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FOCUS TOPICS WOMEN’S HEALTH • NURSE’S ROUNDTABLE • NEUROLOGY

May/June 2020 >> $5

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Nurses’ Roundtable

Naturally Rising to the Top

COVID-19 and should nurses be allowed to practice without physician oversight?

Dr. Michael Osayamen, physician, pharmacist, family man, Olympian

By SUZANNE BOyD

Florence Nightingale may be the world’s best-known nurse and since 2020 is the 200th anniversary of her birth, the World Health Organization has declared this the Year of the Nurse. Nightingale’s role in healthcare far exceeded that Brett Walker Florence Jones of a nurse because she was a leading reformer of health standards and promoted initiatives such as infection control. She also identified that hospital buildings could affect health outcomes and her ward designs (known as Nightingale Wards) were widely adopted. Ironically, many of the issues close to Nightingale’s heart are, once again, in the spotlight during the current pandemic.

When Michael Osayamen, MD, left his home country of Nigeria in 1984 and joined his uncle and older brother in Nashville, his plan was to become a pharmacist.

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Is Alois Alzheimer Still Waiting? A fifty-one-year-old female presented to her physician’s office with complaints of short-term memory loss and altered behavioral symptoms. After gradual but progressive decline, the patient died five years later of Alzheimer’s disease. Her physician, Dr. Alois Alzheimer, in 1906, had no adequate medication to alter the progressive nature of this disease. Little has changed in the subsequent 114 years.

(CONTINUED ON PAGE 4)

New Study Looks at Cost Impact of OTC Birth Control By CINDy SANDERS

On May 9, ‘the pill’ celebrates 60 years of approval from the Food and Drug Administration. While no over-the-counter option is currently available, a growing chorus of women’s health providers, researchers and advocates is calling for improved access to oral contraceptives. In April, new findings on the impact of over-the-counter costs for birth control pills on both use and unintended pregnancy were released in Women’s Health Issues, a peer-reviewed, bimonthly journal of the Jacobs Institute of Women’s Health. “Modeling the Impacts of Price of an Over-the-Counter Progestin-Only Pill on Use and Unintended Pregnancy among U.S. Women” primarily looked at data from a nationally representative 2015 survey of more than 2,500 American women ages 15-44 to assess interest in using an OTC progestin-only pill at different price

Story on page 9.

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As such, 2020 may be best remembered as the Year of the Nurse for the role they and other first responders have played in the pandemic. Each spring, Medical News holds its Nurses’ Roundtable to turn the spotlight on nurses across the area and the issues the profession is facing. Kathy O’Connor Wray Raven Wentworth Obviously, the pandemic has been at the forefront, but there is also state legislation being introduced that could greatly impact the autonomy of Advanced Nurse Practitioners. Medical News gathered four nursing leaders to hear their perspectives on these issues.

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PhysicianSpotlight

Naturally Rising to the Top

Dr. Michael Osayamen, physician, pharmacist, family man, Olympian By LAWRENCE BUSER

When Michael Osayamen, MD, left his home country of Nigeria in 1984 and joined his uncle and older brother in Nashville, his plan was to become a pharmacist. That plan did not change. It just evolved. He earned a degree at Tennessee State University and went on to pharmacy school at the University of Tennessee Center for the Health Sciences (UTHSC). “I came to the United States with all intentions of going to pharmacy school, and I got my PharmD,” Osayamen recalled. He then added with a deep laugh, “But I switched over to medicine because doctors wouldn’t listen to me.” So, he became a medical doctor himself. After medical school at UTHSC, he did internship and residency programs in internal medicine at the Mayo Clinic and the University of Minnesota, and then a fellowship program in cardiology at Vanderbilt University. “It’s been a blessing,” he said. “I hope I’ve used it well.” Osayamen who is board certified in internal medicine and cardiovascular disease, practices at The Jackson Clinic’s Vein & Vascular Clinic which provides minimally invasive procedures to patients with venous disease and various circulatory conditions. “I tell people all the time that the biggest mistake man ever made was standing up,” the doctor said. “When you stand up, the blood pressure inside your legs increases because the heart beats stronger and faster. The blood must get pumped out and carried from your feet back to your heart. That sometimes is a difficult task. “It lays the groundwork for having reflux and leakage in the blood vessels in the veins of the legs. You can also have blockage or clot formations in the arteries, so the combination of those two things presents its own challenges.” Venous reflux disease or venous insufficiency occurs when small valves in the lower extremities that normally force blood back toward the heart no longer function. This causes blood to pool in the legs where the veins become extended. Venous leakage sometimes can be treated with pressure stockings to impact the venous flow back to the heart. “If that doesn’t alleviate the symptoms, then there is endovenous laser ablation therapy where we use ultrasound to establish this venous leakage of the valve not closing very well,” Osayamen said. “Then we use laser technology that would westtnmedicalnews

