ACMS October 2024 Bulletin by alleghenycountyms

BULLETIN

Opinion

Editorial

• Giants

Deval (Reshma) Paranjpe, MD, MBA, FACS

Editorial

• Advocacy

Richard H. Daffner, MD, FACR

Editorial

• Goldilocks & Attention Deficit Hyperactivity Disorder

Robert H. Howland, MD

Society News

ACMS News

• ACMS Distinguished Award Winner Profiles

ACMS News

• Self-Care in Healthcare Campaign Wrap-Up

ACMS News

• Paint and Sip October 2024

ACMS News

• Specialty Group Updates ACMS Staff: Nadine Popovich and Melanie Mayer

Articles

Article

• We Speak Now of Doctors...and Poets

Michael G. Lamb, MD

Article

• ACMS: A Place Where You Belong Kirsten D. Lin, MD

Article

• Where Smiles Have Been Richard Hoffmaster, MD

Cover Photo by Mark E. Thompson, MD Mark E. Thompson, MD specializes in Cardiology Luray Caverns, Virginia

2024

Executive Committee and Board of Directors

President

Raymond E. Pontzer, MD

President-elect

Keith T. Kanel, MD

Secretary

Kirsten D. Lin, MD

Treasurer

William F. Coppula, MD

Board Chair

Matthew B. Straka, MD

Directors

Term Expires 2024

Douglas F. Clough, MD

David J. Deitrick, DO

Jan B. Madison, MD

Raymond J. Pan, MD

G. Alan Yeasted, MD, FACP

Term Expires 2025

Anuradha Anand, MD

Amber Elway, DO

Mark A. Goodman, MD

Elizabeth Ungerman, MD, MS

Alexander Yu, MD

Term Expires 2026

Michael M. Aziz, MD, MPH, FACOG

Michael W. Best, MD

Richard B. Hoffmaster, MD

Micah A. Jacobs, MD, FIDSA

Jody Leonardo, MD

PAMED District Trustee

G. Alan Yeasted, MD, FACP

2024 Board Committees

Bylaws

Kirsten D. Lin, MD

Finance

William Coppula, MD Nominating

Keith T. Kanel, MD

Women’s Committee

Prerna Mewawalla, MD & Meilin Young, MD

Bulletin

Managing Editor

Sara C. Hussey, MBA, CAE ACMS Executive Director shussey@acms.org

Medical Editor

Deval (Reshma) Paranjpe, MD reshma_paranjpe@hotmail.com

Bulletin Designer

Victoria Gricks victoria@thecorcorancollective.com

Term Ending 2024

Richard Daffner, MD; Anthony Kovatch, MD; Andrea Witlin, DO, PhD

Term Ending 2025

Robert Howland, MD; John Williams, MD; Alexandra Johnston, DO; Charles Mount, MD

Administrative Staff

Executive Director Sara Hussey shussey@acms.org

Vice President - Member and Association Services Nadine M. Popovich npopovich@acms.org

Manager - Member and Association Services Position is Vacant

Operations CoordinatorACMS & ACMS Foundation Melanie Mayer mmayer@acms.org

Part-Time Controller Elizabeth Yurkovich eyurkovich@acms.org

Bulletin Designer Victoria Gricks victoria@thecorcorancollective.com

EDITORIAL/ADVERTISING

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Giants

By:

Deval (Reshma) Paranjpe, MD, MBA, FACS

We are so lucky in so many ways to live in Pittsburgh. We live in the best of all possible worlds, as Voltaire’s Candide might say. In Pittsburgh, we are sheltered by the hills and are mostly free from the terrifying tornadoes of the flat Midwest with its lonely plains. Our hills surround us like warm hugs, green and woody and comforting as we look out on them from the city; purple and blue and charcoal in the outlying towns as they are silhouetted against the peachy sunsets. So many of us run back to these hills for protection from the wide open spaces of the rest of the nation. Pittsburgh is our refuge. We are safe from earthquakes, at least so far. Safe from floods, save for the low-lying areas by the rivers during hurricanes and spring snow melts. The terrible flood we had so many years ago, the Johnstown Flood, was manmade. Nature bears us no ill will. We are safe from the hurricanes which plague Florida, and from the tsunamis that threaten the Pacific Rim.

Our town is wet enough to avoid the forest fires that plague California, and dry enough to avoid their mudslides too. We are among the cloudiest cities in the country, but never as bad as Seattle or Portland on the West Coast. Our hills shield us from the wind, and from the dust, and from the storms. We have picturesque mists in our valleys, clouds that descend to kiss the earth good morning in the cool of the dawn.

Little wonder that Native Americans chose to settle here, or that the French and the British followed and fought over this area. Natural beauty, protection and strategic importance are still to be found at the confluence of two mighty

rivers which found a third. Oil paintings from centuries ago show the delicate trees which still grace our landscapes; we may not be able to name them all, but anyone who has grown up here will instinctively recognize a Western Pennsylvania landscape on a canvas or in a photograph, in spite of themselves. Pittsburgh has been the center of many medical firsts whose impact still ripples through communities. I know senior citizens in our local communities who still recall quite clearly how their desperate and grateful parents had them line up for Jonas Salk’s initial polio vaccine tests as children. Thomas Starzl of UPMC and his team notably pioneered organ transplantation as well as the anti-rejection drugs that allow long term transplant survival here. George Magovern Sr. pioneered the first sutureless heart valve as well as performing among the very first heart and lung transplants, inventing the BioPump and Tandem Heart (extracorporeal cardiac assist devices), and establishing a world-class cardiothoracic program. Allegheny General Hospital also had the first accredited trauma program in the region, the first trauma ICU in the state, and the first aeromedical service in the Northeast with the LifeFlight medical helicopter service which continues today.

We stand on the shoulders of giants, or perhaps these days peer out from behind their skirts. Our region’s medical accomplishments are stuff of legend. Our responsibility now is to live up to that legacy. Like the hills of Western Pennsylvania which protect and comfort us, our legacy should allow us

to learn in safety and strive to excel. The health care atmosphere in our region today is focused so much on cost containment, meeting benchmarks and Press-Ganey expectations, and making RVUs. Both sides of the river are continually trying to fill beds and find nurses. Where is the passionate spark, the drive for excellence, the wish to change the world for the better through medical innovation—not just excellence through AI generated cost savings or shareholder satisfaction or corporate earnings? How are our great health care institutions seeking to excel on the world stage and invent revolutionary services for humanity? What would Starzl and Magovern in their prime have candidly thought of this situation? Many of you knew them, worked alongside them or studied under them, and are innovators in your own right-- and might be able to answer that question very well.

