BCMS Medical Record Summer 2022

Your Community Resource for What’s Happening in Healthcare

SUMMER 2022

Medical record BERKS COUNTY MEDICAL SOCIETY

Celebrating Our Medical Leadership

Past and Present

INSIDE:

COVID-19 update by Dr. Debra Powell SCAN TO READ ONLINE

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A Quarterly Publication

To provide news and opinion to support professional growth and personal connections within the Berks County Medical Society community.

Berks County Medical Society MEDICAL RECORD

Raymond C. Truex, Jr., MD, FACS, FAANS, Co-Editor Lucy J. Cairns, MD, Co-Editor

Editorial Board

D. Michael Baxter, MD Shannon Marie Foster, MD, FACS Jillian Ventuzelo, DO T. J. Huckleberry, MPA William Santoro, MD, FASAM, DABAM Raymond C. Truex Jr., MD, FAANS, FACS

Berks County Medical Society Officers Jillian Ventuzelo, DO President William Santoro, MD President Elect Kristen Sandel, MD Chair, Executive Council Ankit Shah, MD Treasurer Jin Xu, MD Secretary Michael L. Haas, MD Immediate Past President T. J. Huckleberry, MPA Executive Director

Berks County Medical Society Phone: 610.375.6555 | Fax: 610.375.6535 Email: info@berkscms.org www.berkscms.org

The opinions expressed in these pages are those of the individual authors and not necessarily those of the Berks County Medical Society. The ad material is for the information and consideration of the reader. It does not necessarily represent an endorsement or recommendation by the Berks County Medical Society.

Manuscripts offered for publication and other correspondence should be sent to 2669 Shillington Rd, Sinking Spring, PA 19608, Ste 501. The editorial board reserves the right to reject and/or alter submitted material before publication.

The Berks County Medical Record (ISSN #0736-7333) is published four times a year by the Berks County Medical Society, 2669 Shillington Rd, Sinking Spring, PA 19608, Ste 501. Subscription $50.00 per year. Periodicals postage paid at Reading, PA, and at additional mailing offices.

Contents

Features

SUMMER 2022

10

Celebrating Our Medical Leadership, Past and Present • Gianfranco Toso, MD • Charles Barbera, MD

18 An Urgent Issue: Climate Change and the Physicians for Social Responsibility Pennsylvania

28 PAMED Quarterly Legislative Update

20 College of Physicians Dr. Mira Irons Interview

31 Members in the News

30 Residents’ Day 2022

22 Keeping Up with COVID-19

34 In Memoriam Eric Holm, MD, FACS, FAAN

23 What to Know About the COVID-19 Virus and Vaccinations in Pennsylvania Children

35 A Berks Health Initiative: 9 Years Getting Gutsy

25 6th Annual Drug Take Back Event 26 Caron Opens First-Of-Its-Kind Center for Medical Research

Medical record BERKS COUNTY MEDICAL SOCIETY

Berks County Medical Society BECOME A MEMBER TODAY! Go to our website at www.berkscms.org and click on “Join Now”

In Every Issue 4 6

President’s Message Compass Points

8

Editor’s Comments

Cover Photo - Wayne Becker, Zerbe Studio of Photography Content Submission: Medical Record magazine welcomes recommendations for editorial content focusing on medical practice and management issues, and health and wellness topics that impact our community. However, we only accept articles from members of the Berks County Medical Society. Submissions can be photo(s), opinion piece or article.

Typed manuscripts should be submitted as Word documents (8.5 x 11) and photos should be high resolution (300dpi at 100% size used in publication). Email your submission to info@berkscms.org for review by the Editorial Board. Thank YOU!

POSTMASTER: Please send address changes to the Berks County Medical Record, 2669 Shillington Rd, Sinking Spring, PA 19608, Ste 501.

Hoffmann Publishing Group, Inc., 2669 Shillington Road, #438, Sinking Spring, PA 19608

w w w. H o f f p u b s . co m

For Advertising Information & Opportunities Contact:

Alicia Lee 610-685-0914 x210 Alicia@Hoffpubs.com Sherry Bolinger 610-685-0914 x202 Sherry@Hoffpubs.com

President’s Message

Dear BCMS Member, Jillian Ventuzelo, DO President

Attention Members with local Rental Properties: Our Medical Students Need Your Help!

As our own Society begins to re-evaluate the values and needs of our medical community, we also must focus on our future. As our Medical School continues to grow and increase its activity in our community, we as Society members must be there to support and mentor these students. To that end, our Executive Committee has begun to explore potential new events, scholarships, and programs to support our new student-members.

Please stayed tuned as these initiatives began to take shape, but in the meantime, there is a pressing issue that perhaps we can help address immediately. With the current economic and housing issues we are facing, it is no surprise that our incoming Medical Students are struggling to find affordable housing opportunities here in Berks County. Every effort is being made to provide housing solutions for these students, but this is a serious and challenging issue and BCMS can help in being part of the solution.

“So here is our ask: if you have or know of any Berks County rental property for our current and incoming medical students, please contact our Executive Director, T.J. Huckleberry, at tjhuckleberry@Berkscms.org.”

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M e d i c a l R e c o r d F e at u r e C o mpa s s P o i n t s

County CME Collaboration Initiative (CCCI)

T.J. Huckleberry, MPA Executive Director

S

tarting in 2023, the County Medical Societies and PAMED will launch a new and exciting endeavor to provide free accredited CME courses for our members,

virtually and/or in person.

The County CME Collaboration Initiative (CCCI) will offer monthly education, fostered by County Medical Societies, and supported by PAMED, which will not only provide free CME but also open dialogue and ideas through new and diverse speakers and content from across Pennsylvania.

Each month, an in-person or virtual educational event will be facilitated by one of our sister counties or PAMED and uploaded to PAMED’s online learning platform for all members to view at their leisure.

Through the work of the CCCI, in the coming months counties will be able to promote an enduring library of instant educational content for our members to utilize. We hope this new and exciting value will not only help alleviate the financial burdens and time restrictions facing all our members, but also attract new members.

6 | www.berkscms.org

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E d i t o r ’ s C o mm e n t s

“EXAMPLE IS NOT THE MAIN THING IN INFLUENCING OTHERS, IT IS THE ONLY THING” – ALBERT SCHWEITZER

by D. Michael Baxter, MD

I

f there ever was a time for inspired, principled, and competent leadership, that time is now. From world affairs to economic policy to just how we live together on this planet, our world is in need of great leaders. Of course, the same is true with health care when the realities of fiscal restraints, universal access, high quality and promising, but costly, technology intersect in a most challenging environment. How we balance these factors in the years ahead will not only affect the lives of all but define us as a society.

In this issue of the Medical Record, we celebrate two significant events in the history of Medicine in Berks County. Charles Barbera, MD, (known to everyone as “Chuck”) has been appointed as the first physician President and CEO of Reading Hospital in its 155-year history, a defining moment for the future of this institution as well as health care in the Berks County region. Also, Gianfranco Toso, MD, former Chief of Otolaryngology at Reading Hospital for over 20 years, is retiring from his medical practice after nearly 60 years serving the patients of Berks County.

While their careers are at least a generation apart, they shared traits which have contributed to the best of health care in Berks County. Both are highly competent in their specialty fields, Dr. Barbera in Emergency Medicine, and Dr. Toso in Otolaryngology.

Dr. Barbera led the busiest Emergency Department in Pennsylvania for many years and oversaw the development of new facilities as well as new innovative programs to improve ED services. Dr. Toso 8 | www.berkscms.org

not only led his section for many years, he also was instrumental in bringing improved innovative care to Berks County, including microsurgery for chronic ear disease and the first successful cochlear implant in Pennsylvania. These are only a few of the contributions they have made for improved health care for patients as well as collegial support for their peers.

While their ages may suggest differences between them, there are also many similarities (and not just an Italian family heritage!). As mentioned, both excelled in their fields, but they did so in a very humane manner with an abundance of talent, professionalism, and humor. It is not surprising when both responded to questions about their approach to medicine and advice for young physicians that it was to “Put the patient first” and “Listen to your patient.”

We celebrate Dr. Barbera’s appointment and the outstanding compassionate career of Dr. Toso. Physician leadership will be essential to our success as a health care system and as a profession. While others certainly contribute expertise to hospital administration, I am reminded that physicians swear an oath “to put patients first.”

Congratulations, Drs. Barbera and Toso and the very best wishes from your admiring colleagues for continued future health and success. You have truly led by example, and we are all better due to your efforts.

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M e d i c a l R e c o r d F e at u r e

Celebrating the Retirement of

Gianfranco Toso, MD

by D. Michael Baxter, MD

Photo - Wayne Becker, Zerbe Studio of Photography

In 1964, a new hot British rock band named “The Beatles” appeared for the first time in America on the Ed Sullivan Show, a new President, Lyndon Johnson, was adjusting to his role while gearing up for a Presidential election against Republican candidate, Senator Barry Goldwater, the Phillies, led by Jim Bunning and Johnny Callison, were on their way to what seemed like an inevitable National League pennant (don’t ask how that turned out), and Gianfranco Toso, MD, opened his Otolaryngology practice on North Fifth Street in Reading.

Now nearly 60 years later, Dr. Toso is retiring from medical practice and as a leader for innovative Ear Nose and Throat care as the Senior physician in Berks E.N.T. Surgical Associates, Inc. The Berks County Medical Society, of which he has been a member for more than 50 years, his many admiring colleagues, friends and patients, join in celebrating his memorable career and thanking him and his wife, Kathleen, for their long commitment to Berks County.