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ablate the vessel and prevent its reflux and leakage. “There is a superficial venous system and a deep venous system. We don’t ablate the deep venous system. That’s the one that links to your heart and causes blood clots that go to the lungs. So, this procedure is done in the superficial venous system, which is the one that causes varicose veins.” He said that some 25 million people worldwide suffer from venous disease, more than twice the number of those with coronary disease. Another 4.6 million suffer from peripheral artery disease with blockage in the arteries of the legs. “If the biggest mistake man ever made was standing up, the number one cause for venous disease and varicose veins is that you chose the wrong parents,” he said. “If you have a family member with a history of varicose veins, the chance of an off-

spring ending up with varicose vein disease is over 40 percent. “Then, as people age, the risk increases by 10 percent each decade after age 30. All that standing and walking around the rest of your life presents its own challenges. There’s about a two-to-one ratio of women to men with varicose veins, but then men catch up by about age 60.” Osayamen, who has been in practice some 24 years, chose cardiovascular medicine because of the challenge and its critical importance for human health. The body has some 60,000 miles of blood vessels to keep working. “Cardiovascular medicine includes every single artery in your entire body, from head to toe, and includes arterial and venous disease which is very common pathology for people of all ages,” he said. “A lot of focus for a long time was on just the heart, the cardiac portion, but I think society is appreciating more the broadness and extent of vascular medicine and how important it is to pay attention to vascular medicine. Patients with any vascular disease have increased risk of heart disease, not just the vascular disease itself. There is a significant cross link, which is what our focus and efforts are on now.” Osayamen has seen many changes in the field since he began practicing, including advancements in imaging technology, therapeutics and virtual or telemedicine. “Thanks to imaging, if you’ve got anything wrong with your heart or your vascular system, we should be able to find out. We would not have been able to say that 20 or 25 years ago,” the doctor said. “Also of importance, are the changes in therapies. When I was in pharmacy school many, many years ago, so many

medicines available that were contraindicated in the treatment of heart disease are now becoming the primary medicines to use, particularly with heart failure and those kinds of things. Knowledge is expanding and there are paradigm shifts taking place. “I see virtual medicine has a future, even before the COVID-19 era. You can assess people from anywhere in the world. I’ve been pretty impressed with that,” he said. Another significant advancement has been in design of pacemakers that once were the size of a hockey puck and had wires or batteries. “Today they are about the size of a coin or a small fishhook,” said Osayamen. “We now have injectable pacemakers where we take a catheter through the groin to the heart and actually inject it into the heart muscle. It’s like a microchip. It lasts 13 years, has MRI compatibility and you have zero risk of infection. I put one in a patient yesterday. To me, the future is bright.” When he is not working, the doctor is busy with family - he is the father of five and trying to master the frustrating game of golf. Less frustrating to him is the game of table tennis. As a teenager, Osayamen won a bronze medal in the 1980 Olympics in Moscow with the national team from Nigeria. “That was 56 pounds ago,” he said with a laugh. “I started at 7 or 8 years old when my best friend’s father was the state coach in Nigeria. His dad was expecting him to become the next greatest table tennis player, but he never really was interested so I became the substitute. With the national team we played tournaments in other countries and then in the Olympics. I think we put together a great team. I think a team succeeds more than an individual person. The approach is to build something in a structure.”

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Nurses’ Roundtable, continued from page 1 If you’re not on the frontline, as a healthcare professional, you are watching – what are your thoughts?

Florence Jones, RN A native of Louisville, Kentucky, Methodist Healthcare North Hospital’s President, Florence Jones, said back in the 1950’s when she was growing up, most role models for women were nurses. Her mother, as well as other relatives, were nurses and that is where her passion for service and taking care of others came from. Her career in healthcare started with a summer job in the environmental services department. “As I grew in my career, I had different mentors along the way who encouraged me to work to improve on things or pursue a degree,” said Jones. “And while they may have told me things I didn’t want to hear but needed to, I knew they came from a place of love.”

How has the COVID-19 virus affected your work/practice/ organization?

As the manager of a dedicated COVID-19 unit at Baptist Memorial Hospital - Memphis, Brett Walker has been on the frontline of the pandemic. The 38-bed inpatient unit treats pending or positive COVID-19 test patients who do not require ICU care. Since it saw its first case on March 7, the unit averaged 20 patients daily through the end of April. “We learned a lot on the fly using guidelines from the CDC as a roadmap along with what we were learning from China,” said Walker. “Collaboration on the unit between nursing, infectious disease and the pulmonologists has been crucial as we had to adapt to the situation as it unfolded. We would try things that had worked in the past but found that often they would not work on the scale we had. For instance, we had a vast number of isolation patients and had to efficiently manage the large amount of clean and dirty Personal Protection Equipment required. We have tables for clean items and those that need cleaning. Our team implemented the use of tables between rooms so that PPE would not be crosscontaminated.” One big lesson learned, said Walker, is that overall, the country was not prepared. This pandemic was a great learning experience for healthcare. “The Ebola scare made us realize that certain areas of the hospital had to have certain things,” he said. “This time it was on a much bigger scale and we have learned some valuable lessons. Now, you see more units with negative pressure rooms, and I think that will be integrated into new construction and renovation projects going forward. There will also be better infection control overall, including more screening for visitors and employees.” Having been in a professional role in healthcare since 1975, Methodist North Hospital’s president, Florence Jones has seen her share of epidemics but says the COVID-19 pandemic is so different and stressful. “One thing I learned 4