My wish for and challenge to young physicians is that they take advantage of this great city and its great history and institutions—and strive to change our world for the better through passion, research and innovation. The world needs more giants, and Pittsburgh should continue to be an incubator like no other.

“All politics is local.”

Advocacy

By: Richard H. Daffner, MD, FACR

-- Byron Price, 1932 (often attributed to Tip O’Neill, who used the phrase in his first campaign for Congress in 1935)

The future of medicine as a healing art rests on two pillars: 1). Qualified practitioners and 2). Strong leadership. The first pillar relies on our medical schools and residency programs to produce physicians who are skilled in using state-of-the-art techniques in their chosen specialty fields. The second pillar relies on young leaders stepping up to become advocates for their profession and most importantly, for their patients.

Political advocacy is one of the main functions of our professional societies, The American Medical Association (AMA) is generally thought of as the main spokesperson for physicians. However, conflict over changes in Medicare reimbursement, which initially favored primary care specialties (Internal Medicine, Family Practice) over other specialties in the mid 1980’s led to significant defections of specialists, who were also represented by their own specialty societies such as the American College of Surgeons and the American College of Radiology. During this time, I became active in the ACR, serving as chair of several committees of the Pennsylvania Radiological Society (PRS) (Pennsylvania’s ACR chapter) and eventually as a Councilor to the national body. I was also a Councilor for the Society of Skeletal Radiology and an inaugural member and eventually chairperson of the ACR Expert Panel on Appropriateness for Musculoskeletal Disorders.

While still a resident, I began attending annual meetings of the American Roentgen Ray Society (ARRS) and the Radiological Society of North America (RSNA). The leaders of these societies (and the subspecialty societies to which I also belonged) were all from the academic world – department chairs, and a “Who’s Who” of names frequently seen in the literature. All were older men. When I attended my first ACR meeting, I was surprised by whom the leaders were. While there were some well-known academicians in leadership positions, most of the leaders (again, older men) were from private practice. The ACR represents all of radiology – academics and private practice, and functions to establish practice standards, provide education, manage economic issues, and serves as the political arm for the profession. Further, the goals of the ACR were not only academic excellence but were also patient advocacy (“The right study, performed for the right reasons, performed the right way”), and political advocacy.

The ACR recognized the need to begin bringing in some “young blood” to prepare them to become future leaders in the profession. In the early 1990’s they formed the Resident’s and Fellow’s Section (RFS) to allow younger people to share their concerns with the College’s Council. Several years ago I wrote about an issue that the RFS brought up for a vote in the Council1. The young people were concerned that the job market was tight at that time and introduced a resolution asking the College to use its influence to limit the number of residency

positions with the goal of improving the prospects for employment. Historically, resolutions introduced by the RFS were adopted and became College policy. Furthermore, opposition to resolutions proposed by the RFS was viewed by the membership as akin to spitting on the flag. When the resolution was brought to the floor of the Council for discussion, I went to the microphone and said, “Mr. Speaker, I speak against the resolution.” This was followed by a large chorus of boos. After the Speaker restored order, I presented my reasons for opposing the resolution, citing the fact that in our own residency program, we were facing a dramatic decrease in applications. The system was correcting itself. Several other academicians from large and small programs spoke, supporting what I had said and mentioning their own experiences in a decline in residency applications. They, too, agreed that the system was correcting itself and felt the resolution should be defeated. As a result, the Council voted the resolution down, and I truly believe we made the right decision1

Other professional societies have recognized the need to bring younger people aboard and train them to be future leaders. Advocacy should begin early in the training of new physicians. Medical school curricula should include non-scientific topics that include the economics and politics of medicine.

The American Board of Radiology now includes questions on these subjects on their certifying exams.

Political advocacy may be achieved in several ways. Many years ago, at the annual meeting of the ACR, their

Washington lobbyist illustrated who gets the attention of our elected officials and how it occurs. He started out showing a triangle representing the entire population of the United States. At that time 50% of the population were under the age of eighteen years and were ineligible to vote. The triangle lost half of its size. Then he said that 45% of the remaining population didn’t vote and the triangle got smaller still. Finally, he said that only 1% of the remaining population contributed to political campaigns or worked on the campaign staffs of their local representatives. “So,” he said, “Whom do you think the politicians listen to?” Furthermore, he said that a contribution of as little as $100 (at that time) was enough to get

access to the ear of a politician. Medical students and residents should think about political advocacy for medicine early in their careers. Some young people are already politically savvy. A good example is the young man who recently graduated from my alma mater, Albany College of Pharmacy and Health Sciences with his Doctor of Pharmacy degree. He was President of the Student Senate for two years, where one of his duties was to give a report to the Board of Trustees (of which I am a member) at their two meetings each year. The Board was so impressed with his maturity and honesty that they recommended he be considered in the future for a trustee position.

Medical societies should also be actively seeking younger members by encouraging local medical students and residents to join, perhaps at a reduced rate in the annual dues. Membership in ACMS is also tied to membership in the Pennsylvania Medical Society with an optional tie-in to the AMA. Yes, all politics is local, and advocacy should begin at the local level.

References:

1. Daffner RH. A voice of one. ACMS Bulletin November 2019, pp 374 – 375

Dr.Daffner is a retired radiologist.

Jodie A. Bryk, MD

Nathaniel Bedford Primary Care Award

Dr. Bryk, although a Cleveland native, has built her medical career in Pittsburgh. She attended the University of Pittsburgh School of Medicine and then Internal Medicine Residency at the University of Pittsburgh, completing her Chief Residency in 2013. Following her Chief Residency, she completed a combined fellowship in General Internal Medicine through the University of Pittsburgh Division of General and Public Service Psychiatry through Western Psychiatric Institute in 2014.

Since then, in partnership with UPMC Health Plan and the UPMC Division of General Internal Medicine, she built the UPMC Enhanced Care Program in 2014.

