and protective factors for future prevention efforts. Copyright © 2017. Published by Elsevier Ltd.

Rehospitalizations and outpatient contacts of mothers and neonates after hospital discharge after vaginal delivery.

PubMed

Meikle, S F; Lyons, E; Hulac, P; Orleans, M

1998-07-01

Our purpose was to determine whether length of hospital stay after vaginal delivery as determined by the discharging physician is associated with rehospitalizations or increased outpatient contacts by mothers and neonates and to assess the impact of home health care visits. An inception cohort study of all rehospitalizations and outpatient contacts of mothers and neonates after vaginal delivery at St. Joseph Hospital, Denver, Colorado, was done from January 1, 1994, to September 30, 1995. All Kaiser Permanente mother-neonate pairs in which the delivery was vaginal (excluding those with multiple gestations or birth weight < 2500 g) were included. Length of initial hospital stay was divided into three time periods: < or = 24 hours, 25 to 48 hours, and > 48 hours. The Colorado Kaiser Permanente Perinatal Database was used to identify perinatal and demographic factors that might have increased health care use. Additional information was sought in administrative databases, bill records, and inpatient charts. Mothers were followed up for 6 weeks and neonates for 28 days after delivery. Home care visits were provided to more than half the mothers and neonates by means of a standardized protocol. The main outcome measures were rehospitalizations and outpatient visits for mothers and neonate, controlling for home care visits. A total of 4323 mother-neonate pairs were identified. For the mothers, a longer initial hospital stay (> 48 hours) was significantly associated with both readmission (P < .01) and increased outpatient care use (P = .01) in the 6-week postpartum period. Thirty-five mothers (.81%) were rehospitalized by 6 weeks. Maternal factors associated with increased outpatient contacts were preeclampsia, preterm delivery, and instrument delivery. Sixty-seven neonates (1.55%) were readmitted to the hospital. Home care visits reduced the need for both readmissions and outpatient visits. For mothers in this cohort a longer initial hospital stay was significantly

Northern forests, Chapter 7

Treesearch

L.H. Pardo; C.L. Goodale; E.A. Lilleskov; L.H. Geiser

2011-01-01

The Northern Forests ecological region spans much of Canada, from Saskatchewan to Newfoundland; its southern portion extends into the northern United States (CEC 1997). The U.S. component includes the northern hardwood and spruce-fir forest types and encompasses parts of the Northeast (mountainous regions in Pennsylvania, New York, New Jersey, Connecticut,...

Physician Professional Satisfaction and Area of Clinical Practice: Evidence from an Integrated Health Care Delivery System.

PubMed

Caloyeras, John P; Kanter, Michael; Ives, Nicole; Kim, Chong Y; Kanzaria, Hemal K; Berry, Sandra H; Brook, Robert H

2016-01-01

For health care reform to succeed, health care systems need a professionally satisfied primary care workforce. Evidence suggests that primary care physicians are less satisfied than those in other medical specialties. To assess three domains of physician satisfaction by area of clinical practice among physicians practicing in an established integrated health system. Cross-sectional online survey of all Southern California Permanente Medical Group (SCPMG) 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. Primary measure was satisfaction with one's day-to-day professional life as a physician. Secondary measures were satisfaction with quality of care and income. Of the 636 physicians responding to the survey (61.5% response rate), on average, 8 in 10 SCPMG physicians reported satisfaction with their day-to-day professional life as a physician. Primary care physicians were only minimally less likely to report being satisfied (difference of 8.2-9.5 percentage points; p < 0.05) than were other physicians. Nearly all physicians (98.2%) were satisfied with the quality of care they are able to provide. Roughly 8 in 10 physicians reported satisfaction with their income. No differences were found between primary care physicians and those in other clinical practice areas regarding satisfaction with quality of care or income. It is possible to create practice settings, such as SCPMG, in which most physicians, including those in primary care, experience high levels of professional satisfaction.

Physician Professional Satisfaction and Area of Clinical Practice: Evidence from an Integrated Health Care Delivery System

PubMed Central

Caloyeras, John P; Kanter, Michael; Ives, Nicole; Kim, Chong Y; Kanzaria, Hemal K; Berry, Sandra H; Brook, Robert H

2016-01-01

Context: For health care reform to succeed, health care systems need a professionally satisfied primary care workforce. Evidence suggests that primary care physicians are less satisfied than those in other medical specialties. Objective: To assess three domains of physician satisfaction by area of clinical practice among physicians practicing in an established integrated health system. Design: Cross-sectional online survey of all Southern California Permanente Medical Group (SCPMG) 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. Main Outcome Measures: Primary measure was satisfaction with one’s day-to-day professional life as a physician. Secondary measures were satisfaction with quality of care and income. Results: Of the 636 physicians responding to the survey (61.5% response rate), on average, 8 in 10 SCPMG physicians reported satisfaction with their day-to-day professional life as a physician. Primary care physicians were only minimally less likely to report being satisfied (difference of 8.2–9.5 percentage points; p < 0.05) than were other physicians. Nearly all physicians (98.2%) were satisfied with the quality of care they are able to provide. Roughly 8 in 10 physicians reported satisfaction with their income. No differences were found between primary care physicians and those in other clinical practice areas regarding satisfaction with quality of care or income. Conclusion: It is possible to create practice settings, such as SCPMG, in which most physicians, including those in primary care, experience high levels of professional satisfaction. PMID:27057819

Reproductive health outcomes of insured adolescent and adult women who access oral levonorgestrel emergency contraception.

PubMed

Raine-Bennett, Tina; Merchant, Maqdooda; Sinclair, Fiona; Lee, Justine W; Goler, Nancy

2015-04-01

To assess the level of risk for adolescents and women who seek emergency contraception through various clinical routes and the opportunities for improved care provision. This study looked at a retrospective cohort to assess contraception and other reproductive health outcomes among adolescents and women aged 15-44 years who accessed oral levonorgestrel emergency contraception through an office visit or the call center at Kaiser Permanente Northern California from 2010 to 2011. Of 21,421 prescriptions, 14,531 (67.8%) were accessed through the call center. In the subsequent 12 months, 12,127 (56.6%) adolescents and women had short-acting contraception (pills, patches, rings, depot medroxyprogesterone) dispensed and 2,264 (10.6%) initiated very effective contraception (intrauterine contraception, implants, sterilization). Initiation of very effective contraception was similar for adolescents and women who accessed it through the call center-1,569 (10.8%) and office visits-695 (10.1%) (adjusted odds ratio [OR] 1.02, 95% confidence interval [CI] 0.93-1.13). In the subsequent 6 months, 2,056 (9.6%) adolescents and women became pregnant. Adolescents and women who accessed emergency contraception through the call center were less likely to become pregnant within 3 months of accessing emergency contraception than woman who accessed it through office visits (adjusted OR 0.82, 95% CI 0.72-0.94); however, they were more likely to become pregnant within 4-6 months (adjusted OR 1.37, 95% CI 1.16-1.60). Among adolescents and women who were tested for chlamydia and gonorrhea, 689 (7.8%) and 928 (7.9%) were positive in the 12 months before and after accessing emergency contraception, respectively. Protocols to routinely address unmet needs for contraception at every call for emergency contraception and all office visits, including visits with primary care providers, should be investigated.

Reproductive Health Outcomes of Insured Women Who Access Oral Levonorgestrel Emergency Contraception

PubMed Central

Raine-Bennett, Tina; Merchant, Maqdooda; Sinclair, Fiona; Lee, Justine W.; Goler, Nancy

2015-01-01

Objectives To assess the level of risk for women who seek emergency contraception through various clinical routes and the opportunities for improved care provision. Methods This study looked at a retrospective cohort to assess contraception and other reproductive health outcomes among women aged 15-44 who accessed oral levonorgestrel emergency contraception through an office visit or the call center at Kaiser Permanente Northern California from 2010 to 2011. Results Of 21,421 prescriptions, 14,531(67.8%) were accessed through the call center. In the subsequent 12 months, 12,127(56.6%) women had short-acting contraception (pills, patches, rings, depot medroxyprogesterone) dispensed and 2,264(10.6%) initiated very effective contraception (intrauterine contraception, implants, sterilization). Initiation of very effective contraception was similar for women who accessed it through the call center -1,569(10.8%) and office visits – 695(10.1%) (adjusted OR 1.02 95% confidence interval (CI) 0.93-1.13). In the subsequent 6 months, 2,056(9.6%) women became pregnant. Women who accessed emergency contraception through the call center were less likely to become pregnant within 3 months of accessing emergency contraception than woman who accessed it through office visits (adjusted OR 0.82 95% CI 0.72-0.94); however they were more likely to become pregnant within 4-6 months (adjusted OR 1.37 95%CI 1.16-1.60). Among women who were tested for chlamydia and gonorrhea, 689(7.8%) and 928(7.9%) were positive in the 12 months before and after accessing emergency contraception, respectively. Conclusions Protocols to routinely address unmet need for contraception at every call for emergency contraception and all office visits including visits with primary care providers should be investigated. PMID:25751211

Untreated brain arteriovenous malformation

PubMed Central

Al-Shahi Salman, Rustam; McCulloch, Charles E.; Stapf, Christian; Young, William L.

2014-01-01

Objective: To identify risk factors for intracranial hemorrhage in the natural history course of brain arteriovenous malformations (AVMs) using individual patient data meta-analysis of 4 existing cohorts. Methods: We harmonized data from Kaiser Permanente of Northern California (n = 856), University of California San Francisco (n = 787), Columbia University (n = 672), and the Scottish Intracranial Vascular Malformation Study (n = 210). We censored patients at first treatment, death, last visit, or 10-year follow-up, and performed stratified Cox regression analysis of time-to-hemorrhage after evaluating hemorrhagic presentation, sex, age at diagnosis, deep venous drainage, and AVM size as predictors. Multiple imputation was performed to assess impact of missing data. Results: A total of 141 hemorrhage events occurred during 6,074 patient-years of follow-up (annual rate of 2.3%, 95% confidence interval [CI] 2.0%–2.7%), higher for ruptured (4.8%, 3.9%–5.9%) than unruptured (1.3%, 1.0%–1.7%) AVMs at presentation. Hemorrhagic presentation (hazard ratio 3.86, 95% CI 2.42–6.14) and increasing age (1.34 per decade, 1.17–1.53) independently predicted hemorrhage and remained significant predictors in the imputed dataset. Female sex (1.49, 95% CI 0.96–2.30) and exclusively deep venous drainage (1.60, 0.95–2.68, p = 0.02 in imputed dataset) may be additional predictors. AVM size was not associated with intracerebral hemorrhage in multivariable models (p > 0.5). Conclusion: This large, individual patient data meta-analysis identified hemorrhagic presentation and increasing age as independent predictors of hemorrhage during follow-up. Additional AVM cohort data may further improve precision of estimates, identify new risk factors, and allow validation of prediction models. PMID:25015366

Discordant Syphilis Immunoassays in Pregnancy: Perinatal Outcomes and Implications for Clinical Management.

PubMed

Mmeje, Okeoma; Chow, Joan M; Davidson, Lisette; Shieh, Jennifer; Schapiro, Jeffrey M; Park, Ina U

2015-10-01

The reverse sequence algorithm is often used for prenatal syphilis screening by high-volume laboratories, beginning with a treponemal test such as the chemiluminescence immunoassay (CIA), followed by testing of CIA-positive (CIA(+)) specimens with the rapid plasma reagin test (RPR). The clinical significance of discordant serology (CIA(+)/RPR(-)) for maternal and neonatal outcomes is unknown. From August 2007 to August 2010, all pregnant women at Kaiser Permanente Northern California with discordant treponemal serology underwent reflexive testing with Treponema pallidum particle agglutination assay (TP-PA) and were categorized as "TP-PA confirmed" (CIA(+)/RPR(-)/TP-PA(+)) or "isolated CIA positive" (CIA(+)/RPR(-)/TP-PA(-)). Demographic variables and clinical data were abstracted from the medical record and compared by TP-PA status. Of 194 pregnant women, 156 (80%) were CIA(+)/RPR(-)/TP-PA(-) and 38 (20%) were CIA(+)/RPR(-)/TP-PA(+). Among the 77 (49%) CIA(+)/RPR(-)/TP-PA(-) women who were retested, 53% became CIA(-). CIA(+)/RPR(-)/TP-PA(+) (n = 38) women were more likely to be older, have a prior history of sexually transmitted infections, and receive treatment for syphilis during pregnancy than women who were CIA(+)/RPR(-)/TP-PA(-) (all P < .005). Most pregnancies (189/194 [97.5%]) resulted in a live birth; there was no difference in birth outcomes according to TP-PA status and no stillbirths attributable to syphilis. Most pregnant women with discordant serology were CIA(+)/RPR(-)/TP-PA(-); more than half who were retested became CIA(-). CIA(+)/RPR(-)/TP-PA(-) serology in pregnancy is likely to be falsely positive. Reflexive testing of discordant specimens with TP-PA is important to stratify risk given the likelihood of false-positive results in this population. © The Author 2015. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.

A novel telemonitoring device for improving diabetes control: protocol and results from a randomized clinical trial.

PubMed

Pressman, Alice R; Kinoshita, Linda; Kirk, Susan; Barbosa, Gina Monraz; Chou, Cathy; Minkoff, Jerome

2014-02-01

Telemedicine is one approach to managing patients with chronic illness. Several telephone-based monitoring studies of diabetes patients have shown improved glycosylated hemoglobin (HbA1c), blood pressure (BP), and low-density lipoprotein (LDL) levels. The purpose of this study was to evaluate an investigational in-home telemetry device for improving glucose and BP control over 6 months for patients with type 2 diabetes. The device was used to transmit weekly blood glucose, weight, and BP readings to a diabetes care manager. We conducted a two-arm, parallel-comparison, single-blind, randomized controlled trial among Kaiser Permanente Northern California members 18-75 years old with type 2 diabetes mellitus and entry HbA1c levels between 7.5% and 10.0%. Participants were randomly assigned to either the telemonitoring arm or the usual care arm. We observed very small, nonsignificant changes in fructosamine (telemonitoring, -54.9 μmol; usual care, -59.4 μmol) and systolic BP (telemonitoring, -6.3 mm Hg; usual care, -3.2 mm Hg) from baseline to 6 weeks in both groups. At 6 months, we observed no significant intergroup differences in change from baseline for HbA1c, fructosamine, or self-efficacy. However, LDL cholesterol in the telemonitoring arm decreased more than in the usual care arm (-17.1 mg/dL versus -5.4 mg/dL; P=0.045). Although HbA1c improved significantly over 6 months in both groups, the difference in improvement between the groups was not significant. This lack of significance may be due to the relatively healthy status of the volunteers in our study and to the high level of care provided by the care managers in the Santa Rosa, CA clinic. Further study in subgroups of less healthy diabetes patients is recommended.

Older adults' readiness to engage with eHealth patient education and self-care resources: a cross-sectional survey.

PubMed

Gordon, Nancy P; Hornbrook, Mark C

2018-03-27

This study examined access to digital technologies, skills and experience, and preferences for using web-based and other digital technologies to obtain health information and advice among older adults in a large health plan. A primary aim was to assess the extent to which digital divides by race/ethnicity and age group might affect the ability of a large percentage of seniors, and especially those in vulnerable groups, to engage with online health information and advice modalities (eHIA) and mobile health (mHealth) monitoring tools. A mailed survey was conducted with age-sex stratified random samples of English-speaking non-Hispanic white, African-American/black (black), Hispanic/Latino (Latino), Filipino-American (Filipino), and Chinese-American (Chinese) Kaiser Permanente Northern California members who were aged 65-79 years. Respondent data were weighted to the study population for the cross-sectional analyses. Older seniors and black, Latino, and Filipino seniors have less access to digital tools, less experience performing a variety of online tasks, and are less likely to believe that they would be capable of going online for health information and advice compared to younger and white Non-Hispanic seniors. Consequently, they are also less likely to be interested in using eHIA modalities. The same subgroups of seniors that have previously been shown to have higher prevalence of chronic conditions and greater difficulties with healthcare access are also less likely to adopt use of eHIA and mHealth monitoring technologies. At the patient population level, this digital divide is important to take into account when planning health information and chronic disease management programs. At the individual patient level, to provide good patient-centered care, it is important for providers to assess rather than assume digital access, eHealth skills, and preferences prior to recommending use of web-based resources and mHealth tools.

Acute Kidney Injury and Risk of Heart Failure and Atherosclerotic Events.

PubMed

Go, Alan S; Hsu, Chi-Yuan; Yang, Jingrong; Tan, Thida C; Zheng, Sijie; Ordonez, Juan D; Liu, Kathleen D

2018-06-07

AKI in the hospital is common and is associated with excess mortality. We examined whether AKI is also independently associated with a higher risk of different cardiovascular events in the first year after discharge. We conducted a retrospective analysis of a cohort between 2006 and 2013 with follow-up through 2014, within Kaiser Permanente Northern California. We identified all adults admitted to 21 hospitals who had one or more in-hospital serum creatinine test result and survived to discharge. Occurrence of AKI was on the basis of Kidney Disease: Improving Global Outcomes diagnostic criteria. Potential confounders were identified from comprehensive inpatient and outpatient, laboratory, and pharmacy electronic medical records. During the 365 days after discharge, we ascertained occurrence of heart failure, acute coronary syndromes, peripheral artery disease, and ischemic stroke events from electronic medical records. Among a matched cohort of 146,941 hospitalized adults, 31,245 experienced AKI. At 365 days postdischarge, AKI was independently associated with higher rates of the composite outcome of hospitalization for heart failure and atherosclerotic events (adjusted hazard ratio [aHR], 1.18; 95% confidence interval [95% CI], 1.13 to 1.25) even after adjustment for demographics, comorbidities, preadmission eGFR and proteinuria, heart failure and sepsis complicating the hospitalization, intensive care unit (ICU) admission, length of stay, and predicted in-hospital mortality. This was driven by an excess risk of subsequent heart failure (aHR, 1.44; 95% CI, 1.33 to 1.56), whereas there was no significant association with follow-up atherosclerotic events (aHR, 1.05; 95% CI, 0.98 to 1.12). AKI is independently associated with a higher risk of cardiovascular events, especially heart failure, after hospital discharge. Copyright © 2018 by the American Society of Nephrology.

Healthcare Encounters for Pokémon Go: Risks and Benefits of Playing.

PubMed

Barbero, Erika M; Carpenter, Diane M; Maier, Joetta; Tseng, Daniel S

2018-06-01

Our aim was to quantify the health risks and benefits of Pokémon Go, an augmented reality game played on the mobile phone utilizing real-world locations. Healthcare encounters containing references to Pokémon Go in Kaiser Permanente Northern California (KPNC) from July 5, 2016 to November 5, 2016 were reviewed. Subjects were classified according to the nature of the healthcare encounter subsequent to playing Pokémon Go: adverse event/injury, self-reported benefit, or incidental mention. Comparisons were made using the Wilcoxon-Mann-Whitney nonparametric test where variables were continuous and the chi-squared or Fisher's exact test where variables were binomial. Of 222 Pokémon Go players reporting an adverse event or benefit, 75 (33.8%) experienced adverse events and 147 (66.2%) reported benefits. Among our cohort, 114 subjects (54.0%) were obese, and 62 (27.9%) were diabetic or prediabetic. More subjects reporting benefits had an endocrine-related comorbidity than those reporting injuries (40.1% vs. 16.0%, P < 0.001). Median family income was higher in the benefit group than in the adverse event group ($83,846 vs. $70,378, P = 0.027). Of 75 subjects having adverse events, 8 (10.7%) had severe injuries, including fractures and head trauma, with 4 (5.3%) having inpatient stays. Most adverse events were musculoskeletal or skin injuries (n = 51, 68.0%). Injuries were similar to those seen with other light-to-moderate outdoor physical activities. Given KPNC's membership of 3.85 million, the number of severe injuries reported was low; this suggests that the game is safe to play. Pokémon Go may be reaching a population that requires increased physical activity.

Non-recovery from dialysis-requiring acute kidney injury and short-term mortality and cardiovascular risk: a cohort study.

PubMed

Lee, Benjamin J; Hsu, Chi-Yuan; Parikh, Rishi V; Leong, Thomas K; Tan, Thida C; Walia, Sophia; Liu, Kathleen D; Hsu, Raymond K; Go, Alan S

2018-06-11

The high mortality and cardiovascular disease (CVD) burden in patients with end-stage renal disease (ESRD) is well-documented. Recent literature suggests that acute kidney injury is also associated with CVD. It is unknown whether patients with incident ESRD due to dialysis-requiring acute kidney injury (AKI-D) are at higher short-term risk for death and CVD events, compared with incident ESRD patients without preceding AKI-D. Few studies have examined the impact of recovery from AKI-D on subsequent CVD risk. In this retrospective cohort study, we evaluated adult members of Kaiser Permanente Northern California who initiated dialysis from January 2009 to September 2015. Preceding AKI-D and subsequent outcomes of death and CVD events (acute coronary syndrome, heart failure, ischemic stroke or transient ischemic attack) were identified from electronic health records. We performed multivariable Cox regression models adjusting for demographics, comorbidities, medication use, and laboratory results. Compared to incident ESRD patients who experienced AKI-D (n = 1865), patients with ESRD not due to AKI-D (n = 3772) had significantly lower adjusted rates of death (adjusted hazard ratio [aHR] 0.56, 95% CI: 0.47-0.67) and heart failure hospitalization (aHR 0.45, 0.30-0.70). Compared to AKI-D patients who did not recover and progressed to ESRD, AKI-D patients who recovered (n = 1347) had a 30% lower adjusted relative rate of death (aHR 0.70, 0.55-0.88). Patients who transition to ESRD via AKI-D are a high-risk subgroup that may benefit from aggressive monitoring and medical management, particularly for heart failure. Recovery from AKI-D is independently associated with lower short-term mortality.

Distribution of hepatitis C virus genotypes in a diverse US integrated health care population.

PubMed

Manos, M Michele; Shvachko, Valentina A; Murphy, Rosemary C; Arduino, Jean Marie; Shire, Norah J

2012-11-01

Hepatitis C virus (HCV) genotypes influence response to therapy, and recently approved direct-acting antivirals are genotype-specific. Genotype distribution information can help to guide antiviral development and elucidate infection patterns. HCV genotype distributions were studied in a diverse cross-section of patients in the Northern California Kaiser Permanente health plan. Associations between genotype and race/ethnicity, age, and sex were assessed with multivariate logistic regression models. The 10,256 patients studied were median age 56 years, 62% male, 55% White non-Hispanic. Overall, 70% were genotype 1, 16% genotype 2, 12% genotype 3, 1% genotype 4, <1% genotype 5, and 1% genotype 6. Blacks (OR 4.5 [3.8-5.5]) and Asians (OR 1.2 [1.0-1.4]) were more likely to have genotype 1 than 2/3 versus non-Hispanic Whites. Women less likely had genotype 1 versus 2/3 than did men (OR 0.86 [0.78-0.94]). Versus non-Hispanic Whites, Asians (OR 0.38 [0.31-0.46]) and Blacks (OR 0.73 [0.63-0.84]) were less likely genotype1a than 1b; Hispanics (OR 1.3 [1.1-1.5]) and Native Americans (OR 1.9 [1.2-2.8]) more likely had genotype 1a than 1b. Patients age ≥65 years less likely had genotype 1a than 1b versus those age 45-64 (OR 0.34 [0.29-0.41]). The predominance of genotype 1 among all groups studied reinforces the need for new therapies targeting this genotype. Racial/ethnic variations in HCV genotype and subtype distribution must be considered in formulating new agents and novel strategies to successfully treat the diversity of hepatitis C patients. Copyright © 2012 Wiley Periodicals, Inc.

Colorectal Cancer Screening Initiation After Age 50 Years in an Organized Program.

PubMed

Fedewa, Stacey A; Corley, Douglas A; Jensen, Christopher D; Zhao, Wei; Goodman, Michael; Jemal, Ahmedin; Ward, Kevin C; Levin, Theodore R; Doubeni, Chyke A

2017-09-01

Recent studies report racial disparities among individuals in organized colorectal cancer (CRC) programs; however, there is a paucity of information on CRC screening utilization by race/ethnicity among newly age-eligible adults in such programs. This was a retrospective cohort study among Kaiser Permanente Northern California enrollees who turned age 50 years between 2007 and 2012 (N=138,799) and were served by a systemwide outreach and facilitated in-reach screening program based primarily on mailed fecal immunochemical tests to screening-eligible people. Kaplan-Meier and Cox model analyses were used to estimate differences in receipt of CRC screening in 2015-2016. Cumulative probabilities of CRC screening within 1 and 2 years of subjects' 50th birthday were 51% and 73%, respectively. Relative to non-Hispanic whites, the likelihood of completing any CRC screening was similar in blacks (hazard ratio, 0.98; 95% CI=0.96, 1.00); 5% lower in Hispanics (hazard ratio, 0.95; 95% CI=0.93, 0.96); and 13% higher in Asians (hazard ratio, 1.13; 95% CI=1.11, 1.15) in adjusted analyses. Fecal immunochemical testing was the most common screening modality, representing 86% of all screening initiations. Blacks and Hispanics had lower receipt of fecal immunochemical testing in adjusted analyses. CRC screening uptake was high among newly screening-eligible adults in an organized CRC screening program, but Hispanics were less likely to initiate screening near age 50 years than non-Hispanic whites, suggesting that cultural and other individual-level barriers not addressed within the program likely contribute. Future studies examining the influences of culturally appropriate and targeted efforts for screening initiation are needed. Copyright © 2017 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.

Ten-year detection rate of brain arteriovenous malformations in a large, multiethnic, defined population.

PubMed

Gabriel, Rodney A; Kim, Helen; Sidney, Stephen; McCulloch, Charles E; Singh, Vineeta; Johnston, S Claiborne; Ko, Nerissa U; Achrol, Achal S; Zaroff, Jonathan G; Young, William L

2010-01-01

To evaluate whether increased neuroimaging use is associated with increased brain arteriovenous malformation (BAVM) detection, we examined detection rates in the Kaiser Permanente Medical Care Program of northern California between 1995 and 2004. We reviewed medical records, radiology reports, and administrative databases to identify BAVMs, intracranial aneurysms (IAs: subarachnoid hemorrhage [SAH] and unruptured aneurysms), and other vascular malformations (OVMs: dural fistulas, cavernous malformations, Vein of Galen malformations, and venous malformations). Poisson regression (with robust standard errors) was used to test for trend. Random-effects meta-analysis generated a pooled measure of BAVM detection rate from 6 studies. We identified 401 BAVMs (197 ruptured, 204 unruptured), 570 OVMs, and 2892 IAs (2079 SAHs and 813 unruptured IAs). Detection rates per 100 000 person-years were 1.4 (95% CI, 1.3 to 1.6) for BAVMs, 2.0 (95% CI, 1.8 to 2.3) for OVMs, and 10.3 (95% CI, 9.9 to 10.7) for IAs. Neuroimaging utilization increased 12% per year during the time period (P<0.001). Overall, rates increased for IAs (P<0.001), remained stable for OVMs (P=0.858), and decreased for BAVMs (P=0.001). Detection rates increased 15% per year for unruptured IAs (P<0.001), with no change in SAHs (P=0.903). However, rates decreased 7% per year for unruptured BAVMs (P=0.016) and 3% per year for ruptured BAVMs (P=0.005). Meta-analysis yielded a pooled BAVM detection rate of 1.3 (95% CI, 1.2 to 1.4) per 100 000 person-years, without heterogeneity between studies (P=0.25). Rates for BAVMs, OVMs, and IAs in this large, multiethnic population were similar to those in other series. During 1995 to 2004, a period of increasing neuroimaging utilization, we did not observe an increased rate of detection of unruptured BAVMs, despite increased detection of unruptured IAs.

Impact of Social and Built Environment Factors on Body Size among Breast Cancer Survivors: The Pathways Study.

PubMed

Shariff-Marco, Salma; Von Behren, Julie; Reynolds, Peggy; Keegan, Theresa H M; Hertz, Andrew; Kwan, Marilyn L; Roh, Janise M; Thomsen, Catherine; Kroenke, Candyce H; Ambrosone, Christine; Kushi, Lawrence H; Gomez, Scarlett Lin

2017-04-01

Background: As social and built environment factors have been shown to be associated with physical activity, dietary patterns, and obesity in the general population, they likely also influence these health behaviors among cancer survivors and thereby impact survivorship outcomes. Methods: Enhancing the rich, individual-level survey and medical record data from 4,505 breast cancer survivors in the Pathways Study, a prospective cohort drawn from Kaiser Permanente Northern California, we geocoded baseline residential addresses and appended social and built environment data. With multinomial logistic models, we examined associations between neighborhood characteristics and body mass index and whether neighborhood factors explained racial/ethnic/nativity disparities in overweight/obesity. Results: Low neighborhood socioeconomic status, high minority composition, high traffic density, high prevalence of commuting by car, and a higher number of fast food restaurants were independently associated with higher odds of overweight or obesity. The higher odds of overweight among African Americans, U.S.-born Asian Americans/Pacific Islanders, and foreign-born Hispanics and the higher odds of obesity among African Americans and U.S.-born Hispanics, compared with non-Hispanic whites, remained significant, although somewhat attenuated, when accounting for social and built environment features. Conclusions: Addressing aspects of neighborhood environments may help breast cancer survivors maintain a healthy body weight. Impact: Further research in this area, such as incorporating data on individuals' perceptions and use of their neighborhood environments, is needed to ultimately inform multilevel interventions that would ameliorate such disparities and improve outcomes for breast cancer survivors, regardless of their social status (e.g., race/ethnicity, socioeconomic status, nativity). Cancer Epidemiol Biomarkers Prev; 26(4); 505-15. ©2017 AACR See all the articles in this CEBP Focus

Variation of adenoma prevalence by age, sex, race, and colon location in a large population: implications for screening and quality programs.