The following is summarized from a recent interview conducted by the Editorial staff with Dr. Toso.

He was born in Pordenone, Italy, a small city north of Venice, the only child of a local dentist and his wife. While his family was certainly comfortable, Gianfranco emphasizes that in Europe, especially at that time, you were either part of the wealthy elite or not. Much of his childhood was spent under the reign of Benito Mussolini, the dictator who led Italy into World War II. Gianfranco remembers how jubilant he felt as a teenager when American troops liberated his hometown and for the first time in his life, he felt truly free. He feels strongly that contemporary Americans do not appreciate their freedoms and implores us not to throw them away in pursuit of our own demagogues.

10 | www.berkscms.org

He attended medical school at the University of Bologna (1950-56) and then earned a Doctor of Dentistry degree at the same institution in honor of his father’s profession. During medical school he had a foreign roommate (Vito) from the United States who returned home after medical school. Two years later, after graduation from dental school, he had little certainty of what to do next when he received a life-changing letter from St. Francis Hospital in Trenton, N.J, inviting him to apply for an intern position. Vito had recommended him to the St. Francis staff. Speaking almost no English, he took a leap of faith and started his US medical career that would last over 60 years.

According to Gianfranco, he became a favorite of the Nuns at St. Francis and one of them suggested he continue his training at another Catholic Hospital—St. Joseph’s, in some place called Reading, PA. (At St. Francis he had an intern roommate by the name of Christopher Beetle who would later follow him to Reading and practice as a highly regarded General and Cardio Thoracic surgeon.) Following his surgical training, Gianfranco then completed an Otolaryngology residency at Newark Eye & Ear Infirmary, Newark, NJ. As he approached the end of his Otolaryngology residency, he had no idea what he planned next. He decided to drive to Reading on a Sunday, walked into Reading Hospital, and asked the surprised operator on duty if she knew if they needed an Otolaryngologist. She phoned Dr. Wiest, the Chief of Otolaryngology, who came in from home, interviewed him, and practically hired him on the spot (a far cry from the elaborate contemporary process for hiring a new physician!), following a subsequent interview with Dr. McShane, the Chief of the Medical Staff.

The rest is history—and led to Dr. Toso opening a first practice site on North Fifth Street in Reading in 1964, followed by a merger with David Cope, MD, to

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form the Toso-Cope Ear, Nose & Throat Clinic in 1969. Then in 1971 the practice moved to the newly constructed Doctors Office Building in West Reading and became the Berks E.N.T. Surgical Associates, Inc. in 1972.

During his career, Dr. Toso served as the Chair of the Section of Otolaryngology

at the Reading Hospital from 1973-1996.

He has of course seen thousands of patients and conducted similar numbers of surgical procedures. His colleagues have relied on his expertise time and time again for advice and guidance. Among his professional accomplishments he is most proud of his work in developing new treatments for continued on next page > SUMMER 2022 | 11

Celebrating the Retirement of Gianfranco Toso, MD continued from page 11

chronic ear infections and cochlear implants. He performed the first microscopic surgical procedure, a stapedectomy, at Reading Hospital. In addition, he has been recognized for his pioneering work on cochlear implants. Under his direction, Reading Hospital in 1986 was the first hospital in Pennsylvania to successfully complete a cochlear implant. He pointedly credits former Reading Hospital Audiologist, Elca Swigart, PhD, for her forceful advocacy for this surgery. He is also very proud and still somewhat incredulous that he and Dr. Swigart presented their clinical statistics to a prestigious European Conference on Cochlear Implants, held in his home country of Italy, the only Community Hospital represented.

Dr. Toso is also proud of his five accomplished children and his marriage of 52 years to his wife Kathleen. He gives her much credit for his professional success and balance in his life.

They have traveled widely and have acquired an extensive art collection in their beautiful home.

As for advice to his fellow physicians and especially our younger colleagues, he emphasizes two points: 1) Listen to the patient and 2) Accept failure. Regarding this last point, he recounts his experience with a renowned Swedish heart surgeon in the 1950s. As a student, he assisted with a new procedure on a young patient who subsequently died. He was devastated and approached the surgeon, asking if he felt similarly. He

12 | www.berkscms.org

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Dr. Toso also wants to emphasize that although the US health care system is not perfect, this country remains the best place in the world to practice medicine and offers the most opportunity, especially for young physicians.

The Berks County Medical Society joins the many colleagues, friends and patients of Gianfranco Toso, MD, as we honor him for his nearly sixty-year medical career in service to the people of Berks County and our region. His knowledge and skill, his humor,and his commitment to the very best aspects of medical care have made us a healthier community and a better profession.

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301 S 7th Ave Suite 145, West Reading, PA 19611 continued on next page 610-376-6542 SUMMER 2022 | 13

M e d i c a l R e c o r d F e at u r e A Conversation

with

Charles Barbera, MD President

and

CEO, R e a d i n g H o s p i t a l

Photos - Wayne Becker, Zerbe Studio of Photography

Editors: Congratulations, Dr. Barbera, on your selection by the Tower Health Board of Directors as President and CEO of Reading Hospital. Over the past 25 years you have had several roles at Reading Hospital beginning as a young Emergency Medicine physician.

How does it feel at this point to find yourself in this very important leadership position? Could you have imagined this when you first walked through the doors of Reading Hospital those many years ago?

Dr. Barbera: Thank you. I can honestly say that I had never considered entering hospital administration. Actually, it was quite by accident that I became the acting director of Emergency Medicine in 1999.

When I went to medical school, I assumed that my career would consist of 100% Clinical Medicine.

Editors: Would you review your background with us— where you grew up, went to college, medical school, and completed your residency in Emergency Medicine?

Dr. Barbera: I grew up in Northeast Philadelphia. I went to LaSalle University where I earned a Bachelor of Arts degree in communications. I then went on to the University of Pennsylvania to complete their post baccalaureate pre health program. I graduated from the Temple University School of Medicine, and I completed a residency in Emergency Medicine at Thomas Jefferson University Hospital. I also completed a Master of Business Administration degree at Alvernia University and a Master of Public

14 | www.berkscms.org

Health program at the George Washington University.

Editors: What led you to choose a career in medicine and in particular emergency medicine? Were there individuals that helped you choose a career path?

Dr. Barbera: I originally was planning on entering Family Medicine. During my fourth year of medical school, I did my EM rotation, and became excited by the acuity, variety, and flexibility of Emergency Medicine.

Editors: How did you happen to accept your position as an Emergency Medicine Physician at Reading Hospital? Was this your first job out of residency?

Dr. Barbera: This was my first job after residency. My wife, Mary, is from Berks County, and we chose to settle here. I interviewed at many of the hospitals in the area, and this was the place where I felt at home. The culture and environment were exactly where I felt at home.

Editors: You have spent essentially your entire career at Reading Hospital. You and your wife, Mary, have raised your family here. How has this experience in Reading been for you and your family? Do you feel there are benefits to spending a career in one institution as opposed to developing skills at a variety of locations?

Dr. Barbera: Actually, I believe spending my entire career at Reading Hospital has been beneficial for me. Practicing Emergency Medicine at Reading Hospital is a fantastic experience. The facilities are unmatched as are the medical and nursing staff. I have been fortunate to practice in a variety of Tower Health facilities including Chestnut Hill Hospital, Phoenixville Hospital, and Pottstown Hospital. I have also served in a provider capacity at Tower Health Urgent Care. These have allowed me to expand my experiences beyond the walls of Reading Hospital.

Editors: You have quite a list of accomplishments. Somehow during a very busy career in medicine you found both the time and energy to obtain your MBA and MPH degrees. How did you manage that? How will these help you in your new leadership role at Reading Hospital?

Dr. Barbera: One of the benefits of being an emergency physician is that you have some flexibility to arrange to continue your studies. I was fortunate enough to participate in the Alvernia University/Reading Hospital MBA cohort that graduated in continued on next page >

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A Conversation with Charles Barbera, MD, President and CEO, Reading Hospital continued from page 15 of patient care. I will continue to focus on the patients and on our staff. They, by far, are our greatest assets. The priority is to make sure that we can provide access to the patients we serve and have the ability to maintain a strong medical staff to deliver the care our community needs.

Editors: Reading Hospital is one of the largest employers in our area and has a long and respected history of serving the health needs of Berks County and beyond. What are your thoughts about the past, present and future role for Reading Hospital in our community? Will that role change going forward?

December of 2001. It was a great experience as I studied with nine of my fellow physicians, many of whom are still practicing today. As the Reading ED became busier, I began to see that many people used the ED for problems that could be better served elsewhere, yet they had nowhere to go. That was basically the motivation behind my getting the public health education.

Editors: This is of course a challenging time in health care (to put it mildly). Your leadership team has struggled through the worst pandemic in 100 years, faced staffing shortages, seen the impact that non-medical “social determinants of health” have on the lives of our patients and faced the financial realities of US health care, particularly those facing Tower Health at this time. You have a daunting task before you. How will you approach your new role? What are your priorities?