Thuy D. Bui, MD

Richard E. Deitrick Humanity in Medicine Award

Thuy D. Bui, MD, is the director of the Global Health-Underserved Populations track of the internal medicine residency program at UPMC and the Social Medicine Fellowship Program at the University of Pittsburgh School of Medicine (UPSOM). She serves as the Social Medicine Thread Lead for the Three Rivers Curriculum at UPSOM. She is responsible for several curricular initiatives related to social determinants of health (SDH), including the SDH Fast Facts, home and neighborhood visits, structural racism and upstream quality improvement. She was a Peace Corps volunteer and medical specialist at Kamuzu Central Hospital in Malawi from 1995-1997, and has since continued to teach and mentor Malawian students and residents. She first came to Pittsburgh in 1997 working for Primary Care Health Services, Inc. in their Alma Illery Medical Center office in Homewood. She has served on the leadership team of the Birmingham Free Clinic to provide healthcare for uninsured patients and immigrants since 1999. She is committed to supporting harm reduction and street medicine initiatives in SW PA.

Julie W. Childers, MD, FAAHPM, FASAM

Richard E. Deitrick Humanity in

Medicine Award

Julie Childers graduated from the University of Pittsburgh School of Medicine in 2005 and completed her internal medicine residency at the University of Rochester. She returned to Pittsburgh for fellowship training in palliative care in 2009 and obtained a master’s degree in medical education in 2010. She began treating opioid use disorder in 2010, and in 2018 became board certified in Addiction Medicine. She is currently a Professor of Medicine in the Division of General Internal Medicine at the University of Pittsburgh. She attends on both the Palliative Care Consult Service and the Addiction Medicine Consult Service at UPMC Presbyterian Hospital. Her outpatient practice is focused on substance use disorders, including a special program for individuals with palliative care needs.

Familylinks

Benjamin Rush Community Award

Familylinks is one of the Pittsburgh area’s largest, most comprehensive, and most respected human service providers. The agency has served Western Pennsylvania for more than 65 years, bringing vital support services to the most vulnerable members of our community. Familylinks was formed in 2001, through the merger of two organizations: The Whale’s Tale (est. 1970) and Parent & Child Guidance Center (est. 1956). As a result, Familylinks provides a vast array of services for individuals and families in the areas of mental health, substance use, prevention, service coordination, emergency shelter, supportive housing, senior care, and more. Annually, Familylinks serves more than 11,000 individuals throughout 24 counties across Pennsylvania.

Robert W. Mendicino, DPM, FACFAS

Benjamin Rush Individual Award

Dr. Mendicino has over 30 years of experience in the medical and surgical treatment of the foot, ankle and lower leg. He has published over 150 peer reviewed articles on a variety of topics ranging from clubfoot management, limb deformity assessment and ankle reconstruction or replacement. He has patents in computerized orthopedic surgery and has assisted in the development of a wound assessment and protocol program used in hundreds of wound centers across the country. Dr. Mendicino has trained over 100 residents and fellows, many of whome have gone on to academic positions at universities and hospital health systems. During his career, he has held numerous appointments and positions including: Vice Chair of the Department of Surgery at West Penn Hospital; Professor of Surgery at Temple University School of Medicine; Director of Education and Residency Training at West Penn Hospital and Grant Medical Center; Secretary of the Board of Trustees, Rosalind Franklin University/Scholl College of Podiatric Medicine and President, The American College of Foot and Ankle Surgeons.

Darrell J. Triulzi, MD

Ralph C. Wilde Leadership Award

Dr. Triulzi is a Professor of Pathology at the University of Pittsburgh School of Medicine and Director of the Division of Transfusion Medicine in the Department of Pathology. He also serves and Medical Director of Vitalant Clinical Services, Northeast Division. Dr. Triulzi completed a 6 year biomedical program at Rensselaer Polytechnic Institute and Albany Medical College and went on to complete an internship in Internal Medicine at University of Pittsburgh. He then went to Rochester, NY where he completed residency training in pathology and laboratory medicine followed by a fellowship in Transfusion Medicine/Blood Banking at the Johns Hopkins Hospital. He joined the faculty as an Assistant Professor of Pathology at the University of Pittsburgh in 1991. Since then, in partnership with Vitalant, he gradually built the region’s first integrated hospital transfusion service now encompassing 24 hospitals, including the UPMC and AHN networks.

Bruce A. MacLeod, MD

ACMS Spirit of Service Award

Dr. Bruce A. MacLeod, MD, FACEP, is a highly experienced emergency medicine specialist based in Pittsburgh, PA, with over 35 years in the field. He completed his medical degree at the University of Cincinnati College of Medicine in 1987. Dr. MacLeod serves patients at AHN Brentwood Neighborhood Hospital and has been involved with the Allegheny County Medical Society (ACMS) since 1987. His extensive leadership roles include serving on the ACMS Board of Directors, as well as holding numerous positions within the Pennsylvania Medical Society (PAMED), where he was President in 2014. Dr. MacLeod’s expertise extends beyond clinical care, as he has contributed significantly to healthcare policy and governance. He has served on multiple ACMS committees, including the Peer Review Board and Finance Committee, and has been actively involved with PAMED as a trustee and delegate. In addition, Dr. MacLeod is recognized for his work in emergency care, consistently managing a wide range of acute and chronic conditions in high-demand settings.

Where Smiles Have Been

By: Richard Hoffmaster, MD

The long, vibrant days of summer settled into the calm stillness of autumn, and Healthy Aging Month surreptitiously came and went. As a geriatrician, I’m loath to admit to my patients that I was clueless about the occasion, which I might otherwise have celebrated every September since Congress passed a resolution marking the observance month in 2021. It’s a small consolation, at least, that around that time I was invited to share my perspectives on healthy aging on the podcast Good Health, Better World. (My session will be released 11/12/24, and at that time will also be available on Spotify, Apple Podcasts, Pandora, and other podcast services. Check out www.upmchealthplan.com/goodhealth-better-world/season-4 to listen!)