PubMed

Corley, Douglas A; Jensen, Christopher D; Marks, Amy R; Zhao, Wei K; de Boer, Jolanda; Levin, Theodore R; Doubeni, Chyke; Fireman, Bruce H; Quesenberry, Charles P

2013-02-01

Reliable community-based colorectal adenoma prevalence estimates are needed to inform colonoscopy quality standards and to estimate patient colorectal cancer risks; however, minimal data exist from populations with large numbers of diverse patients and examiners. We evaluated the prevalence of adenomas detected by sex, age, race/ethnicity, and colon location among 20,792 Kaiser Permanente Northern California members ≥50 years of age who received a screening colonoscopy examination (102 gastroenterologists, 2006-2008). Prevalence of detected adenomas increased more rapidly with age in the proximal colon (adjusted odds ratio [OR], 2.39; 95% confidence interval [CI], 2.05-2.80; 70-74 vs 50-54 years) than in the distal colon (OR, 1.89; 95% CI, 1.63-2.19). Prevalence was higher among men vs women at all ages (OR, 1.77; 95% CI, 1.66-1.89), increasing in men from 25% to 39% at ≥70 years and in women from 15% at 50-54 years to 26% (P < .001). Proximal adenoma prevalence was higher among blacks than whites (OR, 1.26; 95% CI, 1.04-1.54), although total prevalence was similar, including persons <60 years old (OR, 1.17; 95% CI, 0.91-1.50). Prevalence of detected adenomas increases substantially with age and is much higher in men; proximal adenomas are more common among blacks than whites, although the total prevalence and the prevalence for ages <60 years were similar by race. These demographic differences are such that current adenoma detection guidelines may not be valid, without adjustment, for comparing providers serving different populations. The variation in prevalence and location may also have implications for the effectiveness of screening methods in different demographic groups. Copyright © 2013 AGA Institute. Published by Elsevier Inc. All rights reserved.

Post-marketing safety evaluation of a tetanus toxoid, reduced diphtheria toxoid and 3-component acellular pertussis vaccine administered to a cohort of adolescents in a United States health maintenance organization.

PubMed

Klein, Nicola P; Hansen, John; Lewis, Edwin; Lyon, Liisa; Nguyen, Bessie; Black, Steven; Weston, Wayde M; Wu, Sterling; Li, Ping; Howe, Barbara; Friedland, Leonard R

2010-07-01

Prelicensure clinical studies may not include sufficient numbers of subjects to assess the potential for rare postvaccination adverse events. The aim of this postlicensure study (NCT00297856) was to evaluate uncommon outcomes following vaccination with a tetanus, reduced-antigen-content diphtheria, and acellular pertussis vaccine (Tdap, Boostrix GlaxoSmithKline) in a large adolescent cohort. We monitored safety outcomes among 13,427 10 to 18-year-old adolescents enrolled in the Northern California Kaiser Permanente Health Care Plan who received Tdap vaccination as part of their normal health care. Subjects were evaluated using self-control analysis comparing days 0 to 29 to days 30 to 59 postvaccination for neurologic events, hematologic events and allergic reactions. We evaluated new onset chronic illnesses within 6 months of Tdap vaccination by comparing with historical Td controls matched for age at vaccination, season, sex, and geographic area. We also compared the incidence of events of interest between the Tdap and historical cohorts as exploratory analyses. No increased risk for medically attended neurologic (odds ratio [OR], 0.962; 95% confidence interval [CI], 0.533-1.733) or allergic reactions (OR, 1.091; 95% CI, 0.441-2.729) was observed following Tdap vaccination when comparing the first 30 postvaccination days to the second 30 postvaccination days. There was one hematologic event within 30 days of Tdap, compared with 0 events within days 30 to 59 (P = 1.0). When compared with matched historical Td recipients, no increase in new onset chronic illnesses (OR, 0.634; 95% CI, 0.475-0.840) was seen after Tdap. No deaths occurred in the Tdap cohort during the study. This study provides no evidence for an increased risk for neurologic, hematologic, allergic events, or new onset of chronic illnesses among adolescents vaccinated with Tdap.

Disparities in Prostate, Lung, Breast, and Colorectal Cancer Survival and Comorbidity Status among Urban American Indians and Alaskan Natives.

PubMed

Emerson, Marc A; Banegas, Matthew P; Chawla, Neetu; Achacoso, Ninah; Alexeeff, Stacey E; Adams, Alyce S; Habel, Laurel A

2017-12-01

Cancer is the second leading cause of death among American Indians and Alaskan Natives (AIAN), although cancer survival information in this population is limited, particularly among urban AIAN. In this retrospective cohort study, we compared all-cause and prostate, breast, lung, and colorectal cancer-specific mortality among AIAN ( n = 582) and non-Hispanic white (NHW; n = 82,696) enrollees of Kaiser Permanente Northern California (KPNC) diagnosed with primary invasive breast, prostate, lung, or colorectal cancer from 1997 to 2015. Tumor registry and other electronic health records provided information on sociodemographic, comorbidity, tumor, clinical, and treatment characteristics. Cox regression models were used to estimate adjusted survival curves and hazard ratios (HR) with 95% confidence intervals (CI). AIAN had a significantly higher comorbidity burden compared with NHW ( P < 0.05). When adjusting for patient, disease characteristics, and Charlson comorbidity scores, all-cause mortality and cancer-specific mortality were significantly higher for AIAN than NHW patients with breast cancer (HR, 1.47; 95% CI, 1.13-1.92) or with prostate cancer (HR, 1.87; 95% CI, 1.14-3.06) but not for AIAN patients with lung and colorectal cancer. Despite approximately equal access to preventive services and cancer care in this setting, we found higher mortality for AIAN than NHW with some cancers, and a greater proportion of AIAN cancer patients with multiple comorbid conditions. This study provides severely needed information on the cancer experience of the 71% of AIANs who live in urban areas and access cancer care outside of the Indian Health Services, from which the vast majority of AIAN cancer information comes. Cancer Res; 77(23); 6770-6. ©2017 AACR . ©2017 American Association for Cancer Research.

Documentation of e-cigarette use and associations with smoking from 2012 to 2015 in an integrated healthcare delivery system.

PubMed

Young-Wolff, Kelly C; Klebaner, Daniella; Folck, Bruce; Tan, Andy S L; Fogelberg, Renee; Sarovar, Varada; Prochaska, Judith J

2018-04-01

It is unclear whether use of electronic nicotine delivery systems (ENDS) precedes cigarette smoking initiation, relapse, and/or quitting. Healthcare systems with electronic health records (EHRs) provide unique data to examine ENDS use and changes in smoking. We examined the incidence of ENDS use (2012-2015) based on clinician documentation and tested whether EHR documented ENDS use is associated with twelve-month changes in patient smoking status using a matched retrospective cohort design. The sample was Kaiser Permanente Northern California (KPNC) patients aged ≥12 with documented ENDS use (N = 7926); 57% were current smokers, 35% former smokers, and 8% never-smokers. ENDS documentation incidence peaked in 2014 for current and former smokers and in 2015 for never-smokers. We matched patients with documented ENDS use to KPNC patients without documented ENDS use (N = 7926) on age, sex, race/ethnicity, and smoking status. Documented ENDS use predicted the likelihood of smoking in the following year. Among current smokers, ENDS use was associated with greater odds of quitting smoking (OR = 1.17, 95%CI = 1.05-1.31). Among former smokers, ENDS use was associated with greater odds of smoking relapse (OR = 1.53, 95%CI = 1.22-1.92). Among never-smokers, ENDS use was associated with greater odds of initiating smoking (OR = 7.41, 95%CI = 3.14-17.5). The overall number of current smokers at 12 months was slightly higher among patients with (N = 3931) versus without (N = 3850) documented ENDS use. Results support both potential harm reduction of ENDS use (quitting combustibles among current smokers) and potential for harm (relapse to combustibles among former smokers, initiation for never-smokers). Copyright © 2018 Elsevier Inc. All rights reserved.

From diagnosis through survivorship: health-care experiences of colorectal cancer survivors with ostomies

PubMed Central

Grant, Marcia; McMullen, Carmit K.; Altschuler, Andrea; Mohler, M. Jane; Hornbrook, Mark C.; Herrinton, Lisa J.; Krouse, Robert S.

2014-01-01

Purpose The journey from diagnosis through treatment to survivorship can be challenging for colorectal cancer (CRC) survivors with permanent ostomies. Memories of both the positive and negative health-care interactions can persist years after the initial diagnosis and treatment. The purpose of this paper is to describe the health-care experiences of long-term (>5 years) CRC survivors with ostomies. Methods Thirty-three CRC survivors with ostomies who were members of Kaiser Permanente, an integrated care organization, in Oregon, southwestern Washington and northern California participated in eight focus groups. Discussions from the focus groups were recorded, transcribed, and analyzed for potential categories and themes. Results Health-care-related themes described CRC survivors’ experiences with diagnosis, treatment decision-making, initial experiences with ostomy, and survivorship. Participants discussed both positive and negative health-care-related experiences, including the need for continued access to trained nurses for ostomy self-care, access to peer support, and resources related to managing persistent, debilitating symptoms. Conclusions Long-term CRC survivors with ostomies have both positive and negative health-care experiences, regardless of health-related quality of life (HRQOL) and gender. Long-term support mechanisms and quality survivorship care that CRC survivors with ostomies can access are needed to promote positive adjustments and improved HRQOL. Structured abstract The current literature in CRC survivor-ship suggests that HRQOL concerns can persist years after treatment completion. The coordination of care to manage persistent late- and long-term effects are still lacking for CRC survivors living with an ostomy. Findings from this qualitative analysis will aid in the development of support strategies that foster more positive adjustments for CRC survivors living with an ostomy and support their ongoing ostomy-related needs. PMID:24442998

Changes in medication use after dementia diagnosis in an observational cohort of diabetes patients

PubMed Central

Sarkar, Urmimala; Lyles, Courtney; Steinman, Michael; Huang, Elbert S.; Moffet, Howard H.; Whitmer, Rachel A.; Warton, E. Margaret; Karter, Andrew J.

2017-01-01

Background/objective Clinical guidelines recommend avoidance of polypharmacy in patients with dementia. We assessed changes in medication use following a diagnosis of dementia among patients with type 2 diabetes. Design Difference-in-differences analysis of pre-post changes in the number of dispensed chronic medications, comparing patients with and without newly diagnosed dementia. Setting Integrated health care delivery system, Kaiser Permanente Northern California (KPNC). Participants Patients with type 2 diabetes, enrolled in a baseline survey, ≥50 years of age without prevalent dementia. During 5 years of follow-up, we identified 193 patients with a new diagnosis of dementia and used risk-set sampling to randomly select 5 reference subjects per case, matched on 5-year age categories and sex (965 matched patients). This resulted in an analytic sample of 1,158. Measurements The exposure was new diagnosis of dementia. Our primary outcome was the change in the number (count) of current chronic medications (total, cardiovascular (blood pressure and lipid control), and diabetes) at three time points: (a) pre-index date (one year prior to the index date); (b) index date (date of diagnosis of dementia or matched reference date); and (c) post-index date (up to one year subsequent to the index date). Results After adjustment, the overall number of chronic medications and the subset of cardiovascular medications declined following a dementia diagnosis and among age, sex, and time-matched reference individuals, but the decline was significantly greater among the dementia group (−0.71 medications compared to reference, p<0.05). The number of diabetes medications declined in both groups, but the declines were not statistically different (−0.18 medications compared to reference, p<0.05). Conclusions Patients and their providers reduced use of cardio-metabolic medications subsequent to a diagnosis of dementia as recommended in national guidelines. PMID:27642180

Mixture models for undiagnosed prevalent disease and interval-censored incident disease: applications to a cohort assembled from electronic health records.

PubMed

Cheung, Li C; Pan, Qing; Hyun, Noorie; Schiffman, Mark; Fetterman, Barbara; Castle, Philip E; Lorey, Thomas; Katki, Hormuzd A

2017-09-30

For cost-effectiveness and efficiency, many large-scale general-purpose cohort studies are being assembled within large health-care providers who use electronic health records. Two key features of such data are that incident disease is interval-censored between irregular visits and there can be pre-existing (prevalent) disease. Because prevalent disease is not always immediately diagnosed, some disease diagnosed at later visits are actually undiagnosed prevalent disease. We consider prevalent disease as a point mass at time zero for clinical applications where there is no interest in time of prevalent disease onset. We demonstrate that the naive Kaplan-Meier cumulative risk estimator underestimates risks at early time points and overestimates later risks. We propose a general family of mixture models for undiagnosed prevalent disease and interval-censored incident disease that we call prevalence-incidence models. Parameters for parametric prevalence-incidence models, such as the logistic regression and Weibull survival (logistic-Weibull) model, are estimated by direct likelihood maximization or by EM algorithm. Non-parametric methods are proposed to calculate cumulative risks for cases without covariates. We compare naive Kaplan-Meier, logistic-Weibull, and non-parametric estimates of cumulative risk in the cervical cancer screening program at Kaiser Permanente Northern California. Kaplan-Meier provided poor estimates while the logistic-Weibull model was a close fit to the non-parametric. Our findings support our use of logistic-Weibull models to develop the risk estimates that underlie current US risk-based cervical cancer screening guidelines. Published 2017. This article has been contributed to by US Government employees and their work is in the public domain in the USA. Published 2017. This article has been contributed to by US Government employees and their work is in the public domain in the USA.

Assessment of a New Lower-Cost Real-Time PCR Assay for Detection of High-Risk Human Papillomavirus: Useful for Cervical Screening in Limited-Resource Settings?

PubMed Central

Schiffman, Mark; Wentzensen, Nicolas H.; Gage, Julia C.; Castle, Philip E.; Raine-Bennett, Tina R.; Fetterman, Barbara; Lorey, Thomas; Poitras, Nancy E.; Befano, Brian; Xie, Yi; Miachon, Lais S.; Dean, Michael

2017-01-01

ABSTRACT Inexpensive and easy-to-perform human papillomavirus (HPV) tests are needed for primary cervical cancer screening in lower-resource regions. In a convenience sample of 516 residual exfoliative cervical specimens from the Kaiser Permanente Northern California and U.S. National Cancer Institute Persistence and Progression Study, we assessed the agreement and clinical performance of a simple, inexpensive real-time PCR assay for the detection of 13 carcinogenic HPV types (the H13 assay; Hybribio, Hong Kong) that is marketed in limited-resource settings compared to previous testing by the Hybrid Capture 2 assay (HC2; Qiagen, Germantown, MD) and the Onclarity assay (BD Diagnostics, Sparks, MD). The test set was chosen to include many HPV-positive specimens. The reference standard was a combination of HC2 and Onclarity results for HPV detection and histologic diagnosis of controls (less than cervical intraepithelial neoplasia grade 2 [

Automated Cervical Screening and Triage, Based on HPV Testing and Computer-Interpreted Cytology.

PubMed

Yu, Kai; Hyun, Noorie; Fetterman, Barbara; Lorey, Thomas; Raine-Bennett, Tina R; Zhang, Han; Stamps, Robin E; Poitras, Nancy E; Wheeler, William; Befano, Brian; Gage, Julia C; Castle, Philip E; Wentzensen, Nicolas; Schiffman, Mark

2018-04-11

State-of-the-art cervical cancer prevention includes human papillomavirus (HPV) vaccination among adolescents and screening/treatment of cervical precancer (CIN3/AIS and, less strictly, CIN2) among adults. HPV testing provides sensitive detection of precancer but, to reduce overtreatment, secondary "triage" is needed to predict women at highest risk. Those with the highest-risk HPV types or abnormal cytology are commonly referred to colposcopy; however, expert cytology services are critically lacking in many regions. To permit completely automatable cervical screening/triage, we designed and validated a novel triage method, a cytologic risk score algorithm based on computer-scanned liquid-based slide features (FocalPoint, BD, Burlington, NC). We compared it with abnormal cytology in predicting precancer among 1839 women testing HPV positive (HC2, Qiagen, Germantown, MD) in 2010 at Kaiser Permanente Northern California (KPNC). Precancer outcomes were ascertained by record linkage. As additional validation, we compared the algorithm prospectively with cytology results among 243 807 women screened at KPNC (2016-2017). All statistical tests were two-sided. Among HPV-positive women, the algorithm matched the triage performance of abnormal cytology. Combined with HPV16/18/45 typing (Onclarity, BD, Sparks, MD), the automatable strategy referred 91.7% of HPV-positive CIN3/AIS cases to immediate colposcopy while deferring 38.4% of all HPV-positive women to one-year retesting (compared with 89.1% and 37.4%, respectively, for typing and cytology triage). In the 2016-2017 validation, the predicted risk scores strongly correlated with cytology (P < .001). High-quality cervical screening and triage performance is achievable using this completely automated approach. Automated technology could permit extension of high-quality cervical screening/triage coverage to currently underserved regions.

Age-stratified 5-year risks of cervical precancer among women with enrollment and newly detected HPV infection.

PubMed

Gage, Julia C; Katki, Hormuzd A; Schiffman, Mark; Fetterman, Barbara; Poitras, Nancy E; Lorey, Thomas; Cheung, Li C; Castle, Philip E; Kinney, Walter K

2015-04-01

It is unclear whether a woman's age influences her risk of cervical intraepithelial neoplasia grade 3 or worse (CIN3+) upon detection of HPV. A large change in risk as women age would influence vaccination and screening policies. Among 972,029 women age 30-64 undergoing screening with Pap and HPV testing (Hybrid Capture 2, Qiagen, Germantown, MD) at Kaiser Permanente Northern California (KPNC), we calculated age-specific 5-year CIN3+ risks among women with HPV infections detected at enrollment, and among women with "newly detected" HPV infections at their second screening visit. Women (57,899, 6.0%) had an enrollment HPV infection. Among the women testing HPV negative at enrollment with a second screening visit, 16,724 (3.3%) had a newly detected HPV infection at their second visit. Both enrollment and newly detected HPV rates declined with age (p < 0.001). Women with enrollment versus newly detected HPV infection had higher 5-year CIN3+ risks: 8.5% versus 3.9%, (p < 0.0001). Risks did not increase with age but declined slightly from 30-34 years to 60-64 years: 9.4% versus 7.4% (p = 0.017) for enrollment HPV and 5.1% versus 3.5% (p = 0.014) for newly detected HPV. Among women age 30-64 in an established screening program, women with newly detected HPV infections were at lower risk than women with enrollment infections, suggesting reduced benefit vaccinating women at older ages. Although the rates of HPV infection declined dramatically with age, the subsequent CIN3+ risks associated with HPV infection declined only slightly. The CIN3+ risks among older women are sufficiently elevated to warrant continued screening through age 65. © 2014 UICC.

Assessment of a New Lower-Cost Real-Time PCR Assay for Detection of High-Risk Human Papillomavirus: Useful for Cervical Screening in Limited-Resource Settings?

PubMed

Fokom Domgue, Joel; Schiffman, Mark; Wentzensen, Nicolas H; Gage, Julia C; Castle, Philip E; Raine-Bennett, Tina R; Fetterman, Barbara; Lorey, Thomas; Poitras, Nancy E; Befano, Brian; Xie, Yi; Miachon, Lais S; Dean, Michael

2017-08-01

Inexpensive and easy-to-perform human papillomavirus (HPV) tests are needed for primary cervical cancer screening in lower-resource regions. In a convenience sample of 516 residual exfoliative cervical specimens from the Kaiser Permanente Northern California and U.S. National Cancer Institute Persistence and Progression Study, we assessed the agreement and clinical performance of a simple, inexpensive real-time PCR assay for the detection of 13 carcinogenic HPV types (the H13 assay; Hybribio, Hong Kong) that is marketed in limited-resource settings compared to previous testing by the Hybrid Capture 2 assay (HC2; Qiagen, Germantown, MD) and the Onclarity assay (BD Diagnostics, Sparks, MD). The test set was chosen to include many HPV-positive specimens. The reference standard was a combination of HC2 and Onclarity results for HPV detection and histologic diagnosis of controls (less than cervical intraepithelial neoplasia grade 2 [

Effect of Several Negative Rounds of Human Papillomavirus and Cytology Co-testing on Safety Against Cervical Cancer: An Observational Cohort Study.

PubMed

Castle, Philip E; Kinney, Walter K; Xue, Xiaonan; Cheung, Li C; Gage, Julia C; Zhao, Fang-Hui; Fetterman, Barbara; Poitras, Nancy E; Lorey, Thomas S; Wentzensen, Nicolas; Katki, Hormuzd A; Schiffman, Mark

2018-01-02

Current U.S. cervical cancer screening and management guidelines do not consider previous screening history, because data on multiple-round human papillomavirus (HPV) and cytology "co-testing" have been unavailable. To measure cervical cancer risk in routine practice after successive negative screening co-tests at 3-year intervals. Observational cohort study. Integrated health care system (Kaiser Permanente Northern California, Oakland, California). 990 013 women who had 1 or more co-tests from 2003 to 2014. 3- and 5-year cumulative detection of (risk for) cervical intraepithelial neoplasia grade 3, adenocarcinoma in situ, and cervical cancer (≥CIN3) in women with different numbers of negative co-tests, overall and within subgroups defined by previous co-test results or baseline age. Five-year ≥CIN3 risks decreased after each successive negative co-test screening round (0.098%, 0.052%, and 0.035%). Five-year ≥CIN3 risks for an HPV-negative co-test, regardless of the cytology result, nearly matched the performance (reassurance) of a negative co-test for each successive round of screening (0.114%, 0.061%, and 0.041%). By comparison, ≥CIN3 risks for the cytology-negative co-test, regardless of the HPV result, also decreased with each successive round, but 3-year risks were as high as 5-year risks after an HPV-negative co-test (0.199%, 0.065%, and 0.043%). No interval cervical cancer cases were diagnosed after the second negative co-test. Independently, ≥CIN3 risks decreased with age. Length of previous screening interval did not influence future ≥CIN3 risks. Interval-censored observational data. After 1 or more negative cervical co-tests (or HPV tests), longer screening intervals (every 5 years or more) might be feasible and safe. National Cancer Institute Intramural Research Program.

Age-Stratified 5-Year Risks of Cervical Precancer among Women with Enrollment and Newly Detected HPV Infection

PubMed Central

Gage, Julia C.; Katki, Hormuzd A.; Schiffman, Mark; Fetterman, Barbara; Poitras, Nancy E.; Lorey, Thomas; Cheung, Li C.; Castle, Philip E.; Kinney, Walter K.

2014-01-01

It is unclear whether a woman's age influences her risk of cervical intraepithelial neoplasia grade 3 or worse (CIN3+) upon detection of HPV. A large change in risk as women age would influence vaccination and screening policies. Among 972,029 women age 30-64 undergoing screening with Pap and HPV testing (Hybrid Capture 2, Qiagen, Germantown, MD, USA) at Kaiser Permanente Northern California (KPNC), we calculated age-specific 5-year CIN3+ risks among women with HPV infections detected at enrollment, and among women with “newly detected” HPV infections at their second screening visit. 57,899 women (6.0%) had an enrollment HPV infection. Among the women testing HPV negative at enrollment with a second screening visit, 16,724 (3.3%) had a newly detected HPV infection at their second visit. Both enrollment and newly detected HPV rates declined with age (p<.001). Women with enrollment vs. newly detected HPV infection had higher 5-year CIN3+ risks: 8.5% vs. 3.9%, (p<.0001). Risks did not increase with age but declined slightly from 30-34 years to 60-64 years: 9.4% vs. 7.4% (p=0.017) for enrollment HPV and 5.1% vs. 3.5% (p=0.014) for newly detected HPV. Among women age 30-64 in an established screening program, women with newly detected HPV infections were at lower risk than women with enrollment infections, suggesting reduced benefit vaccinating women at older ages. Although the rates of HPV infection declined dramatically with age, the subsequent CIN3+ risks associated with HPV infection declined only slightly. The CIN3+ risks among older women are sufficiently elevated to warrant continued screening through age 65. PMID:25136967

Relative Performance of HPV and Cytology Components of Cotesting in Cervical Screening.

PubMed

Schiffman, Mark; Kinney, Walter K; Cheung, Li C; Gage, Julia C; Fetterman, Barbara; Poitras, Nancy E; Lorey, Thomas S; Wentzensen, Nicolas; Befano, Brian; Schussler, John; Katki, Hormuzd A; Castle, Philip E

2018-05-01

The main goal of cervical screening programs is to detect and treat precancer before cancer develops. Human papillomavirus (HPV) testing is more sensitive than cytology for detecting precancer. However, reports of rare HPV-negative, cytology-positive cancers are motivating continued use of both tests (cotesting) despite increased testing costs. We quantified the detection of cervical precancer and cancer by cotesting compared with HPV testing alone at Kaiser Permanente Northern California (KPNC), where 1 208 710 women age 30 years and older have undergone triennial cervical cotesting since 2003. Screening histories preceding cervical cancers (n = 623) and precancers (n = 5369) were examined to assess the relative contribution of the cytology and HPV test components in identifying cases. The performances of HPV testing and cytology were compared using contingency table methods, general estimating equation models, and nonparametric statistics; all statistical tests were two-sided. HPV testing identified more women subsequently diagnosed with cancer (P < .001) and precancer (P < .001) than cytology. HPV testing was statistically significantly more likely to be positive for cancer at any time point (P < .001), except within 12 months (P = .10). HPV-negative/cytology-positive results preceded only small fractions of cases of precancer (3.5%) and cancer (5.9%); these cancers were more likely to be regional or distant stage with squamous histopathology than other cases. Given the rarity of cancers among screened women, the contribution of cytology to screening translated to earlier detection of at most five cases per million women per year. Two-thirds (67.9%) of women found to have cancer during 10 years of follow-up at KPNC were detected by the first cotest performed. The added sensitivity of cotesting vs HPV alone for detection of treatable cancer affected extremely few women.

Why does cervical cancer occur in a state-of-the-art screening program?

PubMed

Castle, Philip E; Kinney, Walter K; Cheung, Li C; Gage, Julia C; Fetterman, Barbara; Poitras, Nancy E; Lorey, Thomas S; Wentzensen, Nicolas; Befano, Brian; Schussler, John; Katki, Hormuzd A; Schiffman, Mark

2017-09-01

The goal of cervical screening is to detect and treat precancers before some become cancer. We wanted to understand why, despite state-of-the-art methods, cervical cancers occured in relationship to programmatic performance at Kaiser Permanente Northern California (KPNC), where >1,000,000 women aged ≥30years have undergone cervical cancer screening by triennial HPV and cytology cotesting since 2003. We reviewed clinical histories preceding cervical cancer diagnoses to assign "causes" of cancer. We calculated surrogate measures of programmatic effectiveness (precancers/(precancers and cancers)) and diagnostic yield (precancers and cancers per 1000 cotests), overall and by age at cotest (30-39, 40-49, and ≥50years). Cancer was rare and found mainly in a localized (treatable) stage. Of 623 cervical cancers with at least one preceding or concurrent cotest, 360 (57.8%) were judged to be prevalent (diagnosed at a localized stage within one year or regional/distant stage within two years of the first cotest). Non-compliance with recommended screening and management preceded 9.0% of all cancers. False-negative cotests/sampling errors (HPV and cytology negative), false-negative histologic diagnoses, and treatment failures preceded 11.2%, 9.0%, and 4.3%, respectively, of all cancers. There was significant heterogeneity in the causes of cancer by histologic category (p<0.001 for all; p=0.002 excluding prevalent cases). Programmatic effectiveness (95.3%) and diagnostic yield were greater for squamous cell versus adenocarcinoma histology (p<0.0001) and both decreased with older ages (p trend <0.0001). A state-of-the-art intensive screening program results in very few cervical cancers, most of which are detected early by screening. Screening may become less efficient at older ages. Copyright © 2017 Elsevier Inc. All rights reserved.

The population impact of HPV/cytology cervical cotesting at 3-year intervals: reduced cervical cancer risk and decreased yield of precancer per screen

PubMed Central

Silver, Michelle I.; Schiffman, Mark; Fetterman, Barbara; Poitras, Nancy; Gage, Julia C.; Wentzensen, Nicolas; Lorey, Thomas; Kinney, Walter; Castle, Philip E.

2016-01-01

Background Cervical screening aims to detect and treat precancer to prevent cervical cancer mortality and morbidity, while minimizing overtreatment of benign human papillomavirus (HPV) infections and related minor abnormalities. HPV/cytology cotesting at extended 5-year intervals is now a recommended screening strategy in the US, but the interval extension is controversial. We studied the impact of a decade of an alternative, 3-year cotesting, on rates of precancer and cancer at Kaiser Permanente Northern California. We also considered the effect on screening efficiency, defined as numbers of cotests/colposcopy visits needed to detect a precancer. Methods Two cohorts were defined. The “open cohort” included all women screened at least once during the study period; >1 million cotests were performed. In a fixed “long-term screening cohort”, we considered the cumulative impact of repeated screening at 3-year intervals by restricting to women first cotested in 2003–4 (i.e., no women entering screening later were added to this group). Results Detection of CIN3/AIS increased in the open cohort (2004–6, 82.0/100,000 women screened; 2007–9, 140.6/100,000; and 2010–12, 126.0/100,000); cancer diagnoses were unchanged. In the long-term screening cohort, detection of CIN3/AIS increased then decreased to the original level (2004–6, 80.5/100,000; 2007–9, 118.6/100,000; and 2010–2, 84.9/100,000). Cancer diagnoses decreased. Seen in terms of screening efficiency, the number of colposcopies performed todetect a single CIN3/AIS increased in the cohort with repeat screening. Conclusion Repeated cotesting at a 3-year interval eventually lowers population rates of precancer and cancer; however, a greater number of colposcopies is required to detect a single precancer. PMID:27657992

Risk Factors for the Development of Obstetric Anal Sphincter Injuries in Modern Obstetric Practice.

PubMed

Ramm, Olga; Woo, Victoria G; Hung, Yun-Yi; Chen, Hsuan-Chih; Ritterman Weintraub, Miranda L

2018-02-01

To characterize the rate of obstetric anal sphincter injuries and identify key risk factors of obstetric anal sphincter injuries, including duration of the second stage of labor. This retrospective cohort study included all singleton, term, cephalic vaginal deliveries within Kaiser Permanente Northern California between January 2013 and December 2014 (N=22,741). Incidence of obstetric anal sphincter injuries, defined as third- or fourth-degree perineal lacerations, was the primary outcome. Multiple logistic regression models were conducted to identify obstetric anal sphincter injury risk factors and high-risk subpopulations. The overall incidence rate of obstetric anal sphincter injuries was 4.9% (3.6% of women who delivered spontaneously vs 24.0% of women who had a vacuum-assisted vaginal delivery, P<.001, CI 18.1-22.6%). In bivariate and multivariate analyses, obstetric anal sphincter injury incidence was higher among women with second stage of labor longer than 2 hours, Asian race, nulliparity, vaginal birth after cesarean delivery, episiotomy, and vacuum delivery. Women with a vacuum-assisted vaginal delivery had four times the odds of obstetric anal sphincter injury (adjusted odds ratio [OR] 4.23, 95% CI 3.59-4.98) and those whose second stage of labor lasted at least 180 minutes vs less than 60 minutes had three times the odds of incurring obstetric anal sphincter injury (adjusted OR 3.20, 95% CI 2.62-3.89). Vacuum-assisted vaginal delivery conferred the highest odds of obstetric anal sphincter injury followed by prolonged duration of the second stage of labor, particularly among certain subpopulations. Understanding these risk factors and their complex interactions can inform antepartum and intrapartum decision-making with the goal of reducing obstetric anal sphincter injury incidence.