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is that I am taking care of the caregivers, and I take that seriously,” she said. “When this first started, people looked to me for answers. They were concerned for themselves as well as their families. I had the same emotions but had to stay calm, stay positive and be transparent. I am fortunate to be part of a great system that pulled together to address the needs of those on the frontlines. Our staff feel their needs are being met and I am thankful to them for what they are doing, for without their dedication we could not deliver on our mission.” As the owner of a primary care clinic as well as a Nurse Practitioner, Kathy O’Connor Wray’s frontline is a bit different than in the hospital setting. Being both administrator and provider is stressful since she must make sure patients are getting the care they need while the clinic is open, then having to perform on the management side after hours. “Our practice is primary care and also acute care, so normally we would take all walk-ins. Now, we are technically appointment only due to social distancing. If someone has to be seen urgently,

we have to have them wait in the car,” said Wray. “Our practice is seeing about half the number of patients we used to because people are waiting to go to the doctor for fear of exposure to COVID19. Beside a decline in patient revenue, we also run the risk of missing abnormalities and such that would be caught on routine physicals and exams that are now being put on hold.” From an administrative side, Wray said it has been a struggle to keep the doors open. “We have gone to a lot of expense that we would not normally incur. We are having to navigate the financial side of things including cost reporting, lost revenues, etc. as we work with our accountants, as well as with our EHR to get the information needed to apply for stimulus money,” she said. “We have had to cut employee hours back, both owners have not taken paychecks so we can pay others and stay open. Our goal is to be able to re-hire workers and get back up to speed as soon as possible.”

As an associate professor at Freed Hardeman University as well as president of District 6 of the Tennessee Nursing Association, which includes the Jackson area, Raven Wentworth viewed the frontlines from a distance. Acting as a liaison between the TNA main office and area members, Wentworth’s role was to ensure that the concerns of nurses in her area were heard. She said these ranged from reduction in working hours due to decreased censuses that impacted their pay checks, to PPE supply levels and personal safety, which caused the most anxiety among nurses. On the education front, clinical rotations were impacted immediately and what they will look like in the future is still uncertain. “In March, students were taken out of clinical placements,” said Wentworth. “Since we did not know when or if our senior level nursing students would get to complete their clinical rotations, we had to develop simulation case studies that would be acceptable to the Nursing Board. With the future of students in the hospital still uncertain, we are continuing to look at ways we can get them some form of that experiential learning. While we need the students in the hospital setting, we certainly respect the hospital’s needs.”

Other than COVID-19, what are the main nursing issues on your mind today?

Across the panel, having an adequate supply of nurses was a central theme and one that circled back to lessons learned in the midst of the pandemic. Walker expressed his concern for the shortage of nurses at the bedside due to the increasing number of nursing opportunities away from the bedside, which could greatly impact smaller hospitals. He also felt that the comradery developed during the pandemic, especially among nurses, may help

Brett Walker, RN Born in Lexington, Tennessee, Brett Walker is an RN with Baptist Memorial Hospital - Memphis where he oversees two units, one that became a COVID-19 dedicated unit as the pandemic began. Walker says he did not really have a mentor in the healthcare field, it was just something his mother had encouraged him to pursue all his life. When his grandfather suffered a stroke in 1997, Walker witnessed nursing up close and personal across the gamut from EMS to the emergency room to surgery, ICU, rehab and ultimately, hospice. After earning his Bachelor of Science in microbiology at the University of Memphis, Walker was skeptical at first about nursing as a career but soon realized it was what he wanted to do. He earned his Associate Degree in Nursing at Jackson State Community College. He went on to earn his Bachelor of Nursing from the University of Memphis, where he is currently pursuing his Master of Nursing through the Executive program.

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keep some at the bedside. Jones mirrored that concern for a nursing shortage. “In 2022, there is going to be a shortage of seasoned nurses,” she said. “I truly believe how we deliver care Post-COVID is going to be different. How that will look, I don’t know but I feel there will be an even greater focus on quality care and outcomes as well as ensuring safe care. We will look at simple things, eliminate waste and engage patients to help take care of themselves. I believe nursing will take a prominent role in this evolution because there is evidence that people trust nursing as a profession. My big concern is that nurses are going to need time to deliver on quality care, education and waste prevention but unfortunately our global healthcare system is not set up to accommodate those types of things. As things move forward and evolve, it will be important to engage nurses to take care of those items.” For Wentworth, there was a continuation of common themes such as compassion fatigue and burnout among nurses. “We are also seeing more discussion centering on workplace violence as well as verbal and physical abuse,” she said. “Nurses are also concerned about the time devoted to paperwork and charting. While technology is great, a lot of time devoted to EHRs takes nurses away from patients or it has to be done away from or after work hours to stay on top of it.”

Tennessee doctors are in opposition of legislation that would allow nurses to practice without physician oversight. What is your position on this and why?