During my time as a guest speaker, I had the pleasure of chatting with my colleagues about what it means to experience whole-person wellness as we age gracefully. It was a topic that I was eager to discuss, as an opportunity to flex my expertise in the field of elder care. I was caught off-guard, however, when our conversation quickly and naturally drifted away from the clinical pearls that often form my counsel for patients and their families. Rather than deliberating on DEXA scans and gait speed, I found myself wading into the more philosophical waters of my patients’ outlooks and connections

“None are so old as those who have outlived enthusiasm.” —Henry David Thoreau

A recurring theme that popped up in our conversation on healthy aging was that of purpose. The reason you get up in the morning, which they call

“ikigai” in Okinawa, Japan, and “plan de vida” in Nikoya, Costa Rica. These two communities were identified by the Blue Zones project1 as being home to some of the longest-living populations in the world. Full disclosure: I’m quite skeptical about the demographics of supercentenarians (Saul Justin Newman makes a fairly compelling argument that many people reportedly aged over 100 years are actually either already dead and/or committing pension fraud2). Regardless, research consistently suggests that being active, having hobbies, and maintaining strong social connections leads to improved quality of life and overall health, including physical and cognitive function.3,4,5 Specifically, loneliness in older adults is linked to higher rates of dementia, cardiovascular and lung disease, and ultimately depression, the latter being well-associated with cognitive and physical debility.6,7,8,9

All of that is not to say that we shouldn’t be thinking about the clinical aspects of living well. It’s long been clear that a healthy lifestyle is critically important, not only in preventing disease as we age, but also in maintaining quality of life. As diligent physicians, we will continue to pester our patients about the robust literature showing that smoking cessation adds years to their lives.10 We will wag our fingers at them for not exercising regularly to reduce their risk of metabolic disorders and cardiovascular disease.11 I suppose that it’s possible that you were the very first doctor to scold your patient for their unhealthy choices over the past many decades of their life. It’s more probable, however,

that you’ll instead face an eyeroll and polite nodding.

“In the end, it's not the years in your life that count. It's the life in your years.” —Abraham Lincoln

In my experience, it’s not very likely that you’ll scare your average patient with the threat of missing out on living to 100. If we’re aiming to truly motivate our patients to change their lifestyle and live healthfully, we need to focus on what matters most to them. Older adults tend to view health-related goals within a broad variety of contexts that include physical well-being and longevity, as well as socialization, life experience, legacy, and physical and cognitive independence.12 As we learn what our older patients value, we might point out that quitting smoking and exercising regularly will reduce their risk of developing dementia, and lessen the danger of falling, both of which may extend the time in which they can continue to live at home independently.13,14 We can encourage our patients to teach their grandchildren how to cook a heart-healthy and dementia-resistant dinner,13 passing down family recipes composed of fresh vegetables, poultry, seafood, nuts and olive oil. They might also trade stories with their family over a glass of red wine. Research suggests that sharing a meal with others is linked to being happier, more content with life, and more engaged in your community.15

“Growing old is mandatory. Growing up is optional.” —Walt Disney

Ultimately, the key to being healthy is to live well. The National Healthy Aging® Campaign reinforces that “the focus [of healthy aging] is on passion for life

rather than the perils and diseases of adulthood.”16 There are as many paths to wellness as there are stories, told by our patients, as we guide them through life. To preserve health is to strive for joy, by being active, physically, mentally and socially. As Mark Twain quipped: “wrinkles should merely indicate where smiles have been.”

10 TIPS FOR HEALTHY AGING®

Move More, Sit Less. Get 150 minutes of moderate-intensity physical activity per week and two days of musclestrengthening training.

Get Motivated with free websites and apps like AllTrails to find parks and trails around you, American Heart Association with ideas on how to join a walking club, or the CDC with ideas for individuals with a disability.

Get Those Annual Check-Ups. Make this the time to set up your annual physical and other health screenings. Volunteer. Being of service is an excellent way to bring happiness into your life and not focus on yourself. United Way, the American Red Cross, VolunteerMatch, and AmeriCorps are all helpful resources.

Beat Back Loneliness. Don’t wait for the phone to ring. Be proactive and call someone for a lunch date. Try to mix up your get-togethers with old friends and new acquaintances.

Rekindle or Follow a New Passion. Take a hard look at what you like to do rather than what other people tell you to do to meet new people. Pick some activities where you might meet new friends.

Get a Dog. If you don’t have one, get one and walk. You will be amazed how many people you will meet through your dog. Can’t have one? Check your local humane society to see if they need dog walkers.

Be Realistic About What You Can Accomplish. Learn to say no, and don’t overwhelm yourself with a to-do list. The non-profit Mental Health America offers more tips for reducing or controlling stress.

Plan for What’s Next. Capitalize on your career experience and start a new one. Yes, enjoy a brief “retirement.” Travel, and spend more time with family and friends. Develop new hobbies. Redefining your purpose to maintain a sense of identity and purpose is essential to a healthy lifestyle.

Adapted with permission from the National Healthy Aging® Campaign16

References:

1. https://www.bluezones.com/

2. Newman, SJ. The global pattern of centenarians highlights deep problems in demography. Preprint, 2024.

3. Hughes TF, Chang CC, Vander Bilt J, Ganguli M. Engagement in reading and hobbies and risk of incident dementia: the MoVIES project. Am J Alzheimers Dis Other Demen. 2010 Aug;25(5).

4. Noice T, Noice H, Kramer AF. Participatory arts for older adults: a review of benefits and challenges. Gerontologist. 2014 Oct;54(5).

5. Cornwell B, Laumann EO. The health benefits of network growth: new evidence from a national survey of older adults. Soc Sci Med. 2015 Jan;125.

6. Hu J, Fitzgerald SM, Owen AJ, Ryan J, Joyce J, Chowdhury E, Reid CM, Britt C, Woods RL, McNeil JJ, Freak-Poli R. Social isolation, social support, loneliness and cardiovascular disease risk factors: A cross-sectional study among older adults. Int J Geriatr Psychiatry. 2021 Nov;36(11).

7. Kobayashi LC, Steptoe A. Social Isolation, Loneliness, and Health Behaviors at Older Ages: Longitudinal Cohort Study. Ann Behav Med. 2018 May 31;52(7).

8. Donovan NJ, Wu Q, Rentz DM, Sperling RA, Marshall GA, Glymour MM. Loneliness, depression and cognitive function in older U.S. adults. Int J Geriatr Psychiatry. 2017 May;32(5).

9. Carney RM, Freedland KE. Depression and coronary heart disease. Nat Rev Cardiol. 2017 Mar;14(3).

10. Cho ER, Brill IK, Gram IT, Brown PE, Jha P. Smoking Cessation and Shortand Longer-Term Mortality. NEJM Evid

2024;3(3).

11. Blair SN, Kampert JB, Kohl HW 3rd, Barlow CE, Macera CA, Paffenbarger RS Jr, Gibbons LW. Influences of cardiorespiratory fitness and other precursors on cardiovascular disease and all-cause mortality in men and women. JAMA 1996; 276.

12. Burton, E., Chonody, J., Teater, B. et al. Goal setting in later life: an international comparison of older adults’ defined goals. BMC Geriatr 2024;24(443).