Dr. Barbera: Well, I am afraid I do not have a magic answer to the questions that you pose. My approach is the same as my approach has always been throughout my career. They are the lessons I learned from my professor in my freshman year at Temple medical school. His name was Dr. D. Michael Baxter. He taught me to put people first, to do the right thing, and to pay attention to all the details including the biology, psychology, and social aspects

16 | www.berkscms.org

Dr. Barbera: Reading Hospital has been here for over 150 years. It is my intention to ensure that it will be here another 150 years. Reading Hospital has always been a prominent part of the healthcare and economic community in Berks County. In addition to employing nearly 8000 people, many in our community receive care at Reading Hospital whether from our obstetrical unit which delivers over 3000 babies a year to our emergency department which is the busiest in Pennsylvania. Reading will continue to be a major healthcare and educational influence in Berks County. We house over 100 graduate medical residents, and have other programs in nursing, surgical technology, diagnostic imaging, and laboratory sciences. We also partner with the Drexel University School of Medicine.

Editors: Since your arrival in Berks County, you have been an active member of the Berks County Medical Society including serving a term as President. Would you share your thoughts about the importance of the Medical Society even as interest in such organizations seems to be waning among many physicians? After almost 200 years, is there still a role for our Medical Society promoting health care and supporting physicians in 2022?

Dr. Barbera: Now more than ever, in 2022, organized medicine is important. The operations and finances of healthcare have long

Tompkins Healthcare Services Suite been delegated by physicians to those in the non-clinical arena.

As we go forward and continue providing state of the art, cost efficient quality care, it is important that the providers of this care be present to direct public policy. The beauty of the Berks County Medical Society is that it is not related to a single Health System.

The medical society can bring together physicians without regard to where they practice, what they practice or who they treat. The medical society focus is on professionalism, education, collegiality, and advocacy. These issues will continue to be important to ensure quality healthcare for our community.

Editors: Your son Spencer is a medical student at Tulane University in New Orleans. What advice do you offer him, and would you offer our next generation of physicians who are entering health care at a time of great challenges but great opportunities?

Dr. Barbera: I think the most important message I could give someone is that this is truly a rewarding career. There are challenges, but the benefits of being a physician outweigh any trials that we may face. Being a physician is not an occupation, it is a vocation. It is also a privilege. There should never be a time when any of us take that privilege for granted. It is true that medicine will not be the same in our children’s lives as it was in our parents’ lives.

However, the students of today are able to mold what medicine will look like for generations to come. If I could do it all again, I would take the same route. I am honored to be able to be included in the medical community.

Editors: Thank you for sharing your thoughts with us. We certainly offer our support and best wishes to you as you lead Reading Hospital forward. Do you have any additional comments for your colleagues as you look toward the future of health care in Berks County and beyond?

Dr. Barbera: I think the message I would like to leave with my colleagues is that now more than ever, our profession needs us.

But it is also important for us to understand that the needs of our community, and the needs of our future physicians, may be different than they were for us. That is okay. One thing we learned in medicine is that we are never done learning and we are never done evolving. That is how we become better. Thank you for allowing me to share these thoughts with you.

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ALL SURGERY PERFORMED IN BERKS COUNTY

Steven M. Presciutti, MD Fellowship-Trained Spinal Surgeon

• Pain Management • Physical Therapy • Epidural Injections • Spinal Surgery

2607 Keiser Blvd, Suite 200, Wyomissing, PA 19610 484-509-0840

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M e d i c a l R e c o r d F e at u r e

An Urgent Issue:

Climate Change and the Physicians for Social Responsibility Pennsylvania

by Susan Robbins, MD, MPH, Poune Saberi, MD, MPH, and Tonyehn Verkitus

P

hysicians for Social Responsibility Pennsylvania (PSR PA) is a non-profit organization through which a variety of health professionals in the state address “the greatest threats to public health” and advance the greatest public health opportunities of our century. Its mission is to “promote socially and environmentally responsible practices, policies and programs to safeguard and improve public health” with particular concentration on climate change and environmental health issues along with efforts to prevent violence and ban nuclear weapon proliferation (with the last item being a founding objective of the national PSR organization). As the World Health Organization in 2021 described climate change as the “single biggest health threat facing humanity” while it called for organizations to “act with urgency,” it is certainly appropriate that PSR PA considers addressing climate change to be one of its highest priorities.

Climate change is of great concern throughout our state, our country and the world because of the magnitude and rapid rate of the change that is occurring. Human activity has led to increased greenhouse gases in the atmosphere and deforestation, considered two of the primary causes of climate change, with much of the greenhouse gas emissions from the U.S. being due to the burning of fossil fuels for electricity, heat and transportation. According to the U.S. Department of the Interior, Earth’s rise in surface temperature is leading to a decrease in sea ice and land ice (glaciers), an increase in permafrost thawing, an increase in heat waves along with heavy precipitation in many areas, and decreased water resources in semi-arid regions. Each of these changes is having devastating effects around the globe. In the northeast of the United States, the number of heavy precipitation events have increased by more than 70% since the 1950s and the climate stands to get hotter and wetter in the next decades.

Why is climate change a threat to health? Some of the threats include the following: • Warmer climates are causing increases in water-borne, food-borne, and vector-borne diseases including Zika and Lyme disease, which is now being reported in every Pennsylvania county • Air pollution, especially from the burning of fossil fuels, is multiplied in a warming climate and adversely affects those with asthma and other respiratory ailments and is even associated with increased death rates • Increasing numbers of floods, storms and heat waves are causing injuries, accidents and death to thousands • Rising sea levels are destroying homes, communities and places of employment • Drought and flooding are affecting food production and access, leading to more incidences of food insecurity and hunger • Longer periods of warm weather are leading to longer pollen seasons (particularly affecting those with allergy-related disorders), and more smog and mold issues

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Along with such life-altering experiences, often not taken into consideration are the mental health issues that are additionally occurring with climate change – partially due to more physical illnesses, family deaths, home and job losses, food insecurity, and other challenges. Depression, anxiety, social unrest and post-traumatic stress disorder all have been linked to persons experiencing the adverse effects of climate change.

As with most health issues, people living in poverty, particularly minorities, along with the very young, the elderly and those with chronic health conditions, are being most adversely affected by climate change. Children in particular are also being affected by what is being called “eco-anxiety.” Children are paying attention and they understand that their future health and prosperity are being threatened from inaction by those in charge, and they feel powerless to do anything about it. According to Dr. Ned Ketyer, pediatrician and PSR PA’s board president, “Children’s fears about climate change are well founded and shouldn’t be dismissed by the adults in their lives.” When possible, having children see responsible adults take positive actions on climate change helps to reassure them that their concerns are being addressed, and their futures are being considered.

What strategy is PSR PA using to address the issue of climate change?

1. Ensure that public health professionals and public health messaging are front-and-center in Pennsylvania’s efforts to tackle climate change.

2. Ensure that decision makers are hearing from health professionals about their concerns surrounding climate change.

3. Mobilizing and expanding the network of public health organizations, officials and experts in Pennsylvania who can speak to the issue of the threats posed by climate change.

Knowing that time is of the essence to address climate change, PSR PA is on the move using its strategy noted above. Currently it is participating in or leading conferences on climate change and environmental health such as The Pennsylvania Climate Convergence, and COP27: A Regional Response to Climate Action Health and Equity, both conferences taking place in June 2022.

More conferences are planned. PSRPA is also offering two CME programs regarding climate change: 1. The Climate Emergency Film Club, a 5-part science documentary and panel discussion series which explores how human activity is setting off Earth’s own warming loops that

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are pushing the climate to a point of no return and what can be done to stop them; and 2. OCAREER, a certificate program to assist practitioners in assessing how climate change is impacting health. The new mnemonic, OCAREER, stands for occupation, conditions, activities, residence, environmental conditions, education and resources. OCAREER has eight online, asynchronous modules which contain a slide deck and an article to read. 4 CME credits are available to physician participants, 4 CEUs for pharmacists, and 4 CEs for nurses.

For those interested in learning more, PSR PA can provide knowledgeable speakers and presentations, particularly through their Education and Advocacy Council, and can conduct general advocacy skills trainings, especially suited for health care professionals or students. Additional information regarding past PSR PA activities, including educational presentations on climate change, can be found on its website: www.psrpa.org. There you will also find archived informative videos, articles, op-eds, and relevant interviews with PSR PA speakers.

PSR PA welcomes health care professionals and students who are interested in and concerned about climate change to reach out and join its efforts, especially by signing up through the Education and Advocacy Council (email: info@psrpa.org). Utilizing their background knowledge and expertise, the professionals and students can work alongside PSR PA staff to send messages that have weight. Their voices are needed to speak out about the health threats posed by climate change — an urgent issue!

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M e d i c a l R e c o r d F e at u r e

Dr. Mira Irons, President and CEO of The College of Physicians of Philadelphia

by Karen L. Chandler

Leading The College of Physicians of Philadelphia since August 2021, Mira Bjelotomich Irons, M.D., FACMGG, FAAP, FCPP, talks of her past, the journey which brought her to her current role, and her hopes for the future of The College.

As the first woman leader in the College’s history, Dr. Mira Irons is inspired to bring her skills to both the organization and the surrounding area to both address current issues and share the impacts of medicine.

“Women like to be collaborative,” Irons said. “We like to bring groups of people together to work together. There are many organizations in the Philadelphia area: medical schools, and hospitals, the county medical society and specialty societies, in addition to cultural institutions. Identifying ways that the College can work with some of the other groups in Philadelphia to advance their mission and convene around important issues is one thing that benefits from being able to bring people together. I’d like to be able to do that.”

A Chicago native, Dr. Mira Irons was the only child of World War II refugees from the former Yugoslavia. Irons’ upbringing focused on the importance of education and the breadth of opportunities available in the United States.

The emphasis on education impacted Irons’ early life, as she remained an engaged student who committed to a career as a physician during her high school years.

