CONTACTS
0201 - Kaiser Permanente
020101 - Dr. Craig M. Boulris, M.D.; Orthopedic Surgeon
020102 - Orthopedic Department
SUBJECTS
Medical, Kaiser
Exam 990910 Knee Treatments
Decisions Shared
Questions, Suggestions
Report Omits Medical History, New Therapies
0807 -
0807 - ..
0808 - Summary/Objective
0809 -
080901 - Follow up ref SDS 77 0000, ref SDS 76 0000.
080902 -
080903 - Craig submitted an excellent report that helps formulate treatment
080904 - plans under Kaiser's partnership procedure. Email can help avoid
080905 - delay in submitting medical history that hampered review. Need
080906 - clarification on using Glucosamine.
080907 -
080908 - [On 990927 requested clarifications. ref SDS 78 0001]
080910 - ..
080911 - [On 990928 Craig received the letter. ref SDS 79 0001]
080913 - ..
080914 - [On 991008 submitted request for response. ref SDS 81 0001]
080916 - ..
080917 - [On 991011 received response from Craig. ref SDS 82 0001]
080918 -
080919 -
080921 - ..
0810 -
0811 -
0812 - Progress
081301 - ..
081302 - Report Clarifies Issues, Need Review of Med History, New Treatments
081303 -
081304 - Received report, ref DRT 1 0001, from Craig for the meeting on 990910,
081305 - ref SDS 68 0001, per request. ref SDS 68 3555
081306 -
081307 - The report does not cite the letter, ref DIP 1 0001, prepared on
081308 - 990913, ref SDS 71 7728, which explains understandings from the
081309 - meeting on 990910. ref SDS 68 0001 This occurred because it was not
081310 - forwarded until 990916, ref SDS 74 0001, and Craig's letter was
081311 - evidently dictated three days earlier, on 990913, even though it was
081312 - not transcribed until 990921, ref DRT 1 3420, and received on 990925.
081314 - ..
081315 - These are coordination issues discussed on 990915. ref SDS 73 0001
081317 - ..
081318 - Once communications with Kaiser are mobilized we should be able to get
081319 - everyone in sync with partnership goals reviewed on 990625.
081320 - ref SDS 43 4185 Email can improve this record that required 15 days
081321 - to deliver mail a distance of 2 miles.
081323 - ..
081324 - As a result of Craig not receiving the letter on 990913...
081325 -
081326 - 1. The report does not cite medical history reported on 990625.
081327 - ref SDS 43 5152, requested in a letter to Craig on 990913.
081328 - ref DIP 1 4224
081329 -
081330 - This reflects practice reported on 990910. ref SDS 68 9130
081331 - Medical history is not a life and death issue in this case,
081332 - however, it is always good management to review background.
081334 - ..
081335 - Medical history should be cited, or else explain why not in
081336 - this case. It should not require life and death issues to
081337 - take a look at the record. ref SDS 43 5152
081339 - ..
081340 - [On 991011 Craig says he reviewed the record. ref SDS 82 2303]
081342 - ..
081343 - 2. The report does not review all eight (8) of the treatments
081344 - submitted for consideration, which was a goal of the
081345 - examination 990910, cited in patient history on 990625.
081346 - ref SDS 43 5400
081348 - ..
081349 - The report relates possible use of injectables which include
081350 - cortisone, hydriodic acid, Synvisc. The pros and cons of
081351 - these were all discussed with the patient. ref DRT 1 3955
081353 - ..
081354 - Need review of all eight (8) published remedies brought
081355 - forward by the patient for comment. ref OF 3
081357 - ..
081358 - [On 991011 Craig says he reviewed the article, but does not comment
081359 - on all of the therapies because they are not all relevant.
081360 - ref SDS 82 2304]
081361 -
081363 - ..
081364 - Left Knee Has Greater Wear, Why is Pain in Right Knee Comparable?
081365 -
081366 - The left knee is reviewed in detail. ref DRT 1 2376
081367 -
081368 - Doctor Boulris says in particular...