13. Dhana K, Evans DA, Rajan KB, Bennett DA, Morris MC. Healthy lifestyle and the risk of Alzheimer dementia: Findings from 2 longitudinal studies. Neurology. 2020 Jul 28;95(4).

14. Sun M, Min L, Xu N, Huang L, Li X. The Effect of Exercise Intervention on Reducing the Fall Risk in Older Adults: A Meta-Analysis of Randomized Controlled Trials. Int J Environ Res Public Health. 2021 Nov 29;18(23).

15. Dunbar, RIM. Breaking Bread: the Functions of Social Eating. Adaptive Human Behavior and Physiology 3, 2017.

16. https://healthyaging.net/healthyaging-month/september-is-healthyaging-month-2024

Dr. Rick Hoffmaster is a family physician, geriatrician, palliative care specialist, and educator whose career has focused on helping guide patients of all ages in creating healthy and joyful lives, with a focus on effective communication around health-related values and goals.

Goldilocks & Attention Deficit Hyperactivity Disorder

By: Robert H. Howland, MD

In 1798, Alexander Crichton published a three-volume book on the nature and origin of mental derangement. In a chapter “On Attention, and its Diseases”, Crichton describes a disorder with “the incapacity of attending with a necessary degree of constancy to any object”. He further states: “It may be either born with a person, or it may be the effect of accidental diseases”, and “When born with a person it becomes evident at a very early period of life, and has a very bad effect, inasmuch as it renders him incapable of attending with constancy to any one object of education”.

In 1932, Franz Kramer and Hans Pollnow published their paper ‘‘On a hyperkinetic disease of infancy’’, in which they describe a marked motor restlessness in affected children. Five years later, Charles Bradley published a report describing a positive effect of the stimulant drug Benzedrine in children with various behavior disorders. Benzedrine had been first marketed in the 1930s as an overthe-counter inhaler to treat nasal congestion.

With the 1968 publication of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the diagnostic category “Hyperkinetic Reaction of Childhood” was introduced. The revised third edition of the DSM in 1987 described what we now call attention deficit hyperactivity disorder (ADHD). Subsequent DSM editions revised and significantly broadened the definition of ADHD.

As the diagnostic criteria for ADHD evolved over the decades, diagnosis rates of ADHD in children, adolescents

and adults have grown. A controversial and vigorously debated issue is whether the true prevalence of ADHD is being underestimated or overestimated, or is, as Goldilocks might say, “just right”. Because treatment naturally follows from diagnosis, a corollary concern therefore is whether ADHD is being overtreated, undertreated, or treated “just right”.

ADHD has been diagnosed routinely in children and adolescents for many decades. A 2021 systematic review of 334 studies documented consistently increasing rates of ADHD diagnosis between 1989 and 2017. Additionally, there were substantial increases in pharmacological treatment for ADHD between 1971 and 2018. The authors of this review operationally defined overdiagnosis as occurring when a person is clinically diagnosed with a condition, but the net effect of diagnosis is unfavorable. They found evidence of overdiagnosis and subsequent overtreatment of ADHD in children and adolescents.

Whether ADHD is overdiagnosed and overtreated in adults has not been scrutinized to the same degree as in children and adolescents. Substantially more than half of youths with ADHD continue to have clinical symptoms into adulthood, but it appears that adults without clear evidence of childhood onset are being increasingly diagnosed with ADHD. One recent study found that ADHD diagnoses among adults had grown four times faster than among children during a 10-year period (20072016). In this analysis, the prevalence of ADHD increased by only 26% among children compared with the 123%

increase observed in adults.

An obvious concern with overdiagnosis is overtreatment. In a prescription culture, increased rates of diagnoses necessarily result in increases in drug therapies. An analysis of trends in office-based treatment of adults with stimulants in the United States reported a 6-fold increase from 1994 to 2009 in the proportion of psychiatrist visits in which stimulants were prescribed. Curiously, an even greater 8-fold increase in stimulant prescription visits was documented among non-psychiatrist physicians.

In the United Kingdom, a prescription database analysis found that the prevalence of ADHD drug prescriptions increased more than 4-fold among adults from 2003 to 2008. More than 90% of these prescriptions were for stimulant drugs.

When stimulant prescription data from the Massachusetts Prescription Drug Monitoring Program were analyzed from 2011 to 2021, stimulant prescriptions were found to increase by 70% during that era. The increase was substantially greater among adults than among children and adolescents. Surprisingly, the highest percentage change was found in adults older than 64 years, who showed a tremendous 175% change.

An analysis of 2018-2022 data from a commercial database (the National Prescription Audit) examined trends in prescriptions for five classes of psychotropic medications: antidepressants, benzodiazepines, stimulants, nonstimulant ADHD drugs, and buprenorphine-containing medications for opioid use disorder.

Trends for antidepressants, benzodiazepines, and buprenorphine did not significantly change from 2018 to 2022. However, stimulant prescriptions among adults increased by 30%, whereas nonstimulant ADHD drug prescriptions increased by 81%. The greatest increases in prescriptions were seen with nurse practitioner prescribers: 57% increase in stimulant drugs and 74% increase in nonstimulant drugs. By contrast, stimulant prescribing by non-psychiatrist physicians increased 10%, but decreased 1% with psychiatrist prescribers. Nonstimulant prescriptions from psychiatrists rose 12%, compared to an increase of 27% from non-psychiatrist physicians.

The two broad categories of FDAapproved medications for ADHD are stimulant drugs and non-stimulant drugs. Stimulant medications include various formulations of methylphenidate-based and amphetamine-based drugs. Nonstimulant medications include Atomoxetine, Viloxazine, Guanfacine, and Clonidine. Certain drugs are sometimes prescribed off-label for ADHD, including Bupropion, tricyclic antidepressants (such as Nortriptyline), Venlafaxine, Duloxetine, and Modafinil.

Historically and contemporaneously, the most common prescribed medications for ADHD are stimulant drugs. Overtreatment with stimulant drugs is not without short-term and long-term risks. Certain risks might be considered relatively minor and manageable: Increased anxiety, insomnia, appetite suppression and modest weight loss. Motor and vocal tics can be triggered or exacerbated although it should be noted that ADHD commonly co-occurs with tic disorders. Stimulant drugs are prone to tolerance, dependence, misuse/abuse, and diversion.