Irons was accepted into a six-year medical program at Northwestern University, an event which decided her future. She graduated from medical school at age 23 and entered a threeyear pediatric residency at Children’s Memorial Hospital, the Northwestern pediatric program in Chicago, followed by a three-

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year fellowship in medical and biochemical genetics in Boston.

Her move to Boston set in place the next thirty years of Irons’ career in medicine.

The years in Boston were spent in a fellowship in Genetics at the Boston Children’s Hospital and Massachusetts General Hospital, followed by caring for patients as a pediatric geneticist at Tufts Medical Center, and a return to Boston Children’s Hospital where she served as the clinical Chief of Genetics and Metabolism.

Irons also acted as program director for the Harvard Medical medical genetics and laboratory training programs, continued a busy clinical practice, and remained active in research during her time in Boston.

A job opportunity arose for Irons to become the Senior Vice President of Academic Affairs at the American Board of Medical Specialties (ABMS), the umbrella organization of medical certifying boards, and allowed Irons to move back to Chicago to be nearer to her parents.

“I had participated in a lot of national leadership work in genetics and medical education, so when this opportunity came up it was really to do something different. It was to impact medical care on a national basis as opposed to only within my specialty,” Irons said.

A position as the Chief Health and Science Officer for the American Medical Association followed the ABMS. Irons describes the role as giving her a deeper understanding of how to work with advocacy groups at the AMA at both the state and national levels to support physicians and help protect patients.

“The pandemic hit while I was there and given my role, I became the point person to provide the necessary thought leadership with regard to the pandemic, to work with all the groups across the AMA and inform their efforts. It was COVID, 24/7, all COVID

all the time. We were all going through it together,” Irons said. “I can’t tell you how much I learned from the advocacy group at the AMA about really advocating for physicians to be able to care for their patients in the manner they should be cared for and to be sure people are cared for appropriately.”

Almost two years later, Irons decided to accept her role at the College of Physicians, a historic institution she describes as sitting at the intersection of medicine, public health, and the public, serving to convene important conversations that are not just within medicine, but impact public health and the public.

Physicians have always been aware of history, according to Irons, and she believes that this understanding of the progression of science and how that informs new diagnoses and new therapies positively impacts health and provides hope for many people.

“It’s important that we are reminding people of medical progress and making them aware of the human stories of newly characterized diseases and new therapies,” Irons said of the mission of the College.

The College of Physicians also has a history of inspiring young people to careers in medicine, according to Irons. She speaks with pride of the programs which target historically underrepresented students from the Philadelphia community and focus on stimulating interest in STEM and health care careers.

Irons said, “I’d love to expand our educational programs and be able to provide more programs for other young people who may not have a clear path to medicine. There were no doctors in my family, so I had no idea how to follow that path, but fortunately I had a guidance counselor who helped, and I asked a lot of questions. We could be that resource for young people. “ Looking toward the future, Irons hopes the College can provide both enhanced exhibition spaces and public events to continue sharing the history of medicine in Philadelphia, stories of innovation and the impacts of medicine, plus providing a place for the public to ask questions or raise concerns.

Irons is enjoying her life in the Philadelphia area, noting how she loves the diversity, the people, and the history of the city.

“You can’t escape history when you walk around the city and how history is juxtaposed with innovation and learning and moving toward the future. You see it in the architecture, and you see it in the educational systems,” she said.

Currently a resident of Moorestown, New Jersey, Irons has a daughter who is following in her footsteps toward a career in medicine and a son who is a teacher.

The importance of her role at the College of Physicians and its place in Philadelphia is not lost on Irons as she reaches a year in her position as its president and CEO. “I love Philadelphia and it’s the perfect city for the College because Philadelphia is the birthplace of American medicine, the first college, the first medical school, as well as the home to many specialties and societies. There are many firsts from a historical perspective, but there are also a lot of firsts from today: mRNA vaccines, cancer immunotherapy, gene therapy. All of that happened in Philadelphia and continues to happen in Philadelphia. We are telling those stories to not only inspire young people to careers in science and health care but also to inspire patients and provide hope.”

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Keeping up with COVID–19

by Debra Powell, MD Chief, Division of Infectious Diseases Medical Director, Infection Prevention Tower Health WHERE ARE WE NOW REGARDING COVID-19, VARIANTS, INFECTION RATES, AND SEVERITY INCLUDING HOSPITALIZATIONS AND DEATHS? We are in a fortunate position where we have a significant proportion of the population immunized or with some natural immunity, and the current COVID-19 variant causes predominately milder symptoms than prior variants, although it is more infectious.

There is a small percentage of patients that still develop severe disease and require hospitalization.

We continue to see COVID-19 variant evolution and are currently seeing the COVID-19 Omicron variant BA.2.12.1 as the predominant strain. There are new COVID-19 Omicron variants circulating, named BA.4 and BA.5, which will probably become the predominant strain in the next few weeks. These variants are more infectious than prior variants but do not produce more severe symptoms.

WHAT IS YOUR BEST GUESS AT WHERE WE ARE HEADED OVER THE NEXT SEVERAL MONTHS? I anticipate that we will have new COVID vaccines by the fall that will be modified to cover the emerging variants. Vaccine

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manufacturers are developing a bivalent vaccine to target both the original strain plus the Omicron variant.

I also expect that the Novavax vaccine will be approved shortly which will provide an alternative vaccine using a traditional proteinbased technology. This may be better accepted by those patients who were vaccine hesitant due to the mRNA technology.

PARTICULARLY AS HEALTH CARE PROFESSIONALS, WHAT CAN/SHOULD WE BE DOING AT THIS POINT TO REDUCE INFECTION RATES AND PLAN FOR ANY FUTURE SURGES ESPECIALLY IN FALL AND WINTER? I would recommend that health care professionals recommend that their patients, and themselves, stay up to date on their COVID-19 vaccinations. This is especially important for persons with significant risk factors. Vaccination lowers the risk of severe disease requiring hospitalization and prevents death. When the vaccine is approved for all ages, younger children should also be vaccinated to COVID-19.

M e d i c a l R e c o r d F e at u r e

What to Know About the COVID-19 Virus and Vaccinations in Pennsylvania Children

C

by Rachel Hahn, MPH, Berks Immunization Coalition, Immunization Coalition Coordinator, PA Chapter, American Academy of Pediatrics

an children be infected with COVID-19 at the same rate as adults? What are the side effects of COVID-19 infection in children? Can they suffer from long-term COVID? Is the COVID-19 vaccine needed? These questions, along with many others, have been racing in parents’ minds since the start of the pandemic in 2020.

With the Pfizer-BioNtech and Moderna COVID-19 vaccines having recently received Emergency Use Authorization from the CDC now for children 6 months to 4 years of age as well older children and adolescents, the side effects of COVID 19 and these vaccines is a topic that deserves to be addressed and clarified for parents in Berks County.

Circulating unscientific reports give the impression that the side effects of the vaccination are worse than the effects of being infected with the actual virus. These reports are often propagated through avenues such as social media. For example, a common misconception is that myocarditis, inflammation of the heart muscle, is a likely side effect of the COVID-19 vaccine when in reality, it is more likely to develop from a COVID-19 infection. According to CDC data updated on May 4, 2022, the overall risk of heart conditions after a COVID-19 infection is higher than after the first

shot. Taking all ages, genders, and both vaccine doses into account, the risk of a heart issue after a COVID-19 infection was anywhere from 1.8-5.6 times higher when compared to vaccination.1 In the U.S., children under age 18 are contracting COVID-19 at the same rate as adults. As of May 26, 2022, over 13 million children have tested positive for COVID-19.2 The symptoms of the COVID-19 virus are similar in both adults and children, as is the risk of developing long-term effects from the infection. While the symptoms of the disease in children are mild in most cases, the side effects of the COVID-19 vaccine can be even milder and are shorter in duration. The side effects that occur from the COVID vaccination are no different from the side effects that amount (substitute arise for amount) from any other routine childhood immunization. These side effects can include a sore arm at the injection site, mild fever, headache, chills, nausea, and tiredness, and all typically subside 24-48 hours after receiving the vaccine.

Children can also receive the COVID-19 vaccine simultaneously as their other routine immunizations, like the influenza vaccine.