The sponsors and proponents of this legislation, including the Tennessee Nurses Association, propose to change state law to remove requirements for nurses to maintain a collaborative relationship with a physician that would allow

Raven Wentworth, DNP, APRN, AGPCNP-BC, FNP-BC Hailing from Lobelville, a small Middle Tennessee town that is about as rural as it gets, Raven Wentworth, RN, holds a multitude of roles in the nursing profession: President of District 6 of the Tennessee Nursing Association, which includes the Jackson area; Associate Professor of Nursing at Freed Hardeman University; and, a Nurse Practitioner at Walk-In Medical Clinic in Linden. Wentworth, who says she has gotten just about every nursing degree there is, attributes her heart for service to watching her mother and grandmother in the roles of caregivers, to her grandfather who suffered with rheumatoid arthritis and a cousin who had a traumatic brain injury. She says she has had mentors throughout her career that have had a lasting impact on her. One in particular is Mary Deal, who she still stays in touch with. “I think every nurse educator tries to be a mentor and there is always a student that you connect with and build a relationship that lasts into their careers,” said Wentworth. “One thing I always tell my students is that God will open a door for you if you pray about it. I never intended to be an educator, yet here I am.”

complete independent (unsupervised) practice for advance practice nurses in Tennessee. During the pandemic, Governor Bill Lee suspended collaborative practice rules to allow for access to care in a time of crisis. This has fueled the case in some people’s eyes for this legislation to be passed. Jones pointed out that there is already support from Health and Human Services and government for APN’s to work independently. “Advanced Practice Nurses are well received by patients and there is a large body of evidence that supports care given by them is safe, effective, can eliminate waste and reduce costs,” said Jones. “It doesn’t take much to substantiate that, it just gets emotional. If you put the patient at the center and look at

issues such as access to care, affordability and education on chronic disease, allowing access to an APN, makes sense. This issue will evolve over time and we are going to have to work together with both doctors and nurses for what is best for the patient.” Walker saw firsthand the benefit an NP can bring when he worked in an Emergency Department but remains in the middle on the legislation. “Doctors can have up to three to eight additional years of post-graduate training before they practice autonomously,” said Walker. “I think ANP’s need some transitional phase commensurate with that of a physician to ensure they meet all the requirements to practice on their own. I think NPs can be a great resource, especially for rural areas,

Kathy O’Connor Wray, DNP, MSN Born in Louisville, Kentucky, Kathy O’Connor Wray, owner of Primary Care Clinic of Jackson, got into healthcare thanks in part to the Armed Services Vocational Aptitude Battery (ASVAB) test she took when she joined the Navy. The test showed she had a heart for caregiving and she tested high for qualities for the corpsman ranking which is an enlisted member of a medical unit. As a field hospital corpsman with the marines, she provided medical support for the unit wherever it landed and would often have a field hospital established within eight hours. Wray says she has had a lot of mentors along the road from her associate degree to doctorate and would not have made it without them. “From people that I worked with to my professors, I have had many people that were the type of people you say you want to be just like when you grow up,” she said. “They inspired me to own my own clinic so that I can advocate for those who are suffering.”

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there just needs to be some oversight to ensure quality care is provided.” Wray said there has been a lot of commentary from doctors about the difference in education. “I have been to school for 14 years earning my ASN, BSN, MBA, MSN and doctorate. Not everyone does it like I did, but I wanted that knowledge and advancement,” she said. “There has been a push for all NPs at the entry level to be like pharmacists and have their doctoral degree. I would wholeheartedly support that.” Wentworth tries not to get discouraged on the issue. “When I graduated from Vanderbilt with my master’s, my best friend from Montana left and opened her own practice. Fourteen years later, we cannot do that in that state I live in without oversight,” said Wentworth. “Tennessee is 44th in health outcomes. We have to have a plan to improve that because it is unacceptable. I support full practice authority since it can increase access to care, especially in rural areas. As other states work through this issue, I think it is a matter of time before Tennessee does the same.” As a nurse practitioner who owns her own clinic, Wray’s perspective on the issue is from firsthand experience. “It really does limit care. If I have an order that needs a doctor’s signature and that does not happen in a timely manner, the care is delayed. Also having to pay for a physician to sign off on things takes money away from direct patient care,” she said. “We are not going anywhere soon. Research shows that APNs can have great health outcomes and provide quality care to patients without doctor supervision. As the pandemic caused the suspension of collaborative supervision, I hope we can look at the outcomes in our state and see what we have been able to do without doctor oversight and let that guide this legislation.” MAY/JUNE 2020

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New Study Looks at Cost, continued from page 1 points. The analysis also utilized the National Survey of Family Growth 2013-15, which was released from the National Center for Health Statistics in 2016, as well as 2017 population data from the U.S. Census. According to the analytical study: “In a model assuming no out-of-pocket costs, more than 12.5 million adults and 1.75 million teens reported likely use of an OTC progestin-only pill if available. Among adults, this resulted in an estimated 8 percent decrease in unintended pregnancy in one year. Adult and teen women on average were willing to pay $15 and $10, respectively, resulting in 7.1

million adult and 1.3 million teen users and an estimated 5 percent decrease in unintended pregnancy among adults.” Lead author Alexandra Wollum, MPH, senior project manager with Ibis Reproductive Health, noted, “These results show that an overthe-counter, progestin-only birth control Alli Wollum pill at a low or no outof-pocket cost has the potential to decrease unintended pregnancy rates and expand access for people

of all ages.” Improving affordable, equitable access to healthcare is a timely topic with experts at the International Monetary Fund projecting a nearly 6 percent contraction in the U.S. economy in 2020. In the wake of layoffs resulting from COVID-19 business closures, more than 26 million Americans filed for unemployment over a five-week period between March and April, wiping out nearly a decade’s worth of job gains and decreasing access to employer-sponsored insurance coverage. “The findings of this study are particularly important in the middle of the public health crisis we’re facing now,” said