Potentially more serious side effects are possible with stimulant drugs. A recently published casecontrol study of individuals 16-35 years old hospitalized for mania or

psychosis found that the odds of psychosis and mania were increased for individuals with recent prescription amphetamine use but not with recent methylphenidate use. A positive dose-response relationship was observed, such that higher doses of amphetamines was associated with a 5-fold increase in the odds of psychosis or mania.

A case-control study in Sweden with a longitudinal follow-up of 14 years found that long-term use of simulant and non-stimulant ADHD medications among individuals 6-64 years old was associated with an increased risk of cardiovascular disease, especially hypertension and arterial disease. The risk was higher for stimulant medications.

Childhood onset is required for the diagnosis of ADHD, but this criterion may not be present or easily confirmed in adults. Attention and concentration are core cognitive functions that can be affected by various brain disorders or factors acting on the brain. Recalling what Crichton said about the incapacity

of attending with a necessary degree of constancy may be the effect of accidental diseases, it is relevant to note that attention and concentration are adversely affected in anxiety, depressive and other mood disorders, with substance use disorders, with the use of concurrent prescription and over-the-counter drugs, and when various other factors are present in adults. As a result, attention deficit in adults may be mistakenly attributed to ADHD.

Given the absence of established objective biomarkers for diagnosing ADHD, a comprehensive assessment in adults should include review of multiple and collateral sources of information, detailed clinical interviews, childhood documentation, and neuropsychological testing. Self-report measures and screening questionnaires that rely on simple symptom checklists are not diagnostically valid. Comprehensive assessments may be time consuming but will be more likely to result in a “just right” outcome for patients.

We Speak Now of Doctors… and Poets

By: Michael G. Lamb, MD

The Long Road by the Hospital (in lieu of WCW MD) That long avenue, trees line it on both sides. Here and there, a few flower pots are coldly dwarfed. How many times did we walk that road?

Sleep deprived cliches from last year's TV shows, walking the long white halls, wearing the short white coats. We discuss our cases. But we were far removed from the diseases of that day. Out this high window, I see the same long road. Here and there cars are parked. They look like small toys. And the roads end is obscured. And so I ask again, how many times did we walk that road?

Bill was a highly competent nurse who essentially ran the small ER at the Oakland Veterans hospital. “Good luck with this one doc, probably septic”. It was said with more than a hint of sarcasm. He handed me the chart and pointed to a young man lying on a gurney in the corner. He was a 28-yearold alcoholic with cirrhosis who had fallen down the basement steps of his dilapidated home and fractured his hip. He lay there three days before his mom found him. His eyes and skin were a glowing fluorescent yellow. The fellow was poorly clothed and covered from head to toe with feces and urine. A deep pressure ulcer that was oozing foul smelling pus lay over his hip fracture. Maggots were crawling in and out of the wound. He was having rigors and as his arms and legs shook, fragments of fecal

matter fell to the floor. The stench was terrible.

I tried to summon up as much courtesy and professionalism as possible and introduced myself. He barely glanced at me and replied, “just call me dirtbag”. The combination of the reply and the atmosphere was suffocating. Briefly I had to excuse myself and collect my thoughts. As was often the case, I recalled that I must imagine that this man was a member of my family, a brother, a favorite uncle, or a close cousin. I was trying hard to do that when I remembered THE POEM. It was a few lines from EE Cummings “A Man Who Had Fallen Among Thieves”; “ Brushing from whom the stiffened puke, I put him in my arms, and staggered, banged with terror through a million billion trillion stars.” I looked over to Bill and said, “First thing let's clean him up completely and quickly, new sheets, new hospital gown, underwear, everything.” We did that and then focused our attention on the seemingly hopeless and daunting challenge of saving his life. A fierce aura of determination and composure rose within me. THE POEM had definitely helped.

My love of poetry began in 7th grade with Mr. Roger Babusci, an extraordinary English Literature teacher. In 1982, the year I completed my Internal Medicine residency, Mr. Babusci was honored as the “Pennsylvania Teacher of the Year”. He also became an editor of several English Literature textbooks. It was he who first introduced me to the works of EE Cummings, Robert Frost, TS Eliot, Edward Arlington Robinson, and

William Carlos Williams. It was he who pointed out that Williams was also a pediatrician. In relation to my patient in the VA emergency room, Dr. William Carlos Williams once wrote “there is nothing like a difficult patient to show us ourselves” (1). There are many other poet/writers of note who either briefly studied medicine or became practicing physicians, including John Keats, Oliver Wendell Holmes, Anton Chekov, Somerset Maughan, John Stone, Rafael Campo, and the University of Pittsburgh’s own internist/ poet, Dr. Jack Coulehan.

Jack Coulehan, MD

Internal medicine icon Sir William Osler, although not a poet, was very literary and was at least somewhat influenced by Walt Whitman, the poet, who was his patient. This relationship is described well in Philip Leon’s book “Walt Whitman and Sir William Osler, A Poet and His Physician”. Osler advised medical students “that nothing will sustain you more potently than the power to recognize in your hum drum routine the poetry of the commonplace, of the ordinary man, of the plain toil

worn woman, with their loves and their joys, their sorrows and their griefs” (2). One can imagine that Whitman’s rejoinder would be from his poem, “Song of Myself”. “Behold, I do not give you lectures or a little charity, when I give, I give myself”.

Clearly, medicine and poetry deal with big issues, suffering, death, illness, health, living and loving, the how and the why. Internist/Cardiologist John Stone grasped this and used his poetry as part of the healing process and as a cornerstone of his teaching. Stone won many accolades for his superb clinical skills. He was equally honored for his poetry. He, like many physician poets, realized that his art made him a better physician. Medicine is one of the “health sciences” but it is also one of the “healing arts”. A poet is a keen observer of the human condition. Perhaps, that is why I use William’s imagist poem “The Red Wheelbarrow” in the teaching of physical diagnosis. Leaders in medical education around the country have realized that poetic insights benefit doctors, patients and their families. It's a worthy field of study. Most medical schools now sustain medical humanities programs. That's a good trend and easily justified. Doctor John Stone put it this way: “ there will be the arts and some will call these soft data, whereas in fact they are the hard data by which our lives are lived. For everyone comes to the arts too late” (3).