Since the start of the pandemic in 2020, there has been a decline in routine childhood and adolescent immunizations. According to recent Pennsylvania data, more than three-quarters of providers continued on next page >

helpfightcovid.com

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M e d i c a l R e c o r d F e at u r e What to Know About the COVID-19 Virus and Vaccinations in Pennsylvania Children continued from page 23 in the state reported having to close at some point during the pandemic, which resulted in thousands of missed routine childhood visits. Recently, the Pennsylvania Immunization Coalition (PAIC) conducted research on the difference in routine childhood and adolescent immunization rates from 2018 to 2021, pre- and mid-pandemic.3 The goal of this research was to determine if any counties in Pennsylvania were susceptible to outbreaks of preventable diseases due to diminished immunization rates. The data for this research was taken from the Pennsylvania State Immunization Law Report (SILR), which is accessible through the PA Department of Health website and includes the following

Valuable vaccination work is underway worldwide that allows us to answer these questions and provide resources for county residents, including work that is being done right here in Berks County. Working underneath the umbrella of the PA Immunization Coalition (PAIC) and the PA American Academy of Pediatrics, the Berks Immunization Coalition (BIC) is an organization that promotes recommended immunizations for all Berks County residents across the lifespan. Berks County currently has over 62% of its residents fully vaccinated for COVID-19, ranking it in the top 30% of all Pennsylvania counties.5 To improve these numbers, the Berks Immunization Coalition is conducting various campaigns throughout the county. Currently, the coalition is advocating for The vaccine is safe and effective COVID-19 vaccinations for children and with billboard and bus adolescents. advertisements (see photos of ads to left and on page 23). These advertisements because nearly 1 in 5 COVID-19 will collect millions of cases are in children. impressions throughout their run and direct viewers to the COVID Resources helpfightcovid.com page at HelpFightCOVID. com. On this page, visitors can find scientific and reputable information about vaccines: measles, mumps, and rubella (MMR); polio; chickenpox COVID-19, the COVID-19 vaccine, and how and where to receive (Varicella); hepatitis B; diphtheria, tetanus, and pertussis (Dtap/ their vaccine. In addition, the BIC is advertising with commercials DTP/DT); tetanus, diphtheria, and pertussis (Tdap/Td); and on Q102 Philly and Y102 Reading with ads airing every day meningococcal disease (MCV). When looking at the childhood that direct listeners to the same webpage as the billboard and bus vaccines (Dtap/DTP/DT, HepB, MMR, and Polio), there was a advertisements. For more information on the BIC, scan the QR less than 1% decrease from 2018 to the 2020-2021 school year. codes to be taken to their webpage on the PAIC website or the However, when looking at the adolescent doses of vaccines, there BIC Twitter page! was approximately a 4% decrease (~10,000 students) in the same 1 date range. Looking at this data, it’s clear that the pandemic not “Cardiac Complications After SARS-CoV-2 Infection and mRNA COVID-19 Vaccination — PCORnet, United States, January 2021–January 2022”, Morbidity and only has an impact on children regarding COVID-19, but it also Mortality Weekly Report (MMWR), Centers for Disease Control and Prevention, https:// has an effect on routine medical visits and immunizations that take www.cdc.gov/mmwr/volumes/71/wr/mm7114e1.htm#:~:text=Previous%20CDC%20 place throughout their lives. estimates%20found%20the,19%20vaccine%20dose%20(5).

I vaxxed my kid.

Another common question is whether to vaccinate your child even if they have already contracted COVID-19. The short answer – yes. Although contracting the virus provides a form of natural immunity, it does not last as long as the immunity provided by the vaccine. People who already had COVID-19 and do not get vaccinated after their recovery are more likely to get COVID-19 again.4 Not only does the vaccine provide stronger immunity, but vaccinating your child also decreases transmission from new variants. The virus transmits efficiently between unvaccinated children and adults — getting vaccinated reduces the virus’ chance of mutating into new, potentially more dangerous variants.

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“Children and COVID-19: State-Level Data Report”, Critical Updates on COVID-19, American Academy of Pediatrics, last modified May 19, 2022, https://www.aap. org/en/pages/2019-novel-coronavirus-covid-19-infections/children-and-covid-19state-level-data- report/#:~:text=Since%20the%20pandemic%20began%2C%20 children,hospitalizations%20and%20mortality%20by%20age.

2

“Pennsylvania Routine Immunization Rates: Pre-Pandemic and Now (2018-2021)”, Blog, Pennsylvania Immunization Coalition, last modified May 17, 2022, https:// www.immunizepa.org/pennsylvania-routine-immunization-rates-pre-pandemic-andnow-2018-2021/ 3

“Getting a COVID-19 Vaccine”, COVID-19 – Vaccines, Centers for Disease Control and Prevention, last modified March 4, 2022, https://www.cdc.gov/coronavirus/2019ncov/vaccines/expect.html.

4

“COVID-19 Vaccine Dashboard”, Coronavirus Vaccine, Pennsylvania Department of Health, last modified June 8, 2022, https://www.health.pa.gov/topics/disease/coronavirus/ Vaccine/Pages/Dashboard.aspx 5

M e d i c a l R e c o r d F e at u r e

6th Annual

Drug Take Back Event

On Saturday, April 23rd, the Berks County Medical Society hosted its 6th Annual Drug Take Back Event.

BCMS once again partnered with District Attorney John Adams, the Federal Drug Enforcement Administration, the Reading Fightin Phils, and the SOS Berks to encourage residents to safely dispose of any unnecessary medications.

Held at First Energy Stadium, it was a drive-through event where participants received complimentary tickets to a Fightin Phils baseball game, later this summer.

This year, about two hundred cars came through, and 472 lbs. of unused prescription drugs were collected, of which 122 were controlled substances.

This year we were especially pleased to be joined by enthusiastic students from the Drexel/Tower Health Medical school.

Thank you to all our volunteers and sponsors for another extremely successful event.

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Caron Opens First-Of-Its-Kind Center for Medical Research

The Fran and Doug Tieman Center for Research, named for Caron Treatment Centers’ former President and CEO, announced the opening of a first-of-its-kind to be located at a nonprofit addiction treatment facility with a focus on medical research. Caron, a leading, internationally recognized nonprofit dedicated to addiction and behavioral healthcare treatment, research, prevention, and addiction medicine education, has already demonstrated a track record of success in medical research. However, the revamped building, featuring state-of-the-art equipment and labs, now offers much-needed space to facilitate more studies. It will also allow for recruitment of individuals interested in participating in research from outside Caron.

The focus of the Center for Research includes crucial components of substance use disorder prevention, treatment and recovery such as identifying genetic markers associated with increased risk for addiction, relapse prediction, and repurposing medications approved by the FDA to treat other diseases.

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“Addiction is a disease of the brain so it’s important for us to understand the biological mechanisms involved,” said Dr. Olapeju Simoyan, MD, MPH, BDS, FAAFP, FASAM, Caron’s Founding Executive Director of Research. “Just as with cancer, diabetes or cardiovascular disease, research is essential to advance our field.”

The Center for Research will also focus on expanding academic partnerships to foster research and train healthcare professionals to apply the most up-to-date, evidence-based treatments in their practices.

The Center for Research is also establishing a pipeline program to engage high school and college students interested in pursuing careers in research and healthcare.

“Research done well requires proper funding, precision, patience and diligence,” said Dr. Joseph Garbely, DO, DFASAM, FAPA, who is the Chief Medical Officer and the Executive Vice President for Medical Strategy, Education and Research at Caron Treatment Centers. “By making this investment, we can substantially improve our understanding of relapse, increase treatment options, and identify tools and markers to make addiction a significantly more preventable and treatable disease.”

Current studies at the Fran and Doug Tieman Center for Research Caron Treatment Centers

• Use of a Glucagon-like Peptide-1 Agonist to Treat Opioid Use Disorder (OUD) UG3/UH3 Grant – Funded by the National Institute on Drug Abuse (NIDA): Collaboration with Penn State College of Medicine The goal of this study is to determine whether an existing FDA approved diabetic/obesity medication (liraglutide) will be effective in treating Opioid Use Disorder (OUD). Liraglutide is a safe and effective medication for weight loss. It works by helping people to feel satiated, thereby reducing cravings and allowing them to make healthier choices. In collaboration with Penn State Hershey and with funding from NIDA, the Caron research team is evaluating whether liraglutide can be repurposed to reduce cravings in people with OUD. • The Efficacy of Suvorexant in the Residential Treatment of Patients with Substance Use Disorder and Insomnia: A Pilot Open Trial in partnership with Penn State College of Medicine.

Research shows that sleep plays a significant role in people’s ability to establish and maintain emotional, mental and physical wellness.

The goal of this collaborative study is to explore whether suvorexant, a sleep medication approved by the FDA, can help reduce the risk of relapse by improving the quality of sleep and reducing cravings.

• Bridge Device Utilization for Opioid Withdrawal in Opioid Use Disorder (OUD) patients: Exploring the use of the Bridge device (an auricular percutaneous nerve field stimulator) as a modality for reducing symptoms of opioid withdrawal in patients during inpatient detoxification. (Anticipated start date: Fall, 2022) Research shows alternative approaches to chronic pain are gaining traction as legitimate options in healthcare. In this instance, we are evaluating whether a nerve stimulation device offers sufficient relief from withdrawal symptoms when compared with a placebo device. If effective, the device could allow for decreased need for pharmacological intervention.

M e d i c a l R e c o r d F e at u r e

Quarterly Legislative Update A

lot of legislation has been going on in Harrisburg in the last couple of months. There was a big win for international medical graduates in April when Governor Tom Wolf signed House Bill 245 into law, which establishes a licensing parity for graduates of international medical schools. This reduces the clinical residency requirement from three years to two years from IMGs to apply for a medical license. PAMED championed this legislation and celebrated this win.

On May 17th, Pennsylvania held is primary election day and there were a lot of interesting results. One loss we saw was for House Appropriations Committee Chair, Stan Saylor (R-) by over 10 percent to his challenger. Another highlight to note, the race for the 86th PA State House District pitted incumbent Rep. John Hershey against incumbent Rep. Perry Stambaugh; Stambaugh won re-election in the new district by 10 percent.

As the legislative session ends in June, there has been a lot of movement on bills we are keeping an eye on: • Venue Rule (House Bill 2660) – Introduced by State Representative Rob Kauffman, institutes Constitutional amendment that will strip the Supreme Court’s ability to establish venue and place the matter in the hands of the legislature. While the Supreme Court has not acted on the proposed venue rule change, it continues to be a threat. PAMED supports the proposed amendment to keep the current venue rule in place.