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Wollum. “As people struggle with mounting job losses and economic insecurity as a result of the COVID-19 pandemic, they must be able to obtain an affordable birth control pill over the counter to control their reproductive health. This study highlights the need for low or no out-of-pocket cost progestin-only birth control pills that are available over the counter to better meet people’s healthcare needs.” “This study shows that people are willing to pay something out-of-pocket for the convenience of getting progestin-only pills over the counter,” added co-author Dan Grossman, MD, professor in the Department of Obstetrics, Gynecology and Reproductive Science at the University of California San Francisco and director of Advancing New Standards in Reproductive Health (ANSRH) at UCSF. “But in order to best meet people’s needs and help them plan their fertility, over-the-counter pills should be fully covered by insurance without co-pays and available at a very low cost or no cost for those without insurance,” An earlier study published in February 2015 in the journal Contraception demonstrated affordability as a key factor for using OTC oral contraceptives among low-income populations. However, that study – led by Diana G. Foster, PhD, of ANSRH and co-authored by Grossman – did not use data that specifically looked at progestin-only pills (POP) in comparison to combined oral contraceptives (COC), which use both estrogen and progestin to prevent unintended pregnancies. While there are a wider choice of prescription COC options compared to prescription POPs (also known as the minipill), both are effective forms of contraception if taken appropriately. The new study specifically looked at the POP option, which has garnered growing consensus among industry groups as the more likely version to gain FDA approval to become the first oral contraceptives available without prescription. The American College of Obstetricians and Gynecologists (ACOG) has issued a committee opinion highlighting barriers to access as one of the key reasons women don’t use contraceptives consistently. Furthermore, the committee also found cost to be part of the larger access issue. “Pharmacist-provided contraception may be a necessary intermediate step to increase access to contraception, but over-the-counter access to hormonal contraception should be the ultimate goal,” the opinion states. In addition to OTC oral contraceptives, ACOG has also called for similar access to vaginal rings, the contraceptive patch and depot medroxyprogesterone acetate injections without age restrictions. The Jacobs Institute of Women’s Health was founded in 1990 and is part of the Milken Institute School of Public Health at George Washington University in Washington, D.C. Women’s Health Issues focuses on research related to women’s healthcare and related public health policy.

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Self-Care on the Front Lines of Coronavirus By CINDY SANDERS

With coronavirus dominating news cycles for weeks now, it seems difficult … if not impossible … to escape the mounting death toll, case load, unemployment figures and economic havoc that COVID19 has left in its wake. For healthcare providers, first responders and other workers on the front lines, it’s far too easy to forget self-care when the focus is so strongly on caring for others. Yet, ignoring warning signals of the physical and emotional toll the pandemic has taken could have farreaching consequences. Joshua Morganstein, MD, serves as chair of the American Psychiatric Association (APA) Committee on the Psychiatric Dimensions of Disaster. “The committee’s role is to provide education, consultation and resources to APA members, our statelevel district branches and leadership,” he Dr. Joshua Morganstein explained. Morganstein added the committee’s focus has primarily been in response to non-military disasters. However, he noted, some similarities have been drawn between the current global COVID-19 outbreak and the type of stressors and reactions seen in a prolonged conflict. “In a pandemic like this, it’s sort of an ongoing disaster,” he pointed out. This sense of being at war is particularly true for those fighting the coronavirus on the front lines, With an infectious disease outbreak, he said adverse psychological and behavioral responses might include difficulty sleeping, feeling unsafe, irritability or anger, distractibility, and increased use of alcohol or other substances as a way of managing. Healthcare workers have additional challenges including increased concerns of exposure for themselves and their families, managing the distress of patients separated from family members, and shortages of staff and equipment.

Is the missing

Self-Care

The best defense, said Morganstein, is a good offense in the form of proactive self-care. He said eating regularly, getting sleep and taking a breather when needed allow people to make better decisions and strengthen the immune system. “I would really encourage healthcare workers in general to work on … and encourage each other … to take care of basic needs,” said Morganstein. “I would also encourage having a battle buddy,” he continued. Morganstein noted a battle buddy in the military has their friend’s back and is more likely to notice early warning signs of struggle, such as increased irritability. “We need people looking out for each other. Battle buddies don’t let someone go off a cliff.” Some organizations assign battle

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buddies and others have team members choose their own support partner. Either option can be effective, Morganstein said. He added the responsibilities are pretty straightforward. Battle buddies check in on each other via text or in person, encourage one another during a tough day and remind one another to take a break. Morganstein said it’s also important to stay informed on current information regarding the pandemic from trusted sources, as accurate information plays an important role in controlling the spread of the disease and can also help alleviate uncertainty to a degree. The caveat, however, is to get the day’s information and then step away. “People want to be encouraged to use media wisely,” cautioned Morganstein. “There is a good body of evidence that increasing exposure to disaster-related media in particular increases stress, makes sleep worse, increases people’s use of alcohol and results in higher rates of post-traumatic stress and depressive symptoms.”

