A Focus on KP HealthConnect
••Fall 2004/Vol. 8, No. 4

Letters to the Editor

From Our Readers ... | pdf >>

Dear Journal Staff;

I read with interest your article by Dr Hayek and Ms Beatty in the Winter 2004 Journal (Human Embryonic Stem Cells and Type 1 Diabetes: How Far to the Clinic? Perm J 2004 Winter;8(1):11-4). However, although the article was titled "Human Embryonic Stem Cells ...," I am still puzzled that there is not a single nod of recognition of the successful use of adult and umbilical cord blood stem cells (this latter being an intermediate category of stem cells between adult and embryonic) in several areas of medicine. This seems to be the trend in everything I read in the mainstream media concerning stem cells. But this trend would indicate to me either 1) sloppiness/laziness in rigor for literature research, or 2) an ideological taint or slanting of the articles chosen for publication, neither of which is appropriate for scholarly publications.

Keith L Griffin, MSN, PhD
Brea, CA

--Reply

The article was an update on human embryonic stem cells and not a discussion of adult stem cells. There has been one article in the scientific literature showing, in mice, that bone-marrow-derived stem cells generate a few cells in the pancreas that produce insulin with the tags that indicate origin in the donor cell. Two more recent articles have been unable to reproduce those results. Concerning umbilical stem cells, we have not seen any paper showing that such conversion is possible either in mice or humans. Most reports of differentiation of adult stem cells into other organs appear to be due to cellular fusion. For a wonderful review of this subject, please see: Wagers AJ and Weissman I, Cell 116:639, 2004.

Alberto Hayek, MD, and Gillian Beattie, BSc
La Jolla, CA

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Mr Stewart,

I recently read with great interest your article on narrative medicine and advocacy journalism (Perm J 2004 Spring;8(2):80-1). My own experience in practice bears out the validity of your article. About 20 years ago, I read an interesting fictional book about midwives written by a certified nurse midwife. In it she described using a positional method for conducting the labor of a patient with a direct OP presentation. This kind of labor is not only very painful but increases the risk of operative or assisted delivery. Her method was very simple--place the patient in knee-chest position. This adds a centimeter to the pelvic outlet, decreases the pain, and affords the fetal head a better chance of rotating to an anterior presentation, thus increasing the chances of a less painful and spontaneous delivery.

Several days after reading this information, I was assisting with the labor of a patient who had this problem. After consulting with her physician, we tried the maneuver with great success--two pushes and an easy, spontaneous delivery. Since then, I have used this information many times with the same success, including with my own daughter. She was able to progress to 5 cm at home, had a spontaneous ROM as soon as she reached the hospital, and with the assistance of a well-timed epidural was fully dilated just two hours later. After two more hours of pushing (not bad for a primip), she had a wonderful NSVD of a beautiful baby girl.

Such evidence-based narratives are of great use to us in the health care professions if we only look at them for their basis in scientific fact and then try them! Thanks for a great article.

Mary Lou Shookhoff,
TLC Case Manager, Mid-Atlantic

--Reply

Thanks for your wonderful letter. Your own story is a great example of narrative medicine.

Jon Stewart
Communications Editor
Communications Practice Leader,
Government Relations and Health Policy
Oakland, CA

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Dear Dr Felitti,

I recently read your article in The Permanente Journal entitled "Hemochromatosis Update" (2004 Winter;8(1):39-44). I found this article very informative and interesting.

I am an Internal Medicine nurse at the KP center at City Plaza in Baltimore, Maryland. We are treating one patient with hemochromatosis who will be coming to the office tomorrow for therapeutic phlebotomy.

I would like to inquire as to the possibility of acquiring a copy of the video that you provide for patients and any other patient-education materials that are available.

Margaret Cannoles, RN
Baltimore, MD

--Reply

I'm glad you found the article helpful. Yes, I'll send you a copy of that video. Here in San Diego, having screened several hundred thousand adults for iron overload, we have many hundreds of patients in the phlebotomy program. The cost of once-in-a-lifetime screening, if properly set up, is more than offset by the value of the derived blood. The last time I checked, about 40% of all blood transfused at KFH San Diego came from our phlebotomy program.

You may feel free to copy the video for further distribution. Bulk reproduction costs should be <$4 a copy. DVD would be even less. Sending patients a copy of the video before they come in for consultation radically changes the nature of that meeting from a feeble attempt at complex information transfer with a frightened patient to a meaningful discussion of the implications of the diagnosis with a knowledgeable person.

Vincent J Felitti, MD, Book Review Editor
Kaiser Permanente Medical Care Program
San Diego, CA

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To the Editors:

In the article on Bariatric Surgery (2004 Sum;8(3):10-13) you state, "The standard measurement to define obesity is the body mass index (BMI), calculated as the weight in kilograms divided by the height in square meters." Height is a one-dimensional attribute. The sentence should read "The standard measurement to define obesity is the body mass index (BMI), calculated as the weight in kilograms divided by the height in METERS SQUARED.