• Prior Authorization (Senate Bill 225) – The Prior Authorization bill was passed by the Senate on a vote of 50-0. It now goes to the PA House for further consideration. PAMED has been supporting and advocating for prior authorization reform and is supportive of the amended version of Senate Bill 225.

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• Pharmacists Performing Immunizations (House Bill 2679 & Senate Bill 511) – The temporary waiver issuing Pharmacists to perform vaccinations is set to expire on June 30th. The Pennsylvania Pharmacists Association has been advocating for a permanent position for pharmacists to perform all vaccines for children. Working in coordination with the PA Chapter of the American Academy of Pediatrics, the PA Academy of Family Physicians, POMA, and the PA Chapter of the American College of Physicians, an agreement has been reached to allow pharmacists to administer seasonal flu and COVID vaccines to their customers aged 5 and above. The legislation, House Bill 2679, along with Senate Bill 511, contains the compromise language. At this time, it is uncertain as to what vehicle will be approved and sent to the Governor.

• Mental Health Services (House Bill 2686) – Introduced by Rep. Wendi Thomas, this legislation aims to improve access to mental health care in Pennsylvania through the Collaborative Care Model, an integrated care model that can deliver timely psychiatric care in the primary care setting. This grant would create a program for small and solo practices to cover their Collaborative Care Model start-up costs, prioritizing those practices in rural and underserved areas of Pennsylvania. PAMED is in support of these services, and the bill has been referred to the Health and Human Services Committee.

• Fentanyl Strips (House Bill 1393) – This bill amends The Controlled Substance, Drug, Device and Cosmetic Act of 1972, which includes the definition of drug paraphernalia. The Pennsylvania House of Representatives unanimously approved the bill which would legalize fentanyl test strips. PAMED supports this legislation, and the bill has been referred to the Judiciary Committee in the Senate.

• Patient Test Result Information Act Amendment (House Bill 1280) – The proposed legislation amends the current Patient Test Result Information Act to remove the definition of “significant abnormality” and require diagnostic imaging entities to provide patients with written notice that their results will be sent to the ordering health care practitioner, at the time of any imaging service. PAMED supports this legislation and is awaiting approval from the Health and Human Services Committee. We remain hopeful that the bill will win final approval before the end of the legislative session in late November.

In addition, PAMED has written letters in support of the following: • Primary Care Loan Repayment PAMED sent a letter to representatives in support of an increase in funding for the Pennsylvania Primary Care Loan Repayment Program in the 2022-2023 state budget.

• Access to Vision Medications PAMED wrote a letter to the PA Senate Banking and Insurance Committee in support of Senate Bill 1201, expanding access to important sight-saving medicine by authorizing refills for prescriptions at 70% of the original cost.

At the beginning of this year, PAMED launched a new legislative community platform. The platform is a way to get physicians more engaged with legislation and to provide an opportunity to keep up to date on regulation and calls to action.

For more information about any of the items mentioned above, please visit the Advocacy Section of PAMED’s web site at www.pamedsoc.org/advocacy.

As we know very well, Pennsylvania’s prior authorization process is burdensome and inefficient, causing delays in patient care and increasingly undermining decisions made between physicians and their patients.

Now that the PA Senate has approved Senate Bill 225, thank your State Senator for their support and reach out to your representative to encourage their support for passage by the PA House of Representatives.

At the beginning of this year, the American Medical Association issued new survey results on how prior authorization hurts a patient’s workforce productivity.

According to the AMA survey: • 51% of physicians who care for patients in the workforce reported that prior authorization had interfered with a patient’s job responsibilities.

• 34% of physicians reported that prior authorization led to a serious adverse event, such as hospitalization, disability, or even death, for a patient in their care.

• Nine in 10 physicians (93%) reported care delays while waiting for health insurers to authorize necessary care, and more than four in five physicians (82%) said patients abandon treatment due to authorization struggles with health insurers.

PAMED Members, it is time to take action.

With prior authorization nearing action for a vote, it is imperative that you contact your State Representative to support Senate Bill 225. We encourage you to add any personal stories on how prior authorization has negatively impacted your patients in your message.

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M e d i c a l R e c o r d F e at u r e

Residents’ Day 2022

Cardiac Amyloidosis: A Diagnostic Dilemma and The Role of a Novel Electrocardiogram Criterion Muhammad Asad Hanif1, Tuoyo Omasan Mene-Afejuku2, Olivera Chandler2, Julian Diaz-Fraga2 1. Department of Medicine, Tower Health, Reading Hospital, West Reading, PA, USA 2. Department of Cardiology, Tower Health, Reading Hospital, West Reading, PA, USA INTRODUCTION

CASE DESCRIPTION

DISCUSSION

! Symptoms and signs of cardiac amyloidosis are nonspecific which makes diagnosis a challenge.

! A 70-year-old male with significant cardiac history presented to the emergency department after a syncopal episode.

! In retrospect, we found out that our patient’s score on the EKG criterion described by Sharma et al. [1] for patients with a bundle branch block was indicative of cardiac amyloidosis.

! An electrocardiogram (EKG) criterion of total QRS score divided by average left ventricular wall thickness can be used to aid in diagnosis in men with a bundle branch block as described by Sharma et al [1].

! The episode was preceded by lightheadedness, shortness of breath and fatigue.

! The criterion uses the total QRS score, calculated as the sum of the total QRS amplitude in all 12 EKG leads, divided by the average left ventricular wall thickness on TTE.

! Vital signs were normal.

! A score of less than 92.5 is 100% sensitive and 83.3% specific for cardiac amyloidosis.

! We present a case of cardiac amyloidosis to stress upon the utility of this novel EKG criterion.

On May 13th, Berks County Medical Society held its first Residents’ Day and Memorial Lecture after a two-year hiatus. This year’s lecture and presentations were held virtually but the content and quality of posters and presentations was excellent.

! Physical exam revealed an elevated JVP, bibasilar lung crackles and bilateral lower extremity edema.

! Our patient had a total QRS score of 138 and an average left ventricular wall thickness of 1.65cm on TTE.

! He had a mild troponin elevation and an elevated BNP.

! His ratio comes out to be 83.6 which points towards a diagnosis of amyloid cardiomyopathy.

! EKG showed normal sinus rhythm, left axis deviation, and a left bundle branch block (figure 1).

! Hence, this score may be utilized in patients with a bundle branch block who have evidence of significant ventricular hypertrophy on TTE and refractory heart failure or syncope to screen for cardiac amyloidosis.

! CTA chest was indicative of fluid overload. ! Transthoracic echocardiogram (TTE) revealed a normal ejection fraction, moderate to severe concentric left ventricular hypertrophy, dilated left atrium and a low stroke volume (figure 2). ! Patient was diuresed aggressively but continued to feel dyspneic and fatigued.

Figure 1. Electrocardiogram

! Cardiac MRI was performed which was highly suggestive of amyloidosis (figure 3). ! Serum lambda free light chains were elevated, and a bone marrow biopsy was positive for plasma cell myeloma and amyloid deposition (figure 4). ! A diagnosis of cardiac amyloid light chain amyloidosis was made, and chemotherapy initiated.

It is our hope that this program will be held live next year. In the meantime, congratulations to these winning posters!

! Patient was subsequently discharged to rehab where he suffered a cardiac arrest eight days after discharge and passed away.

Figure 2. Transthoracic Echocardiogram

Figure 3. Cardiac MRI showing diffuse heterogeneous enhancement overlying the entire subendocardial circumference extending into at least 50% of the myocardial thickness (white arrows).

REFERENCES 1. Sharma S, Labib SB, Shah SP. Electrocardiogram Criteria to Diagnose Cardiac Amyloidosis in Men With a Bundle Branch Block. The American Journal of Cardiology. 2021 May 1;146:89-94.

Figure 4. Congo red stain of the bone marrow biopsy showing amyloid deposits in the vessel walls (black arrow).

L iv e r R e s e c t io n a s D e f in it iv e M a n a g e m e n t f o r In f e c t e d E m b o liz a t io n C o ils a f t e r P s e u d o a n e u r y s m E m b o liz a t io n f o r G r a d e I V L iv e r I n ju r y Elise F. Heidorn, M.D.1, Filip Moshkovsky, D.O.1, Gary Xiao, M.D.2 & David Sacks, M.D.3 Tower Health, Reading Hospital, West Reading, PA 1. Department of Surgery 2. Department of Hepatopancreatobiliary Surgery 3. Department of Interventional Radiology BACKGROUND

Liver injuries after blunt abdominal trauma are very common.

According to the National Trauma Database (NTDB), 22.2% of patients who suffer blunt trauma will have a liver injury. Nonoperative approaches to liver injuries, such as arterial coil embolization, are now standard of care for many patients.

However, the long-term complications associated with coil embolization can be challenging to manage.

A

DISCUSSION

B

The management of blunt liver trauma is based on patient hemodynamic stability and grade of injury. Per NTDB, approximately 83% are managed non-operatively1. While studies show that angioembolization of liver injuries improves survival, they also show that these patients have an increased number of complications, including hospital length of stay, sepsis, acute respiratory distress syndrome (ARDS) and time on the ventilator2. Additionally, the complications associated with non-operative management, as seen in our patient, can lead to the need for further interventions. These complications can be complex and challenging to manage. One study cited an 11% complication rate after angioembolization3. These complications included liver necrosis, gallbladder necrosis, bile leak and abscess3.

CASE REPORT

A 29-year-old male with a history of an ATV accident resulted in a grade IV liver laceration requiring IR embolization of the right hepatic artery. Three weeks post-procedure, he developed a pseudoaneurysm requiring direct percutaneous transhepatic embolization.