081369 -
081370 - His radiographs show mild to moderate arthritis of the left
081371 - knee with diminution of the medial joint space in particular
081372 - with some calcification in the meniscal area. There are some
081373 - early osteophytes which are formed on the femoral condyles.
081374 - ref DRT 1 TK4G
081376 - ..
081377 - This aligns with understandings from the meeting on 990910, after
081378 - getting an xray. Craig and I looked at the xray film together, and it
081379 - seemed to show the joint space narrower on the inside of the left
081380 - knee, where calcification and osteophytes occur that give the
081381 - impression the upper femoral bone is now extending into the space
081382 - where cartilage was removed in the 1974 knee surgery. ref SDS 68 OE68
081383 -
081385 - ..
081386 - The right knee has less explanation. ref DRT 1 0720
081388 - ..
081389 - The report does not recognize that pain in the right knee is currently
081390 - as severe as the left, shown on 990910. ref SDS 68 1224
081392 - ..
081393 - Graphics prepared during the meeting to analyse conditions that can
081394 - account for comparable pain in both knees, are not included nor cited
081395 - in the report. ref SDS 68 7872
081396 -
081397 - Need professional opinion on comparable knee pain.
081398 -
081399 - Failure to review comparable experience in both knees which have
081400 - evident different physical states, may overlook a common cause
081401 - that is not evident, but requires inquiry.
081403 - ..
081404 - If not, say we don't have a good explanation at this time.
081406 - ..
081407 - [On 991011 craig responded, essentially saying the cause of pain in
081408 - the right knee is unknown. ref SDS 82 3088]
081409 -
081410 -
081411 -
0815 -
SUBJECTS
Synvisc Injection Therapy
Cortisone
1204 -
120501 - ..
120502 - Cortisone, Synvisc Possible Treatment Options
120503 -
120504 - The report recommends using cortisone and Synvisc. ref DRT 1 3955
120505 -
120506 - a. Cortisone was explained on 990910 as pain relief that does
120507 - not treat deterioration causing pain. ref SDS 68 5394
120509 - ..
120510 - Initial goal is to treat deterioration, not pain, per se.
120511 -
120512 - [On 990927 notified Craig of plan to avoid using
120513 - cortisone, and try initially glucosamine. ref SDS 78 0001]
120515 - ..
120516 - [On 991011 Craig says he uses cortisone and it is the
120517 - standard of care nationally. ref SDS 82 3955]
120519 - ..
120520 - b. The record on 990910 shows that Synvisc was expressly
120521 - not recommended. ref SDS 68 7802
120523 - ..
120524 - Further review may have adjusted the original opinion, and in
120525 - that case it would be helpful to report information that
120526 - supports this change.
120528 - ..
120529 - Were colleagues consulted, other experts?
120531 - ..
120532 - Did Craig see the report on Synvisc, ref OF 4 5672, submitted
120533 - on 990731? ref SDS 56 0001
120535 - ..
120536 - Is the record on 990910 incorrect? ref SDS 68 7802 If so,
120537 - say that.
120538 -
120539 - [On 991011 Craig confirmed recommendation to use Synvisc
120540 - (which is Hyaluronic Acid injection treatment).
120541 - ref SDS 82 3942]
120543 - ..
120544 - c. Synvisc in a series of three injections is proposed, after
120545 - use of cortisone. ref DRT 1 3955
120547 - ..
120548 - Injectables are discussed in a general way.
120550 - ..
120551 - Need to review application relative to Kaiser's experience,
120552 - and report by vendor, ref OF 4 5678, reviewed on 990719,
120553 - ref SDS 53 4628, and submitted to Kaiser on 990731.
120554 - ref SDS 56 0001
120555 -
120556 - [On 990927 requested response to these action items.
120557 - ref SDS 78 0001]
120559 - ..
120560 - [On 990928 notified Kathy that her submission of Synvisc
120561 - on 990719, has been favorably reviewed. ref SDS 80 0001]
120563 - ..
120564 - [On 991011 Craig does not address issue, merely says
120565 - success of Synvisc has not been as high as he would like.