Titan's Stratospheric Condensibles at High Northern Latitudes During Northern Winter

NASA Technical Reports Server (NTRS)

Anderson, Carrie; Samuelson, R.; Achterberg, R.

2012-01-01

The Infrared Interferometer Spectrometer (IRIS) instrument on board Voyager 1 caught the first glimpse of an unidentified particulate feature in Titan's stratosphere that spectrally peaks at 221 per centimeter. Until recently, this feature that we have termed 'the haystack,' has been seen persistently at high northern latitudes with the Composite Infrared Spectrometer (CIRS) instrument onboard Cassini, The strength of the haystack emission feature diminishes rapidly with season, becoming drastically reduced at high northern latitudes, as Titan transitions from northern winter into spring, In contrast to IRIS whose shortest wavenumber was 200 per centimeter, CIRS extends down to 10 per centimeter, thus revealing an entirely unexplored spectral region in which nitrile ices have numerous broad lattice vibration features, Unlike the haystack, which is only found at high northern latitudes during northern winter/early northern spring, this geometrically thin nitrile cloud pervades Titan's lower stratosphere, spectrally peaking at 160 per centimeter, and is almost global in extent spanning latitudes 85 N to 600 S, The inference of nitrile ices are consistent with the highly restricted altitude ranges over which these features are observed, and appear to be dominated by a mixture of HCN and HC3N, The narrow range in altitude over which the nitrile ices extend is unlike the haystack, whose vertical distribution is significantly broader, spanning roughly 70 kilometers in altitude in Titan's lower stratosphere, The nitrile clouds that CIRS observes are located in a dynamically stable region of Titan's atmosphere, whereas CH4 clouds, which ordinarily form in the troposphere, form in a more dynamically unstable region, where convective cloud systems tend to occur. In the unusual situation where Titan's tropopause cools significantly from the HASI 70.5K temperature minimum, CH4 should condense in Titan's lower stratosphere, just like the aforementioned nitrile clouds, although

Northern Pintail

USGS Publications Warehouse

Clark, Robert G.; Fleskes, Joseph P.; Guyn, Karla L.; Haukos, David A.; Austin, Jane E.; Miller, Michael R.

2014-01-01

This medium-sized dabbling duck of slender, elegant lines and conservative plumage coloration is circumpolar in distribution and abundant in North America, with core nesting habitat in Alaska and the Prairie Pothole Region of southern Canada and the northern Great Plains. Breeders favor shallow wetlands interspersed throughout prairie grasslands or arctic tundra. An early fall migrant, the species arrives on wintering areas beginning in August, after wing molt, often forming large roosting and feeding flocks on open, shallow wetlands and flooded agricultural fields. The birds consume grains, marsh plant seeds, and aquatic invertebrates throughout fall and winter.Northern Pintails are among the earliest nesting ducks in North America, beginning shortly after ice-out in many northern areas. Individuals form new pair bonds each winter but are highly promiscuous during the nesting season, with mated and unmated males often involved in vigorous, acrobatic Pursuit Flights. Annual nest success and productivity vary with water conditions, predation, and weather. Females build nests on the ground, often far from water. Only the female incubates; her mate leaves shortly after incubation begins. Ducklings hatch together in one day, follow the female to water after a day in the nest, and fledge by July or August. Adults and ducklings consume mainly aquatic invertebrates during the breeding season.Predators and farming operations destroy many thousands of Northern Pintail nests annually; farming has also greatly reduced the amount of quality nesting cover available. Winter habitats are threatened by water shortages, agricultural development, contamination, and urbanization. Periods of extended drought in prairie nesting regions have caused dramatic population declines, usually followed by periods of recovery. Over the long term, however, the continental population of Northern Pintails has declined significantly from 6 million birds in the early 1970s to less than 3 million in

Reporting on a Talk I Gave Some Months Ago, the Headline in "La Opinion," Los Angeles' Premier Spanish Language Newspaper, Declared the City's School System "en crisis permanente." No One Wrote in to Disagree. The Claremont Letter. Volume 3, Issue 1

ERIC Educational Resources Information Center

Kerchner, Charles T.

2008-01-01

Reporting on a talk the author gave some months ago, the headline in "La Opinion," Los Angeles' premier Spanish language newspaper, declared the city's school system "en crisis permanente." No one wrote in to disagree. Indeed, at the end of "Learning from L.A.: Institutional Change in American Public Education" (Harvard Education Press) the author…

Milan Army Ammunition Plant focused feasibility study for the northern industrial area soil. Final report

DOE Office of Scientific and Technical Information (OSTI.GOV)

Locandro, R.R.; Okusu, N.M.; Case, J.

1995-04-01

ICF Kaiser Engineers (ICF) and Environmental Resources Management (ERM) have been contracted by the US Army Environmental Center (USAEC) to perform a Focused Feasibility Study (FS) for contaminated soil within the northern industrial areas of Milan Army Ammunition Plant (MAAP), Tennessee. The purpose of the Focused FS is to develop and evaluate remedial alternatives such that an appropriate remedy can be selected for the site. The MAAP Remedial Investigation (RI) performed in 1989--1991 confirmed that the O-Line Ponds area, facility drainage ditches that received industrial wastewater, and manufacturing and disposal areas have been sources of groundwater contamination. One finding ofmore » the RI Report was that sufficient information was available concerning the O-Line Ponds area to proceed with a Focused FS. The O-Line Ponds area was further divided into two operable units (OUs): OU1 is the groundwater immediately downgradient of the O-Line Ponds area, and OU2 is the soil, surface water, and sediment at the O-Line Ponds area. A Proposed Plan and Record of Decision (ROD) for OU1 were finalized in 1992, which called for groundwater extraction, treatment, and reinjection of the treated water upgradient of the O-Line Ponds. The design of this system was completed in 1993, and construction of the system is currently underway. For OU2, the Proposed Plan and ROD (finalized in 1993) called for the extension of the existing multi-layered cap to cover the contaminated soil around the perimeter of the existing cap. The design of the cap extension was completed in 1994, and construction will begin in late 1994.« less

Comparison of northern goshawk nesting habitat in Appalachian oak and northern hardwood forests of Pennsylvania

Treesearch

J.T. Kimmel; R.H. Yahner

1991-01-01

The Northern Goshawk (Accipiter gentilis) is a rare to uncommon woodland raptor in Pennsylvania. Although it is primarily a boreal species, the goshawk nests in Northern Hardwoods and Appalachian oak forests along the southern margin of its range in Pennsylvania. This study compared the nesting habitat of goshawks in Appalachian oak and Northern...

Comprehensive grief care for children and families: Policy and practice implications.

PubMed

Griese, Brook; Burns, Michaeleen R; Farro, Samantha A; Silvern, Louise; Talmi, Ayelet

2017-01-01

Since the 1998 publication of the groundbreaking Adverse Childhood Experiences (ACE) Study conducted by the Centers for Disease Control and Prevention and Kaiser Permanente, increased research and funding has focused on mitigating experiences that place children at risk for developmental disruption. Surprisingly, the death of a parent, sibling, or other important attachment figure-often noted as one of the most disruptive and potentially traumatic experiences for a child-has received relatively little attention in these efforts. This article explores the current landscape of support for grieving children and families- including significant barriers to care and gaps in empirical knowledge. Given the complexity of the issue and the nascent state of the childhood bereavement field, it is fertile ground for social innovations that challenge current norms. In addition, the argument is made for a strengths-based, wellness approach to childhood bereavement that seizes upon opportunities to both promote adaptive adjustment and prevent further complications of unaddressed grief and trauma. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

NFP Investor Conference. Growth is back in sight.

PubMed

Haugh, Richard

2002-06-01

In a whirlwind of high-stakes meetings in New York City in mid-May, two dozen of the nation's largest hospitals and health systems strutted their stuff with a single goal: securing their future. Their message was clear: back-to-basics works, and now it's time to grow the business. Executives from 23 providers outlined their work on increasing revenue, boosting margins and shoring up balance sheets. They presented their market positions, strategic initiatives and financial results for investment analysts, credit raters and bond traders. The third annual Non-Profit Healthcare Investor Conference was co-sponsored by the American Hospital Association, Health Forum, the Healthcare Financial Management Association and Salomon Smith Barney. The focus on growth doesn't come without challenges Several common themes emerged from the presentations, among them pressure on reimbursement, workforce shortages, liability insurance issues and capacity constraints. Yet executives agree: it all comes down to the basics, and building the strength to keep their missions alive. As Thomas Meier, vice president and treasurer of Oakland, Calif.-based Kaiser Permanente, put it: "No margin, no mission, no más."

Physician Update: Total Health

PubMed Central

Tuso, Phillip

2014-01-01

As an integrated prepaid health care system, Kaiser Permanente (KP) is in a unique position to demonstrate that affordability in health care can be achieved by disease prevention. During the past decade, KP has significantly improved the quality care outcomes of its members with preventable diseases. However, because of an increase in the incidence of preventable disease, and the potential long-term and short-term costs associated with the treatment of preventable disease, KP has developed a new strategy called Total Health to meet the current and future needs of its patients. Total Health means healthy people in healthy communities. KP’s strategic vision is to be a leader in Total Health by making lives better. KP hopes to make lives better by 1) measuring vital signs of health, 2) promoting healthy behaviors, 3) monitoring disease incidence, 4) spreading leading practices, and 5) creating healthy environments with our community partners. Best practices, spread to the communities we serve, will make health care more affordable, prevent preventable diseases, and save lives. PMID:24694316

Psychotherapist mindfulness and the psychotherapy process.

PubMed

Bruce, Noah; Bruce, Noah G; Shapiro, Shauna L; Constantino, Michael J; Manber, Rachel

2010-03-01

[Correction Notice: An erratum for this article was reported in Vol 47(2) of Psychotherapy: Theory, Research & Practice (see record 2010-13424-005). the order of authorship and the affiliations of the authors was incorrectly printed. The correct order and affiliations are as follows: Noah Bruce, Shauna L. Shapiro, Michael J. Constantino, and Rachel Manber; Kaiser Permanente, Santa Clara University, University of Massachusetts, Stanford University] A psychotherapist's ability to relate to his or her patients is essential for decreasing patient suffering and promoting patient growth. However, the psychotherapy field has identified few effective means for training psychotherapists in this ability. In this conceptual article, we propose that mindfulness practice may be a means for training psychotherapists to better relate to their patients. We posit that mindfulness is a means of self-attunement that increases one's ability to attune to others (in this case, patients) and that this interpersonal attunement ultimately helps patients achieve greater self-attunement that, in turn, fosters decreased symptom severity, greater well-being, and better interpersonal relationships. PsycINFO Database Record (c) 2010 APA, all rights reserved

Implementation and Effectiveness of a Mailed FIT Outreach Program in Safety Net Clinics

Cancer.gov

Gloria Coronado, PhD, is an epidemiologist and the Mitch Greenlick Endowed Senior Investigator in Health Disparities Research at Kaiser Permanente Center for Health Research in Portland, OR. Her research focuses on understanding and addressing disparities in the occurrence and burden of disease in underserved populations, with a special emphasis on testing cancer prevention intervention in underserved and Medicaid-enrolled populations. She has developed several innovative and cost-effective interventions to improve rates of participation in cancer screening among patients served by community health centers. Her work has led to partnerships with large health plans, state institutions, and clinics who serve migrants and the uninsured. Dr. Coronado received her PhD in epidemiology from the University of Washington and became a research associate professor in the university’s Department of Epidemiology, in addition to receiving training at Stanford. She currently directs or co-directs three programs that use systems-based approaches to raise the rates of colorectal cancer screening in health plans and clinics in Washington, Oregon and California.

"Presumed fair: Ironic effects of organizational diversity structures": Correction to Kaiser et al. (2013).

PubMed

2016-06-01

Reports an error in "Presumed fair: Ironic effects of organizational diversity structures" by Cheryl R. Kaiser, Brenda Major, Ines Jurcevic, Tessa L. Dover, Laura M. Brady and Jenessa R. Shapiro (Journal of Personality and Social Psychology, 2013[Mar], Vol 104[3], 504-519). In the article, a raw data merging error in one racial discrimination claim condition from Experiment 6 inadvertently resulted in data analyses on an inaccurate data set. When the error was discovered by the authors and corrected, all analyses reported in Experiment 6 for claim validity, seriousness of the claim, and support for the claimant were inaccurate and none were statistically significant. The conclusions should be altered to indicate that participants with management experience who reflected on their own workplace diversity policies did not show the predicted effects. The literature review, remaining five studies, and remaining conclusions in the article are unaffected by this error. Experiment 6 should also report that 26.4% (not 26.4.7%) of participants had a graduate degree and eight participants (not 8%) did not provide educational data. Experiment 5 should have referred to the claim validity measure as a six-item measure ( .92) rather than a five-item measure; analyses on claim validity are accurate in text. Table 2's note should have said standard errors, not standard deviations. (The following abstract of the original article appeared in record 2012-31077-001.) This research tests the hypothesis that the presence (vs. absence) of organizational diversity structures causes high-status group members (Whites, men) to perceive organizations with diversity structures as procedurally fairer environments for underrepresented groups (racial minorities, women), even when it is clear that underrepresented groups have been unfairly disadvantaged within these organizations. Furthermore, this illusory sense of fairness derived from the mere presence of diversity structures causes high

Trophic ecology of largemouth bass and northern pike in allopatric and sympatric assemblages in northern boreal lakes

USGS Publications Warehouse

Soupir, Craig A.; Brown, Michael L.; Kallemeyn, Larry W.

2000-01-01

Largemouth bass (Micropterus salmoides) and northern pike (Esox lucius) are top predators in the food chain in most aquatic environments that they occupy; however, limited information exists on species interactions in the northern reaches of largemouth bass distribution. We investigated the seasonal food habits of allopatric and sympatric assemblages of largemouth bass and northern pike in six interior lakes within Voyageurs National Park, Minnesota. Percentages of empty stomachs were variable for largemouth bass (38-54%) and northern pike (34.7-66.7%). Fishes (mainly yellow perch, Perca flavescens) comprised greater than 60% (mean percent mass, MPM) of the northern pike diet during all seasons in both allopatric and sympatric assemblages. Aquatic insects (primarily Odonata and Hemiptera) were important in the diets of largemouth bass in all communities (0.0-79.7 MPM). Although largemouth bass were observed in the diet of northern pike, largemouth bass apparently did not prey on northern pike. Seasonal differences were observed in the proportion of aquatic insects (P = 0.010) and fishes (P = 0.023) in the diets of northern pike and largemouth bass. Based on three food categories, jackknifed classifications correctly classified 77 and 92% of northern pike and largemouth bass values, respectively. Percent resource overlap values were biologically significant (greater than 60%) during at least one season in each sympatric assemblage, suggesting some diet overlap.

Survival and growth of planted northern red oak in northern West Virginia

Treesearch

Charles A. McNeel; David M. Hix; Edwin C. Townsend

1993-01-01

The survival and growth of northern red oak (Quercus rubra L.) seedlings planted beneath a shelterwood in northern West Virginia were evaluated one year after planting. The use of 1.5 m (5 ft) tall TUBEX tree shelters on planted seedlings was also examined. The study was conducted on both excellent and good sites (site indices of 27 m (89 ft) and 22...

Response of nesting northern goshawks to logging truck noise in northern Arizona

Treesearch

Teryl G. Grubb; Larry L. Pater; Angela E. Gatto; David K. Delaney

2013-01-01

We recorded 94 sound-response events at 3 adult-occupied northern goshawk (Accipiter gentilis) nests 78 m, 143 m, and 167m from the nearest United States Forest Service maintenance level 3, improved gravel road on the Kaibab Plateau in northern Arizona. During 4 test sessions on 7, 8, 10, and 11 June 2010, we recorded 60 experimentally controlled logging trucks; 30 non...

The Risk of Pneumonia in Older Adults Using Nonbenzodiazepine Hypnotics.

PubMed

Jung, Stephen; Spence, Michele M; Escasa, Nina M; Lee, Eric A; Hui, Rita L; Gibbs, Nancy E

2016-08-01

Previous studies have shown an increased risk of pneumonia with benzodiazepines (BZD) and an increased risk of any infection with non-BZD hypnotics, but no analysis has specifically investigated the risk of pneumonia with non-BZD hypnotic use. To evaluate the risk of pneumonia associated with non-BZD hypnotic use in the elderly. This was a retrospective case-control study of members aged 65 years and older enrolled in an integrated health care system. Cases were identified as patients aged 65 years and older with a diagnosis of pneumonia from January 2011 to December 2012. Controls were matched in a 4:1 ratio to cases based on age, gender, and active enrollment. Non-BZD hypnotic exposure was evaluated for all cases and controls 1 year before the index date. Proximity of exposure to index date and duration of use were analyzed. Conditional logistic regression adjusted for covariates was performed. We identified 51,029 cases with pneumonia and matched 188,391 controls without pneumonia. Of the cases with pneumonia, 5.5% (2,790) of cases had exposure to a non-BZD hypnotic, compared with 3.4% (6,345) of controls. Non-BZD hypnotic exposure was associated with an increased risk of pneumonia (OR = 1.14; 95% CI = 1.08-1.20). When exposure was stratified by proximity to index date, only current exposure was associated with an increased risk of pneumonia (OR = 1.27; 95% CI = 1.18-1.36). Short-term exposure was associated with a relatively higher risk of pneumonia (OR = 1.57; 95% CI = 1.39-1.77) compared with long-term use (OR = 1.16; 95% CI = 1.06-1.25). Current use of non-BZD hypnotics in older adults is associated with an increased risk of pneumonia. The findings of this study provide additional support for reducing the use of non-BZD hypnotics in older adults and for pursuing safer alternatives for treating insomnia. No outside funding supported this study. At the time of this study, Jung was a PGY2 resident in drug information at Kaiser Permanente Drug Information

One-Year Outcomes of an Integrated Multiple Sclerosis Disease Management Program.

PubMed

Groeneweg, Marti; Forrester, Sara H; Arnold, Beth; Palazzo, Lorella; Zhu, Weiwei; Yoon, Paul; Scearce, Tim

2018-05-01

finding remained when the analysis was limited to MS-related visits only. Average annual health plan spend per patient on MS medications significantly increased ($55,835 after vs. $40,883 before, P < 0.001). Specialty pharmacy and chronic disease management for patients with MS can increase the proportion of patients adherent to medication. The increase in health plan spend on MS medications is not offset by savings in health care resource utilization. This study was funded by Kaiser Permanente Washington Health Research Institute and Kaiser Permanente Washington Pharmacy Administration. The authors have no disclosures to report.

Risk of Gastric Cancer Among Patients With Intestinal Metaplasia of the Stomach in a US Integrated Health Care System.

PubMed

Reddy, Kavya M; Chang, Jonathan I; Shi, Jiaxiao M; Wu, Bechien U

2016-10-01

Gastric intestinal metaplasia (GIM) is a common finding from routine endoscopies. Although GIM is an early step in gastric carcinogenesis, there is controversy regarding routine surveillance of patients with GIM in regions with a low prevalence of gastric cancer. We aimed to determine the incidence of gastric cancer among patients with GIM and risk factors for gastric cancer. We performed a retrospective cohort study of patients from the Kaiser Permanente Southern California region diagnosed with GIM from 2000 through 2011. GIM was identified by a keyword search of pathology reports; gastric cancer cases were identified by cross-reference with an internal cancer registry. The incidence of gastric cancer in patients with GIM (n = 923; median age at diagnosis, 68 y) was compared with that of an age- and sex-matched reference population (controls). Risk factors such as ethnicity, smoking status, history of Helicobacter pylori infection, and family history of gastric cancer were evaluated by individual Cox proportional hazards regression. We then performed a second case-cohort study to evaluate the risk of gastric cancer based on the location and extent of GIM. The median duration of follow-up evaluation was 4.6 years (interquartile range, 3.0-6.7 y). We identified 25 patients with GIM who developed gastric cancers. Seventeen cases of cancer were diagnosed at the same time as the diagnosis of GIM. Eight cases of cancer were identified within a median time period of 4.6 years after a diagnosis of GIM (interquartile range, 2-5.7 y). The overall incidence rate for the cohort was 1.72 (95% confidence interval, 0.74-3.39). Among the risk factors evaluated, only family history (hazard ratio, 3.8; 95% confidence interval, 1.5-9.7; P = .012) and extent of GIM (odds ratio, 9.4; 95% confidence interval, 1.8-50.4) increased the risk for gastric cancer. The incidence rate for gastric cancer in patients with a positive family history was 8.12 (95% confidence interval, 1

Fertilization of Northern Hardwoods

Treesearch

R. Lea; D.G. Brockway

1986-01-01

Northern hardwoods grow over a considerable range of climatic and edaphic conditions and exhibit a wide range in productivity.Many northern hardwood forests are capable of high production relative to other forest types, but are often slow to reach maximum productivity because of low nutrient availability.Altering the patterns of biomass accumulation so that managers...

Adaptability of black walnut, black cherry, and Northern red oak to Northern California

Treesearch

Philip M. McDonald

1987-01-01

When planted in sheltered sites in northern California, only 49% of black walnut (Juglans nigra L.) and 58% of black cherry (Prunus serotina Ehrh.) survived for 15 years, and 20% of northern red oak (Quercus rubra L.) survived for 10 years. The black walnut trees averaged 0.6 inches diameter at breast...

From the Northern Eurasia Earth Science Partnership Initiative to the Northern Eurasia Future Initiative

NASA Astrophysics Data System (ADS)

Streletskiy, D. A.; Groisman, P. Y.; Shugart, H. H., Jr.; Gulev, S.; Maksyutov, S. S.; Qi, J.

2017-12-01

Since 2004, the Northern Eurasia Earth Science Partnership Initiative (NEESPI) - an interdisciplinary program of internationally-supported Earth systems and science research - has addressed large-scale and long-term manifestations of climate and environmental changes over Northern Eurasia and their impact on the Global Earth system. With 40 books and more than 1500 peer-reviewed journal publications to its credit, NEESPI's output can now be used to directly support decision-making for societal needs. Specifically, it was decided to shift gradually the foci of regional studies in Northern Eurasia towards applications with the following major Science Question: "What dynamic and interactive change(s) will affect societal well-being, activities, and health, and what might be the mitigation and adaptation strategies that could support sustainable development and decision-making activities in Northern Eurasia?" To answer this question requires a stronger socio-economic component in the ongoing and future regional studies focused on sustainable societal development under changing climatic and environmental conditions. The NEESPI Research Team has reorganized itself into "Northern Eurasia Future Initiative" (NEFI) and developed a new Science Plan released in June 2016. The Plan underwent a 6-month-long public review and was finalized at the end of 2016. Its description was thereafter split between two review papers: Groisman et al. (2017) and Monier et al. (2017). The first paper describes the Plan rationale and a new set of topical questions. The second paper describes a major modeling approach that will be employed in addressing the "what to do" questions of the NEFI Research (cf., presentation by Monier et al. at this Session). In the current presentation, we outline the new NEFI research foci and present latest NEFI findings including international projects in the Eurasian Arctic, boreal zone, and the Dry Land Belt of Northern Eurasia (cf., also presentations at sister

Movements of a polar bear from northern Alaska to northern Greenland

USGS Publications Warehouse

Durner, George M.; Amstrup, Steven C.

1995-01-01

Using satellite telemetry, we monitored the movements of an adult female polar bear (Ursus maritimus) as she traveled from the Alaskan Beaufort Sea coast to northern Greenland. She is the first polar bear known to depart the Beaufort Sea region for an extended period, and the first polar bear known to move between Alaska and Greenland. This bear traveled for four months across the polar basin and came within 2 degrees of the North Pole. During the first year following her capture, she traveled 5256 km. Evidence to suggest her use of maternity dens in northern Alaska and in northern Greenland demonstrates the potential for genetic exchange between two widely separate populations of polar bears. The long life spans of polar bears and the rarity of their long-range movements means the significance of interpopulation movement can be assessed after long-term monitoring of individuals.

What are northern hardwoods?

Treesearch

Richard M. Godman

1992-01-01

The term "northern hardwoods" was used in the early 1900's to separate the hardwoods of the northern region from those growing in the South. With continued usage in the North the term now represents all dense hardwood species both in the Lake States and Northeast. Unfortunately, this has complicated describing and applying silvicultural practices for...

Design thinking.

PubMed

Brown, Tim

2008-06-01

In the past, design has most often occurred fairly far downstream in the development process and has focused on making new products aesthetically attractive or enhancing brand perception through smart, evocative advertising. Today, as innovation's terrain expands to encompass human-centered processes and services as well as products, companies are asking designers to create ideas rather than to simply dress them up. Brown, the CEO and president of the innovation and design firm IDEO, is a leading proponent of design thinking--a method of meeting people's needs and desires in a technologically feasible and strategically viable way. In this article he offers several intriguing examples of the discipline at work. One involves a collaboration between frontline employees from health care provider Kaiser Permanente and Brown's firm to reengineer nursing-staff shift changes at four Kaiser hospitals. Close observation of actual shift changes, combined with brainstorming and rapid prototyping, produced new procedures and software that radically streamlined information exchange between shifts. The result was more time for nursing, better-informed patient care, and a happier nursing staff. Another involves the Japanese bicycle components manufacturer Shimano, which worked with IDEO to learn why 90% of American adults don't ride bikes. The interdisciplinary project team discovered that intimidating retail experiences, the complexity and cost of sophisticated bikes, and the danger of cycling on heavily trafficked roads had overshadowed people's happy memories of childhood biking. So the team created a brand concept--"Coasting"--to describe a whole new category of biking and developed new in-store retailing strategies, a public relations campaign to identify safe places to cycle, and a reference design to inspire designers at the companies that went on to manufacture Coasting bikes.

QL-10NEURO-ONCOLOGY TELEMEDICINE FOLLOW-UP VISITS

PubMed Central

Green, Richard; Woyshner, Emily

2014-01-01

We report our 18 month experience with the use of a videoconferencing system to perform neuro-oncology follow-up visits. The Neuro-oncology Program at the Kaiser Permanente-Los Angeles Medical center serves the majority of Kaiser HMO patients in the Southern California region. We installed a videoconferencing system (Cisco TelePresence EX90, Cisco Systems, San Jose, CA) in our office in Los Angeles and in a medical office building in Anaheim, CA at a distance of 35 miles. Established neuro-oncology patients from Orange County chose between in-person and remote visits. Patients were seated in an examination room and the neuro-oncology provider alerted by text page. A focused history and physical examination was performed, followed by desktop sharing of clinical and laboratory data using an electronic medical record (Epic Systems Corporation, Verona, WI) and of neuroimages (Phillips iSite PACS, Andover, MA). Patients were asked, but not required, to complete an anonymous online 16 question satisfaction survey after each visit. Visits were performed by either a neuro-oncologist (179) or a Physician's Assistant (12). Of the 191 visits, 174 included evaluation of neuroimaging and 77 included evaluation of response to ongoing chemotherapy. During 12 visits chemotherapy was initiated, and during 15 visits the chemotherapy regimen was changed based on imaging findings. One-hundred and eleven surveys (58% of visits) were completed. Patients reported a high level of satisfaction with the visits (average 9.6, on a 1-10 scale). The average estimated travel time saved was 118 minutes per visit. Four surveys reported technical problems and 1 indicated a preference for an in-person visit. No adverse events could be attributed to use of the telemedicine system. These data suggest that neuro-oncology follow-up visits can be practiced safely and effectively using a telemedicine system, with high levels of patient satisfaction.

Anabolic androgen use in the management of hereditary angioedema: Not so cheap after all.

PubMed

Tse, Kevin Y; Zuraw, Bruce L; Chen, Qiaoling; Christiansen, Sandra C

2017-04-01

Hereditary angioedema due to C1 inhibitor deficiency (HAE) is a rare, life-threatening disease that imposes a significant burden on affected patients. 17α-alkylated androgens (anabolic androgens) decrease attack frequency and severity but carry the risk of potentially serious dose-related adverse effects. Despite the emergence of targeted therapies for HAE, continued anabolic androgen use has been driven in part by their low cost. To examine the hidden cost of anabolic androgen use related to the risk of developing non-HAE comorbidities. Patients with HAE were identified in the Southern California Kaiser Permanente database using clinical and laboratory findings compatible with HAE. These patients were stratified into anabolic androgen exposed and nonexposed groups. Matched controls were selected from the Kaiser database who did not have HAE or anabolic androgen exposure. Using multivariate analysis, we determined the number of non-HAE comorbidities linked to anabolic androgen use. We next determined the association between dosing and increasing exposure to anabolic androgens and the likelihood of having various comorbidities. Patients with HAE exposed to anabolic androgens had a 28% increase (P = .04) in non-HAE comorbidities when compared with their matched (nonexposed) controls. With each gram per month increase in exposure, a 12% increase in non-HAE comorbidities is observed (P < .01). The most commonly occurring non-HAE comorbidities were psychiatric, muscle cramps, obesity, and hyperlipidemia. Our data suggest that long-term anabolic androgen use enhances the risk of developing comorbid health conditions, thus amplifying the cost of care. Our report provides additional support for the preferred use of newer, targeted therapies for the management of HAE. Copyright © 2017 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.

Northern homelands, northern frontier: linking culture and economic security in contemporary livelihoods in boreal and cold temperate forest communities in northern Canada

Treesearch

Andrew J. Chapeskie

2001-01-01

This paper highlights the environmental pressures that have historically been brought to bear on the northern forests of Canada. It then presents the idea of the northern frontier forests of Canada as Indigenous landscapes whose ecological diversity and abundance have historically been nurtured in no small measure by their original inhabitants. It then proposes how...