A man who didn't come upon poetry too late was Dr Jack Coulehan. Jack was born in Pittsburgh and obtained both his medical degree and MPH from the University of Pittsburgh. Doctor Coulehan became a national leader in the medical humanities and was acknowledged by many as America's premier physician poet. He has written at least six books of poetry. My own focus on poetry was solidified by Dr. Jack Coulehan. As a medical student I was briefly his patient. During my internship he was our clinic preceptor. I wrote to him a few times regarding his poetry and the life of a physician/ poet. I last saw him five years ago at a

Pitt medical alumni reunion (my 40th, his 50th). In an article dealing with the “Joy of Medicine” Jack wrote about the symbiotic relationship between the arts and medical science. “When I say medicine needs poetry I am speaking of certain moments of insight and awareness. I am not suggesting that all physicians should write or even read poetry. Rather I am saying that we need to pay attention to those “aha” moments that sustain us and make us better healers if we respond appropriately”(4).

The young man in the Veteran's Hospital ER represented one of those “aha” moments. I learned his real name and much about his past. He was indeed septic, but he also had portal hypertension, hepatic encephalopathy, a hip abscess, and meningitis. Despite all of these problems and a terrible prognosis, our team was able to save his life, heal his fracture, and cure his infections. I felt that we had established a good rapport, but socioeconomic problems and years of bad habits are difficult to change. He followed up in my clinic several times and then never returned despite being urged otherwise. Two years later, he was readmitted in critical condition and died of liver failure. But at least for a few weeks, I had held him tightly in my arms amid a maze of stars firing a dark night. (5)

References:

1. Porter, Joel, “Where Does it Hurt? An Explanation of the Impact of William Carlos Williams’ Vocation on His Avocation”; http://writing, colostate.edu.

2. Osler, William, “The Student Life, The Collected Essays of William Osler Volume II, The Educational Essays, Classics of Medicine Library, Gryphon Editions Ltd. Birmingham, Alabama 1985 pg. 423.

3. Smith, Jay, W. M.D., Editorial, John Stone M.D., Am. J. Med, Oct. 2009 Vol 122 Issue 10, pages 888-889.

4. Coulehan, Jack M.D., “Astonished Harvest, The Joy of Medicine”, The Pharos/Autumn 2017.

5. Iniesta, Ivan MD, The Iatroversalia (Doctor Poems) of William Carlos Williams, Clin. Med. 2012 Feb 12(1): 92-93.

ACMS: A Place Where You Belong

By: Kirsten D. Lin, MD — ACMS Board Secretary

In the classic TV sitcom Cheers, the theme song famously says, "Sometimes you want to go where everybody knows your name." This simple yet powerful line speaks to a universal human desire: the need for connection, belonging, and recognition. In today’s fast-paced and ever-evolving medical field, physicians are increasingly experiencing feelings of isolation and burnout. More than ever, having a strong, supportive professional community can provide much-needed support. For physicians, the Allegheny County Medical Society (ACMS) offers just such a place—a community where you matter, and where you can connect with others who understand your experiences, challenges, and goals. Just like the bar in Cheers, ACMS is a space where everybody knows your name, and that sense of belonging brings numerous personal and professional benefits.

Why the Sense of Mattering is Critical Psychologists have long studied the human need to feel that we are significant, valued, and have an impact on the world around us. This concept, known as "mattering," is a core part of our psychological well-being. When individuals feel that they matter to others, they experience higher levels of self-esteem, lower levels of depression, and an overall greater sense of satisfaction in life. In a high-stress field like healthcare, where burnout and feelings of isolation can be common, fostering a sense of mattering within a professional community can be transformative.

According to researchers, mattering has three key dimensions:

1. Attention: Feeling that others

notice us and are aware of our presence.

2. Importance: Believing that others care about us and value what we bring to the table.

3. Dependence: Knowing that others rely on us and that we have a meaningful role in their lives. For physicians, these aspects of mattering are not only relevant in patient care but also within their professional networks. The ACMS offers a platform where physicians can feel noticed, valued, and integral to the larger medical community.

Belonging to a Professional Community

Joining ACMS is about more than just accessing tangible benefits— though these are abundant, as we'll discuss below. It’s about being part of a professional family. Being a physician can sometimes feel isolating, especially with the demanding schedules and emotional toll that often accompany the job. But when you belong to a group like ACMS, you are not navigating the complexities of the medical profession alone. You are part of a greater collective of physicians who understand your experiences and challenges. This sense of belonging can ease feelings of isolation and strengthen your connection to your profession.

Belonging is a core psychological need, as shown in numerous studies. People who feel a strong sense of belonging are more likely to be engaged and motivated in their work. Within the context of ACMS, this belonging is amplified by a shared mission: advancing healthcare in Allegheny County and improving the lives of both

patients and medical professionals.

Practical Benefits of ACMS

Membership

While the emotional and psychological benefits of belonging to ACMS are profound, there are also many practical advantages. Membership provides access to resources that help members stay informed, connected, and protected. These include:

• Advocacy: ACMS represents its members in local, state, and national medical affairs, ensuring that your voice is heard on issues that affect your practice and patients.

• Continuing Medical Education (CME): Members have access to professional development opportunities, helping them stay current with the latest medical knowledge and meet licensure requirements.

• Networking: Membership provides opportunities to connect with peers, share best practices, collaborate on solutions to common challenges, or enjoy being together in a social setting.

• Community Engagement: Through volunteer opportunities and public health initiatives, members can give back to the local community, further enhancing their sense of purpose and impact.

• Member Discounts: ACMS members have access to discounts on a variety of products and services, including insurance, artificial intelligence, PR/marketing, and even Lululemon clothing.

An Investment in Yourself and Your Peers

For new members, the ACMS offers an introductory membership rate of just $95. This is a modest investment that yields substantial returns, both in terms of professional development and personal fulfillment. Becoming a member at this rate allows you to experience firsthand the advantages of organized medicine. For those who are already part of ACMS, there is an important role you can play: encourage your peers to join. Word of mouth and personal recommendations are among the most effective ways to grow and

strengthen the community. Current members can serve as ambassadors for ACMS, sharing their positive experiences and emphasizing the benefits of membership to colleagues who may be hesitant or unaware of the opportunity. When colleagues actively encourage one another to join a professional organization like ACMS, it fosters an environment of mutual support and shared goals. It also strengthens the collective voice of the medical community in advocating for positive changes in healthcare policy and practice.

We Want to Hear from You!

What specific resources, events, or services would you like to see the ACMS offer that would better support your professional needs and goals?

Share any feedback you have for the ACMS Membership Task Force by emailing drlin@directcarepgh.com, or by going to www.surveymonkey.com/r/ SZ5698R. You can also scan the QR code below!