Paul Dieter, MD
Pasadena, CA

Dear Dr Felitti,

I was sitting on a bench while my son was playing a jazz tune for his trombone audition, and it gave me the chance to catch up on some reading. It provided the perfect background for your TPJ article on hemochromatosis. Your article is one of the best things I have ever read about the complex interplay of genes, environment, what it means, and how to think about it. Thank you. I love the example of the two sisters. And you are exactly right--it provides an excellent model for thinking about other conditions.

When I was a med student (in the UCB-UCSF) program, I was an assistant on MC King's research on familial breast cancer (ultimately her group identified the BrCA gene, I believe), and I visited cohorts of Mormon families (collecting blood samples) and later did a project in health policy that had to do with screening for sickle cell. I was impressed by how challenging it is to think about these issues, talk about them, develop policy, and communicate with families and patients.

Your article is a tour de force!

Brigid McCaw, MD, MS, MPH
Clinical Lead, Family Violence Prevention Services
Oakland, CA

To the Editorial Staff of The Permanente Journal:

I received my copy of the Summer 2004 issue and was simply shocked to see the photograph that was chosen for the cover.

The picture depicts pampas grass in full bloom.

For the uninformed: this is one of the most invasive, introduced, nonnative plants that is ravaging the western coast of the US. It is a plant, native to Argentina, that was introduced as an ornamental plant in the US many years ago, before it escaped and its seriously invasive nature was recognized. It is not only very invasive but is also very hard to eradicate.

As a 25-year resident of the gorgeous coast of Northern California, I have witnessed the gradual replacement of our native coastal flora by the amazing uncontrolled growth of pampas grass. As you drive from San Francisco to Carmel, the cliffs along Highway 1 are now literally covered by this pest plant.

There is very little state funding to deal with this serious ecological problem. Local efforts exist in many coastal communities, but they are unable to make a significant dent.

I consider that using that image was a serious mistake for an organization like TPMG. Perhaps the remedy could involve in-depth coverage of this problem and getting TPMG and HP employees involved in the local eradication of this pest.

And with the next issue, please don't include a photo of a cigarette butt.

Maurice Franco, MD
Hayward Medical Center,
Hayward, CA

--Reply

Dr Franco,

The Staff of The Permanente Journal (which is produced and published by The Permanente Federation of all Permanente Medical Groups, not by TPMG) can claim some expertise in distinguishing an exceptional photograph from the run-of-the-mill, but we acknowledge our lack of expertise in terms of the flora and fauna of California--or any other state, most of which have some invasive plant. In short, most of us can't tell a weed from a wildflower, an invasive from a native, or an exotic from a neurotic. A little research in the book "Invasive Plants of California's Wildlands" (UC Press, 2000) bears out the writer's exhortations about Argentine Pampas Grass, which seems to be every bit as nasty, aggressive, and voracious as claimed. We urge anyone concerned about such threats to biodiversity to join any of a number of worthy organizations fighting to reverse the invasions, such as the California Native Plant Society in that state. As for us, we offer our apologies--not for printing a beautiful photograph, but for our inability to tell one blade of grass from another.

Jon Stewart
Communications Editor
Communications Practice Leader,
Government Relations and Health Policy, Oakland, CA

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Dear Dr Felitti,

I am preparing to submit an application for a workshop for the International Critical Incident Stress Foundation's Eighth World Congress on the subject of Helping Children Touched By Trauma. I read an article in The Permanente Journal entitled, The Relation Between Adverse Childhood Experiences and Adult Health: Turning Gold into Lead (Perm J 2002 Winter;6(1):44-7). I would like your permission to reprint the article as a handout for the workshop.

Nancy E Crump, MS
Director of Family Care Services
Kansas City, MO

--Reply

I'm sure that will be fine, as long as you credit the Journal. I'll send you text of an article I published in Germany that relates addiction to adverse childhood experiences. Lastly, the ACE Study Web site at www.acestudy.org might be of interest to your audience; it contains a full bibliography of the 30 Study-derived publications.

Vincent J Felitti, MD, Book Review Editor
Kaiser Permanente Medical Care Program
San Diego, CA

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Hello,

I read your article entitled Thrive in TPJ (Perm J 2004 Summer;8(3):2) about KP's new "Thrive" Campaign. I think the campaign is a step in the right direction for KP, and I wish the company the best success with it. I have seen the billboards throughout my home area (San Francisco Bay Area), and I think the billboards/posters are really cool.

Good luck to Kaiser Permanente with the new campaign.

T Williams
San Francisco, CA

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