Moderately premature infants at Kaiser Permanente Medical Care Program in California are discharged home earlier than their peers in Massachusetts and the United Kingdom

PubMed Central

Profit, J; Zupancic, J A F; McCormick, M C; Richardson, D K; Escobar, G J; Tucker, J; Tarnow‐Mordi, W; Parry, G

2006-01-01

Objective To compare gestational age at discharge between infants born at 30–34+6 weeks gestational age who were admitted to neonatal intensive care units (NICUs) in California, Massachusetts, and the United Kingdom. Design Prospective observational cohort study. Setting Fifty four United Kingdom, five California, and five Massachusetts NICUs. Subjects A total of 4359 infants who survived to discharge home after admission to an NICU. Main outcome measures Gestational age at discharge home. Results The mean (SD) postmenstrual age at discharge of the infants in California, Massachusetts, and the United Kingdom were 35.9 (1.3), 36.3 (1.3), and 36.3 (1.9) weeks respectively (p  =  0.001). Compared with the United Kingdom, adjusted discharge of infants occurred 3.9 (95% confidence interval (CI) 1.4 to 6.5) days earlier in California, and 0.9 (95% CI −1.2 to 3.0) days earlier in Massachusetts. Conclusions Infants of 30–34+6 weeks gestation at birth admitted and cared for in hospitals in California have a shorter length of stay than those in the United Kingdom. Certain characteristics of the integrated healthcare approach pursued by the health maintenance organisation of the NICUs in California may foster earlier discharge. The California system may provide opportunities for identifying practices for reducing the length of stay of moderately premature infants. PMID:16449257

CB4-03: An Eye on the Future: A Review of Data Virtualization Techniques to Improve Research Analytics

PubMed Central

Richter, Jack; McFarland, Lela; Bredfeldt, Christine

2012-01-01

Background/Aims Integrating data across systems can be a daunting process. The traditional method of moving data to a common location, mapping fields with different formats and meanings, and performing data cleaning activities to ensure valid and reliable integration across systems can be both expensive and extremely time consuming. As the scope of needed research data increases, the traditional methodology may not be sustainable. Data Virtualization provides an alternative to traditional methods that may reduce the effort required to integrate data across disparate systems. Objective Our goal was to survey new methods in data integration, cloud computing, enterprise data management and virtual data management for opportunities to increase the efficiency of producing VDW and similar data sets. Methods Kaiser Permanente Information Technology (KPIT), in collaboration with the Mid-Atlantic Permanente Research Institute (MAPRI) reviewed methodologies in the burgeoning field of Data Virtualization. We identified potential strengths and weaknesses of new approaches to data integration. For each method, we evaluated its potential application for producing effective research data sets. Results Data Virtualization provides opportunities to reduce the amount of data movement required to integrate data sources on different platforms in order to produce research data sets. Additionally, Data Virtualization also includes methods for managing “fuzzy” matching used to match fields known to have poor reliability such as names, addresses and social security numbers. These methods could improve the efficiency of integrating state and federal data such as patient race, death, and tumors with internal electronic health record data. Discussion The emerging field of Data Virtualization has considerable potential for increasing the efficiency of producing research data sets. An important next step will be to develop a proof of concept project that will help us understand to benefits

U.S. Northern Command > Newsroom > Press Releases

Science.gov Websites

Skip to main content (Press Enter). Toggle navigation U.S. Northern Command Search Search USNORTHCOM: Search Search USNORTHCOM: Search U.S. Northern Command U.S. Northern Command Home Leadership , 2018 NORAD and USNORTHCOM to host change of command ceremony Nov. 30, 2017 United States, Mexico to

Ripples and Dunes

NASA Technical Reports Server (NTRS)

2006-01-01

21 July 2006 This Mars Global Surveyor (MGS) Mars Orbiter Camera (MOC) image shows a small portion of the floor of Kaiser Crater in the Noachis Terra region, Mars. The terrain in the upper (northern) half of the image is covered by large windblown ripples and a few smoother-surfaced sand dunes. The dominant winds responsible for these features blew from the west/southwest (left/lower left).

Location near: 47.2oS, 341.3oW Image width: 3 km (1.9 mi) Illumination from: upper left Season: Southern Winter

Scalable and expressive medical terminologies.

PubMed

Mays, E; Weida, R; Dionne, R; Laker, M; White, B; Liang, C; Oles, F J

1996-01-01

The K-Rep system, based on description logic, is used to represent and reason with large and expressive controlled medical terminologies. Expressive concept descriptions incorporate semantically precise definitions composed using logical operators, together with important non-semantic information such as synonyms and codes. Examples are drawn from our experience with K-Rep in modeling the InterMed laboratory terminology and also developing a large clinical terminology now in production use at Kaiser-Permanente. System-level scalability of performance is achieved through an object-oriented database system which efficiently maps persistent memory to virtual memory. Equally important is conceptual scalability-the ability to support collaborative development, organization, and visualization of a substantial terminology as it evolves over time. K-Rep addresses this need by logically completing concept definitions and automatically classifying concepts in a taxonomy via subsumption inferences. The K-Rep system includes a general-purpose GUI environment for terminology development and browsing, a custom interface for formulary term maintenance, a C+2 application program interface, and a distributed client-server mode which provides lightweight clients with efficient run-time access to K-Rep by means of a scripting language.

Postoperative antibiotic use and the incidence of intra-abdominal abscess in the setting of suppurative appendicitis: a retrospective analysis.

PubMed

Bae, Esther; Dehal, Ahmed; Franz, Vanessa; Joannides, Michael; Sakis, Nicholas; Scurlock, Joshua; Nguyen, Patrick; Hussain, Farabi

2016-12-01

Although guidelines exist for postoperative antibiotic use in acute appendicitis that is perforated, gangrenous, or simple/uncomplicated, there are less data about its use in suppurative appendicitis. Here, we targeted this subgroup of patients to determine whether postoperative antibiotic administration affects incidence of intra-abdominal abscess formation. We retrospectively examined 1,192 patients who underwent laparoscopic appendectomy for acute appendicitis at Kaiser Permanente Fontana Hospital between August 2010 and August 2013. Suppurative appendicitis was described for 143 (12%) patients. Fifty-two patients received postoperative antibiotics for at least 1 week on discharge home, 91 did not. Of 143 patients with suppurative appendicitis, 1 (1.9%) who received postoperative antibiotics came back with an intra-abdominal abscess within 1 month. Of the 91 patients in the no antibiotic group, 1 (1.1%) came back with an intra-abdominal abscess. The administration of postoperative antibiotic in the setting of suppurative appendicitis has no effect on the rate of intra-abdominal abscess formation. Routine postoperative antibiotics may not be necessary in this patient population, and more evidence is needed to justify its use. Copyright © 2016 Elsevier Inc. All rights reserved.

Outcomes in Patients Treated with a Novel, Simple Method for Hemostasis of Dermal Avulsion Injuries.

PubMed

Dowling, Sean Taylor; Lin, Brian Wai

2017-10-01

A recently described technique proposes a simple method to achieve permanent hemostasis of distal fingertip dermal avulsion injuries. It is simple to learn and easy to perform with readily available materials found in most emergency departments. However, long-term outcomes for patients treated with this technique have not yet been evaluated. A primary objective of the current article is to provide safety data for the technique using an off-label product indication. Emergency department of Kaiser Permanente Medical Center, San Francisco, California. Six patients were treated in the emergency department for fingertip dermal avulsion injuries using a tourniquet and tissue adhesive glue (Dermabond by Ethicon, Somerville, New Jersey). Patients were subsequently contacted to assess healing and satisfaction with cosmetic outcome through interview and photographs of their wounds at 9 months following the date of injury. All 6 patients were satisfied with the cosmetic outcome of treatment, and none received a diagnosis of serious complications. This series demonstrates cosmetic outcomes for injuries treated with the technique, highlights potential problems that may be perceived by patients during their clinical course, and creates the groundwork for a larger clinical study examining the use of the technique.

Examining HIV Viral Load in a Matched Cohort of HIV Positive Individuals With and Without Psoriasis.

PubMed

Wu, Jashin J; Gilbert, Kathleen E; Batech, Michael; Manalo, Iviensan F; Towner, William J; Raposo, Rui André Saraiva; Nixon, Douglas F; Liao, Wilson

2017-04-01

BACKGROUND: HIV-associated psoriasis is well-documented. Genetic, cellular, and cytokine profiles have been used as evidence to suggest psoriasis activates antiviral pathways. There has been a lack of epidemiologic evidence investigating whether psoriasis patients have lower HIV viral counts compared to non-psoriasis patients.

OBJECTIVE: Compare the viral load set point of HIV positive patients with and without psoriasis.

METHODS: A retrospective matched cohort study of HIV positive patients with and without psoriasis using the Kaiser Permanente Southern California Health Plan database.

RESULTS: We identified 101 HIV-positive psoriasis cases; 19 met inclusion criteria and were matched with 3-5 control patients; 94 total patients were analyzed. The mean age was 41.4 (12.07) years and 83% were male. Overall, the median log of the viral load of cases was slightly higher than controls (4.3 vs 4.2; P less than 0.01).

CONCLUSIONS: The serum viral load set point of patients with HIV and psoriasis was slightly higher than the viral load set point of HIV patients without psoriasis.

J Drugs Dermatol. 2017;16(4):372-377.

Association of Serum Level of Vitamin D at Diagnosis With Breast Cancer Survival: A Case-Cohort Analysis in the Pathways Study.

PubMed

Yao, Song; Kwan, Marilyn L; Ergas, Isaac J; Roh, Janise M; Cheng, Ting-Yuan David; Hong, Chi-Chen; McCann, Susan E; Tang, Li; Davis, Warren; Liu, Song; Quesenberry, Charles P; Lee, Marion M; Ambrosone, Christine B; Kushi, Lawrence H

2017-03-01

There are long-standing interests in the potential benefits of vitamin D for preventing breast cancer recurrence and mortality, yet data from prospective cohort studies are limited. To investigate a serum biomarker of vitamin D status, 25-hydroxyvitamin D (25OHD) measured at the time of breast cancer diagnosis, to determine the association with prognosis. The Pathways Study is a prospective cohort study of breast cancer survivors established in 2006. Enrollment was completed in 2013; follow-up is ongoing. The cohort was established in Kaiser Permanente Northern California, a large integrated health care delivery system in northern California. Women with a diagnosis of incident invasive breast cancer were typically consented and enrolled within 2 months of diagnosis. The overall enrollment rate was 46% (4505 of 9820). Participants are followed for health outcomes and comorbidities at 12, 24, 48, 72, and 96 months after baseline interview. A case-cohort design was used for efficiency assay of 25OHD, selecting 1666 cohort members with serum samples and ensuring representation in the subcohort of races and clinical subtypes. The data analysis was performed from January 5, 2014, to March 15, 2015. Primary outcomes are breast cancer recurrence, second primary cancer, and death. Mean (SD) age was 58.7 (12.4) years. Serum 25OHD concentrations were lower in women with advanced-stage tumors, and the lowest in premenopausal women with triple-negative cancer. Levels were also inversely associated with hazards of disease progression and death. Compared with the lowest tertile, women with the highest tertile of 25OHD levels had superior overall survival (OS). This association remained after adjustment for clinical prognostic factors (hazard ratio [HR], 0.72; 95% CI, 0.54-0.98). Among premenopausal women, the association with OS was stronger, and there were also associations with breast cancer-specific survival and invasive disease-free survival (OS: HR, 0.45; 95% CI, 0

Outcomes of a disease-management program for patients with recent osteoporotic fracture.

PubMed

Che, M; Ettinger, B; Liang, J; Pressman, A R; Johnston, J

2006-01-01

The purpose of this study was to evaluate outcomes of a disease-management program designed to increase rates of bone-mineral-density (BMD) testing and initiation of osteoporosis medication among patients with a recent osteoporotic fracture. We identified 744 consecutive patients aged>or=55 years who were seen at either of 2 of 14 Kaiser Permanente medical facilities in Northern California (KPNC) after sustaining a fracture of the hip, spine, wrist, or humerus between April 2003 and May 2004. These patients were invited to participate in a study of the Fragile Fracture Management Program, whose protocol used fracture-risk assessment tools to determine treatment recommendations. Postfracture care of study participants was compared with usual postfracture care received by osteoporotic-fracture patients at 12 other KPNC facilities. Of the 744 patients who were invited to participate in the study, 293 (39%) agreed to participate, and 169 (23%) completed the evaluation. Of these 169 patients (127 women, 42 men), 65 (51%) of the women and 7 (17%) of the men qualified for drug treatment; of these 72 patients, 6 (86%) of the men and 41 (63%) of the women accepted the offered treatment. At the two study locations, rates of care (BMD testing or prescribing osteoporosis medication) were about twice as high as rates of usual postfracture care observed at 12 other medical centers in KPNC. Compared with patients who received usual care for osteoporotic fracture, patients participating in a postfracture disease management program had substantially higher rates of medical attention given for osteoporosis; however, the overall yield of the program was low. This low uptake rate was related to factors not previously appreciated: many patients refused participation in the program; a high proportion of younger women-and men of all ages-did not qualify for treatment; and treatment was refused by one in three study-qualified women and by one in seven study-qualified men. Additional

Changes in Consumer Purchases in Stores Participating in an Obesity Prevention Initiative.

PubMed

Woodward-Lopez, Gail; Kao, Janice; Kuo, Elena S; Rauzon, Suzanne; Taylor, Anthony C; Goette, Christina; Collins, Carole; Gonzalez, Esmeralda P; Ronshausen, Danielle R; Boyle, Kathryn; Williamson, Dana; Cheadle, Allen

2018-05-01

enough proportion of stores where residents shop that would be required to get measurable impacts at the community level. This article is part of a supplement entitled Building Thriving Communities Through Comprehensive Community Health Initiatives, which is sponsored by Kaiser Permanente, Community Health. Copyright © 2018 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.

A Cohort Study of Metformin and Colorectal Cancer Risk among Patients with Diabetes Mellitus.

PubMed

Bradley, Marie C; Ferrara, Assiamira; Achacoso, Ninah; Ehrlich, Samantha F; Quesenberry, Charles P; Habel, Laurel A

2018-05-01

Background: Several epidemiologic studies have reported strong inverse associations between metformin use and risk of colorectal cancer, although time-related biases, such as immortal time bias, may in part explain these findings. We reexamined this association using methods to minimize these biases. Methods: A cohort study was conducted among 47,351 members of Kaiser Permanente Northern California with diabetes and no history of cancer or metformin use. Follow-up for incident colorectal cancer occurred from January 1, 1997, until June 30, 2012. Cox regression was used to calculate HRs and 95% confidence intervals (CIs) for colorectal cancer risk associated with metformin use (ever use, total duration, recency of use, and cumulative dose). Results: No association was observed between ever use of metformin and colorectal cancer risk (HR, 0.90; 95% CI, 0.76-1.07) and there was no consistent pattern of decreasing risk with increasing total duration, dose, or recency of use. However, long-term use (≥5.0 years) appeared to be associated with reduced risk of colorectal cancer in the full population (HR, 0.78; 95% CI, 0.60-1.02), among current users (HR, 0.78; 95% CI, 0.59-1.04), and in men (HR, 0.65; 95% CI, 0.45-0.94) but not in women. Higher cumulative doses of metformin were associated with reduced risk. In initial users of sulfonylureas, switching to or adding metformin was also associated with decreased colorectal cancer risk. Conclusions: Our findings showed an inverse association between long-term use of metformin and colorectal cancer risk. Findings, especially the risk reduction among men, need to be confirmed in large, well-conducted studies. Impact: If our findings are confirmed, metformin may have a role in the chemoprevention of colorectal cancer. Cancer Epidemiol Biomarkers Prev; 27(5); 525-30. ©2018 AACR See related commentary by Jackson and García-Albéniz, p. 520 . ©2018 American Association for Cancer Research.

Benchmarking CIN3+ risk as the basis for incorporating HPV and Pap cotesting into cervical screening and management guidelines

PubMed Central

Katki, Hormuzd A.; Schiffman, Mark; Castle, Philip E.; Fetterman, Barbara; Poitras, Nancy E.; Lorey, Thomas; Cheung, Li C.; Raine-Bennett, Tina R.; Gage, Julia C.; Kinney, Walter K.

2013-01-01

Objective In 2012, the United States Preventive Services Task Force (USPSTF) and a consensus of 25 organizations endorsed concurrent cytology and HPV testing (“cotesting”) for cervical cancer screening. Past screening and management guidelines were implicitly based on risks defined by Pap-alone, without consideration of HPV test results. To promote management that is consistent with accepted practice, new guidelines incorporating cotesting should aim to achieve equal management of women at equal risk of cervical intraepithelial neoplasia grade 3 and cancer (CIN3+). Methods We estimated cumulative 5-year risks of CIN3+ for 965,360 women aged 30–64 undergoing cotesting at Kaiser Permanente Northern California 2003–2010. We calculated the implicit risk thresholds for Pap-alone and applied them for new management guidance on HPV and Pap cotesting, citing 2 examples: HPV-positive/ASC-US and HPV-negative/Pap-negative. We call this guidance process “benchmarking”. Results LSIL, for which immediate colposcopy is prescribed, carries 5-year CIN3+ risk of 5.2%, suggesting that test results with similar risks should be managed with colposcopy. Similarly, ASC-US (2.6% risk) is managed with 6–12 month follow-up and Pap-negative (0.26% risk) is managed with 3-year follow-up. The 5-year CIN3+ risk for women with HPV-positive/ASC-US was 6.8% (95%CI 6.2% to 7.6%). This is greater than the 5.2% risk implicitly leading to referral to colposcopy, consistent with current management recommendations that HPV-positive/ASC-US should be referred for immediate colposcopy. The 5-year CIN3+ risk for women with HPV-negative/Pap-negative was 0.08% (95%CI 0.07% to 0.09%), far below the 0.26% implicitly required for a 3-year return and justifying a longer (e.g., 5-year) return. Conclusions Using the principle of “equal management of equal risks,” benchmarking to implicit risk thresholds based on Pap-alone can be used to achieve safe and consistent incorporation of cotesting. PMID

Is migraine a risk factor for pediatric stroke?

PubMed

Gelfand, Amy A; Fullerton, Heather J; Jacobson, Alice; Sidney, Stephen; Goadsby, Peter J; Kurth, Tobias; Pressman, Alice

2015-12-01

Our understanding of risk factors for childhood stroke is incomplete. In adults, migraine with aura is associated with a two-fold increase in ischemic stroke risk. In this cohort study we examine the association between migraine and stroke among children in Kaiser Permanente Northern California (KPNC). Children ages 2-17 years who were members of KPNC for ≥6 months between 1997 and 2007 were included. Migraine cohort members had one or more of: an ICD-9 code for migraine, migraine listed as a significant health problem, or a prescription for a migraine-specific medication. The comparison group was children with no evidence of headache. Main outcome measures included stroke incidence rates and incidence rate ratios (IR). Among the 1,566,952 children within KPNC during the study period, 88,164 had migraine, and 1,323,142 had no evidence of headache. Eight migraineurs had a stroke (three (38%) hemorrhagic; five (63%) ischemic). Eighty strokes occurred in children without headache (53 (66%) hemorrhagic; 27 (34%) ischemic). The ischemic stroke incidence rate was 0.9/100,000 person-years in migraineurs vs. 0.4/100,000 person-years in those without headache; IR 2.0 (95% CI 0.8-5.2). A post-hoc analysis of adolescents (12-17 years) showed an increased risk of ischemic stroke among those with migraine; IR 3.4 (95% CI 1.2-9.5). The hemorrhagic stroke incidence rate was 0.5/100,000 person-years in migraineurs and 0.9/100,000 person-years in those without headache; IR 0.6 (95% CI 0.2-2.0). There was no statistically significant increase in hemorrhagic or ischemic stroke risk in pediatric migraineurs in this cohort study. A post-hoc analysis found that ischemic stroke risk was significantly elevated in adolescents with migraine. Future studies should focus on identifying risk factors for ischemic stroke among adolescent migraineurs. Based on adult data, we recommend that migraine aura status should be studied as a possible risk factor for ischemic stroke among adolescent

Risks of CIN 2+, CIN 3+, and Cancer by Cytology and Human Papillomavirus Status: The Foundation of Risk-Based Cervical Screening Guidelines.

PubMed

Demarco, Maria; Lorey, Thomas S; Fetterman, Barbara; Cheung, Li C; Guido, Richard S; Wentzensen, Nicolas; Kinney, Walter K; Poitras, Nancy E; Befano, Brian; Castle, Philip E; Schiffman, Mark

2017-10-01

The next round of the American Society for Colposcopy and Cervical Pathology (ASCCP)-sponsored cervical cancer screening and management guidelines will recommend clinical actions based on risk, rather than test-based algorithms. This article gives preliminary risk estimates for the screening setting, showing combinations of the 2 most important predictors, human papillomavirus (HPV) status and cytology result. Among 1,262,713 women aged 25 to 77 years co-tested with HC2 (Qiagen) and cytology at Kaiser Permanente Northern California, we estimated 0-5-year cumulative risk of cervical intraepithelial neoplasia (CIN) 2+, CIN 3+, and cancer for combinations of cytology (negative for intraepithelial lesion or malignancy [NILM], atypical squamous cells of undetermined significance [ASC-US], low-grade squamous intraepithelial lesion [LSIL], atypical squamous cells cannot exclude HSIL [ASC-H], high-grade squamous intraepithelial lesion [HSIL], atypical glandular cells [AGC]) and HPV status. Ninety percent of screened women had HPV-negative NILM and an extremely low risk of subsequent cancer. Five-year risks of CIN 3+ were lower after HPV negativity (0.12%) than after NILM (0.25%). Among HPV-negative women, 5-year risks for CIN 3+ were 0.10% for NILM, 0.44% for ASC-US, 1.8% for LSIL, 3.0% for ASC-H, 1.2% for AGC, and 29% for HSIL+ cytology (which was very rare). Among HPV-positive women, 5-year risks were 4.0% for NILM, 6.8% for ASC-US, 6.1% for LSIL, 28% for ASC-H, 30% for AGC, and 50% for HSIL+ cytology. As a foundation for the next guidelines revision, we confirmed with additional precision the risk estimates previously reported for combinations of HPV and cytology. Future analyses will estimate risks for women being followed in colposcopy clinic and posttreatment and will consider the role of risk modifiers such as age, HPV vaccine status, HPV type, and screening and treatment history.

Patient attitudes about the clinical use of placebo: qualitative perspectives from a telephone survey.

PubMed

Ortiz, Robin; Chandros Hull, Sara; Colloca, Luana

2016-04-04

To examine qualitative responses regarding the use of placebo treatments in medical care in a sample of US patients.Survey studies suggest a deliberate clinical use of placebos by physicians, and prior research has found that although most US patients find placebo use acceptable, the rationale for these beliefs is largely unknown. Members of the Outpatient Clinic at the Kaiser Permanente Northern California interviewed research participants who had been seen for a chronic health problem at least once in the prior 6 months. 853 women (61%) and men, white (58%) and non-white participants aged 18-75 years. Qualitative responses on perceptions of placebo use from one-time telephone surveys were analysed for common themes and associations with demographic variables. Prior results indicated that a majority of respondents felt it acceptable for doctors to recommend placebo treatments. Our study found that a lack of harm (n=291, 46.1%) and potential benefit (n=250, 39.6%) were the most common themes to justify acceptability of placebo use. Responses citing potential benefit were associated with higher education (r=0.787; p<0.024). Of the minority of respondents who judged it never acceptable for doctors to recommend placebo treatments, the most often referenced rationale was obligation of the doctor to do more (n=102, 48.3%). Additional themes emerged around the issue of whether a doctor was transparent about placebo use, including honesty, patient's right to know and power of the mind. Older age was associated with likelihood to cite overall physician, as opposed to treatment, related themes (r=0.753; p<0.002). Participants seem to appreciate and understand the lack of harm and potential benefit associated with placebo treatments, while valuing the role of the physician and the patient in its implementation. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Back pain in seniors: the Back pain Outcomes using Longitudinal Data (BOLD) cohort baseline data.

PubMed

Jarvik, Jeffrey G; Comstock, Bryan A; Heagerty, Patrick J; Turner, Judith A; Sullivan, Sean D; Shi, Xu; Nerenz, David R; Nedeljkovic, Srdjan S; Kessler, Larry; James, Kathryn; Friedly, Janna L; Bresnahan, Brian W; Bauer, Zoya; Avins, Andrew L; Deyo, Richard A

2014-04-23

Back pain represents a substantial burden globally, ranking first in a recent assessment among causes of years lived with disability. Though back pain is widely studied among working age adults, there are gaps with respect to basic descriptive epidemiology among seniors, especially in the United States. Our goal was to describe how pain, function and health-related quality of life vary by demographic and geographic factors among seniors presenting to primary care providers with new episodes of care for back pain. We examined baseline data from the Back pain Outcomes using Longitudinal Data (BOLD) registry, the largest inception cohort to date of seniors presenting to a primary care provider for back pain. The sample included 5,239 patients ≥ 65 years old with a new primary care visit for back pain at three integrated health systems (Northern California Kaiser-Permanente, Henry Ford Health System [Detroit], and Harvard Vanguard Medical Associates [Boston]). We examined differences in patient characteristics across healthcare sites and associations of patient sociodemographic and clinical characteristics with baseline patient-reported measures of pain, function, and health-related quality of life. Patients differed across sites in demographic and other characteristics. The Detroit site had more African-American patients (50%) compared with the other sites (7-8%). The Boston site had more college graduates (68%) compared with Detroit (20%). Female sex, lower educational status, African-American race, and older age were associated with worse functional disability as measured by the Roland-Morris Disability Questionnaire. Except for age, these factors were also associated with worse pain. Baseline pain and functional impairment varied substantially with a number of factors in the BOLD cohort. Healthcare site was an important factor. After controlling for healthcare site, lower education, female sex, African-American race, and older age were associated with worse

Development of disability in chronic obstructive pulmonary disease: beyond lung function.

PubMed

Eisner, Mark D; Iribarren, Carlos; Blanc, Paul D; Yelin, Edward H; Ackerson, Lynn; Byl, Nancy; Omachi, Theodore A; Sidney, Stephen; Katz, Patricia P

2011-02-01

COPD is a major cause of disability, but little is known about how disability develops in this condition. The authors analysed data from the Function, Living, Outcomes and Work (FLOW) Study which enrolled 1202 Kaiser Permanente Northern California members with COPD at baseline and re-evaluated 1051 subjects at 2-year follow-up. The authors tested the specific hypothesis that the development of specific non-respiratory impairments (abnormal body composition and muscle strength) and functional limitations (decreased lower extremity function, poor balance, mobility-related dyspnoea, reduced exercise performance and decreased cognitive function) will determine the risk of disability in COPD, after controlling for respiratory impairment (FEV(1) and oxygen saturation). The Valued Life Activities Scale was used to assess disability in terms of a broad range of daily activities. The primary disability outcome measure was defined as an increase in the proportion of activities that cannot be performed of 3.3% or greater from baseline to 2-year follow-up (the estimated minimal important difference). Multivariable logistic regression was used for analysis. Respiratory impairment measures were related to an increased prospective risk of disability (multivariate OR 1.75; 95% CI 1.26 to 2.44 for 1 litre decrement of FEV(1) and OR 1.57 per 5% decrement in oxygen saturation; 95% CI 1.13 to 2.18). Non-respiratory impairment (body composition and lower extremity muscle strength) and functional limitations (lower extremity function, exercise performance, and mobility-related dyspnoea) were all associated with an increased longitudinal risk of disability after controlling for respiratory impairment (p<0.05 in all cases). Non-respiratory impairment and functional limitations were predictive of prospective disability, above-and-beyond sociodemographic characteristics, smoking status and respiratory impairment (area under the receiver operating characteristic curve increased from 0.65 to

Comparative Effectiveness of Three Prophylactic Strategies to Prevent Clinical Macular Edema after Phacoemulsification Surgery.

PubMed

Shorstein, Neal H; Liu, Liyan; Waxman, Michael D; Herrinton, Lisa J

2015-12-01

To study the relationship of chemoprophylaxis and other factors with the occurrence of acute, clinical, postoperative macular edema. Retrospective cohort study. The drug regimens consisted of postoperative topical prednisolone acetate (PA) alone or with a nonsteroidal anti-inflammatory drug (NSAID) or intraoperative subconjunctival injection of 2 mg triamcinolone acetonide (TA) alone. Patients undergoing phacoemulsification at Kaiser Permanente, Diablo Service Area, Northern California, from 2007 through 2013. We identified incident macular edema diagnoses that had been recorded 5 to 120 days after phacoemulsification with visual acuity 20/40 or worse and evidence of macular thickening by optical coherence tomography. Odds ratios (ORs) and 95% confidence intervals (CIs) were obtained from logistic regression analysis, conditioned on the surgeon and adjusted for year, patient age and race, diabetic retinopathy status, other ocular comorbidities, systemic comorbidities, and posterior capsular rupture status. Incident rates of acute, clinical, postoperative macular edema. We confirmed 118 cases among 16 070 cataract surgeries (incidence, 0.73%). Compared with PA alone, the OR for the relationship of macular edema with PA+NSAID was 0.45 (95% CI, 0.21-0.95) and that for TA injection was 1.21 (95% CI, 0.48-3.06). The frequency of intraocular pressure spikes of 30 mmHg or more between postoperative days 16 and 45 was 0.6% in the topical PA group, 0.3% in the topical PA+NSAID group (P = 0.13), and 0.8% for the TA group (P = 0.52). Black race was associated with a risk of macular edema (OR, 2.86; 95% CI, 1.41-5.79). Adding a prophylactic NSAID to PA treatment was associated with a reduced risk of macular edema with visual acuity of 20/40 or worse. The risk and safety of TA injection were similar to those of PA alone. Further research is needed on the prognostic significance of postoperative macular edema, the role of prophylaxis, the risk among black people, and the

Safety of DTaP-IPV/Hib vaccine administered routinely to infants and toddlers.