Approximately a year later, the patient presented after experiencing intermittent fevers, fatigue and a recurring chest wall wound with purulent drainage. Workup revealed this was a fistulous tract at the site of an old percutaneous drain which was draining an encapsulated liver abscess at the site of his prior liver injury. Initially, more conservative management was attempted with local wound exploration, fistula excision and antibiotics.

A multidisciplinary discussion was held between Trauma Surgery, Thoracic Surgery, Interventional Radiology and Hepatobiliary Surgery to discuss the best option for definitive treatment.

The patient subsequently underwent surgical management with a partial liver resection, fistula tract excision and diaphragm repair. Intra-operatively, an abscess cavity was discovered at the confluence of segments V, VI, VII & VIII containing coils.

Additionally, intraoperative ultrasound was performed to identify structures.

C

D

Managing complications after these procedures can be very challenging and require a multidisciplinary approach to provide the patient with the best outcome. Our patient developed a pseudoaneurysm after initial embolization of his liver injury, which required percutaneous transhepatic direct embolization.

The subsequent hepatic infection in this area required further drainage, leading to a fistulous tract and chronically draining wound in our patient. In this case, we present a definitive management strategy for these complex patients.

Figure 1: (A) Right chest wall wound (B) X-ray demonstrating embolization coils. (C) Abscess cavity. (D) Segment of resected liver with coils.

REFERENCES 1. Tinkoff G, Esposito T, Reed J, et al. American Association for the Surgery of Trauma Organ Injury Scale I: Spleen, Liver and Kidney Validation Based on the National Trauma Data Bank. J Am Coll Surg. 2008; 207: 646-655.

2. Sivrikoz E, Teixeira P, Resnick S, et al. Angiointervention: an independent predictor of survival in high-grade blunt liver injuries. Am J Surg. 2015; 209: 742-746.

3. Misselbeck TS, Teicher EJ, Cipolle MD, Pasquale MD, Shah, KT, Dangleben DA, Badellino MM. Hepatic angioembolization in trauma patients: indications and complications. J Trauma. 2009 Oct;67(4):769-773.

SPONTANEOUS INTRAMURAL SMALL BOWEL HEMATOMA - CASE REPORT Sigrid Williamson, M.D., Aishwarya Suresh B.A., Adrian Ong, M.D.

Department of Surgery, Division of Trauma and Critical Care, Reading Hospital, Tower Health System

Discussion

Learning Objectives • • • • •

! Nontraumatic SISBH is related to anticoagulant therapy, greatest association with Warfarin toxicity.1-5

Nontraumatic SISBH should be considered in patients with coagulopathy who present with small bowel obstruction and hematochezia.

CT imaging is effective in diagnosis of SISBH. Initial management is conservative. Surgical intervention reserved for signs of perforation.

Early recognition of SISBH is important; • symptoms may mirror pathologies requiring surgical intervention.

• Anticoagulants can be stopped or reversed as soon as possible Resolution of SISBH typically occurs within 4-7 days with conservative management alone.3,6

! Risk factors: Anticoagulant therapy, hematologic malignancies, coagulopathies, chemotherapy, and vasculitides. 1-5 ! Presentation: Non-specific including abdominal pain, nausea, emesis, signs of GI bleed or obstruction, peritonitis, or hemorrhagic shock.4,5 ! Imaging: CT showing circumferential long segment bowel wall thickening, intramural hyperdensity, luminal narrowing. Hyperdensity limited to the intramural region on imaging can help distinguish from neoplasm.7

Case Report

History of Present Illness: A 67 year old male with a history of multiple myeloma treated with chemoradiation presented to the ED with two days of constipation, hematochezia, epigastric pain, and nausea. Most recent chemotherapy session was four days prior to onset of symptoms. Patient was not on anticoagulants.

Surgical History: Unknown bowel surgery in childhood, ventral hernia repair x3, cholecystectomy, appendectomy.

Physical Exam: Abdominal Distention, right lower quadrant tenderness, no signs of peritonitis. Large midline and mid-transverse abdominal scars Labs: White Blood Cell Count 1000/µL, Hemoglobin 7.4g/dL, Platelets 4000/µL. Imaging: CT abdomen showed partial SBO and masslike hyperintense segment of ileum with circumferential wall thickening and an intraluminal foci of active extravasation.

Results: Patient conservatively managed with correction of electrolyte abnormalities, bowel rest, and Nasogastric tube decompression. He received 2 units of packed red blood cells, 2 units of platelets, and filgrastim to stimulate white blood cell proliferation.

Hospital Day 3: non-bloody bowel movements. Oral diet was reintroduced Hospital Day 4: repeat CT with resolution of the small bowel lesion.

Hospital Day 5: discharged

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CT Abdomen showing long segment area of circumferential wall thickening and a small amount of active extravasation (blue arrow).

There is resultant partial small bowel obstruction proximal to this area (red arrow).

! Pathophysiology: Likely due to slow bleeding of small submucosal vessels of the bowel wall causing intramural osmotic gradient, promoting further hematoma expansion.7 ! Management: No clear guidelines established. Conservative management recommended including discontinuation of anticoagulation, reversal of hypercoagulable state, bowel rest and decompression, fluid restriction, transfusion of blood product.1,3,6 ! Surgical intervention is reserved for patients presenting with peritonitis, ischemia, perforation, or refractory symptoms.3 ! Symptoms typically resolve within 4-7 days with this conservative management.3,6

References

1. Abbas, M. A., Collins, J. M., Olden, K. W., & Kelly, K. A. (2002). Spontaneous intramural small-bowel hematoma: clinical presentation and longterm outcome. Archives of surgery (Chicago, Ill. : 1960), 137(3), 306–310. https://doi.org/10.1001/archsurg.137.3.306 2. Kang, E. A., Han, S. J., Chun, J., Lee, H. J., Chung, H., Im, J. P., Kim, S. G., Kim, J. S., Yoon, H., Shin, C. M., Park, Y. S., Kim, N., Lee, D. H., & Jung, H. C. (2019). Clinical features and outcomes in spontaneous intramural small bowel hematoma: Cohort study and literature review.

Intestinal research, 17(1), 135–143. https://doi.org/10.5217/ir.2018.00085 3. Abdel Samie, A., & Theilmann, L. (2012). Detection and management of spontaneous intramural small bowel hematoma secondary to anticoagulant therapy. Expert review of gastroenterology & hepatology, 6(5), 553–559. https://doi.org/10.1586/egh.12.33 4. Kones, O., Dural, A. C., Gonenc, M., Karabulut, M., Akarsu, C., Gok, I., Bozkurt, M. A., Ilhan, M., & Alıs, H. (2013). Intramural hematomas of the gastrointestinal system: a 5-year single center experience. Journal of the Korean Surgical Society, 85(2), 58– 62. https://doi.org/10.4174/jkss.2013.85.2.58 5. Acar, N., Acar, T., Gungor, F., Kamer, E., Karasu, S., Karaisli, S., & Dilek, O. N. (2019). A Rare Complication of Anticoagulant Therapy: Intramural Hematoma of the Small Bowel. Archives of Iranian medicine, 22(11), 653–658.

6. Yoldaş, T., Erol, V., Çalışkan, C., Akgün, E., & Korkut, M. (2013). Spontaneous intestinal intramural hematoma: What to do and not to do. Ulusal cerrahi dergisi, 29(2), 72–75. https://doi.org/10.5152/UCD.2013.41 7. Abbas, M. A., Collins, J. M., & Olden, K. W. (2002). Spontaneous intramural small-bowel hematoma: imaging findings and outcome. AJR. American journal of roentgenology, 179(6), 1389–1394. https://doi.org/10.2214/ajr.179.6.1791389

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Dr. Olapeju Simoyan awarded the National Humanism in Medicine Medal by the Arnold P. Gold Foundation

www.gold-foundation.org/2022gala

O

n Thursday, June 9th, the Arnold P. Gold Foundation honored Dr. Olapeju Simoyan, the Founding Executive Director of Research at Caron Treatment Centers, along with 10 other extraordinary Gold Humanism Honor Society (GHHS) members with the National Humanism in Medicine Medal. The event took place at the at the Ziegfeld Ballroom in New York City. These GHHS members are representative of the thousands of committed leaders who have helped to make the honor society what it is today. In 2022, on its 20th anniversary, GHHS now encompasses 181 chapters around the world, nearly 45,000 members, and millions of moments of humanistic connection in the care of patients.

Olapeju Simoyan, MD, MPH, BDS, FASAM, FAAFP, is the Founding Executive Director of Research at the Fran and Doug Tieman Center for Research at Caron Treatment Centers. She is a Professor in the Department of Psychiatry at Drexel University College of Medicine and holds an adjunct faculty position

at Penn State University College of Medicine.

Dr. Simoyan’s commitment to bridging the gap between the arts and sciences led her to become a strong advocate for the inclusion of the arts and humanities in medical education. She incorporates her artistic passions of music and writing into her professional work and serves as editor of the New Voices column of Pulse - Voices from the Heart of Medicine. With seed funding from the Gold Foundation, she led the establishment of a literary journal, Black Diamonds, serving as its Editor in Chief for several years. She has represented the GHHS proudly ever since her days as a student and resident. A 2006 recipient of the Leonard Tow Humanism in Medicine award, she was also a Gold Student Summer Fellow and a Gold Humanism Scholar at the Harvard Macy Institute, in addition to being a GHHS faculty advisor.