role in supporting their workers, noted Morganstein. Citing a 2018 review of social and occupational factors impacting healthcare workers during an infectious disease outbreak (Journal of Occupational and Environmental Medicine, March 2018, S.K. Brooks, PhD, et al.), Morganstein said a number of measures were shown to improve outcomes. Ensuring people have adequate training in a timely manner and have equipment they understand how to use and that will protect them are the first steps in mitigating stress. Regular communication from the organization and leadership is also critical. Similarly, finding ways to foster collegiality and recognizing the seriousness of the situation but creating positives whenever possible both encourage a sense of camaraderie and help alleviate feelings of aloneness or separation from the larger group. Videos of healthcare workers praying, dancing or singing together that have appeared on social media and broadcast channels are good examples. Although it won’t replace organizational support, Morganstein said there is well documented evidence of the impor(CONTINUED ON PAGE 10)

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Is Alois Alzheimer Still Waiting? A fifty-one-year-old female presented to her physician’s office with complaints of short-term memory loss and altered behavioral symptoms. After gradual but progressive decline, the patient died five years later of Alzheimer’s disease. Her physician, Dr. Alois Alzheimer, in 1906, had no adequate medica- By LEE STEIN, MD tion to alter the progressive nature of this disease. Little has changed in the subsequent 114 years. During the latter portion of the 20th century and early 21st century, there have been substantial advances in the treatment of Neurologic disease. Advancements have particularly been noted in multiple sclerosis, Parkinson’s disease, epilepsy, ALS, headache, and have resulted in effective forms of treatment. Also, notable in the past 20 years has been substantial progress in defining the pathophysiology and neurogenetics of Alzheimer’s, but treatment for the degenerative aspects of this disease is still lacking. Alzheimer’s is a neurodegenerative disease consisting of behavioral and cognitive changes impairing social, functional and occupational endeavors and activities of daily living. No cure or treatment to slow progression has been uncovered. There are over 6 million Americans with the diagnosis of Alzheimer’s today. Numbers are expected to rise to 13.8 million by 2050. A long preclinical phase is suspected, followed by a chronic progressive course. Amyloid plaques and neurofibrillary tangles develop in the cerebral cortex and deep brain structures. It is also suspected that this preclinical period may extend for years prior to onset of symptoms. Clinical symptomatology includes memory loss, decrease in language skills, changes in personality, judgement, mood and agitation. Diagnosis is typically made with review of history, exam, and clinical exclusion of alternate etiologies. MRI and PET scans can be helpful in establishment of diagnosis. Checking spinal fluid levels of Tau and Amyloid can also be helpful, but rarely utilized outside of the research setting. A recent serum study has been developed which can detect Tau protein. FDA approved medications are available for symptomatic improvement only and have no effect on long term prognosis. Psychotropic medications have been utilized for treatment of depression, anxiety, agitation and hallucinations. Numerous Alzheimer clinical trials for disease modifying therapy have been performed with almost 100 percent failure. These trials have increasingly focused on patients with mild, moderate or westtnmedicalnews

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prodromal disease. Trials for the most part have failed to reach cognitive endpoints or were terminated secondary to adverse events. A number of complicating issues in previous trials have included patient population, small age spread, reduction in heterogeneity, requirement for more extensive biomarkers, drug toxicity, late intervention, bioavailability and potential need for combination drugs. Several drugs for symptomatic improvement of cognitive function are avail-

able, but typically the effectiveness of these medications is quite limited. Despite multiple Alzheimer trial failures in the past 15 years, there was a notable report in October 2019 with reference to the monoclonal antibody Aducanamab. The Engage/Emerge Phase III trials for Aducanamab had actually been closed in March 2019 secondary to a “futility analysis.� This analysis had been based on limited data which predicted that both studies would not meet their endpoints. Over sub-

sequent months, additional data was reviewed and suggested that Aducanamab was effective in slowing cognitive decline. In October 2019, Biogen announced these results and reported plans to file with the FDA and to resume the trial as a redosing study. The Coronavirus pandemic has, at least in the short term, affected the ability to maintain many of these trials which require IV treatments. Patient safety in this (CONTINUED ON PAGE 10)

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Self-Care, continued from page 8 tance of community support, as well. “A feeling of strength among community members is protective,” he said, adding the ‘community’ might be a city, zip code, neighborhood, faith group, military unit or sports team. “There is no small act of kindness and generosity … there are only acts of kindness and generosity,” he reminded. Whether it’s clapping for a healthcare worker, giving to a food bank or waving at a neighbor, receiving and giving kindness is important. “Those things will help our society emerge from this in the most positive way possible,” he noted.

The Long View

“Crisis experiences change us and create a new normal,” said Morganstein. For some there will be delayed reactions. He noted some people compartmentalize in order to cope and manage in the moment but then have to deal with issues down the road. “To the degree people are able to care for themselves and find support and be able to find outlets to release some of the stress, that can help to reduce the burden they carry forward with them even if it doesn’t eliminate it.” Fortunately, Morganstein said, “The vast majority of people, including those who have difficulty along the way, will ultimately do well.”