PubMed

Hansen, John; Timbol, Julius; Lewis, Ned; Pool, Vitali; Decker, Michael D; Greenberg, David P; Klein, Nicola P

2016-07-29

The combination DTaP-IPV/Hib vaccine was licensed in the United States in 2008 for children ages 6weeks through 4years with doses administered at 2, 4, 6, and 15-18months of age. The aim of this study was to assess the safety of DTaP-IPV/Hib vaccine routinely administered as part of clinical care to infants at Kaiser Permanente Northern California. This was an observational, retrospective study that included all 2-month-old infants vaccinated with either DTaP-IPV/Hib or another DTaP-containing vaccine. We monitored all subjects for non-elective hospitalizations, emergency department visits and selected outpatient outcomes (seizures, Guillain-Barré Syndrome, encephalopathy, encephalitis, alteration of consciousness, meningitis, hypersensitivity reactions, immune thrombocytopenic purpura, hemolytic anemia, type 1 diabetes, and Kawasaki disease) beginning with their first dose through 6months after a 4th dose or until 24months of age. We calculated incidence rate ratios (IRRs) in the primary analysis by comparing rates of outcomes during the post-vaccination risk interval with rates during a comparison interval more remote from vaccination. Secondary analyses compared outcomes after DTaP-IPV/Hib with those after other DTaP-containing vaccines. We reviewed the medical records of selected outcomes. From October 1, 2008 through July 31, 2010, 14,042 subjects received a first dose of DTaP-IPV/Hib, 13,194 received 2 doses, 12,548 received 3 doses and 6702 received 4 doses. Overall, there were 166 comparisons with significantly elevated IRRs and 165 comparisons with significantly reduced IRRs. Medical record review of outcomes with significantly elevated IRRs in both the primary and secondary analyses did not suggest any relationship with DTaP-IPV/Hib. This study did not detect any safety concerns following DTaP-IPV/Hib and provides reassurance that DTaP-IPV/Hib administered as part of routine care was not associated with unexpected safety risks. Clinical

Cancer incidence and mortality risks in a large US Barrett's oesophagus cohort.

PubMed

Cook, Michael B; Coburn, Sally B; Lam, Jameson R; Taylor, Philip R; Schneider, Jennifer L; Corley, Douglas A

2018-03-01

Barrett's oesophagus (BE) increases the risk of oesophageal adenocarcinoma by 10-55 times that of the general population, but no community-based cancer-specific incidence and cause-specific mortality risk estimates exist for large cohorts in the USA. Within Kaiser Permanente Northern California (KPNC), we identified patients with BE diagnosed during 1995-2012. KPNC cancer registry and mortality files were used to estimate standardised incidence ratios (SIR), standardised mortality ratios (SMR) and excess absolute risks. There were 8929 patients with BE providing 50 147 person-years of follow-up. Compared with the greater KPNC population, patients with BE had increased risks of any cancer (SIR=1.40, 95% CI 1.31 to 1.49), which slightly decreased after excluding oesophageal cancer. Oesophageal adenocarcinoma risk was increased 24 times, which translated into an excess absolute risk of 24 cases per 10 000 person-years. Although oesophageal adenocarcinoma risk decreased with time since BE diagnosis, oesophageal cancer mortality did not, indicating that the true risk is stable and persistent with time. Relative risks of cardia and stomach cancers were increased, but excess absolute risks were modest. Risks of colorectal, lung and prostate cancers were unaltered. All-cause mortality was slightly increased after excluding oesophageal cancer (SMR=1.24, 95% CI 1.18 to 1.31), but time-stratified analyses indicated that this was likely attributable to diagnostic bias. Cause-specific SMRs were elevated for ischaemic heart disease (SMR=1.39, 95% CI 1.18 to 1.63), respiratory system diseases (SMR=1.51, 95% CI 1.29 to 1.75) and digestive system diseases (SMR=2.20 95% CI 1.75 to 2.75). Patients with BE had a persistent excess risk of oesophageal adenocarcinoma over time, although their absolute excess risks for this cancer, any cancer and overall mortality were modest. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a

Safety of quadrivalent live attenuated influenza vaccine in subjects aged 2-49years.

PubMed

Baxter, Roger; Eaton, Abigail; Hansen, John; Aukes, Laurie; Caspard, Herve; Ambrose, Christopher S

2017-03-01

Quadrivalent live attenuated influenza vaccine (Q/LAIV) was licensed in 2012 and replaced trivalent live attenuated influenza vaccine in the United States during the 2013-2014 influenza season. This study assessed the safety of Q/LAIV in children and adults aged 2-49years. This was a prospective observational cohort study using data collected from Kaiser Permanente Northern California. Post-vaccination events of interest were any hospitalization, hospitalization for lower respiratory tract infection, and the following medically attended events: hypersensitivity, seizures/convulsions, lower respiratory tract infection, wheezing, Guillain-Barré syndrome, Bell's palsy, encephalitis, neuritis, vasculitis, and narcolepsy/cataplexy. The rates of these events during the risk interval post-vaccination were compared with rates observed during reference periods later in the follow-up (within-cohort analysis) and with rates observed in frequency-matched unvaccinated controls and inactivated influenza vaccine (IIV) recipients. A total of 62,040 eligible Q/LAIV recipients were identified during the 2013-2014 influenza season. Within-cohort comparisons of all Q/LAIV recipients as well as comparisons between Q/LAIV recipients and unvaccinated controls or IIV recipients did not show any significantly higher risk of hospitalizations or medically attended events following administration of Q/LAIV. Additional analyses by setting (clinic visits, emergency department visits, and hospital admissions) and age group (2-4, 5-8, 9-17, and 18-49years) also did not reveal clinically consistent findings that suggested any increased risk after administration of Q/LAIV. In this large population study of individuals aged 2-49years, no safety signals associated with the administration of Q/LAIV were observed. A much larger study population would be needed to confidently reject any association between Q/LAIV and very rare events, specifically those with an incidence of <1 event/10,000 person

Greatest Challenges of Rectal Cancer Survivors: Results of a Population-Based Survey

PubMed Central

McMullen, Carmit K.; Bulkley, Joanna E.; Altschuler, Andrea; Wendel, Christopher S.; Grant, Marcia; Hornbrook, Mark C.; Sun, Virginia; Krouse, Robert S.

2016-01-01

Background Eliciting cancer survivors’ priorities is essential to address the specific needs of cancer survivor subgroups. Objective To describe long-term rectal cancer survivors’ greatest challenges related to treatment. Design Observational study with cross-sectional survey. Setting Members of Kaiser Permanente, Northern California and Northwest health plans. Patients A survey was mailed to long-term (≥5 years post diagnosis) rectal cancer survivors who had an anastomosis, temporary ostomy, or permanent ostomy. Main Outcome Measures An open-ended question about the greatest challenge related to cancer surgery. We categorized responses using a grounded theory approach with double coding for reliability. Bonferroni-adjusted X2 values were used to assess differences in the proportions of subgroups who mentioned challenges within each response category. Results The survey completion rate was 61% (577/953); 76% (440/577) of participants responded to the greatest challenge question. Respondents’ greatest challenges were bowel/ostomy management (reported by 44%), negative psychosocial effects (37%), late effects of treatment (21%), comorbidities and aging (13%), postoperative recovery (5%), and negative health care experiences (5%). Survivors with temporary ostomy or anastomosis were more likely than survivors with permanent ostomy to report late effects (p<0.0001 and p=0.01, respectively). Survivors with anastomosis were less likely than survivors with permanent ostomy to report negative psychosocial impacts (p=0.0001). Conclusions Our results reveal the need for bowel/ostomy management, psychosocial services and surveillance for late effects in survivorship and supportive care services for all rectal cancer survivors, regardless of ostomy status. The perspective of long-term survivors with anastomosis reveals challenges that may not be anticipated during treatment decision-making. Limitations Generalizability is restricted by the lack of ethnically and

A Study of HPV Typing for the Management of HPV-Positive ASC-US Cervical Cytologic Results

PubMed Central

Schiffman, Mark; Vaughan, Laurence; Raine-Bennett, Tina R.; Castle, Philip E.; Katki, Hormuzd A.; Gage, Julia C.; Fetterman, Barbara; Befano, Brian; Wentzensen, Nicolas

2015-01-01

Background In US cervical screening, immediate colposcopy is recommended for women with HPV-positive ASC-US (equivocal) cytology. We evaluated whether partial typing by Onclarity™ (BD) might identify HPV-positive women with low enough CIN3+ risk to permit 1-year follow-up instead. Methods The NCI-Kaiser Permanente Northern California Persistence and Progression Cohort includes a subset of 13,890 women aged 21+ with HC2 (Qiagen)-positive ASC-US at enrollment; current median follow-up is 3.0 years. Using stratified random sampling, we typed 2,079 archived enrollment specimens including 329 women subsequently diagnosed with CIN3+, 563 with CIN2, and 1,187 with

A study of HPV typing for the management of HPV-positive ASC-US cervical cytologic results.

PubMed

Schiffman, Mark; Vaughan, Laurence M; Raine-Bennett, Tina R; Castle, Philip E; Katki, Hormuzd A; Gage, Julia C; Fetterman, Barbara; Befano, Brian; Wentzensen, Nicolas

2015-09-01

In US cervical screening, immediate colposcopy is recommended for women with HPV-positive ASC-US (equivocal) cytology. We evaluated whether partial typing by Onclarity™ (BD) might identify HPV-positive women with low enough CIN3+ risk to permit 1-year follow-up instead. The NCI-Kaiser Permanente Northern California Persistence and Progression cohort includes a subset of 13,890 women aged 21+ with HC2 (Qiagen)-positive ASC-US at enrollment; current median follow-up is 3.0years. Using stratified random sampling, we typed 2079 archived enrollment specimens including 329 women subsequently diagnosed with CIN3+, 563 with CIN2, and 1187 with

Epidemiologic Evidence That Excess Body Weight Increases Risk of Cervical Cancer by Decreased Detection of Precancer.

PubMed

Clarke, Megan A; Fetterman, Barbara; Cheung, Li C; Wentzensen, Nicolas; Gage, Julia C; Katki, Hormuzd A; Befano, Brian; Demarco, Maria; Schussler, John; Kinney, Walter K; Raine-Bennett, Tina R; Lorey, Thomas S; Poitras, Nancy E; Castle, Philip E; Schiffman, Mark

2018-04-20

Purpose Obesity has been inconsistently linked to increased cervical cancer incidence and mortality; however, the effect of obesity on cervical screening has not been explored. We investigated the hypothesis that increased body mass might decrease detection of cervical precancer and increase risk of cervical cancer even in women undergoing state-of-the-art screening. Methods We conducted a retrospective cohort study of 944,227 women age 30 to 64 years who underwent cytology and human papillomavirus DNA testing (ie, cotesting) at Kaiser Permanente Northern California (January 2003 to December 2015). Body mass index was categorized as normal/underweight (< 25 kg/m 2 ), overweight (25 to < 30 kg/m 2 ), or obese (≥ 30 kg/m 2 ). We estimated 5-year cumulative risks of cervical precancer and cancer by category of body mass index using logistic Weibull survival models. Results We observed lower risk of cervical precancer (n = 4,489) and higher risk of cervical cancer (n = 490) with increasing body mass index. Specifically, obese women had the lowest 5-year risk of precancer (0.51%; 95% CI, 0.48% to 0.54% v 0.73%; 95% CI, 0.70% to 0.76% in normal/underweight women; P trend < .001). In contrast, obese women had the highest 5-year risk of cancer (0.083%; 95% CI, 0.072% to 0.096% v 0.056%; 95% CI, 0.048% to 0.066% in normal/underweight women; P trend < .001). Results were consistent in subgroups defined by age (30 to 49 v 50 to 64 years), human papillomavirus status (positive v negative), and histologic subtype (glandular v squamous). Approximately 20% of cervical cancers could be attributed to overweight or obesity in the women in our study who underwent routine cervical screening. Conclusion In this large, screened population, overweight and obese women had an increased risk of cervical cancer, likely because of underdiagnosis of cervical precancer. Improvements in equipment and/or technique to assure adequate sampling and visualization of women with elevated body mass

Adherence patterns to extended cervical screening intervals in women undergoing human papillomavirus (HPV) and cytology cotesting.

PubMed

Rendle, Katharine A; Schiffman, Mark; Cheung, Li C; Kinney, Walter K; Fetterman, Barbara; Poitras, Nancy E; Lorey, Thomas; Castle, Philip E

2018-04-01

Although guidelines have recommended extended interval cervical screening using concurrent human papillomavirus (HPV) and cytology ("cotesting") for over a decade, little is known about its adoption into routine care. Using longitudinal medical record data (2003-2015) from Kaiser Permanente Northern California (KPNC), which adopted triennial cotesting in 2003, we examined adherence to extended interval screening. We analyzed predictors of screening intervals among 491,588 women undergoing routine screening, categorizing interval length into early (<2.5years), adherent (2.5<3.5years), or late (3.5<6.0years). We also examined repeated early screening in a subgroup of 50,691 women. Predictors examined included: cohort year (defined by baseline cotest, 2003-2009), race/ethnicity, and baseline age. Compared to the 2003 cohort, women in the 2009 cohort were significantly less likely to screen early (aOR=0.22, 95% CI=0.21, 0.23) or late (aOR=0.47, 95% CI=0.45, 0.49). African American (AA) and Hispanic women were less adherent overall than Non-Hispanic White women, with increased early [(AA: aOR=1.21, 95%CI=1.17, 1.25) (Hispanic: aOR=1.08, 95%CI=1.06, 1.11)] and late screening [(AA: aOR=1.23, 95%CI=1.19, 1.27) (Hispanic: aOR=1.06, 95%CI=1.03, 1.08)]. Asian women were slightly more likely to screen early (aOR=1.03, 95%CI=1.01, 1.05), and less likely to screen late (aOR=0.92, 95% CI=0.90, 0.94). Women aged 60-64years were most likely to screen early for two consecutive intervals (aOR=2.09, 95%CI=1.91, 2.29). Our study found that widespread and rapid adoption of extended interval cervical cancer screening is possible, at least in this managed care setting. Further research examining multilevel drivers promoting or restricting extended interval screening across diverse healthcare settings is needed. Copyright © 2018 Elsevier Inc. All rights reserved.

A cohort study of cervical screening using partial HPV typing and cytology triage.

PubMed

Schiffman, Mark; Hyun, Noorie; Raine-Bennett, Tina R; Katki, Hormuzd; Fetterman, Barbara; Gage, Julia C; Cheung, Li C; Befano, Brian; Poitras, Nancy; Lorey, Thomas; Castle, Philip E; Wentzensen, Nicolas

2016-12-01

HPV testing is more sensitive than cytology for cervical screening. However, to incorporate HPV tests into screening, risk-stratification ("triage") of HPV-positive women is needed to avoid excessive colposcopy and overtreatment. We prospectively evaluated combinations of partial HPV typing (Onclarity, BD) and cytology triage, and explored whether management could be simplified, based on grouping combinations yielding similar 3-year or 18-month CIN3+ risks. We typed ∼9,000 archived specimens, taken at enrollment (2007-2011) into the NCI-Kaiser Permanente Northern California (KPNC) HPV Persistence and Progression (PaP) cohort. Stratified sampling, with reweighting in the statistical analysis, permitted risk estimation of HPV/cytology combinations for the 700,000+-woman KPNC screening population. Based on 3-year CIN3+ risks, Onclarity results could be combined into five groups (HPV16, else HPV18/45, else HPV31/33/58/52, else HPV51/35/39/68/56/66/68, else HPV negative); cytology results fell into three risk groups ("high-grade," ASC-US/LSIL, NILM). For the resultant 15 HPV group-cytology combinations, 3-year CIN3+ risks ranged 1,000-fold from 60.6% to 0.06%. To guide management, we compared the risks to established "benchmark" risk/management thresholds in this same population (e.g., LSIL predicted 3-year CIN3+ risk of 5.8% in the screening population, providing the benchmark for colposcopic referral). By benchmarking to 3-year risk thresholds (supplemented by 18-month estimates), the widely varying risk strata could be condensed into four action bands (very high risk of CIN3+ mandating consideration of cone biopsy if colposcopy did not find precancer; moderate risk justifying colposcopy; low risk managed by intensified follow-up to permit HPV "clearance"; and very low risk permitting routine screening.) Overall, the results support primary HPV testing, with management of HPV-positive women using partial HPV typing and cytology. © 2016 UICC.

The population impact of human papillomavirus/cytology cervical cotesting at 3-year intervals: Reduced cervical cancer risk and decreased yield of precancer per screen.

PubMed

Silver, Michelle I; Schiffman, Mark; Fetterman, Barbara; Poitras, Nancy E; Gage, Julia C; Wentzensen, Nicolas; Lorey, Thomas; Kinney, Walter K; Castle, Philip E

2016-12-01

The objective of cervical screening is to detect and treat precancer to prevent cervical cancer mortality and morbidity while minimizing overtreatment of benign human papillomavirus (HPV) infections and related minor abnormalities. HPV/cytology cotesting at extended 5-year intervals currently is a recommended screening strategy in the United States, but the interval extension is controversial. In the current study, the authors examined the impact of a decade of an alternative, 3-year cotesting, on rates of precancer and cancer at Kaiser Permanente Northern California. The effect on screening efficiency, defined as numbers of cotests/colposcopy visits needed to detect a precancer, also was considered. Two cohorts were defined. The "open cohort" included all women screened at least once during the study period; > 1 million cotests were performed. In a fixed "long-term screening cohort," the authors considered the cumulative impact of repeated screening at 3-year intervals by restricting the cohort to women first cotested in 2003 through 2004 (ie, no women entering screening later were added to this group). Detection of cervical intraepithelial neoplasia 3/adenocarcinoma in situ (CIN3/AIS) increased in the open cohort (2004-2006: 82.0/100,000 women screened; 2007-2009: 140.6/100,000 women screened; and 2010-2012: 126.0/100,000 women screened); cancer diagnoses were unchanged. In the long-term screening cohort, the detection of CIN3/AIS increased and then decreased to the original level (2004-2006: 80.5/100,000 women screened; 2007-2009: 118.6/100,000 women screened; and 2010-2012: 84.9./100,000 women screened). The number of cancer diagnoses was found to decrease. When viewed in terms of screening efficiency, the number of colposcopies performed to detect a single case of CIN3/AIS increased in the cohort with repeat screening. Repeated cotesting at a 3-year interval eventually lowers population rates of precancer and cancer. However, a greater number of

Risks of CIN 2+, CIN 3+, and Cancer by Cytology and Human Papillomavirus Status: The Foundation of Risk-Based Cervical Screening Guidelines

PubMed Central

Demarco, Maria; Lorey, Thomas S.; Fetterman, Barbara; Cheung, Li C.; Guido, Richard S.; Wentzensen, Nicolas; Kinney, Walter K.; Poitras, Nancy E.; Befano, Brian; Castle, Philip E.; Schiffman, Mark

2017-01-01

Objectives The next round of the American Society for Colposcopy and Cervical Pathology (ASCCP)-sponsored cervical cancer screening and management guidelines will recommend clinical actions based on risk, rather than test-based algorithms. This article gives preliminary risk estimates for the screening setting, showing combinations of the 2 most important predictors, human papillomavirus (HPV) status and cytology result. Materials and Methods Among 1,262,713 women aged 25 to 77 years co-tested with HC2 (Qiagen) and cytology at Kaiser Permanente Northern California, we estimated 0–5-year cumulative risk of cervical intraepithelial neoplasia (CIN) 2+, CIN 3+, and cancer for combinations of cytology (negative for intraepithelial lesion or malignancy [NILM], atypical squamous cells of undetermined significance [ASC-US], low-grade squamous intraepithelial lesion [LSIL], atypical squamous cells cannot exclude HSIL [ASC-H], high-grade squamous intraepithelial lesion [HSIL], atypical glandular cells [AGC]) and HPV status. Results Ninety percent of screened women had HPV-negative NILM and an extremely low risk of subsequent cancer. Five-year risks of CIN 3+ were lower after HPV negativity (0.12%) than after NILM (0.25%). Among HPV-negative women, 5-year risks for CIN 3+ were 0.10% for NILM, 0.44% for ASC-US, 1.8% for LSIL, 3.0% for ASC-H, 1.2% for AGC, and 29% for HSIL+ cytology (which was very rare). Among HPV-positive women, 5-year risks were 4.0% for NILM, 6.8% for ASC-US, 6.1% for LSIL, 28% for ASC-H, 30% for AGC, and 50% for HSIL+ cytology. Conclusions As a foundation for the next guidelines revision, we confirmed with additional precision the risk estimates previously reported for combinations of HPV and cytology. Future analyses will estimate risks for women being followed in colposcopy clinic and posttreatment and will consider the role of risk modifiers such as age, HPV vaccine status, HPV type, and screening and treatment history. PMID:28953116

Improving treatment intensification to reduce cardiovascular disease risk: a cluster randomized trial

PubMed Central

2012-01-01

Background Blood pressure, lipid, and glycemic control are essential for reducing cardiovascular disease (CVD) risk. Many health care systems have successfully shifted aspects of chronic disease management, including population-based outreach programs designed to address CVD risk factor control, to non-physicians. The purpose of this study is to evaluate provision of new information to non-physician outreach teams on need for treatment intensification in patients with increased CVD risk. Methods Cluster randomized trial (July 1-December 31, 2008) in Kaiser Permanente Northern California registry of members with diabetes mellitus, prior CVD diagnoses and/or chronic kidney disease who were high-priority for treatment intensification: blood pressure ≥ 140 mmHg systolic, LDL-cholesterol ≥ 130 mg/dl, or hemoglobin A1c ≥ 9%; adherent to current medications; no recent treatment intensification). Randomization units were medical center-based outreach teams (4 intervention; 4 control). For intervention teams, priority flags for intensification were added monthly to the registry database with recommended next pharmacotherapeutic steps for each eligible patient. Control teams used the same database without this information. Outcomes included 3-month rates of treatment intensification and risk factor levels during follow-up. Results Baseline risk factor control rates were high (82-90%). In eligible patients, the intervention was associated with significantly greater 3-month intensification rates for blood pressure (34.1 vs. 30.6%) and LDL-cholesterol (28.0 vs 22.7%), but not A1c. No effects on risk factors were observed at 3 months or 12 months follow-up. Intervention teams initiated outreach for only 45-47% of high-priority patients, but also for 27-30% of lower-priority patients. Teams reported difficulties adapting prior outreach strategies to incorporate the new information. Conclusions Information enhancement did not improve risk factor control

["A decision meaning a new foundation...": from the Kaiser Wilhelm Institute for Anthropology, Human Genetics and Eugenics to the Max Planck Institute for Molecular Genetics].

PubMed

Sachse, Carola

2011-01-01

The Max Planck Institute for Molecular Genetics (MPIMG) in Berlin-Dahlem dates its establishment to 1964. Its homepage makes no mention of its predecessor institutes, the Kaiser Wilhelm Institute for Anthropology, Human Genetics and Eugenics (KWIA) and the subsequent MPI for Comparative Genetics and Hereditary Pathology (MPIVEE). This article traces the two critical phases of transition regarding the constellations of academic staff, institutional and epistemic ruptures and continuities specific to the era. Only one of the five department heads from the final war years, Hans Nachtsheim, remained a researcher within the Max Planck Society (MPG); he nevertheless continued to advocate the pre-war and wartime eugenic agenda in the life sciences and social policy. The generational change of 1959/60 became a massive struggle within the institute, in which microbial genetics (with Fritz Kaudewitz) was pitted against human genetics (with Friedrich Vogel) and managed to establish itself after a fresh change in personnel in 1964/65. For the Dahlem institute, this involved a far-reaching reorientation of its research, but for the genetically oriented life sciences in the Max Planck Society as a whole it only meant that molecular biology, which was already being pursued in the West German institutes, gained an additional facility. With this realignment of research traditions, the Society was able to draw a line under the Nazi past without having to address it head-on.

Neuropathological research at the "Deutsche Forschungsanstalt fuer Psychiatrie" (German Institute for Psychiatric Research) in Munich (Kaiser-Wilhelm-Institute). Scientific utilization of children's organs from the "Kinderfachabteilungen" (Children's Special Departments) at Bavarian State Hospitals.

PubMed

Steger, Florian

2006-09-01

During National Socialism, the politically motivated interest in psychiatric genetic research lead to the founding of research departments specialized in pathological-anatomical brain research, the two Kaiser Wilhelm-Institutes (KWI) in Berlin and Munich. The latter was indirectly provided with brain material by Bavarian State Hospitals, to three of which "Kinderfachabteilungen" (Special Pediatric Units) were affiliated. As children became victims of the systematically conducted child "euthanasia" in these Special Pediatric Units, this paper will address the question whether and to which extent the organs from victims of child "euthanasia" were used for (neuro-) pathological research at the KWI in Munich. By means of case studies and medical histories (with focus on the situation in Kaufbeuren-Irsee), I will argue that pediatric departments on a regular base delivered slide preparations, that the child "euthanasia" conduced in these departments systematically contributed to neuropathological research and that slide preparations from victims of child "euthanasia" were used in scientific publications after 1945.

Effect of electrode contact area on the information content of the recorded electrogastrograms: An analysis based on Rényi entropy and Teager-Kaiser Energy

NASA Astrophysics Data System (ADS)

Alagumariappan, Paramasivam; Krishnamurthy, Kamalanand; Kandiah, Sundravadivelu; Ponnuswamy, Mannar Jawahar

2017-06-01

Electrogastrograms (EGG) are electrical signals originating from the digestive system, which are closely correlated with its mechanical activity. Electrogastrography is an efficient non-invasive method for examining the physiological and pathological states of the human digestive system. There are several factors such as fat conductivity, abdominal thickness, change in electrode surface area etc, which affects the quality of the recorded EGG signals. In this work, the effect of variations in the contact area of surface electrodes on the information content of the measured electrogastrograms is analyzed using Rényi entropy and Teager-Kaiser Energy (TKE). Two different circular cutaneous electrodes with approximate contact areas of 201.14 mm2 and 283.64 mm2, have been adopted and EGG signals were acquired using the standard three electrode protocol. Further, the information content of the measured EGG signals were analyzed using the computed values of entropy and energy. Results demonstrate that the information content of the measured EGG signals increases by 6.72% for an increase in the contact area of the surface electrode by 29.09%. Further, it was observed that the average energy increases with increase in the contact surface area. This work appears to be of high clinical significance since the accurate measurement of EGG signals without loss in its information content, is highly useful for the design of diagnostic assistance tools for automated diagnosis and mass screening of digestive disorders.

Confirmation of the Northern Delta Aquariids (NDA, IAU #26) and the Northern June Aquilids (NZC, IAU #164)

NASA Astrophysics Data System (ADS)

Holman, David; Jenniskens, Peter

2012-10-01

This paper resolves confusion surrounding the Northern delta-Aquariids (NDA, IAU #26). Low-light level video observations with the Cameras for All-sky Meteor Surveillance project in California show distinct showers in the months of July and August. The July shower is identified as the Northern June Aquilids (NZC, IAU #164), while the August shower matches most closely prior data on the Northern delta-Aquariids. This paper validates the existence of both showers, which can now be moved to the list of established showers. The August beta-Piscids (BPI, #342) is not a separate stream, but identical to the Northern delta-Aquariids, and should be discarded from the IAU Working List. We detected the Northern June Aquilids beginning on June 14, through its peak on July 11, and to the shower's end on August 2. The meteors move in a short-period sun grazing comet orbit. Our mean orbital elements are: q = 0.124 ± 0.002 AU, 1/a = 0.512 ± 0.014 AU^{-1}, i = 37°63 ± 0°35, omega = 324°90 ± 0°27, and Omega = 107°93 ± 0°91 (N = 131). This orbit is similar to that of sungrazer comet C/2009 U10.

AmeriFlux CA-Man Manitoba - Northern Old Black Spruce (former BOREAS Northern Study Area)

DOE Data Explorer

Amiro, Brian [University of Manitoba

2016-01-01

This is the AmeriFlux version of the carbon flux data for the site CA-Man Manitoba - Northern Old Black Spruce (former BOREAS Northern Study Area). Site Description - 55.880° N, 98.481° W, elevation of 259 m, Boreal coniferous: Black spruce; occasional larch present in poorly-drained areas. Groundcover is moss (feathermosses and Sphagnum), Labrador Tea, Vaccinium, and willows are a main component of the understory. It was established in 1993 as a BOREAS site.

7 CFR 457.143 - Northern potato crop insurance-quality endorsement.

Code of Federal Regulations, 2013 CFR

2013-01-01

... 7 Agriculture 6 2013-01-01 2013-01-01 false Northern potato crop insurance-quality endorsement... Northern potato crop insurance—quality endorsement. The Northern Potato Crop Insurance Quality Endorsement...) Both FCIC and reinsured policies: Northern Potato Crop Insurance Quality Endorsement 1. Definitions...

7 CFR 457.143 - Northern potato crop insurance-quality endorsement.

Code of Federal Regulations, 2014 CFR

2014-01-01

... 7 Agriculture 6 2014-01-01 2014-01-01 false Northern potato crop insurance-quality endorsement... Northern potato crop insurance—quality endorsement. The Northern Potato Crop Insurance Quality Endorsement...) Both FCIC and reinsured policies: Northern Potato Crop Insurance Quality Endorsement 1. Definitions...

7 CFR 457.143 - Northern potato crop insurance-quality endorsement.

Code of Federal Regulations, 2012 CFR

2012-01-01

... 7 Agriculture 6 2012-01-01 2012-01-01 false Northern potato crop insurance-quality endorsement... Northern potato crop insurance—quality endorsement. The Northern Potato Crop Insurance Quality Endorsement...) Both FCIC and reinsured policies: Northern Potato Crop Insurance Quality Endorsement 1. Definitions...

7 CFR 457.143 - Northern potato crop insurance-quality endorsement.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 7 Agriculture 6 2011-01-01 2011-01-01 false Northern potato crop insurance-quality endorsement... Northern potato crop insurance—quality endorsement. The Northern Potato Crop Insurance Quality Endorsement...) Both FCIC and reinsured policies: Northern Potato Crop Insurance Quality Endorsement 1. Definitions...

Executive Summary: Forests of the Northern United States

Treesearch

Stephen R. Shifley; Francisco X. Aguilar; Nianfu Song; Susan I. Stewart; David J. Nowak; Dale D. Gormanson; W. Keith Moser; Sherri Wormstead; Eric J. Greenfield

2012-01-01

This executive summary provides an overview of the 200-page report, Forests of the Northern United States, which covers in detail current forest conditions, recent trends, issues, threats and opportunities in the forests in the 20 Northern States. It provides a context for subsequent Northern Forest Futures Project analyses that will forecast alternative future...

Phototaxis of larval and juvenile northern pike

USGS Publications Warehouse

Zigler, S.J.; Dewey, M.R.