120566 - ref SDS 82 3942]
120568 - ..
120569 - [On 991125 notified Steve about Synvisc. ref SDS 85 7654]
120570 -
120571 -
120572 -
120573 -
120574 -
1206 -
SUBJECTS
Glucosamine Chronditrin
Glucosamine Chondoten Recommended for Arthritis in Knee by Doctor Bou
1604 -
160501 - ..
160502 - Glucosamine May Improve Osteoarthritis, Need Prescribed Usage
160503 -
160504 - Glucosamine is the medication that may slow or reverse loss of
160505 - cartilage, ref DRT 1 5200, commonly called osteoarthritis.
160506 -
160507 - It has been combined with Chondroitin sulfate, and efficacy of
160508 - Chondroitin sulfate is somewhat more questionable
160509 -
160510 - This is the preferred initial effort to reduce ware and replace
160511 - cartilage, discussed on 990910. ref SDS 68 5628
160513 - ..
160514 - Need a clearer prescription on dosage?
160516 - ..
160517 - Reporting that efficacy is questionable does not really disclose
160518 - whether to use both, or not. From recollection Craig seemed to
160519 - indicate on 990910 that Glucosamine should be taken by itself,
160520 - but the record is unclear, ref SDS 68 5628, so an express
160521 - recommendation should be made by the doctor.
160522 -
160523 - [On 990927 requested more specific prescription for using
160524 - Glucosamine and Chrondriton. ref SDS 78 0001]
160526 - ..
160527 - [On 991011 research on the web indicates that Chontroitin
160528 - with Glucosamine repairs cartilage. ref SDS 82 5933]
160530 - ..
160531 - [On 991026 Don Harms, tennis friend, reports good results
160532 - using Glucosamine with Chondroitin for 6 months. ref SDS 84
160533 - 3392]
160535 - ..
160536 - [On 991125 notified Steve about this research. ref SDS 85
160537 - 0001]
160539 - ..
160540 - [On 000121 Jeanne Bradley at Kaiser submitted guidance on
160541 - dosage. ref SDS 86 1680
160543 - ..
160544 - [On 030807 case study shows personal history using liquid
160545 - Glucosamine Chondroiten and clincial research. ref SDS 87
160546 - FN9N
160548 - ..
160549 - [On 040529 0248 report that Glucosamine Chondroitin in liquid
160550 - form relieved knee pain from hiking 3 - 10 miles per day.
160551 - ref SDS 88 MN9P
160553 - ..
160554 - [On 050421 received inquiry on the Internet about working
160555 - with Doctor Boulris at kaiser, ref SDS 89 EU5I, reported good
160556 - results solving knee pain with Glucosamine Chondroitin.
160557 - ref SDS 89 5A7W
160559 - ..
160560 - [On 090306 0800 NIH of Complementary and Alternative Medicine
160561 - (CAM) study found Glucosamine Chondroiten not effective for
160562 - mild osteoarthritis (OA), further found this treatment
160563 - provides significant relief for patients suffering severe
160564 - knee pain. ref SDS 90 8Q8G
160566 - ..
160567 - Possibly instructions come with purchasing the medication;
160568 - however, typically doctors prescribe dosage, for how long, and
160569 - indicate conditions to monitor for adjusting continued use.
160571 - ..
160572 - Any side effects to anticipate and take precautions to minimize?
160574 - ..
160575 - Is the dosage the same for humans as for dogs and horses, noted
160576 - on 990910? ref SDS 68 5628 Are these applications marketed
160577 - separately, so this is not an issue?
160579 - ..
160580 - Is there a reason to defer treatment until after cortisone and
160581 - Synvisc, which seem to have a higher priority in the report?
160583 - ..
160584 - Is medication taken concurrent with activity like tennis that
160585 - stresses the target area, or, should such activity be avoided
160586 - for a period to permit recovery of cartilage to occur?
160588 - ..
160589 - Is there a web site to review?
160590 -
160591 -
160592 -
1606 -
SUBJECTS
Premedicate
Motrin, Tylenol
Neoprene Brace
1805 -
180601 - ..