Reaching Out for Help The healthcare workforce is regularly subjected to high-pressure, highly stress(CONTINUED ON health PAGE 6) data shows a ful situations, even prior to the current pandemic. Mental

higher rate of suicide in physicians than in the general population … yet many providers do not seek help that is available. The Medscape National Physician Burnout & Depression Report 2019 found 44 percent of physicians surveyed described themselves as ‘burned out’ and another 15 percent as either colloquially or clinically depressed. Yet tellingly, 64 percent said they had not sought professional care to address these issues. In the updated 2020 report, which took a generational approach, 61 percent of millennials, 64 percent of generation X and 63 percent of baby boomers said they have not sought professional care for their burnout and/or depression. In the general U.S. population – where one in five Americans has a behavioral health disorder – the stigma attached to seeking help is beginning to give way

GrandRounds Methodist Announces Measures to Address Financial Challenges Related to COVID-19

Methodist Le Bonheur Healthcare has announced measures it is taking to address financial challenges created by the unprecedented COVID-19 pandemic. This public health crisis has created a ripple effect across all segments of the economy in ways most of us have never seen according to Michael Ugwueke, Methodist Le Bonheur Healthcare CEO. Methodist, like other health care systems in the Mid-South and around the country, has seen a significant decline in revenues as a result of a more than 40 percent decline in patient volumes related to the closure of nonessential services and the mandated cancellation of non-emergency procedures to prepare for COVID patients. To minimize the impact on its employees, the organization is taking a number of steps to reduce its expenses, including lowering senior executive pay by 20 percent, and making staffing adjustments through a combination of reduced work hours, use of PTO, and voluntary and involuntary furloughs. MLH will cover all health plan premiums for any Associate who is out on furlough. The changes will not affect the safety and quality of patient care. Ugwueke said they are committed to fairness, consistency and shared sacrifice by:

under the weight of the sheer pervasiveness of mental health issues and increased acknowledgement of the powerful, effective resources available both to assist in times of acute need and to maintain emotional health. Although some career concerns linger among physicians over seeking help, there is a strong recognition among industry organizations that behavioral health issues must be addressed. Rather than being seen as a weakness to search out help, there is a growing understanding that recognizing a need and reaching out for assistance is actually a sign of strength. If you would encourage an individual in physical distress to seek help from a clinician, then heed your own advice if experiencing acute emotional distress or ongoing behavioral health issues that have become a cause for concern.

For Immediate Help: Disaster Distress Helpline: Call 800-985-5990 or text TalkWithUs to 66746 National Suicide Prevention Lifeline: Call 800-273-8255 or suicidepreventionlifeline.org/chat Crisis Textline: Text TALK to 741741

For Connection to Assistance: Many professional healthcare organizations, including the American Medical Association, have created resources for members experiencing behavioral health challenges. Check your specialty organization or go online to AMA-assn.org for additional information. While by no means an exhaustive list, other resources for seeking care, include: Anxiety and Depression Association of America: adaa.org Mental Health America: mhanational.org National Institute of Mental Health: nimh.nih.gov/health/find-help National Alliance on Mental Illness: nami.org Substance Abuse and Mental Health Services Administration: Online at samhsa.gov or FindTreatment.gov or call the SAMHSA Treatment Referral Helpline at 800-662-HELP (4357)

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Is Alois Alzheimer Still Waiting? continued from page 9 elderly population with risk of exposure to COVID-19 has in a very practical fashion affected comfort levels of patients, families, research staff and physicians. Study sponsors have taken these problems into account while attempting to maintain patient population to continue recruitment. These efforts appear to be successful in continuing most trials. Present and future therapeutic strategies include: 1) Reduce Amyloid Beta production. 2) Increase Amyloid Beta clearance from the CNS. 3) Prevention Tau aggregation. 4) Enhance an anti-inflammatory mechanism. 5) Accelerate microglial breakdown. At present there are several active Phase III trials. There remain high expectations for these Amyloid and Tau targeted studies. Future trials and better understanding of this disease process should lead to increasingly effective forms of treatment. Alois Alzheimer’s long wait may be coming to an end. Lee Stein, MD, is a long-time Memphis neurologist who has been with The Neurology Clinic for the past 20 years and practiced for 15 years at SemmesMurphey prior to that. He is lead investigator for the clinic’s research division having conducted numerous clinical trials primarily on Multiple Sclerosis and Alzheimer’s disease.

• Focusing first on reassigning Associates to other departments, facilities or roles. • Reducing overtime and agency staffing, and eliminating open positions where possible. • Those actions are ongoing, but as the pandemic has extended from weeks to months, MLH leaders finally had to consider making adjustments that would affect work schedules more broadly across the organization. These measures are temporary. MLH will continue to monitor the situation and adjust its organization as needed. As always, providing high quality patient care and protecting the safety of patients, Associates and providers remains Methodist Le Bonheur Healthcare’s top priority.