1995-01-01

Age- Phi northern pike Esox lucius prefer vegetated habitats that are difficult to sample with standard towed gears. Light traps can be effective for sampling larval fishes in dense vegetation, given positive phototaxis of fish. We evaluated the phototactic response of young northern pike by comparing the catches of larvae and juveniles obtained with plexiglass traps deployed with a chemical light stick versus traps deployed without a light source (controls) in a laboratory raceway and in a vegetated pond. In the laboratory tests, catches of protolarvae and mesolarvae in lighted traps were 11-35 times greater than catches in control traps. The catches of juvenile northern pike in field and laboratory experiments were 3-15 times greater in lighted traps than in control traps, even though the maximum body width of the larger juveniles was similar to the width of the entrance slots of the traps (5 mm). Larval and juvenile northern pike were photopositive; thus, light traps should effectively sample age-0 northern pike for at least 6 weeks after hatching.

Utilization and costs of home-based and community-based care within a social HMO: trends over an 18-year period

PubMed Central

Leutz, Walter; Nonnenkamp, Lucy; Dickinson, Lynn; Brody, Kathleen

2005-01-01

Abstract Purpose Our objective was to describe the utilization and costs of services from 1985 to 2002 of a Social Health Maintenance Organization (SHMO) demonstration project providing a benefit for home-based and community-based as well as short-term institutional (HCB) care at Kaiser Permanente Northwest (KPNW), serving the Portland, Oregon area. The HCB care benefit was offered by KPNW as a supplement to Medicare's acute care medical benefits, which KPNW provides in an HMO model. KPNW receives a monthly per capita payment from Medicare to provide medical benefits, and Medicare beneficiaries who choose to join pay a supplemental premium that covers prescription drugs, HCB care benefits, and other services. A HCB care benefit of up to $12,000 per year in services was available to SHMO members meeting requirement for nursing home certification (NHC). Methods We used aggregate data to track temporal changes in the period 1985 to 2002 on member eligibility, enrollment in HCB care plans, age, service utilization and co-payments. Trends in the overall costs and financing of the HCB care benefit were extracted from quarterly reports, management data, and finance data. Results During the time period, 14,815 members enrolled in the SHMO and membership averaged 4,531. The proportion of SHMO members aged 85 or older grew from 12 to 25%; proportion meeting requirements for NHC rose from 4 to 27%; and proportion with HCB care plans rose from 4 to 18%. Costs for the HCB care benefit rose from $21 per SHMO member per month in 1985 to $95 in 2002. The HCB care costs were equivalent to 12% to 16% of Medicare reimbursement. The HCB program costs were covered by member premiums (which rose from $49 to $180) and co-payments from members with care plans. Over the 18-year period, spending shifted from nursing homes to a range of community services, e.g. personal care, homemaking, member reimbursement, lifeline, equipment, transportation, shift care, home nursing, adult day care

Northern Nutrition.

ERIC Educational Resources Information Center

Northwest Territories Dept. of Education, Yellowknife.

This guide contains nutrition information and nutrition education strategies aimed at residents of the Canadian Arctic. Section I: (1) defines nutrition terms; (2) describes the sources and functions of essential nutrients; (3) explains Canada's food guide and special considerations for the traditional northern Native diet and for lactose…

Sowing pregerminated northern red oak acorns

Treesearch

Richard M. Godman; Gilbert A. Mattson

1992-01-01

Northern red oak is extremely difficult to regenerate, although it has produced good acorn crops nearly half of the last 32 years in northern Wisconsin. Field trials have shown that for successful seeding, you must protect acorns from predation by wildlife and sow them when temperatures are most favorable for germination.

Success of Underplanting Northern Red Oaks

Treesearch

Martin A. Spetich; Daniel C. Dey; Paul S. Johnson; David L. Graney

2004-01-01

We summarize results of the growth and survival of northern red oak (Quercus rubra L.) seedlings 11 years after planting in shelterwoods in the Boston Mountains of Arkansas. Shelterwood overstories were harvested 3 years after underplanting > 4,000 northern red oak seedlings. Woody vegetation that was competing with planted seedlings received two...

Northern Australia

Atmospheric Science Data Center

2013-04-16

article title:  Tropical Northern Australia   ... view. Water appears in blue shades in the right image, for example, because glitter makes the water look brighter at the aft camera's view ... MD. The MISR data were obtained from the NASA Langley Research Center Atmospheric Science Data Center in Hampton, VA. Image ...

Are the different gully morphologies due to different formation processes on the Kaiser dune field on Mars?

NASA Astrophysics Data System (ADS)

Pasquon, K.; Gargani, J.; Nachon, M.; Conway, S. J.; Massé, M.; Jouannic, G.; Balme, M. R.; Costard, F.; Vincendon, M.

2017-12-01

Diverse gully morphologies are seen on Mars and differences are often neglected for simplification. Here we describe in detail the morphology and present-day activity of two gully-systems on the Kaiser dune field in the southern hemisphere of Mars. We then compare their activity with that of the morphologically distinct linear dune gullies present on the same dunes. The studied gully-systems have large depositional aprons (named "large apron gullies") and occur on dune faces oriented westward. They are active from mid-autumn to late winter (i.e. from Ls 50° to Ls 180°) coinciding with CO2 ice condensation/sublimation cycles. Sandy material collapses from the alcove flanks onto the alcove floor sporadically throughout this period. This accumulated sand is remobilized by punctuated mass flows which we estimate to be up to 7100 m3 in volume. These flows run out on to the apron and occur between Ls 120° and Ls 160°. These mass flow events occur when the number of "digitate flows" is at its seasonal maximum. Digitate flows are characterized by long-narrow zig-zagging low-albedo tracks and do not seem to transport appreciable sediment, and they can number in the hundreds. Small pits appear at their termini or midway along and sometimes these pits are re-deepened by subsequent flows. These events repeat every year and using volume balance calculations we find that the whole system could be built on a timescale of hundreds of martian ears. These large apron gullies differ in morphology and timing from the linear dune gullies. The linear dune gullies are active in late winter, or beginning of spring when the CO2 frost finally sublimates, which occurs after the activity of the large apron gullies. Due to the difference of orientation between large apron gullies and linear dune as well as timing, we infer that insolation, which may influence (i) the depth to ground ice, (ii) the amount of volatiles deposits, is the main cause their differences. Sediment transport by CO2

Holocene climate and climate variability of the northern Gulf of Mexico and adjacent northern Gulf Coast: A review

USGS Publications Warehouse

Poore, Richard Z.

2008-01-01

Marine records from the northern Gulf of Mexico indicate that significant multidecadal- and century-scale variability was common during the Holocene. Mean annual sea-surface temperature (SST) during the last 1,400 years may have varied by 3°C, and excursions to cold SST coincide with reductions in solar output. Broad trends in Holocene terrestrial climate and environmental change along the eastern portion of the northern Gulf Coast are evident from existing pollen records, but the high-frequency details of climate variability are not well known. Continuous and well-dated records of climate change and climate variability in the western portion of the northern Gulf Coast are essentially lacking.Information on Holocene floods, droughts, and storm frequency along the northern Gulf Coast is limited. Records of floods may be preserved in continental shelf sediments, but establishing continuity and chronologies for sedimentary sequences on the shelf presents challenges due to sediment remobilization and redeposition during storms. Studies of past storm deposits in coastal lakes and marshes show promise for constructing records of past storm frequency. A recent summary of sea-level history of the northern Gulf Coast indicates sea level was higher than modern sea level several times during the last few thousand years.

27 CFR 9.70 - Northern Sonoma.

Code of Federal Regulations, 2011 CFR

2011-04-01

... 27 Alcohol, Tobacco Products and Firearms 1 2011-04-01 2011-04-01 false Northern Sonoma. 9.70 Section 9.70 Alcohol, Tobacco Products and Firearms ALCOHOL AND TOBACCO TAX AND TRADE BUREAU, DEPARTMENT OF THE TREASURY LIQUORS AMERICAN VITICULTURAL AREAS Approved American Viticultural Areas § 9.70 Northern Sonoma. (a) Name. The name of the...

27 CFR 9.70 - Northern Sonoma.

Code of Federal Regulations, 2012 CFR

2012-04-01

... 27 Alcohol, Tobacco Products and Firearms 1 2012-04-01 2012-04-01 false Northern Sonoma. 9.70 Section 9.70 Alcohol, Tobacco Products and Firearms ALCOHOL AND TOBACCO TAX AND TRADE BUREAU, DEPARTMENT OF THE TREASURY LIQUORS AMERICAN VITICULTURAL AREAS Approved American Viticultural Areas § 9.70 Northern Sonoma. (a) Name. The name of the...

27 CFR 9.70 - Northern Sonoma.

Code of Federal Regulations, 2013 CFR

2013-04-01

... 27 Alcohol, Tobacco Products and Firearms 1 2013-04-01 2013-04-01 false Northern Sonoma. 9.70 Section 9.70 Alcohol, Tobacco Products and Firearms ALCOHOL AND TOBACCO TAX AND TRADE BUREAU, DEPARTMENT OF THE TREASURY ALCOHOL AMERICAN VITICULTURAL AREAS Approved American Viticultural Areas § 9.70 Northern Sonoma. (a) Name. The name of the...

27 CFR 9.70 - Northern Sonoma.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 27 Alcohol, Tobacco Products and Firearms 1 2010-04-01 2010-04-01 false Northern Sonoma. 9.70 Section 9.70 Alcohol, Tobacco Products and Firearms ALCOHOL AND TOBACCO TAX AND TRADE BUREAU, DEPARTMENT OF THE TREASURY LIQUORS AMERICAN VITICULTURAL AREAS Approved American Viticultural Areas § 9.70 Northern Sonoma. (a) Name. The name of the...

27 CFR 9.70 - Northern Sonoma.

Code of Federal Regulations, 2014 CFR

2014-04-01

... 27 Alcohol, Tobacco Products and Firearms 1 2014-04-01 2014-04-01 false Northern Sonoma. 9.70 Section 9.70 Alcohol, Tobacco Products and Firearms ALCOHOL AND TOBACCO TAX AND TRADE BUREAU, DEPARTMENT OF THE TREASURY ALCOHOL AMERICAN VITICULTURAL AREAS Approved American Viticultural Areas § 9.70 Northern Sonoma. (a) Name. The name of the...

Human genetics and politics as mutually beneficial resources: The case of the Kaiser Wilhelm Institute for Anthropology, Human Heredity and Eugenics during the Third Reich.

PubMed

Weiss, Sheila Faith

2006-01-01

This essay analyzes one of Germany's former premier research institutions for biomedical research, the Kaiser Wilhelm Institute for Anthropology, Human Heredity and Eugenics (KWIA) as a test case for the way in which politics and human heredity served as resources for each other during the Third Reich. Examining the KWIA from this perspective brings us a step closer to answering the questions at the heart of most recent scholarship concerning the biomedical community under the swastika: (1) How do we explain why the vast majority of German human geneticists and eugenicists were willing to work for the National Socialist state and, at the very least, legitimized its exterminationist racial policy; and (2) what accounts for at least some of Germany's most renowned medically trained professionals' involvement in forms of morally compromised science that wholly transcend the bounds of normal scientific practice? Although a complete answer to this question must await an examination of other German biological research centers, the present study suggests that during the Nazi period the symbiotic relationship between human genetics and politics served to radicalize both. The dynamic between the science of human heredity and Nazi politics changed the research practice of some of the biomedical sciences housed at the KWIA. It also simultaneously made it easier for the Nazi state to carry out its barbaric racial program leading, finally, to the extermination of millions of so-called racial undesirables.

Base of fresh ground water, northern Louisiana Salt-Dome Basin and vicinity, northern Louisiana and southern Arkansas

USGS Publications Warehouse

Ryals, G.N.

1980-01-01

The National Waste Terminal Storage Program is an effort by the U.S. Department of Energy to locate and develop sites for disposal or storage of commercially produced radioactive wastes. As part of this program, salt domes in the northern Louisiana salt-dome basin are being studied to determine their suitability as repositories. Part of the U.S. Geological Survey 's participation in the program has been to describe the regional geohydrology of the northern Louisiana salt-dome basin. A map based on a compilation of published data and the interpretation of electrical logs shows the altitude of the base of freshwater in aquifers in the northern Louisiana salt-dome basin. (USGS)

U.S. Northern Command > Newsroom > Fact Sheets

Science.gov Websites

Operations Command, North U.S. Marine Forces Northern Command U.S. Fleet Forces Command Air Forces Northern U.S. Army North Joint Task Force North Joint Task Force Civil Support Joint Task Force Alaska Joint

Imaging Lithospheric-scale Structure Beneath Northern Altiplano in Southern Peru and Northern Bolivia

NASA Astrophysics Data System (ADS)

Kumar, A.; Wagner, L. S.; Beck, S. L.; Zandt, G.; Long, M. D.

2014-12-01

The northern Altiplano plateau of southern Peru and northern Bolivia is one of the highest topographic features on the Earth, flanked by Western and Eastern Cordillera along its margin. It has strongly influenced the local and far field lithospheric deformation since the early Miocene (Masek et al., 1994). Previous studies have emphasized the importance of both the crust and upper mantle in the evolution of Altiplano plateau (McQuarrie et al., 2005). Early tomographic and receiver function studies, south of 16° S, show significant variations in the crust and upper mantle properties in both perpendicular and along strike direction of the Altiplano plateau (Dorbath et. al., 1993; Myers et al., 1998; Beck and Zandt, 2002). In order to investigate the nature of subsurface lithospheric structure below the northern Altiplano, between 15-18° S, we have determined three-dimensional seismic tomography models for Vp and Vs using P and S-wave travel time data from two recently deployed local seismic networks of CAUGHT and PULSE. We also used data from 8 stations from the PERUSE network (PERU Subduction Experiment). Our preliminary tomographic models show a complex variation in the upper mantle velocity structure with depth, northwest and southeast of lake Titicaca. We see the following trend, at ~85 km depth, northwest of lake Titicaca: low Vp and Vs beneath the Western Cordillera, high Vs beneath the Altiplano and low Vp and Vs beneath the Eastern Cordillera. This low velocity anomaly, beneath Eastern Cordillera, seems to coincide with Kimsachata, a Holocene volcano in southern Peru. At depth greater than ~85 km: we find high velocity anomaly beneath the Western Cordillera and low Vs beneath the Altiplano. This high velocity anomaly, beneath Western Cordillera, coincides with the well-located Wadati-Benioff zone seismicity and perhaps represents the subducting Nazca slab. On the southeast of lake Titicaca, in northern Bolivia, we see a consistently high velocity anomaly

Cretaceous planktic foraminiferal biostratigraphy of the Calera Limestone, Northern California, USA

USGS Publications Warehouse

Sliter, W.V.

1999-01-01

The Calera Limestone is the largest, most stratigraphically extensive limestone unit of oceanic character included in the Franciscan Complex of northern California. The aim of this paper is to place the Calera Limestone at its type locality (Rockaway Beach, Pacifica) in a high-resolution biostratigraphy utilizing planktic foraminifers studied in thin section. A section, about 110 m-thick, was measured from the middle thrust slice exposed by quarrying on the southwest side of Calera Hill at Pacifica Quarry. Lithologically, the section is divided in two units; a lower unit with 73 m of black to dark-grey limestone, black chert and tuff, and an upper unit with 36.8 m of light-grey limestone and medium-grey chert. Two prominent black-shale layers rich in organic carbon occur 11 m below the top of the lower black unit and at the boundary with overlying light-grey unit, yielding a total organic content (TOC) of 4.7% and 1.8% t.w., respectively. The fossiliferous Calera Limestone section measured at Pacifica Quarry, from the lower black shale, contains eleven zones and three subzones that span approximately 26 m.y. from the early Aptian to the late Cenomanian. The zones indentified range from the Globigerinelloides blowi Zone to the Dicarinella algeriana Subzone of the Rotalipora cushmani Zone. Within this biostratigraphic interval, the Ticinella bejaouaensis and Hedbergella planispira Zones at the Aptian/Albian boundary are missing as are the Rotalipora subticinensis Subzone of the Biticinella breggiensis Zone and the overlying Rotalipora ticinensis Zone in the late Albian owing both to low-angle thrust faulting and to unconformities. The abundance and preservation of planktic foraminifers are poor in the lower part and improve only within the upper G. algerianus Zone. The faunal relationship indicate that the lower black shale occurs in the upper part of the G. blowi Zone and correlates with the Selli Event recognized at global scale in the early Aptian. The upper black

7 CFR 457.146 - Northern potato crop insurance-storage coverage endorsement.

Code of Federal Regulations, 2014 CFR

2014-01-01

... 7 Agriculture 6 2014-01-01 2014-01-01 false Northern potato crop insurance-storage coverage... Northern potato crop insurance—storage coverage endorsement. The Northern Potato Crop Insurance Storage... for insurance provider) Both FCIC and reinsured policies: Northern Potato Crop Insurance Storage...

7 CFR 457.146 - Northern potato crop insurance-storage coverage endorsement.

Code of Federal Regulations, 2012 CFR

2012-01-01

... 7 Agriculture 6 2012-01-01 2012-01-01 false Northern potato crop insurance-storage coverage... Northern potato crop insurance—storage coverage endorsement. The Northern Potato Crop Insurance Storage... for insurance provider) Both FCIC and reinsured policies: Northern Potato Crop Insurance Storage...

7 CFR 457.146 - Northern potato crop insurance-storage coverage endorsement.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 7 Agriculture 6 2011-01-01 2011-01-01 false Northern potato crop insurance-storage coverage... Northern potato crop insurance—storage coverage endorsement. The Northern Potato Crop Insurance Storage... for insurance provider) Both FCIC and reinsured policies: Northern Potato Crop Insurance Storage...

7 CFR 457.146 - Northern potato crop insurance-storage coverage endorsement.

Code of Federal Regulations, 2013 CFR

2013-01-01

... 7 Agriculture 6 2013-01-01 2013-01-01 false Northern potato crop insurance-storage coverage... Northern potato crop insurance—storage coverage endorsement. The Northern Potato Crop Insurance Storage... for insurance provider) Both FCIC and reinsured policies: Northern Potato Crop Insurance Storage...

Going beyond the Kaiser redshift-space distortion formula: A full general relativistic account of the effects and their detectability in galaxy clustering

NASA Astrophysics Data System (ADS)

Yoo, Jaiyul; Hamaus, Nico; Seljak, Uroš; Zaldarriaga, Matias

2012-09-01

Kaiser redshift-space distortion formula describes well the clustering of galaxies in redshift surveys on small scales, but there are numerous additional terms that arise on large scales. Some of these terms can be described using Newtonian dynamics and have been discussed in the literature, while the others require proper general relativistic description that was only recently developed. Accounting for these terms in galaxy clustering is the first step toward tests of general relativity on horizon scales. The effects can be classified as two terms that represent the velocity and the gravitational potential contributions. Their amplitude is determined by effects such as the volume and luminosity distance fluctuation effects and the time evolution of galaxy number density and Hubble parameter. We compare the Newtonian approximation often used in the redshift-space distortion literature to the fully general relativistic equation, and show that Newtonian approximation accounts for most of the terms contributing to velocity effect. We perform a Fisher matrix analysis of detectability of these terms and show that in a single tracer survey they are completely undetectable. To detect these terms one must resort to the recently developed methods to reduce sampling variance and shot noise. We show that in an all-sky galaxy redshift survey at low redshift the velocity term can be measured at a few sigma if one can utilize halos of mass M≥1012h-1M⊙ (this can increase to 10-σ or more in some more optimistic scenarios), while the gravitational potential term itself can only be marginally detected. We also demonstrate that the general relativistic effect is not degenerate with the primordial non-Gaussian signature in galaxy bias, and the ability to detect primordial non-Gaussianity is little compromised.

From the Northern Eurasia Earth Science Partnership Initiative (NEESPI) towards the Northern Eurasia Future Initiative (NEFI)

NASA Astrophysics Data System (ADS)

Groisman, Pavel; Gutman, Garik; Gulev, Sergey; Maksyutov, Shamil

2015-04-01

Northern Eurasia Earth Science Partnership Initiative (NEESPI, http://neespi.org) was launched in 2004. With its multidisciplinary focus, the internationally funded NEESPI (more than 170 individual international projects during the past decade) has challenged participants to research climate-ecosystem interactions, societal impacts from extreme events in Northern Eurasia, and the feedbacks of these interactions and impacts to the global Earth system. NEESPI was endorsed by major ESSP Programs and Projects and the cornerstone support for the NEESPI studies was provided by the NASA Land Cover and Land Use Change Program and the Russian Academy of Sciences. Now it is the time to synthesis the main achievements of the NEESPI researchers and to re-assess its Science Questions and Objectives of the regional research within the new Future Earth Program paradigm with the focus on interdisciplinary solution-oriented approach that will allow effective policy-making in environment management and control. At the sequence of Workshops (the last of them will be in Prague one week prior to this Assembly) we formulated a major Science Question of the new Northern Eurasia Future Initiative (NEFI): "What will the changes in the regional ecosystems dynamics and interactions mean for the societal well-being, activities, health, and strategic planning in Northern Eurasia?" The major NEFI challenge will be the services aimed on providing in Northern Eurasia a sustainable societal development in changing climate, ecosystems, and societies. At this presentation we shall brief the audience about the main results of the NEESPI researchers, and lay down the plans for the future NEFI studies. At the side event of the Meeting, we shall initiate preparation of the book which will synthesize major NEESPI achievements.

Predation on Northern krill (Meganyctiphanes norvegica Sars).

PubMed

Simard, Yvan; Harvey, Michel

2010-01-01

We consider predation as a function of prey concentration with a focus on how this interaction is influenced by biological-physical interactions, and wider oceanographic processes. In particular, we examine how the anti-predation behaviour of Northern krill interacts with ocean-circulation process to influence its vulnerability to predation. We describe how three-dimensional (3D) circulation interacts with in situ light levels to modulate predator-prey interactions from small to large scales, and illustrate how the stability of the predator-prey system is sometimes perturbed as a consequence. Northern krill predators include a wide range of species from the pelagic and benthic strata, as well as birds. Many exhibit adaptations in their feeding strategy to take advantage of the dynamic physical-biological processes that determine the distribution, concentration and vulnerability of Northern krill. Among them, baleen whales appear to have developed particularly efficient predation strategies. A literature search indicates that Northern krill are a major contributor to ecosystem function throughout its distributional range, and a key species with respect to the flow of energy to upper trophic levels. A list of future research needed to fill gaps in our understanding of Northern krill predator-prey interaction is provided. Copyright © 2010 Elsevier Ltd. All rights reserved.

Survival and growth of northern white-cedar and balsam fir seedlings in riparian management zones in northern Minnesota, USA

Treesearch

Brian J. Palik; Brooke K. Haworth; Andrew J. David; Randall K. Kolka

2015-01-01

Northern white-cedar (Thuja occidentalis) and balsam fir (Abies balsamea.) are co-occurring species in riparian forests of the western Great Lakes region. Throughout much of the region, northern white-cedar has been experiencing population declines due to herbivory by white-tailed deer (Odocoileus virginianus)....

Human epidermal growth factor receptor 2 assessment in a case-control study: comparison of fluorescence in situ hybridization and quantitative reverse transcription polymerase chain reaction performed by central laboratories.

PubMed

Baehner, Frederick L; Achacoso, Ninah; Maddala, Tara; Shak, Steve; Quesenberry, Charles P; Goldstein, Lynn C; Gown, Allen M; Habel, Laurel A

2010-10-01

The optimal method to assess human epidermal growth factor receptor 2 (HER2) status remains highly controversial. Before reporting patient HER2 results, American Society of Clinical Oncology (ASCO)/College of American Pathologists (CAP) guidelines mandate that laboratories demonstrate ≥ 95% concordance to another approved laboratory or methodology. Here, we compare central laboratory HER2 assessed by fluorescence in situ hybridization (FISH) and quantitative reverse transcriptase polymerase chain reaction (RT-PCR) using Oncotype DX in lymph node-negative, chemotherapy-untreated patients from a large Kaiser Permanente case-control study. Breast cancer specimens from the Kaiser-Genomic Health study were examined. Central FISH assessment of HER2 amplification and polysomy 17 was conducted by PhenoPath Laboratories (ratios > 2.2, 1.8 to 2.2, and < 1.8 define HER2 positive, HER2 equivocal, and HER2 negative, respectively). HER2 expression by RT-PCR was conducted using Oncotype DX by Genomic Health (normalized expression units ≥ 11.5, 10.7 to < 11.5, and < 10.7 define HER2 positive, HER2 equivocal, and HER2 negative, respectively). Concordance analyses followed ASCO/CAP guidelines. HER2 concordance by central FISH and central RT-PCR was 97% (95% CI, 96% to 99%). Twelve percent (67 of 568 patients) and 11% (60 of 568 patients) of patients were HER2 positive by RT-PCR and FISH, respectively. HER2-positive patients had increased odds of dying from breast cancer compared with HER2-negative patients. Polysomy 17 was demonstrated in 12.5% of all patients and 33% of FISH-positive patients. Nineteen of 20 FISH-positive patients with polysomy 17 were also RT-PCR HER2 positive. Although not statistically significantly different, HER2-positive/polysomy 17 patients tended to have the worst prognosis, followed by HER2-positive/eusomic, HER2-negative/polysomy 17, and HER2-negative/eusomic patients. There is a high degree of concordance between central FISH and quantitative RT

Evidence for an east-west regional gravity trend in northern Tunisia: Insight into the structural evolution of northern Tunisian Atlas

NASA Astrophysics Data System (ADS)

Jallouli, Chokri; Mogren, Saad; Mickus, Kevin; Turki, Mohamed Moncef

2013-11-01

The Atlas orogeny in northern Algeria and Tunisia led to the destruction of Tethys oceanic lithosphere and cumulated in a collision of microplates rifted off the European margin with the North African continental margin. The location of the boundary between African plate and Kabylian microplate is expressed in northern Algeria by a crustal wedge with double vergence of thrust sheets, whereas in northern Tunisia the geologic environment is more complex and the location of the plate boundary is ambiguous. In this study, we analyzed gravity data to constrain the crustal structure along the northern margin of Tunisia. The analysis includes a separation of regional and residual gravity anomalies and the application of gradient operators to locate density contrast boundaries. The horizontal gradient magnitude and directional gradient highlight a prominent regional E-W gravity gradient in the northern Tunisian Atlas interpreted as a deep fault (active since at least the Early Mesozoic) having a variable kinematic activity depending on the tectonic regime in the region. The main E-W gravity gradient separates two blocks having different gravitational and seismic responses. The southern block has numerous gravity lineaments trending in different directions implying several density variations within the crust, whereas the northern block shows a long-wavelength negative gravity anomaly with a few lineaments. Taking into account the geologic context of the Western Mediterranean region, we consider the E-W prominent feature as the boundary between African plate and Kabylian microplate in northern Tunisia that rifted off Europe. This hypothesis fits most previous geological and geophysical studies and has an important impact on the petroleum and mineral resource prospection as these two blocks were separated by an ocean and they did not belong to the same margin.

Dermatophytosis in northern Africa.

PubMed

Nweze, E I; Eke, I

2016-03-01

Infections caused by dermatophytes are a global problem and a major public health burden in the world today. In Africa, especially in the northern geographical zone, dermatophytic infections are being reported at an alarming rate. This is mostly because of some local but unique cultural practices, socioeconomic and environmental conditions, lack of reliable diagnostic personnel and facilities and ineffective treatment. Interestingly, the pathogen spectrum and the clinical manifestation are most times different from what is seen in other continents. Several epidemiological studies have been performed on the incidence and aetiology of dermatophytoses in northern Africa. However, there is currently no review article with up-to-date information on the relevant findings reported so far in this region. This information is necessary for clinicians who treat dermatophytic infections all over the world since agents of dermatophytes are no longer restricted because of the rapid mobility of humans from one part of the world to another. Moreover, the epidemiology of dermatophytoses is known to change over time, thus requiring the update of information from time to time. A review of relevant studies published on dermatophytoses in northern Africa is presented. This covers all of old Sudan, Algeria, Egypt, Libya, Tunisia and Morocco. © 2015 Blackwell Verlag GmbH.

War Nurseries: Lessons in Quality.

ERIC Educational Resources Information Center

Hurwitz, Sally C.

1998-01-01

Describes development of the Kaiser Child Service Centers at the Kaiser Shipbuilding Company (Portland, Oregon) during World War II, child-care centers created through the Lanham Act. Describes staff recruitment and the services provided. Maintains that the Kaiser Center set a new standard for child care and helped to shape the field of early…

Harvesting systems for the northern forest hardwoods

Treesearch

Chris B. LeDoux

2011-01-01

This monograph is a summary of research results and environmental compliance measures for timber harvesting operations. Data are presented from the Northern Research Station's forest inventory and analysis of 20 states in the northern forest hardwoods. Harvesting systems available in the region today are summarized. Equations for estimating harvesting costs are...

Psychometric Evaluation of a Triage Decision Making Inventory

DTIC Science & Technology

2011-06-27

the correlation matrix and inter-item correlations were reviewed. The Bartlett’s test of sphericity and the Kaiser - Meyer Olkin (KMO) were examined to...nursing experience. Principal component factor analysis with Varimax rotation was conducted using SPSS version 16. The Kaiser - Meyer - Olkin Measure of...Component Analysis. Rotation Method: Varimax with Kaiser Normalization. a. Rotation converged in 7 iterations

eHealth Advances in Support of People with Complex Care Needs: Case Examples from Canada, Scotland and the US.

PubMed

Gray, Carolyn Steele; Mercer, Stewart; Palen, Ted; McKinstry, Brian; Hendry, Anne

2016-01-01

Information technology (IT) in healthcare, also referred to as eHealth technologies, may offer a promising solution to the provision of better care and support for people who have multiple conditions and complex care needs, and their caregivers. eHealth technologies can include electronic medical records, telemonitoring systems and web-based portals, and mobile health (mHealth) technologies that enable information sharing between providers, patients, clients and their families. IT often acts as an enabler of improved care delivery, rather than being an intervention per se. But how are different countries seeking to leverage adoption of these technologies to support people who have chronic conditions and complex care needs? This article presents three case examples from Ontario (Canada), Scotland and Kaiser Permanente Colorado (United States) to identify how these jurisdictions are currently using technology to address multimorbidity. A SWOT (strengths, weaknesses, opportunities, threats) analysis is presented for each case and a final discussion addresses the future of eHealth for complex care needs. The case reports presented in this manuscript mark the foundational work of the Multi-National eHealth Research Partnership Supporting Complex Chronic Disease and Disability (the eCCDD Network); a CIHR-funded project intended to support the international development and uptake of eHealth tools for people with complex care needs.