180602 - Avoid Swelling - Medicate Prior to Activity; Use Neoprene Brace
180603 -
180604 - The report recommends Tylenol medication prior to activity so
180605 - that swelling is reduced. ref DRT 1 4088
180606 -
180607 - On 990910 Motrin also avoids swelling. ref SDS 68 7161
180609 - ..
180610 - Craig explained during the meeting why it is helpful to prevent
180611 - swelling, when the goal is to prevent damage to the knee that
180612 - causes swelling. However, I do not remember the answer, and it
180613 - would be helpful to understand it. ref SDS 68 6808
180615 - ..
180616 - The report does not cover this point.
180618 - ..
180619 - If he has time, he might confirm the reasoning on why swelling
180620 - needs to be avoided. ref SDS 0 4524
180621 -
180622 - [On 990927 requested clarification of this point.
180623 - ref SDS 78 0001]
180624 -
180625 - [On 991011 Craig says Tylonol for pain relief is the standard
180626 - of care nationally. He does not explain why it is useful to
180627 - prevent swelling. ref SDS 82 3955]
180628 -
180630 - ..
180631 - Craig mentions wearing a neoprene knee brace to keep the knee warm,
180632 - ref DRT 1 4088, which was discussed on 990910, but not included in
180633 - the record due to oversight, i.e., a mistake.
180634 -
180635 - Getting a report fixed a mistake, which is the purpose of
180636 - "reporting," explained in POIMS. ref OF 5 2300
180638 - ..
180639 - I have used this type of brace, and gave it up because there was
180640 - no evident impact, in that it did not seem to relieve pain. I
180641 - actually had a period of a few years with no pain in either knee,
180642 - so that may have led to abandoning this procedure.
180644 - ..
180645 - I am not sure why keeping the knee warm is helpful. Is it that a
180646 - cold condition is brittle and so is subject to greater injury
180647 - during activity? That is a normal warm up issue, so maybe we are
180648 - enhancing normal warm up because of greater exposure than normal.
180650 - ..
180651 - [On 991011 Craig says neoprene brace keeps knee warm but does not
180652 - explain why this is useful. ref SDS 82 9588]
180653 -
180654 -
180655 -
180656 -
1807 -
SUBJECTS
Debridement, Arthroscopic
Knee Replacement
2004 -
200501 - ..
200502 - Knee Replacement Strong Possibility in Future
200503 - Debridement Interim Alternative to Knee Replacement
200504 -
200505 - The report reviews potential requirement for knee replacement in 10
200506 - years, ref DRT 1 3844, as shown in the record on 990910. ref SDS 68
200507 - 9733
200509 - ..
200510 - The report relates discussion on the possibility of a debridement of
200511 - the knee arthroscopically to try to temporize the need for a total
200512 - knee replacement. ref DRT 1 5200
200513 -
200514 - I do not recall this discussion on 990910, so this is another
200515 - correction and clarification of the record.
200517 - ..
200518 - This appears to be the arthroscopic surgery work performed on
200519 - 881011, which is part of the medical history reported on 990625.
200520 - ref SDS 43 5152 Possibly Craig had a chance to review the record,
200521 - per work on 990915, ref SDS 73 4524, and this prompted inclusion
200522 - in the report.
200524 - ..
200525 - The prior work on 881011 was performed because I got to the point
200526 - that I could not walk. There was constant pain in the left knee,
200527 - as reported on 880922. ref SDS 1 3299 Following the operation,
200528 - Jim reported finding torn material in the knee, ref SDS 2 6800,
200529 - which may have accounted for severe pain.
200531 - ..
200532 - That is not the condition now. Want to work toward avoiding it
200533 - through cartilage repalcement therapies, such as Synvisc and
200534 - Glucosamine, reviewed in Craig's report, or any of the other 8
200535 - remedies submitted for review, per request 2, above. ref SDS 0
200536 - 6734
200537 -
200538 -
200539 -
200540 -
200541 -
200542 -
200543 -
200544 -
2006 -
Distribution. . . . See "CONTACTS"