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GrandRounds Penny Asbell, MD, Leads National Ocular Antibiotic Resistance Study, Publishes in JAMA

The results of a 10-year ongoing study led by Penny A. Asbell, MD, FACS, MBA, FARVO, chair of the Department of Ophthalmology and director of the Hamilton Eye Institute (HEI), have been published recently in the Journal of the American Medical Association (JAMA) Ophthalmology. This surveillance study examines isolates from eye infections across the United States and analyzes trends in antibiotic resistance. The Antibiotic Resistance Monitoring in Ocular micRoorganisms (ARMOR) surveillance study evaluated in vitro antibiotic resistance rates in ocular bacteria collected from 41 states (88 medical centers) from 2009 to 2018. The study, titled Trends in Antibiotic Resistance Among Ocular Microorganisms in the United States From 2009 to 2018, found that antibiotic resistance was prevalent in ocular bacteria (staphylococci), and bacteria that were resistant were also likely to be multidrug resistant. Antibiotic resistance was also found to be higher in the southern and western parts of the United States, as well as more common in older patients. Dr. Asbell and her colleagues will continue the nationwide study, which is sponsored by Bausch + Lomb, a global eye health business. She hopes that the coming years of research will answer more of their questions, leading to even better methods for treating patients with serious eye infections and ultimately, preservation of vision. The recently published article, along with supplemental information, can be found online: https://jamanetwork.com/ journals/jamaophthalmology/fullarticle/2763805. The team has also launched an interactive data site for the ARMOR study: https://armor.ihma.com/.

UTHSC Researcher Awarded $2.1 Million for Hirschprung Disease-Related Research

Hirschsprung-associated enterocolitis (HAEC) is a life-threatening complication of Hirschsprung Disease, a common cause of intestinal obstruction in newborns. Hirschsprung Disease results from incomplete development of the enteric nervous system, or the “brain of the gut,” which is essential to life. HAEC affects 30 to 60 percent of infants with Hirshsprung Disease and is the leading cause of death in babies with the disease. Ankush Gosain, MD, PhD, FACS, FAAP, associate professor of Surgery and Pediatrics in the Department of Surgery at the University of Tennessee Health Science Center, was recently awarded $2.1 million from the National Institutes of Health for his project titled “Dysbiosis in Hirschsprung Ankush Gosain Associated Enterocolitis Pathogenesis,” which will help determine how and why HAEC develops in order to discover prevention and treatment options and improve quality of life for WESTTNMEDICALNEWS

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Hirschsprung Disease patients. Dr. Gosain also explained that dysbiosis, or a microbial imbalance, in HAEC patients results when something happens to upset the normal microbial balance that exists in our intestines and there is loss of beneficial bacteria, increased disease-causing organisms, and decreased overall diversity. Dr. Gosain’s lab is currently the only lab in the United States that is NIH-funded to study Hirschsprung-associated enterocolitis. This proposal builds on research he has performed for the last decade, which has been supported by the National Institutes of Health, multiple societies, and the Children’s Foundation Research Institute at Le Bonheur Children’s Hospital.

West Tennessee Healthcare Announces Promotion and New Hire

Vanessa Patrick was recently named Vice-President of Business Development for West Tennessee Healthcare. Patrick joined the West Tennessee Healthcare organization in 1999 and has developed responsibilities to include provider recruiting, phyVanessa Patrick sician liaison program, corporate health and wellness, and strategic development including acquisitions. She has been married to Chad Patrick for 23 years and they have two daughters, Cameron and Langston, starting at UT Martin in the fall. Scott Krodel was recently named chief information officer for West Tennessee Healthcare. Krodel has over 30 years of experience within healthcare IT, with 20 years being at the executive leadership level. His areas of responsibility are Information Systems and Scott Krodel Communications. Krodel says he feels privileged to be part of an industry that offers healing to those who are sick. He holds a Master in Health Administration and enjoys fishing and sports. Most of his personal time is dedicated towards his 8 children and wife of 30 years this October.

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Open Letter from Dr. Wendy Long Dear Tennessee Nurses: On behalf of the Tennessee Hospital Association (THA), I appreciate the opportunity to recognize you during National Nurse’s Month and thank you for your vital contributions to healthcare. Typically, National Nurses Week begins each year on May 6 and ends on May 12, Florence Nightingale’s birthday, with the purpose of celebrating nurses, who are at the forefront of improving patient care and transforming healthcare. However, this year, National Nurse’s Week has special meaning, not only because the World Health Organization named 2020 the International Year of the Nurse, but because the COVID19 pandemic has increased awareness of your compassion, dedication and professionalism. With this in mind, we are excited to join the American Nurses Association in expanding National Nurses Week to a month-long celebration in May. Over the past several weeks, many of you have had to make difficult personal sacrifices, such as remaining apart from your children or aging parents, taking on new work assignments, coping with furloughs and conserving personal protective equipment. Yet you have remained concerned about patients, working hard to ensure they get the best possible care and offering the emotional support so necessary while they are apart from their families. Whether you are in a leadership role, an area of specialty practice, a retired nurse returning to the workforce, a graduate nurse just entering the workforce or a patient-care nurse on the front lines, we honor you for demonstrating unselfish service to others, the true spirit of nursing. Thank you for the excellent care you provide to Tennesseans. Sincerely, Wendy Long, M.D. President and CEO

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