The Case for Unit-Based Teams: A Model for Front-line Engagement and Performance Improvement

PubMed Central

Cohen, Paul M; Ptaskiewicz, Mark; Mipos, Debra

2010-01-01

Unit-based teams (UBTs)—defined as natural work groups of physicians, managers, and frontline staff who work collaboratively to solve problems, improve performance, and enhance quality—were established by the 2005 national agreement between Kaiser Permanente (KP) and the Coalition of KP Unions. They use established performance-improvement techniques and employee-engagement principles (including social-movement theory) to achieve clinical and operational goals. UBT members identify performance gaps and opportunities within their purview—issues they can address in the course of the day-to-day work, such as workflow or process improvement. By focusing on clear, agreed-on goals, UBTs encourage greater accountability and allow members to perform their full scope of work. UBTs are designed to deliver measurable benefits in clinical outcomes and operations, patient-experience enhancements, and physician-team performance or work life. For many physicians, UBTs will require new ways of engaging with their teams. However, evidence suggests that with organizational and physician support, these teams can achieve their goals. This article presents case examples of successful UBTs' outcomes; physicians' comments on their experience working with teams; an overview of UBTs' employee-engagement principles; and advice on how physicians can support and participate in the work of such teams. PMID:20740124

Economic benefit of chemical dependency treatment to employers.

PubMed

Jordan, Neil; Grissom, Grant; Alonzo, Gregory; Dietzen, Laura; Sangsland, Scott

2008-04-01

Using assessment data from the Substance Abuse Treatment Support System, we estimated the economic benefit of chemical dependency treatment to employers. A cohort of individuals (N = 498) treated at Kaiser Permanente's Addiction Medicine programs in Southern California completed assessments before and at least 30 days after treatment began. Compared to intake, subsequent assessments indicated substantial reduction in the number of patients who missed work, were late for work, were less productive than usual at work, and/or had conflict with coworkers or management. The net economic value of these improvements to their employers depended upon the utilization rate of the benefit and the salary level of the employees receiving treatment. For a utilization rate of 0.9% and a mean annual salary of US$45,000, the net benefit of treatment was US$1,538 for > or = 61 days of treatment. Based solely upon these employment-related measures, without factoring in the medical cost offset or indirect benefits of treatment that may help employees to maintain higher levels of productivity, employers break even on an investment of US$30 per member per year for a chemical dependency treatment benefit if the mean annual salary of the employees participating in treatment is US$36,565.

Creativity and Innovation in Health Care: Tapping Into Organizational Enablers Through Human-Centered Design.

PubMed

Zuber, Christi Dining; Moody, Louise

There is an increasing drive in health care for creativity and innovation to tackle key health challenges, improve quality and access, and reduce harm and costs. Human-centered design (HCD) is a potential approach to achieving organizational innovation. However, research suggests the nursing workforce feels unsupported to take the risks needed for innovation, and leaders may not understand the conditions required to fully support them. The aim of this study was to identify enabling conditions that support frontline nurses in their attempts to behave as champions of innovation and change. An HCD workshop was undertaken with 125 nurses employed in clinical practice at Kaiser Permanente. The workshop included empathy mapping and semistructured questions that probed participant experiences with innovation and change. The data were collated and thematic analysis undertaken through a Grounded Theory approach. The data were analyzed to identify key enabling conditions. Seven enablers emerged: personal need for a solution; challenges that have meaningful purpose; clarity of goal and control of resources; active experimentation; experiences indicating progress; positive encouragement and confidence; and provision of psychological safety. These enablers were then translated into pragmatic guidelines for leaders on how the tools of HCD may be leveraged for innovation and change in health care.

Real World Evidence for Regulatory Decisions: Concomitant Administration of Zoster Vaccine Live and Pneumococcal Polysaccharide Vaccine.

PubMed

Bruxvoort, Katia; Sy, Lina S; Luo, Yi; Tseng, Hung Fu

2018-04-11

The US Food and Drug Administration is charged with expanding the use of real world evidence (RWE) for regulatory decisions. As a test case for RWE to support regulatory decisions, we present the scenario of concomitant vaccination with zoster vaccine live (ZVL) and 23-valent pneumococcal polysaccharide vaccine (PPSV23). The prescribing information states that these vaccines should not be given concurrently, based on a small trial using varicella zoster virus antibody levels as a correlate of ZVL efficacy, even though ZVL protects against herpes zoster via cell-mediated immunity. We conducted an observational cohort study involving >30,000 members of Kaiser Permanente Southern California receiving concomitant ZVL and PPSV23 versus PPSV23 prior to ZVL. Occurrence of herpes zoster was assessed through electronic health records from January 1, 2007 to June 30, 2016. The adjusted hazard ratio comparing incidence rates of herpes zoster in the concomitant vaccination cohort and the prior vaccination cohort was 1.04 (95% CI: 0.92, 1.16). This RWE study provides direct evidence for a lack of vaccine interference, relying on herpes zoster occurrence rather than an intermediate marker of immunity. RWE is essential for regulators and policy makers in addressing evidentiary gaps regarding safety, effectiveness, compliance, and vaccine interactions for the new recombinant zoster vaccine.

The response of the US Centers for Disease Control and Prevention to the obesity epidemic.

PubMed

Dietz, William H

2015-03-18

The recognition of the obesity epidemic as a national problem began in 1999 with the Centers for Disease Control and Prevention's (CDC's) publication of a series of annual state-based maps that demonstrated the rapid changes in the prevalence of obesity. Increasing rates of obesity had been noted in earlier CDC studies, but the maps provided evidence of a rapid, nationwide increase. The urgent need to respond to the epidemic led to the identification of state targets and the first generation of interventions for obesity prevention and control. The CDC's role was to provide setting- and intervention-specific guidance on implementing these strategies, and to assess changes in targeted policies and behaviors. The CDC's efforts were augmented by Congressional funding for community initiatives to improve nutrition and increase physical activity. Complementary investments by Kaiser Permanente, the Robert Wood Johnson Foundation, and the Institute of Medicine improved the evidence base and provided policy recommendations that reinforced the need for a multisectoral approach. Legislative, regulatory, and voluntary initiatives enacted by President Obama's administration translated many of the strategies into effective practice. Whether current efforts to address obesity can be sustained will depend on whether they can be translated into greater grass-roots engagement consistent with a social movement.

Red wine consumption not associated with reduced risk of colorectal cancer.

PubMed

Chao, Chun; Haque, Reina; Caan, Bette J; Poon, Kwun-Yee T; Tseng, Hung-Fu; Quinn, Virginia P

2010-01-01

Red wine contains polyphenol antioxidants that inhibit colorectal cancer (CRC) development in animal studies. We investigated the effect of red wine intake on risk of CRC in the California Men's Health Study (CMHS). CMHS is a prospective, multiethnic cohort of middle-aged men who were members of the Kaiser Permanente (KP) California Health Plans and completed study questionnaires between 2002-2003. Incident CRC were identified from the health plan cancer registries through the end of 2007 (n = 287). To properly account for potential confounding by previous endoscopy screening, we restricted the primary analyses to CMHS men continuously enrolled in KP between 1998-2002 (n = 43,483 and CRC = 176). We used multivariable Cox regression to adjust for important confounders. We did not find an inverse association between moderate red wine intake and risk of CRC. The hazard ratio for consuming >/=1 drink/day (average = 2 drinks/day) was 1.16, 95% confidence intervals 0.56-2.40. There was no linear dose-response. The lack of clear association for red wine intake was consistently observed when we stratified the analyses by CRC stage at diagnosis and cancer site (colon or rectum). Moderate red wine consumption was not associated with reduced risk of colorectal cancer in this population of middle-aged men.

Positive relationship of sleep apnea to hyperaldosteronism in an ethnically diverse population.

PubMed

Sim, John J; Yan, Eric H; Liu, In Lu A; Rasgon, Scott A; Kalantar-Zadeh, Kamyar; Calhoun, David A; Derose, Stephen F

2011-08-01

Approximately, 50-60% of patients with sleep apnea have hypertension. To explore a mechanism of this relationship, we compared its prevalence in a hypertensive population with and without hyperaldosteronism. Using the Kaiser Permanente Southern California database, hypertensive individuals who had plasma aldosterone and plasma renin activity measured between 1 January 2006 and 31 December 2007 were evaluated. Hyperaldosteronism was defined as an aldosterone : renin ratio more than 30 and plasma aldosterone more than 20 ng/dl or an aldosterone : renin ratio more than 50 (ng/dl : ng/ml per h). Hypertension was identified by International Classification of Disease, Ninth Revision (ICD-9) coding and sleep apnea was defined by ICD-9 coding or procedural coding for dispensation of positive airway devices. Of 3428 hypertensive patients, 575 (17%) had hyperaldosteronism. Sleep apnea was present in 18% (105) with hyperaldosteronism vs. 9% (251) without hyperaldosteronism (P < 0.001). Odds ratio for sleep apnea in patients with hyperaldosteronism was 1.8 (95% confidence interval 1.3-2.6) after controlling for other sleep apnea risk factors. No ethnic group was at greater risk for sleep apnea. The prevalence of sleep apnea in a diverse hypertensive population is increased in patients with hyperaldosteronism, even when controlling for other sleep apnea risk factors.

Integrated delivery systems: the cure for fragmentation.

PubMed

Enthoven, Alain C

2009-12-01

Our healthcare system is fragmented, with a misalignment of incentives, or lack of coordination, that spawns inefficient allocation of resources. Fragmentation adversely impacts quality, cost, and outcomes. Eliminating waste from unnecessary, unsafe care is crucial for improving quality and reducing costs--and making the system financially sustainable. Many believe this can be achieved through greater integration of healthcare delivery, more specifically via integrated delivery systems (IDSs). An IDS is an organized, coordinated, and collaborative network that links various healthcare providers to provide a coordinated, vertical continuum of services to a particular patient population or community. It is also accountable, both clinically and fiscally, for the clinical outcomes and health status of the population or community served, and has systems in place to manage and improve them. The marketplace already contains numerous styles and degrees of integration, ranging from Kaiser Permanente-style full integration, to more loosely organized individual practice associations, to public-private partnerships. Evidence suggests that IDSs can improve healthcare quality, improve outcomes, and reduce costs--especially for patients with complex needs--if properly implemented and coordinated. No single approach or public policy will fix the fragmented healthcare system, but IDSs represent an important step in the right direction.

Somatic mutations in benign breast disease tissue and risk of subsequent invasive breast cancer.

PubMed

Rohan, Thomas E; Miller, Christopher A; Li, Tiandao; Wang, Yihong; Loudig, Olivier; Ginsberg, Mindy; Glass, Andrew; Mardis, Elaine

2018-06-06

Insights into the molecular pathogenesis of breast cancer might come from molecular analysis of tissue from early stages of the disease. We conducted a case-control study nested in a cohort of women who had biopsy-confirmed benign breast disease (BBD) diagnosed between 1971 and 2006 at Kaiser Permanente Northwest and who were followed to mid-2015 to ascertain subsequent invasive breast cancer (IBC); cases (n = 218) were women with BBD who developed subsequent IBC and controls, individually matched (1:1) to cases, were women with BBD who did not develop IBC in the same follow-up interval as that for the corresponding case. Targeted sequence capture and sequencing were performed for 83 genes of importance in breast cancer. There were no significant case-control differences in mutation burden overall, for non-silent mutations, for individual genes, or with respect either to the nature of the gene mutations or to mutational enrichment at the pathway level. For seven subjects with DNA from the BBD and ipsilateral IBC, virtually no mutations were shared. This study, the first to use a targeted multi-gene sequencing approach on early breast cancer precursor lesions to investigate the genomic basis of the disease, showed that somatic mutations detected in BBD tissue were not associated with breast cancer risk.

The Alcoholism Situation in a Northern City

ERIC Educational Resources Information Center

Martynov, M. Iu.; Martynova, D. Iu.

2012-01-01

Alcohol abuse in Russia has been increasing in recent years, especially in northern regions, as has the incidence of alcohol-related disease rates. A survey was conducted in Surgut (the Khanty-Mansi autonomous okrug) that determined the factors lending to the prevalence of alcohol abuse among the population of the northern city and assessed the…

Seasonal prevailing surface winds in Northern Serbia

NASA Astrophysics Data System (ADS)

Tošić, Ivana; Gavrilov, Milivoj B.; Marković, Slobodan B.; Ruman, Albert; Putniković, Suzana

2018-02-01

Seasonal prevailing surface winds are analyzed in the territory of Northern Serbia, using observational data from 12 meteorological stations over several decades. In accordance with the general definition of prevailing wind, two special definitions of this term are used. The seasonal wind roses in 16 directions at each station are analyzed. This study shows that the prevailing winds in Northern Serbia have northwestern and southeastern directions. Circulation weather types over Serbia are presented in order to determine the connections between the synoptic circulations and prevailing surface winds. Three controlling pressure centers, i.e., the Mediterranean cyclone, Siberian high, and the Azores anticyclone, appear as the most important large-scale factors that influence the creation of the prevailing winds over Northern Serbia. Beside the synoptic cause of the prevailing winds, it is noted that the orography of the eastern Balkans has a major influence on the winds from the second quadrant. It was found that the frequencies of circulation weather types are in agreement with those of the prevailing winds over Northern Serbia.

Seasonally asymmetric enhancement of northern vegetation productivity

NASA Astrophysics Data System (ADS)

Park, T.; Myneni, R.

2017-12-01

Multiple evidences of widespread greening and increasing terrestrial carbon uptake have been documented. In particular, enhanced gross productivity of northern vegetation has been a critical role leading to observed carbon uptake trend. However, seasonal photosynthetic activity and its contribution to observed annual carbon uptake trend and interannual variability are not well understood. Here, we introduce a multiple-source of datasets including ground, atmospheric and satellite observations, and multiple process-based global vegetation models to understand how seasonal variation of land surface vegetation controls a large-scale carbon exchange. Our analysis clearly shows a seasonally asymmetric enhancement of northern vegetation productivity in growing season during last decades. Particularly, increasing gross productivity in late spring and early summer is obvious and dominant driver explaining observed trend and variability. We observe more asymmetric productivity enhancement in warmer region and this spatially varying asymmetricity in northern vegetation are likely explained by canopy development rate, thermal and light availability. These results imply that continued warming may facilitate amplifying asymmetric vegetation activity and cause these trends to become more pervasive, in turn warming induced regime shift in northern land.

Accessing northern California earthquake data via Internet

NASA Astrophysics Data System (ADS)

Romanowicz, Barbara; Neuhauser, Douglas; Bogaert, Barbara; Oppenheimer, David

The Northern California Earthquake Data Center (NCEDC) provides easy access to central and northern California digital earthquake data. It is located at the University of California, Berkeley, and is operated jointly with the U.S. Geological Survey (USGS) in Menlo Park, Calif., and funded by the University of California and the National Earthquake Hazard Reduction Program. It has been accessible to users in the scientific community through Internet since mid-1992.The data center provides an on-line archive for parametric and waveform data from two regional networks: the Northern California Seismic Network (NCSN) operated by the USGS and the Berkeley Digital Seismic Network (BDSN) operated by the Seismographic Station at the University of California, Berkeley.

Northern Exports of softwood products, 1980-85

Treesearch

James E. Granskog

1988-01-01

Assessment of export opportunities for softwood products from the North has been hampered by a lack of information describing foreign sales from the region. This article describes the value and volume of softwood products exported from the northern United States for 1980 through 1985. Roundwood productsmostly spruce logs from Maine and Vermont- are the largest northern...

Logging truck noise near nesting northern goshawks

Treesearch

Teryl G. Grubb; Larry L. Pater; David K. Delaney

1998-01-01

We measured noise levels of four logging trucks as the trucks passed within approximately 500 m of two active northern goshawk (Accipiter gentilis) nests on the Kaibab Plateau in northern Arizona in 1997. Neither a brooding adult female nor a lone juvenile exhibited any discernable behavioral response to logging truck noise, which peaked at 53.4 and...

Northern Parkway PTA Makes Health a Habit

ERIC Educational Resources Information Center

Ferdinand, Marilyn

2011-01-01

Health and fitness have been on the agenda of Northern Parkway Elementary School for quite some time, thanks to the concerted efforts of its involved and active PTA officers and members. For the past five years, the Northern Parkway PTA has held a popular and well-attended Family Fun and Fitness Night and has complemented the activities and…

Soil organic carbon pools in the northern circumpolar permafrost region

Treesearch

C. Tarnocai; J.G. Canadell; E.A.G. Schuur; P. Kuhry; G. Mazhitova; S. Zimov

2009-01-01

The Northern Circumpolar Soil Carbon Database was developed to determine carbon pools in soils of the northern circumpolar permafrost region. Here we report a new estimate of the carbon pools in soils of the northern permafrost region, including deeper layers and pools not accounted for in previous analyses.

Adapting online learning for Canada's Northern public health workforce.

PubMed

Bell, Marnie; MacDougall, Karen

2013-01-01

Canada's North is a diverse, sparsely populated land, where inequalities and public health issues are evident, particularly for Aboriginal people. The Northern public health workforce is a unique mix of professional and paraprofessional workers. Few have formal public health education. From 2009 to 2012, the Public Health Agency of Canada (PHAC) collaborated with a Northern Advisory Group to develop and implement a strategy to strengthen public health capacity in Canada's 3 northern territories. Access to relevant, effective continuing education was identified as a key issue. Challenges include diverse educational and cultural backgrounds of public health workers, geographical isolation and variable technological infrastructure across the north. PHAC's Skills Online program offers Internet-based continuing education modules for public health professionals. In partnership with the Northern Advisory Group, PHAC conducted 3 pilots between 2008 and 2012 to assess the appropriateness of the Skills Online program for Northern/Aboriginal public health workers. Module content and delivery modalities were adapted for the pilots. Adaptations included adding Inuit and Northern public health examples and using video and teleconference discussions to augment the online self-study component. Findings from the pilots were informative and similar to those from previous Skills Online pilots with learners in developing countries. Online learning is effective in bridging the geographical barriers in remote locations. Incorporating content on Northern and Aboriginal health issues facilitates engagement in learning. Employer support facilitates the recruitment and retention of learners in an online program. Facilitator assets included experience as a public health professional from the north, and flexibility to use modified approaches to support and measure knowledge acquisition and application, especially for First Nations, Inuit and Metis learners. Results demonstrate that

Geologic map of the northern plains of Mars

USGS Publications Warehouse

Tanaka, Kenneth L.; Skinner, James A.; Hare, Trent M.

2005-01-01

The northern plains of Mars cover nearly a third of the planet and constitute the planet's broadest region of lowlands. Apparently formed early in Mars' history, the northern lowlands served as a repository both for sediments shed from the adjacent ancient highlands and for volcanic flows and deposits from sources within and near the lowlands. Geomorphic evidence for extensive tectonic deformation and reworking of surface materials through release of volatiles occurs throughout the northern plains. In the polar region, Planum Boreum contains evidence for the accumulation of ice and dust, and surrounding dune fields suggest widespread aeolian transport and erosion. The most recent regional- and global-scale maps describing the geology of the northern plains are largely based on Viking Orbiter image data (Dial, 1984; Witbeck and Underwood, 1984; Scott and Tanaka, 1986; Greeley and Guest, 1987; Tanaka and Scott, 1987; Tanaka and others, 1992a; Rotto and Tanaka, 1995; Crumpler and others, 2001; McGill, 2002). These maps reveal highland, plains, volcanic, and polar units based on morphologic character, albedo, and relative ages using local stratigraphic relations and crater counts. This geologic map of the northern plains is the first published map that covers a significant part of Mars using topography and image data from both the Mars Global Surveyor and Mars Odyssey missions. The new data provide a fresh perspective on the geology of the region that reveals many previously unrecognizable units, features, and temporal relations. In addition, we adapted and instituted terrestrial mapping methods and stratigraphic conventions that we think result in a clearer and more objective map. We focus on mapping with the intent of reconstructing the history of geologic activity within the northern plains, including deposition, volcanism, erosion, tectonism, impact cratering, and other processes with the aid of comprehensive crater-density determinations. Mapped areas include all

HUBBLE SPOTS NORTHERN HEMISPHERIC CLOUDS ON URANUS

NASA Technical Reports Server (NTRS)

2002-01-01

Using visible light, astronomers for the first time this century have detected clouds in the northern hemisphere of Uranus. The newest images, taken July 31 and Aug. 1, 1997 with NASA Hubble Space Telescope's Wide Field and Planetary Camera 2, show banded structure and multiple clouds. Using these images, Dr. Heidi Hammel (Massachusetts Institute of Technology) and colleagues Wes Lockwood (Lowell Observatory) and Kathy Rages (NASA Ames Research Center) plan to measure the wind speeds in the northern hemisphere for the first time. Uranus is sometimes called the 'sideways' planet, because its rotation axis is tipped more than 90 degrees from the planet's orbit around the Sun. The 'year' on Uranus lasts 84 Earth years, which creates extremely long seasons - winter in the northern hemisphere has lasted for nearly 20 years. Uranus has also been called bland and boring, because no clouds have been detectable in ground-based images of the planet. Even to the cameras of the Voyager spacecraft in 1986, Uranus presented a nearly uniform blank disk, and discrete clouds were detectable only in the southern hemisphere. Voyager flew over the planet's cloud tops near the dead of northern winter (when the northern hemisphere was completely shrouded in darkness). Spring has finally come to the northern hemisphere of Uranus. The newest images, both the visible-wavelength ones described here and those taken a few days earlier with the Near Infrared and Multi-Object Spectrometer (NICMOS) by Erich Karkoschka (University of Arizona), show a planet with banded structure and detectable clouds. Two images are shown here. The 'aqua' image (on the left) is taken at 5,470 Angstroms, which is near the human eye's peak response to wavelength. Color has been added to the image to show what a person on a spacecraft near Uranus might see. Little structure is evident at this wavelength, though with image-processing techniques, a small cloud can be seen near the planet's northern limb (rightmost

All Christians? Experiences of science educators in Northern Ireland

NASA Astrophysics Data System (ADS)

Murphy, Colette; Hickey, Ivor; Beggs, Jim

2010-03-01

In this paper we respond to Staver's article (this issue) on an attempt to resolve the discord between science and religion. Most specifically, we comment on Staver's downplaying of difference between Catholics and Protestants in order to focus on the religion-science question. It is our experience that to be born into one or other of these traditions in some parts of the world (especially Northern Ireland) resulted in starkly contrasting opportunities, identities and practices in becoming and being science educators. The paper starts with a short contextual background to the impact of religion on schooling and higher education in Northern Ireland. We then explore the lives and careers of three science/religious educators in Northern Ireland: Catholic (Jim) and Protestant (Ivor) males who are contemporaries and whose experience spans pre-Troubles to post-conflict and a Catholic female (Colette) who moved to Northern Ireland during the Troubles as a teenager. Finally, we discuss the situation regarding the teaching of creationism and evolution in Northern Ireland—an issue has recently generated high public interest. The Chair of the Education Committee of the Northern Ireland Assembly recently stated that "creationism is not for the RE class because I believe that it can stand scientific scrutiny and that is a debate which I am quite happy to encourage and be part of…" (News Letter 2008). It could be the case that the evolution debate is being fuelled as a deliberate attempt to undermine some of the post-conflict collaboration projects between schools and communities in Northern Ireland.

Carbon Cycling in Northern Peatlands

NASA Astrophysics Data System (ADS)

Schultz, Colin

2010-11-01

Northern peatlands span only 3 million square kilometers, about 3% of the terrestrial area of the globe, yet they represent a significant terrestrial sink for carbon dioxide. They are also important emitters of methane, an even more potent greenhouse gas. Despite their substantial role in the global carbon cycle, peatlands are not typically incorporated into global climate models. The AGU Monograph Carbon Cycling in Northern Peatlands, edited by Andrew J. Baird, Lisa R. Belyea, Xavier Comas, A. S. Reeve, and Lee D. Slater, looks at the disproportionate role peatlands play in the global carbon budget. In this interview, Eos talks with Andy Baird, University of Leeds, Leeds, United Kingdom.

Comparison of survival patterns of northern and southern genotypes of the North American tick Ixodes scapularis (Acari: Ixodidae) under northern and southern conditions

USGS Publications Warehouse

Ginsberg, Howard S.; Rulison, Eric L.; Azevedo, Alexandra; Pang, Genevieve C.; Kuczaj, Isis M.; Tsao, Jean I.; LeBrun, Roger A.

2014-01-01

BackgroundSeveral investigators have reported genetic differences between northern and southern populations of Ixodes scapularis in North America, as well as differences in patterns of disease transmission. Ecological and behavioral correlates of these genetic differences, which might have implications for disease transmission, have not been reported. We compared survival of northern with that of southern genotypes under both northern and southern environmental conditions in laboratory trials.MethodsSubadult I. scapularis from laboratory colonies that originated from adults collected from deer from several sites in the northeastern, north central, and southern U.S. were exposed to controlled conditions in environmental chambers. Northern and southern genotypes were exposed to light:dark and temperature conditions of northern and southern sites with controlled relative humidities, and mortality through time was recorded.ResultsTicks from different geographical locations differed in survival patterns, with larvae from Wisconsin surviving longer than larvae from Massachusetts, South Carolina or Georgia, when held under the same conditions. In another experiment, larvae from Florida survived longer than larvae from Michigan. Therefore, survival patterns of regional genotypes did not follow a simple north–south gradient. The most consistent result was that larvae from all locations generally survived longer under northern conditions than under southern conditions.ConclusionsOur results suggest that conditions in southern North America are less hospitable than in the north to populations of I. scapularis. Southern conditions might have resulted in ecological or behavioral adaptations that contribute to the relative rarity of I. scapularis borne diseases, such as Lyme borreliosis, in the southern compared to the northern United States.

Stratigraphy of the Martian northern plains

NASA Technical Reports Server (NTRS)

Tanaka, K. L.

1993-01-01

The northern plains of Mars are roughly defined as the large continuous region of lowlands that lies below Martian datum, plus higher areas within the region that were built up by volcanism, sedimentation, tectonism, and impacts. These northern lowlands span about 50 x 10(exp 6) km(sup 2) or 35 percent of the planet's surface. The age and origin of the lowlands continue to be debated by proponents of impact and tectonic explanations. Geologic mapping and topical studies indicate that volcanic, fluvial, and eolian deposition have played major roles in the infilling of this vast depression. Periglacial, glacial, fluvial, eolian, tectonic, and impact processes have locally modified the surface. Because of the northern plains' complex history of sedimentation and modification, much of their stratigraphy was obscured. Thus the stratigraphy developed is necessarily vague and provisional: it is based on various clues from within the lowlands as well as from highland areas within and bordering the plains. The results are summarized.

Climate impacts on northern Canada: regional background.

PubMed

Prowse, Terry D; Furgal, Chris; Bonsal, Barrie R; Peters, Daniel L

2009-07-01

Understanding the implications of climate change on northern Canada requires a background about the size and diversity of its human and biogeophysical systems. Occupying an area of almost 40% of Canada, with one-third of this contained in Arctic islands, Canada's northern territories consist of a diversity of physical environments unrivaled around the circumpolar north. Major ecozones composed of a range of landforms, climate, vegetation, and wildlife include: Arctic, boreal and taiga cordillera; boreal and taiga plains; taiga shield; and northern and southern Arctic. Although generally characterized by a cold climate, there is an enormous range in air temperature with mean annual values being as high as -5 degrees C in the south to as low as -20 degrees C in the high Arctic islands. A similar contrast characterizes precipitation, which can be > 700 mm y(-1) in some southern alpine regions to as low as 50 mm y(-1) over islands of the high Arctic. Major freshwater resources are found within most northern ecozones, varying from large glaciers or ice caps and lakes to extensive wetlands and peat lands. Most of the North's renewable water, however, is found within its major river networks and originates in more southerly headwaters. Ice covers characterize the freshwater systems for multiple months of the year while permafrost prevails in various forms, dominating the terrestrial landscape. The marine environment, which envelops the Canadian Arctic Archipelago, is dominated by seasonal to multiyear sea ice often several meters thick that plays a key role in the regional climate. Almost two-thirds of northern Canadian communities are located along coastlines with the entire population being just over 100 000. Most recent population growth has been dominated by an expansion of nonaboriginals, primarily the result of resource development and the growth of public administration. The economies of northern communities, however, remain quite mixed with traditional land

Northern red oak volume growth on four northern Wisconsin habitat types

Treesearch

Michael Demchik; Kevin M. Schwartz; Rory Braun; Eric Scharenbrock

2014-01-01

Northern red oak (Quercus rubra) grows across much of Wisconsin. Using site factors to aid in prediction of volume and basal area increment facilitates management of red oak and other species of interest. Currently, habitat type (Wisconsin Habitat Type Classification System) is often determined when stands are inventoried. If habitat type were...

Building the New Northern Ontario Rural Medical School.

ERIC Educational Resources Information Center

Rourke, James T. B.

2002-01-01

Opening in 2004, the new Northern Ontario Rural Medical School will address the rural doctor shortage in Canada. Supported by Laurentian University and Lakehead University, learning sites will be in hospitals, community clinics, and physicians' offices throughout northern Ontario. The curriculum will be patient-centered and clinical problem-based…

Northern forest lands: resident attitudes and resource use

Treesearch

Herbert E. Echelberger; Albert E. Luloff; Frederick E. Schmidt; Frederick E. Schmidt

1991-01-01

Describes socioeconomic characteristics of residents of northern New Hampshire and northeastern Vermont; their level of participation in outdoor recreational activities; perceptions of community problems; and attitudes concerning local versus regional planning, public ownership of northern forest lands, and other pertinent issues with respect to changes in patterns of...

7 CFR 457.144 - Northern potato crop insurance-processing quality endorsement.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 7 Agriculture 6 2011-01-01 2011-01-01 false Northern potato crop insurance-processing quality... Northern potato crop insurance—processing quality endorsement. The Northern Potato Crop Insurance.... Definitions Broker. Any business enterprise regularly engaged in the buying and selling of processing potatoes...

7 CFR 457.144 - Northern potato crop insurance-processing quality endorsement.

Code of Federal Regulations, 2014 CFR

2014-01-01

... 7 Agriculture 6 2014-01-01 2014-01-01 false Northern potato crop insurance-processing quality... Northern potato crop insurance—processing quality endorsement. The Northern Potato Crop Insurance.... Definitions Broker. Any business enterprise regularly engaged in the buying and selling of processing potatoes...