Tucker Arensberg Lawyers Have Experience in All Major Healthcare Law Issues Including:

• Compliance

• Reimbursement

• Mergers & Acquisitions

• Peer Review and Credentialing for Physicians

• Employment Contracts and Restrictive Covenants

• Tax & Employment Beneﬁts

For additional information contact any of the following attorneys at (412) 566-1212

• Mike Cassidy - Compliance; Contracts, Peer Review, Stark/AKS

• Jeremy Farrell - Labor & Employment and Commercial Litigation

• Adam Appleberry - Mergers & Acquisitions and Physician Contracts

• Jerry Russo - Criminal Defense and Investigations

• Paul Welk - Mergers & Acquisitions

Women in Healthcare

Committee Fall Event

On October 10th, the Women in Healthcare Committee hosted a "Paint and Sip" networking event at the ACMS office space in the Babb Building on the North Side. ACMS members enjoyed appetizers and wine while networking before their two-hour guided painting session with Cara Livorio, owner of Artissima Studio in Fox Chapel. A special thank you to Dollar Bank and Charlie Health for sponsoring this event!

3. Sarahgene Gillianne DeFoe, MD

5. Stacie McKnight, DO

6. Paint and Sip Attendees with their final paintings

7. Cara Livorio, owner of Artissima Studio instructs attendees

1. Amanda Ross from Charlie Health welcomes Attendees

Amy O'Donnell, MD, MPH & Kirsten Lin, MD

Marie Helene Errera, MD & Andreea Coca, MD with their finished portraits

ACMS Team Members Nadine Popovich and Melanie Mayer

CME Opportunity

AHN Women Physician’s Wellness Conference

November 8, 2024

CONFERENCE OVERVIEW

This conference is a full-day CME event focused on women physician wellness and well-being. The agenda will include discussions on physician vitality, avoiding burnout, physical fitness, and other evidence-based medical topics that are generalizable to all specialties!

Hotel Monaco

620 William Penn Place

Pittsburgh, PA 15219

Registration fee: $100

Complimentary for residents & fellows. Scan the code to register.

Allegheny General Hospital designates this live activity for a maximum of 6.5 AMA PRA Category 1 Credits TM

CME ACCREDITATION

Allegheny General Hospital is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Credits to be determined.

Society News

Specialty Group Updates

October 2024

By: Nadine Popovich and Melanie Mayer

Allegheny County Immunization Coalition (ACIC) — 2024 Chair - Patrick Hussey, PharmD, MBA: We had a fantastic general membership meeting on September 19, 2024. Kyle DiPaola, PharmD, BCPS, BCPPS from Sanofi, a pediatric pharmacy specialist focusing on bronchopulmonary dysplasia, delivered an insightful presentation titled: “Nirsevimab for the Prevention of RSV in Infants.” We attended the Immunization Awareness Bingo Night hosted by the Pitt SHRS Wellness Pavilion at the CEC in Homewood on September 24, 2024, and it was a successful event, with 10 of our member volunteers showing up and educating the public in a fun and impactful way.

Our ACIC conference is just one month away on November 6. Registration is still open, and attendees can earn 4.5 credits. “This activity is approved for the following credit: AMA PRA Category 1 Credit™, ANCC, and ACPE. Other healthcare professionals will receive a certificate of attendance confirming the number of contact hours commensurate with the extent of participation” in this activity. Following the conference, we have the Annual Thanksgiving Distribution Event on November 22-23 at the David L. Lawrence Convention Center, hosted by the League of Women Voters of Greater Pittsburgh and the University of Pittsburgh. Help us with vaccination education – no experience needed! Shifts will be broken down, so you’re not expected to volunteer the entire length of the event.

Allegheny County Immunization Coalition membership is free and

funded by our grants. You can attend the conference without being a member. All healthcare professionals with an interest in vaccination are welcome. See our website for full details at www.immunizeallegheny.org.

American College of Surgeons

Southwestern Pennsylvania Chapter (ACS-SWPA) — 2024 President – Richard Fortunato, DO, FACS: The American College of Surgeons – Southwestern Pennsylvania Chapter is excited to announce that we are launching a new website! The updated site will provide enhanced features, easier navigation, and a better user experience for all members. Additionally, starting in 2025, our membership dues process will be streamlined to align with the National ACS dues process, making it more convenient for you to manage your membership. Stay tuned for more details and updates!

Pennsylvania Geriatric Society Western Division (PAGS-WD) — 2024 President - Heather Sakely, PharmD, BCPS, BCGP: Don’t miss the PAGS-WD Fall Program, set for Wednesday, November 6th. This event is a prime opportunity to explore the latest advancements in geriatric care and connect with colleagues dedicated to enhancing the health and well-being of older adults. We will also recognize the 2024 Teacher of the Year Awardees, Lyn Weinberg, MD, Christine RubyScelsi, PharmD, and Fred Rubin, MD as well as the 2024 David C. Martin Award Recipients, John Crookston and Lauren Yu. Registration is open now - https:// pagswd.org/event-5817500

Save the date for the 33rd Annual Virtual Clinical Update in Geriatric

Medicine to be held on April 24-25, 2025. Visit the website for more information and to stay up to date on the conference - https://pagswd.org/ Clinical-Update-in-Geriatric-Medicine

The Pittsburgh Ophthalmology Society (POS) — 2024 PresidentPamela P. Rath, MD: The Pittsburgh Ophthalmology Society will not meet in October, as the American Academy of Ophthalmology (AAO) is scheduled to meet October 18-21, 2024.

The monthly meeting series resumes on November 7 when the Society welcomes Christopher C. Glisson, DO, MS, FAAN Medical Director, Warren Clinic Neurology, St. Francis Health System, Tulsa, OK.

Dr. Glisson is an adult neurologist and adult & pediatric neuroophthalmologist, now serving as the Medical Director of the Warren Neuroscience Institute at Saint Francis Health in Tulsa, Oklahoma. Previously, he was the inaugural medical director of the neuro-ophthalmology program and co-founding program director of the neurology residency at the Hauenstein Neuroscience Center in Grand Rapids, Michigan, and assistant professor of neurology and ophthalmology at Michigan State University.

Thank you to Donald Morris, DO, for inviting Dr. Glisson and to the following sponsors: Alexion Pharmaceuticals, Amgen, and Mallinckrodt Pharmaceuticals.