7 CFR 457.144 - Northern potato crop insurance-processing quality endorsement.

Code of Federal Regulations, 2013 CFR

2013-01-01

... 7 Agriculture 6 2013-01-01 2013-01-01 false Northern potato crop insurance-processing quality... Northern potato crop insurance—processing quality endorsement. The Northern Potato Crop Insurance.... Definitions Broker. Any business enterprise regularly engaged in the buying and selling of processing potatoes...

7 CFR 457.144 - Northern potato crop insurance-processing quality endorsement.

Code of Federal Regulations, 2012 CFR

2012-01-01

... 7 Agriculture 6 2012-01-01 2012-01-01 false Northern potato crop insurance-processing quality... Northern potato crop insurance—processing quality endorsement. The Northern Potato Crop Insurance.... Definitions Broker. Any business enterprise regularly engaged in the buying and selling of processing potatoes...

Site index comparisons among northern hardwoods in northern Wisconsin and Upper Michigan.

Treesearch

Willard H. Carmean

1979-01-01

Compares site index for 13 species found in even-aged northern hardwood stands. Shows that these species differ greatly in site index when growing together, but can be grouped into four general site index classes. Site relations between several species differed with soil drainage.

A Grammar of Northern Mao (Mawes Aas'e)

ERIC Educational Resources Information Center

Ahland, Michael Bryan

2012-01-01

Northern Mao is an endangered Afroasiatic-Omotic language of western Ethiopia with fewer than 5,000 speakers. This study is a comprehensive grammar of the language, written from a functional/typological perspective which embraces historical change as an explanation for synchronic structure. The grammar introduces the Northern Mao people, aspects…

NPDES Permit for Northern Border Pipeline Company in Montana

EPA Pesticide Factsheets

Under NPDES permit MT-0030791, the Northern Border Pipeline Company is authorized to discharge from locations along the Northern Border Gas Transmission Pipeline located within the exterior boundaries of the Fort Peck Indian Reservation, Montana.

An Analysis of Turnover Intentions: A Reexamination of Air Force Civil Engineering Company Grade Officers

DTIC Science & Technology

2012-03-01

edu 75 Appendix C Factor Analysis of Measurement Items Interrole conflict Factor Analysis (FA): Table: KMO and Bartlett’s Test Kaiser-Meyer...Extraction Method: Principal Component Analysis. Rotation Method: Varimax with Kaiser Normalization. 77 POS FA: Table: KMO and Bartlett’s...Tempo FA: Table: KMO and Bartlett’s Test Kaiser-Meyer-Olkin Measure of Sampling Adequacy. .733 Bartlett’s Test of Sphericity Approx. Chi-Square

Identification and Development of Leaders in the Navy Medical Department

DTIC Science & Technology

1990-07-20

multivariate normal population) and the Kaiser - Meyer - Olkin measure of sampling a-equacy (Norusis, 1988b). To allow further analysis of the factors...the Leadership Attribute domain and one from the Leadership Development domain). All factoring procedures passed the Kaiser - Meyer - Olkin Measure of...1.00000 DEVELI .47065 1.00000 MENTOR1 .45338 .69967 1.00000 Kaiser - Meyer - Olkin Measure of Sampling Adequacy = .69463 Bartlett Test of Sphericity

Response of northern hardwood forests to nutrient perturbation

Treesearch

Christopher Eagar; Scott Bailey; Amey Bailey

1999-01-01

Substantial amounts of calcium have been depleted from the soils of northern hardwood forests in northern New Engtand over the past 50 years. Portions of this depleted calcium have been incorporated into the biomass of the aggrading forests; however, significant amounts have been leached into drainage waters and lost from the ecosystem.

Northern Forest DroughtNet: A New Framework to Understand Impacts of Precipitation Change on the Northern Forest Ecosystem

NASA Astrophysics Data System (ADS)

Asbjornsen, H.; Rustad, L.; Templer, P. H.; Jennings, K.; Phillips, R.; Smith, M.

2014-12-01

Recent trends and projections for future change for the U.S. northern forests suggest that the region's climate is becoming warmer, wetter, and, ironically, drier, with more precipitation occurring as large events, separated by longer periods with no precipitation. However, to date, precipitation manipulation experiments conducted in forest ecosystems represent only ~5% of all such experiments worldwide, and our understanding of how the mesic-adapted northern forest will respond to greater frequency and intensity of drought in the future is especially poor. Several important challenges have hampered previous research efforts to conduct forest drought experiments and draw robust conclusions, including difficulties in reducing water uptake by deep and lateral tree roots, logistical and financial constraints to establishing and maintaining large-scale field experiments, and the lack of standardized approaches for determining the appropriate precipitation manipulation treatment (e.g., amount and timing of throughfall displacement), designing and constructing the throughfall displacement infrastructure, identifying key response variables, and collecting and analyzing the field data. The overarching goal of this project is to establish a regional research coordination network - Northern Forest DroughtNet - to investigate the impacts of changes in the amount and distribution of precipitation on the hydrology, biogeochemistry, and carbon (C) cycling dynamics of northern temperate forests. Specific objectives include the development of a standard prototype for conducting precipitation manipulation studies in forest ecosystems (in collaboration with the international DroughtNet-RCN) and the implementation of this prototype drought experiment at the Hubbard Brook Experimental Forest. Here, we present the advances made thus far towards achieving the objectives of Northern Forest DroughtNet, plans for future work, and an invitation to the larger scientific community interested

Survey of northern informal and formal mental health practitioners

PubMed Central

O'Neill, Linda; George, Serena; Sebok, Stefanie

2013-01-01

Background This survey is part of a multi-year research study on informal and formal mental health support in northern Canada involving the use of qualitative and quantitative data collection and analysis methods in an effort to better understand mental health in a northern context. Objective The main objective of the 3-year study was to document the situation of formal and informal helpers in providing mental health support in isolated northern communities in northern British Columbia, northern Alberta, Yukon, Northwest Territories and Nunavut. The intent of developing a survey was to include more participants in the research and access those working in small communities who would be concerned regarding confidentiality and anonymity due to their high profile within smaller populations. Design Based on the in-depth interviews from the qualitative phase of the project, the research team developed a survey that reflected the main themes found in the initial qualitative analysis. The on-line survey consisted of 26 questions, looking at basic demographic information and presenting lists of possible challenges, supports and client mental health issues for participants to prioritise. Results Thirty-two participants identified various challenges, supports and client issues relevant to their mental health support work. A vast majority of the respondents felt prepared for northern practice and had some level of formal education. Supports for longevity included team collaboration, knowledgeable supervisors, managers, leaders and more opportunities for formal education, specific training and continuity of care to support clients. Conclusion For northern-based research in small communities, the development of a survey allowed more participants to join the larger study in a way that protected their identity and confidentiality. The results from the survey emphasise the need for team collaboration, interdisciplinary practice and working with community strengths as a way to

Silvicultural guide for northern hardwoods in the northeast

Treesearch

William B. Leak; Mariko Yamasaki; Robbo. Holleran

2014-01-01

This revision of the 1987 silvicultural guide includes updated and expanded silvicultural information on northern hardwoods as well as additional information on wildlife habitat and the management of mixed-wood and northern hardwood-oak stands. The prescription methodology is simpler and more field-oriented. This guide also includes an appendix of familiar tables and...

Reappraisal of the relationship between the northern Nevada rift and Miocene extension in the northern Basin and Range Province

USGS Publications Warehouse

Colgan, Joseph P.

2013-01-01

The northern Nevada rift is a prominent mafic dike swarm and magnetic anomaly in north-central Nevada inferred to record the Middle Miocene (16.5-15.0 Ma) extension direction in the northern Basin and Range province in the western United States. From the 245°-250° rift direction, Basin and Range extension is inferred to have shifted 45° clockwise to a modern direction of 290°-300° during the late Miocene. The region surrounding the northern Nevada rift was actively extending while the rift formed, and these domains are all characterized by extension oriented 280°-300°. This direction is distinctly different from the rift direction and nearly identical to the modern Basin and Range direction. Although the rate, structural style, and distribution of Basin and Range extension appear to have undergone a significant change in the late Miocene (ca. 10 Ma), the overall spreading direction does not. Middle Miocene extension was directed perpendicular to the axis of the thickest crust formed during Mesozoic shortening and this orientation may reflect gravitational collapse of this thick crust. Orientation of northern Nevada rift dikes may reflect a short-lived regional stress field related to the onset of Yellowstone hotspot volcanism.

Hubble Spots Northern Hemispheric Clouds on Uranus

NASA Technical Reports Server (NTRS)

1997-01-01

Using visible light, astronomers for the first time this century have detected clouds in the northern hemisphere of Uranus. The newest images, taken July 31 and Aug. 1, 1997 with NASA Hubble Space Telescope's Wide Field and Planetary Camera 2, show banded structure and multiple clouds. Using these images, Dr. Heidi Hammel (Massachusetts Institute of Technology) and colleagues Wes Lockwood (Lowell Observatory) and Kathy Rages (NASA Ames Research Center) plan to measure the wind speeds in the northern hemisphere for the first time.

Uranus is sometimes called the 'sideways' planet, because its rotation axis tipped more than 90 degrees from the planet's orbit around the Sun. The 'year' on Uranus lasts 84 Earth years, which creates extremely long seasons - winter in the northern hemisphere has lasted for nearly 20 years. Uranus has also been called bland and boring, because no clouds have been detectable in ground-based images of the planet. Even to the cameras of the Voyager spacecraft in 1986, Uranus presented a nearly uniform blank disk, and discrete clouds were detectable only in the southern hemisphere. Voyager flew over the planet's cloud tops near the dead of northern winter (when the northern hemisphere was completely shrouded in darkness).

Spring has finally come to the northern hemisphere of Uranus. The newest images, both the visible-wavelength ones described here and those taken a few days earlier with the Near Infrared and Multi-Object Spectrometer (NICMOS) by Erich Karkoschka (University of Arizona), show a planet with banded structure and detectable clouds.

Two images are shown here. The 'aqua' image (on the left) is taken at 5,470 Angstroms, which is near the human eye's peak response to wavelength. Color has been added to the image to show what a person on a spacecraft near Uranus might see. Little structure is evident at this wavelength, though with image-processing techniques, a small cloud can be seen near the planet's northern limb

Northern tropical Atlantic climate since late Medieval times from Northern Caribbean coral geochemistry

NASA Astrophysics Data System (ADS)

Kilbourne, K. H.; Xu, Y.

2015-12-01

Paleoclimate reconstructions of different global climate modes over the last 1000 years provide the basis for testing the relative roles of forced and unforced variability climate system, which can help us improve projections of future climate change. The Medieval Climate Anomaly (MCA) has been characterized by a combination of persistent La Niña-like conditions, a positive North Atlantic Oscillation (+NAO), and increased Atlantic Meridional Overturning Circulation (AMOC). The northern tropical Atlantic is sensitive to each of these climate patterns, but not all of them have the same regional fingerprint in the modern northern tropical Atlantic. The relative influence of different processes related to these climate patterns can help us better understand regional responses to climate change. The regional response of the northern tropical Atlantic is important because the tropical Atlantic Ocean is a large source of heat and moisture to the global climate system that can feedback onto global climate patterns. This study presents new coral Sr/Ca and δ18O data from the northern tropical Atlantic (Anegada, British Virgin Islands). Comparison of the sub-fossil corals that grew during the 13th and 14th Centuries with modern coral geochemical data from this site indicates relatively cooler mean conditions with a decrease in the oxygen isotopic composition of the water consistent with lower salinities. Similar average annual cycles between modern and sub-fossil Sr/Ca indicate no change in seasonal temperature range, but a difference in the relative phasing of the δ18O seasonal cycles indicates that the fresher mean conditions may be due to a more northerly position of the regional salinity front. This localized response is consistent with some, but not all of the expected regional responses to a La Niña-like state, a +NAO state, and increased AMOC. Understanding these differences can provide insight into the relative importance of advection versus surface fluxes for

An Exploratory Analysis of Factors Affecting Participation in Air Force Knowledge Now Communities of Practice

DTIC Science & Technology

2004-03-01

reliability coefficients are presented in chapter four in the factor analysis section. Along with Crobach’s Alpha coefficients, the Kaiser - Meyer - Olkin ...the pattern of correlation coefficients > 0.300 in the correlation matrix • Kaiser - Meyer - Olkin Measure of Sampling Adequacy (MSA) > 0.700 • Bartlett’s...exploratory factor analysis. The Kaiser - Meyer - Olkin measure of sampling adequacy yielded a value of .790, and Bartlett’s test of sphericity yielded a

Influences of High Quality Army Enlistments

DTIC Science & Technology

1987-03-01

The second component was formed with the Money for College and Unemployment variables. The Kaiser - Meyer - Olkin (KMO) statistics (Norusis, 1985, p.129...advertising variables were in the same component for moot of the subgroups. The Kaiser - Meyer - Olkin (1MO) values for the a6vertising variables were at...one component. The Kaiser - tMeyer- Olkin (KMO) measure of sampling adequacy indicated that principal component analysis may not be appropriate for

Impacts of Northern Pike on stocked Rainbow Trout in Pactola Reservoir, South Dakota

USGS Publications Warehouse

Scheibel, Natalie C.; Dembkowski, Daniel J.; Davis, Jacob L.; Chipps, Steven R.

2016-01-01

Establishment of nonnative Northern Pike Esox lucius in Pactola Reservoir, South Dakota, has prompted concern among biologists about the influence of this species on the lake’s intensively managed salmonid fisheries. Ancedotal information suggests that catch rates of Rainbow Trout Oncorhynchus mykiss have declined while mean size and abundance of Northern Pike has increased, although quantitative information on diet and growth of the Northern Pike population is lacking. To address potential interactions between Northern Pike and Rainbow Trout, we assessed size-dependent predation by Northern Pike on Rainbow Trout and determined the relative energetic contribution of stocked Rainbow Trout to Northern Pike growth using bioenergetics modeling. Stable isotopes combined with traditional diet analyses revealed that smaller Northern Pike (<600 mm TL) consumed primarily centrarchids and Rainbow Smelt Osmerus mordax, and Rainbow Trout contributed less than 10% to their annual energy consumption. In contrast, larger Northern Pike (≥600 mm TL) consumed primarily Rainbow Trout, which accounted for 56% of their annual energy consumption. Combining estimates of Northern Pike predation with production costs of catchable-size Rainbow Trout revealed that annual economic losses ranged from US$15,259 to $24,801 per year. Over its lifespan, an age-10 Northern Pike was estimated to consume ~117 Rainbow Trout worth approximately $340. Thus, Northern Pike predation substantially influences salmonid management initiatives and is likely a primary factor contributing to reduced Rainbow Trout abundance and return to anglers in Pactola Reservoir. Strategies for reducing Northern Pike predation on Rainbow Trout include increasing the size of stocked fish or altering the timing and spatial distribution of stocking events.

Northern Conference Film and Video Guide on Native and Northern Justice Issues.

ERIC Educational Resources Information Center

Simon Fraser Univ., Burnaby (British Columbia).

Intended for teachers and practitioners, this film and video guide contains 235 entries pertaining to the administration of justice, culture and lifestyle, and education and services in northern Canada. It is divided into eight sections: Native lifestyle (97 items); economic development (28), rights and self-government (20); education and training…

68. Photocopy of drawing (from print, Burlington Northern Engineering Office) ...

Library of Congress Historic Buildings Survey, Historic Engineering Record, Historic Landscapes Survey

68. Photocopy of drawing (from print, Burlington Northern Engineering Office) STRESS DIAGRAM - Burlington Northern Railroad Bridge, Spanning Willamette River at River Mile 6.9, Portland, Multnomah County, OR

Paludification and forest retreat in northern oceanic environments.

PubMed

Crawford, R M M; Jeffree, C E; Rees, W G

2003-01-01

Examination of temperature variations over the past century for Europe and the Arctic from northern Norway to Siberia suggests that variations in the North Atlantic Oscillation are associated with an increase in oceanicity in certain maritime regions. A southward depression of the tree line in favour of wet heaths, bogs and wetland tundra communities is also observed in northern oceanic environments. The physiological basis for this change in ecological succession from forest to bog is discussed in relation to the long-term effects of flooding on tree survival. The heightened values currently detected in the North Atlantic Oscillation Index, together with rising winter temperatures, and increased rainfall in many areas in northern Europe, presents an increasing risk of paludification with adverse consequences for forest regeneration, particularly in areas with oceanic climates. Climatic warming in oceanic areas may increase the area covered by bogs and, contrary to general expectations, lead to a retreat rather than an advance in the northern limit of the boreal forest. High water-table levels are not automatically detrimental to forest survival as can be seen in swamp, bottom land and mangrove forests. Consequently, the inhibitory effects of flooding on tree survival and regeneration in northern regions should not be uncritically accepted as merely due to high water levels. Evidence is discussed which suggests that physiological and ecological factors may interact to inhibit forest regeneration in habitats where there is a risk of prolonged winter-flooding combined with warmer winters and cool moist summers.

Paludification and Forest Retreat in Northern Oceanic Environments

PubMed Central

CRAWFORD, R. M. M.; JEFFREE, C. E.; REES, W. G.

2003-01-01

Examination of temperature variations over the past century for Europe and the Arctic from northern Norway to Siberia suggests that variations in the North Atlantic Oscillation are associated with an increase in oceanicity in certain maritime regions. A southward depression of the treeline in favour of wet heaths, bogs and wetland tundra communities is also observed in northern oceanic environments. The physiological basis for this change in ecological succession from forest to bog is discussed in relation to the long‐term effects of flooding on tree survival. The heightened values currently detected in the North Atlantic Oscillation Index, together with rising winter temperatures, and increased rainfall in many areas in northern Europe, presents an increasing risk of paludification with adverse consequences for forest regeneration, particularly in areas with oceanic climates. Climatic warming in oceanic areas may increase the area covered by bogs and, contrary to general expectations, lead to a retreat rather than an advance in the northern limit of the boreal forest. High water‐table levels are not automatically detrimental to forest survival as can be seen in swamp, bottomland and mangrove forests. Consequently, the inhibitory effects of flooding on tree survival and regeneration in northern regions should not be uncritically accepted as merely due to high water levels. Evidence is discussed which suggests that physiological and ecological factors may interact to inhibit forest regeneration in habitats where there is a risk of prolonged winter‐flooding combined with warmer winters and cool moist summers. PMID:12509342

76 FR 55345 - Northern New Mexico Resource Advisory Committee

Federal Register 2010, 2011, 2012, 2013, 2014

2011-09-07

... DEPARTMENT OF AGRICULTURE Forest Service Northern New Mexico Resource Advisory Committee AGENCY: Forest Service, USDA. ACTION: Notice of meeting. SUMMARY: The Northern New Mexico Resource Advisory Committee (NNM RAC) will meet in Albuquerque, New Mexico. The committee is authorized under the Secure Rural...

76 FR 29722 - Northern New Mexico Resource Advisory Committee

Federal Register 2010, 2011, 2012, 2013, 2014

2011-05-23

... DEPARTMENT OF AGRICULTURE Forest Service Northern New Mexico Resource Advisory Committee AGENCY: Forest Service, USDA. ACTION: Notice of meeting. SUMMARY: The Northern New Mexico Resource Advisory Committee (NNMRAC) will meet in Albuquerque, New Mexico. The committee is authorized under the Secure Rural...

77 FR 48949 - Northern New Mexico Resource Advisory Committee

Federal Register 2010, 2011, 2012, 2013, 2014

2012-08-15

... DEPARTMENT OF AGRICULTURE Forest Service Northern New Mexico Resource Advisory Committee AGENCY: Forest Service, USDA. ACTION: Notice of meeting. SUMMARY: The Northern New Mexico Resource Advisory Committee (NNM RAC) will meet in Albuquerque, New Mexico. The committee is authorized under the Secure Rural...

Developing a topographic model to predict the northern hardwood forest type within Carolina northern flying squirrel (Glaucomys sabrinus coloratus) recovery areas of the southern Appalachians

USGS Publications Warehouse

Evans, Andrew; Odom, Richard H.; Resler, Lynn M.; Ford, W. Mark; Prisley, Stephen

2014-01-01

The northern hardwood forest type is an important habitat component for the endangered Carolina northern flying squirrel (CNFS; Glaucomys sabrinus coloratus) for den sites and corridor habitats between boreo-montane conifer patches foraging areas. Our study related terrain data to presence of northern hardwood forest type in the recovery areas of CNFS in the southern Appalachian Mountains of western North Carolina, eastern Tennessee, and southwestern Virginia. We recorded overstory species composition and terrain variables at 338 points, to construct a robust, spatially predictive model. Terrain variables analyzed included elevation, aspect, slope gradient, site curvature, and topographic exposure. We used an information-theoretic approach to assess seven models based on associations noted in existing literature as well as an inclusive global model. Our results indicate that, on a regional scale, elevation, aspect, and topographic exposure index (TEI) are significant predictors of the presence of the northern hardwood forest type in the southern Appalachians. Our elevation + TEI model was the best approximating model (the lowest AICc score) for predicting northern hardwood forest type correctly classifying approximately 78% of our sample points. We then used these data to create region-wide predictive maps of the distribution of the northern hardwood forest type within CNFS recovery areas.

64. Photocopy of drawing (from print, Burlington Northern Engineering Office, ...

Library of Congress Historic Buildings Survey, Historic Engineering Record, Historic Landscapes Survey

64. Photocopy of drawing (from print, Burlington Northern Engineering Office, Seattle) STRESS SHEET - Burlington Northern Railroad Bridge, Spanning Willamette River at River Mile 6.9, Portland, Multnomah County, OR

The Maritime Cultural Landscape of Northern Patagonia

NASA Astrophysics Data System (ADS)

Lira, Nicolás

2017-12-01

This article is a contribution to the study of the indigenous navigation and its boats in the region of northern Patagonia. This article also aims to contribute to the understanding of indigenous navigation practices and technologies and their origins from prehistoric times to the mid-twentieth century. It presents and discusses the concept of Westerdahl's Maritime Cultural Landscape in relation to other landscape concepts. This model is applied to northern Patagonia in order to discuss if it is possible to speak of a true maritime culture in the region. For this purpose, archaeological, historical and ethnographic data are presented in an integrative and innovative methodology for the discipline. Finally, the Maritime Cultural Landscape model will allow the integration of aquatic and terrestrial landscapes as routes traveled by native inhabitants of northern Patagonia and southern Chile, and propose an important and diversified maritime, river and lake tradition.

Study protocol: The back pain outcomes using longitudinal data (BOLD) registry

PubMed Central

2012-01-01

Background Back pain is one of the most important causes of functional limitation, disability, and utilization of health care resources for adults of all ages, but especially among older adults. Despite the high prevalence of back pain in this population, important questions remain unanswered regarding the comparative effectiveness of commonly used diagnostic tests and treatments in the elderly. The overall goal of the Back pain Outcomes using Longitudinal Data (BOLD) project is to establish a rich, sustainable registry to describe the natural history and evaluate prospectively the effectiveness, safety, and cost-effectiveness of interventions for patients 65 and older with back pain. Methods/design BOLD is enrolling 5,000 patients ≥ 65 years old who present to a primary care physician with a new episode of back pain. We are recruiting study participants from three integrated health systems (Kaiser-Permanente Northern California, Henry Ford Health System in Detroit and Harvard Vanguard Medical Associates/ Harvard Pilgrim Health Care in Boston). Registry patients complete validated, standardized measures of pain, back pain-related disability, and health-related quality of life at enrollment and 3, 6 and 12 months later. We also have available for analysis the clinical and administrative data in the participating health systems’ electronic medical records. Using registry data, we will conduct an observational cohort study of early imaging compared to no early imaging among patients with new episodes of back pain. The aims are to: 1) identify predictors of early imaging and; 2) compare pain, functional outcomes, diagnostic testing and treatment utilization of patients who receive early imaging versus patients who do not receive early imaging. In terms of predictors, we will examine patient factors as well as physician factors. Discussion By establishing the BOLD registry, we are creating a resource that contains patient-reported outcome measures as well as

PS2-5: Prevalence of Migraine in a Diverse Community – Electronic Methods for Migraine Ascertainment in a Large Integrated Health Plan

PubMed Central

Pressman, Alice; Jacobson, Alice; Avins, Andy

2013-01-01

Background/Aims Migraine, a common neurological disorder, is among the top 20 causes of disability worldwide. One-year prevalence of migraine in the US is estimated to range from 8–15%, with women affected at approximately three times the rate of men. Current methods for migraine ascertainment from headache clinics and surveys are costly, affected by clinic-ascertainment bias, and do not work in situations where patient contact is not feasible. With the growing use of electronic medical records (EMR), new methods must be developed for identifying and tracking migraine prevalence over time. We sought to develop an EMR algorithm, to identify migraine, and to characterize its prevalence in Kaiser Permanente Northern California (KPNC). Methods From EMRs of all KPNC members, we collected all outpatient migraine diagnoses (ICD9 code 346.xx) and migraine-specific prescriptions (ergots, triptans, and acetaminophen with caffeine) for 2006–2010. We chart-reviewed a random sample to develop an electronic Migraine Probability Algorithm (score 0–100). We tested the algorithm in a second independent chart review. Using membership data, we calculated prevalences by age, race, and gender. Results We identified 313,174 KPNC members with evidence of migraine - 233,620 women and 79,554 men. The 5-year period-prevalence of migraine among KPNC adults was 17.1% for women and 5.9% for men. Among children, rates did not differ by gender (<2%) until the age of 10, when prevalences were higher - 5.8% for girls and 3.5% for boys. For women, prevalence peaked at ages 25–29. In contrast, males experienced flat prevalence with age (range 5%–6%). Overall, Whites had higher prevalence than Asians, but Blacks did not differ appreciably. Conclusions We used EMR data to capture migraine diagnoses and show prevalence patterns similar to those reported in the literature. Prevalence of diagnosed migraine in KPNC was 2.5–3 times higher in women than men; migraine peaked with age in women

Is Migraine a Risk Factor for Pediatric Stroke?

PubMed Central

Gelfand, Amy A.; Fullerton, Heather J.; Jacobson, Alice; Sidney, Stephen; Goadsby, Peter J.; Kurth, Tobias; Pressman, Alice

2015-01-01

Importance Our understanding of risk factors for childhood stroke is incomplete. In adults, migraine with aura is associated with a two-fold increase in ischemic stroke risk. Objective In this cohort study we examine the association between migraine and stroke among children in Kaiser Permanente Northern California (KPNC). Design, Setting, and Participants Children ages 2-17 years who were members of KPNC for ≥6 months between1997-2007 were included. Migraine cohort members had one or more of: an ICD-9 code for migraine, migraine listed as a significant health problem, or a prescription for a migraine-specific medication. The comparison group was children with no evidence of headache. Main outcome measures stroke incidence rates and incidence rate ratios (IR). Results Among the 1,566,952 children within KPNC during the study period, 88,164 had migraine, and 1,323,142 had no evidence of headache. Eight migraineurs had a stroke (3 [38%] hemorrhagic; 5 [63%]ischemic). Eighty strokes occurred in children without headache, (53 [66%]hemorrhagic;27 [34%] ischemic). The ischemic stroke incidence rate was 0.9/100,000 person-years in migraineurs vs. 0.4/100,000 person-years in those without headache; IR 2.0 (95% CI 0.8-5.2). A post-hoc analysis of adolescents (12-17 years) showed an increased risk of ischemic stroke among those with migraine; IR 3.4(95% CI 1.2-9.5). The hemorrhagic stroke incidence rate was 0.5/100,000 person-years in migraineurs and 0.9/100,000 person-years in those without headache; IR 0.6 (95% CI 0.2-2.0). Conclusions There was no statistically significant increase in hemorrhagic or ischemic stroke risk in pediatric migraineurs in this cohort study. A post-hoc analysis found that ischemic stroke risk was significantly elevated in adolescents with migraine. Future studies should focus on identifying risk factors for ischemic stroke among adolescent migraineurs. Based on adult data, we recommend that migraine aura status should be studied as a possible

Changes in Nutrition Policies and Dietary Intake in Child Care Homes Participating in Healthy Eating and Active Living Initiative.

PubMed

Woodward-Lopez, Gail; Kao, Janice; Kuo, Elena S; James, Paula; Lenhart, Kitty; Becker, Christina; Boyle, Kathryn; Williamson, Dana; Rauzon, Suzanne

2018-05-01

consumed adequate, but not excessive, portions of the balanced meals served to them, suggesting there is no reason to offer unhealthy options. This article is part of a supplement entitled Building Thriving Communities Through Comprehensive Community Health Initiatives, which is sponsored by Kaiser Permanente, Community Health. Copyright © 2018 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.

Role of Insurance Coverage in Contraceptive Use After Abortion.

PubMed

Biggs, M Antonia; Taylor, Diana; Upadhyay, Ushma D

2017-12-01

To assess postaspiration abortion contraceptive use and the role of insurance coverage for abortion in a state that covers abortion and contraception for low-income women. This is a secondary analysis of a previously published prospective study to assess the safety of abortion provision. From 2007 through 2013, women seeking first-trimester aspiration abortion were recruited at 25 clinical facilities within four Planned Parenthood affiliates and Kaiser Permanente of Northern California. Patients' medical charts were reviewed to assess the contraceptive methods received on the day of the abortion. A 4-week follow-up survey assessed contraceptive use and contraceptive-related incidents. Primary outcomes included leaving with any method on the day of the abortion and use of any method at the 4-week assessment. Secondary outcomes included intrauterine device or implant use on the day of the procedure and at 4 weeks and switching to a less effective method at 4 weeks. A total of 19,673 women agreed to participate, and 13,904 (71%) completed the 4-week follow-up survey. Ninety-four percent (18,486/19,673) left their abortion visit with a contraceptive method: 21% (4,111/19,673) with an intrauterine device, implant, or permanent method. By the 4-week survey, 8% (1,135/13,904) switched from a high- or medium-efficacy method to a low-efficacy or no method; 0.4% (60/13,904) experienced a contraceptive incident. In adjusted regression analyses, women who paid for the abortion with Medicaid were significantly more likely to use any method (adjusted odds ratio [OR] 3.70, 95% CI 3.09-4.42) or an intrauterine device or implant (adjusted OR 2.14, 95% CI 1.92-2.38) on the day of the abortion than those who did not pay with insurance. Experiencing a contraceptive-related incident was associated with switching to a low-efficacy or no method by the 4-week survey (adjusted OR 3.98, 95% CI 2.20-7.22). Insurance coverage for abortion is associated with postabortion contraceptive