A former Fulbright scholar and recipient of the Herbert Nickens Faculty Fellowship, Dr. Simoyan continues to support the ideals of the GHHS through her work as a clinician, researcher, and medical educator.

SUMMER 2022 | 31

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Bringing Aid and Comfort to Ukrainian Refugees in Moldova

A Mission Trip Kirill Popovich is a pre-medical student at UNC Chapel Hill and is spending 6 weeks with the BCMS this summer as one of two future physicians selected for the Pat Sharma President’s Scholarship program.

“Hey! What’s your name?” a boy asks me in Ukrainian. “I’m Kirill. What’s your name?” I ask.

“Maxim. Nice to meet you!” he says with a large grin as he stretches out his hand for a handshake.

“Nice to meet you too!” I laugh as I shake his hand. Maxim is one of the many children at a Ukrainian refugee camp in the country of Moldova. He is by far the most energetic 9-yearold I know. I don’t know Maxim’s story. I don’t know what he has seen or what he has been through. All I know is that a few months ago he was living a normal life of a 9-year-old boy in Ukraine, going to school and playing with his friends. Now he and his mother are displaced and had to flee from the bombings in Ukraine. He’s not the only one, though. Thousands of families have been forced out and separated at the border of Ukraine in the past four months. Many of them still live and wait in uncertainty.

When the Russian invasion of Ukraine started, I spent a lot of time reading the news and trying to understand how and why two Slavic nations were, seemingly so similar, killing each other. I was born in Moldova but moved to the US at an early age.

Growing up in the US, I never made a distinction between someone from Russia, Ukraine, Moldova, Belarus, Estonia, etc. I considered all Russianspeaking people the same. We’re all Slavs. We have the same values and similar cultures. We all come from the 15 former republics of the Soviet Union. The war opened my eyes to how divided the nations really are. What struck me the most is the fact that I could’ve easily been one

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of the young men on the front lines in Ukraine.

If I was born in Ukraine or Russia, I very well would’ve been drafted to war. And even though I’m not from Ukraine or Russia, how can I sit in the comfort of my home and watch millions of Ukrainians flee their homes into uncertainty?

I had a desire to go to Eastern Europe but couldn’t go by myself due to the risks involved.

Thankfully, I came across a group called North Carolina Baptists on Mission who were putting together teams to fly to Moldova and work with the refugees. When they found out that I spoke both English and Russian, they were very excited to have me on their team. I was the only one who spoke both languages, and so could translate for them.

The camp we visited in Moldova housed over 200 refugees. Some of them were just passing by on their way to another European country or to the US. Others were there from the start of the war and didn’t know where else to go. People were mostly from the Odesa, Mykolaiv, and Kherson regions of Ukraine, although some were from as far as the Donetsk region. Most of the refugees consisted of women and children, as most men were not allowed out of Ukraine. I remember asking some children where their fathers were.

Some kept in contact with their fathers over the phone, while others couldn’t. Most people were relatively healthy. Others were elderly or disabled and needed medical attention. Once, a medical team from the US stopped by for half a day and saw patients while I helped interpret from English

to Russian, but they could only provide so much aid with a limited supply of medications and tools.

The camp area was clean and welcoming. There was plenty of delicious food thanks to generous donors. Most people helped where help was needed. The children played outside after finishing their online schoolwork. Everyone seemed fine, but something was still visibly wrong. At first, when our team from the US arrived, no one would smile or greet us. But as the weeks went on, people slowly started to trust again. People would smile and say good morning.

Some would come up to us and ask questions or thank us for helping with some task. It was evident that something was changing.

War is terrible. People are dying, and their hopes and dreams for a future are destroyed. I had a brief conversation with an elderly lady who said with tears in her eyes, “When will we see our home again?

There’s nothing to return to. By the time they rebuild everything, we won’t be here anymore.”

I often get asked what exactly we did at the refugee camp. “Well, you know, we helped with some of the construction, and played with the children,” I reply. “We watered the plants and helped clean the kitchen.” But when I think about it, we really tried to give people at least a glimpse of hope in a hopeless situation. When Ukrainians see people from America put their lives on pause to go to a tiny country in Eastern Europe to serve, something in their hearts changes. A simple “good morning,” a smile, or a hug can show a worried or grieving mother that she is not forgotten. A wife who left her husband and son in Ukraine can start smiling again. We still care.

We still pray. We still try to share the gospel, even from the other side of the world. I sometimes have a feeling that I didn’t do enough.

I could’ve made more connections. I could’ve been more outgoing and loving. But in the end, I’ll never impact everyone. The seed that we planted is left for someone else to cultivate. We plant the seeds and let God do the growing. All glory to Him.

SUMMER 2022 | 33

M edical R ecord F eature

In Memoriam Eric Holm, MD, FACS, FAAN

by Raymond C. Truex, Jr., MD, FACS, FAANS

I

first met Eric when he was a General Surgery Intern at Temple University Hospital in 1970, when I began my Neurosurgical Residency at the same institution. Thus, it seems like I’ve known Eric for the most part of my professional career, and his passing came as a shock to me. Although we were, in a way, competitors, we practiced at different hospitals and maintained a congenial and collegiate manner, frequently cross-covering on weekends. We considered Eric to be a worthy colleague, a kind and skilled neurosurgeon.

Eric grew up in Chester County and graduated from Upper Darby High School in 1959. He then attended and graduated from the Pennsylvania State University with an engineering major in 1963, and as long as I knew him, he was a passionate Penn State Nittany Lion football fan. Several times, I had the pleasure of going with him to see a game; he had great seats, too. Eric graduated from Temple University School of Medicine in 1969, and then went across the state to complete his Neurosurgery residency at the University of Pittsburgh under Chairman Anthony Susan, in 1975.

Eric first entered the private practice of Neurosurgery in Johnstown, PA, but after several years there, in 1978, elected to move back east to join Gregory Lignelli in the practice of Neurosurgery at St. Joseph’s Hospital and Pottstown Hospital. It was at these two institutions that he did the majority of his clinical work, while also maintaining privileges at the Reading Hospital and Medical Center. At some point in the early 1990s, Dr. Lignelli elected to concentrate his practice in Pottstown, and Dr. Holm at St. Joseph’s, and at this point he was joined in practice by Dr. David Allen, and they practiced together for many years.

Dr. Holm was a member of the Berks County Medical Society, which honored him for 50 years of medical practice in 2019, and was also a member of the Pennsylvania Medical Society, and an active member of the Pennsylvania Neurosurgical Society. He retired from the surgical practice of Neurosurgery in 2010, and for several years afterward, “kept his hand in” by practicing non-operative diagnostic neurosurgery.

In retirement, Eric enjoyed travel and socializing with his wife, Kathy, and their extended family.

They particularly enjoyed traveling to various tropical Caribbean beaches and were planning their next trip at the time of Eric’s sudden passing. In Kathy, he had found an excellent life companion; she being an expert Neurosurgical nurse and Nursing Instructor in her own right. She fully understood the pressures placed upon a surgeon by the demands of practice, helped him maintain the smooth operation of his practice, and was skilled at defusing delicate situations.

Berks County has lost a hard-working, skilled, and dedicated physician. The Berks County Medical Society mourns his passing, and we extend our condolences to Eric’s wife, Kathy, and to his children and many grandchildren.

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M edical R ecord F eature

A Berks Health Initiative:

9 Years Getting Gutsy

T

he 9th annual Guts and Glory Digestive and Wellness Expo will be taking place live on September 24th from 10am-3pm at Penn State Berks campus. The Expo was originally created and hosted by nonprofit My Gut Instinct and is sponsored by Penn State Health St. Joseph Medical Center.

Guts and Glory is a free, large scale, non-profit communitywide celebration of health for all ages and showcases a farmer’s market, educational booths, community outreach, fresh locally sourced food made by local chefs, fitness zones, yoga, massage meditation, and wellness experts, to name a few features. This year we will also welcome the MEGA Colon exhibit, which provides visitors with an interactive, educational experience of stepping through a large-scale model of the human colon that highlights common disease conditions. We celebrate the spirit of health and wellness at our event and encourage our visitors to find inspiration at Guts and Glory to take an active role in their own well-being all year long.

This free admission, interactive, annual event for all ages is designed to educate the health curious, elevate the understanding of the health conscious, and raise community awareness of the importance of digestive health and overall wellness through the free exchange of information and resources. “We aim to

provide people with health knowledge and empower them to take action to live healthier lives and become beautiful from the inside, out, because we believe beauty starts on the inside,” said founder Aparna Mele, M.D. “We also want to show the community that eating and living healthy is not only easy to do, but it can also be fun and delicious too!”

Aparna Mele, M.D., is a board-certified gastroenterologist with Digestive Disease Associates since 2007. She came to the field of medicine with extensive experience in international relief work overseas and is actively involved in local philanthropic work directed towards patient education and promotion of societal health.

Guts and Glory Digestive and Wellness Expo is a far-reaching, educationally inspiring, community-giving, and feelgood event held annually. The event has enjoyed extensive media coverage and public accolades for their health movement in the community. Numerous community sponsors and volunteers make the event possible. Event-day volunteers and participant registration for sponsors, nonprofits and food vendors is open and details regarding sponsorship types and on-line registration can be found on the website.

For more information about My Gut Instinct and the Guts and Glory event visit www.mygutinstinct.org. Stay up to date with volunteer, sponsor and vendor opportunities as well as enjoy healthy recipes and inspirational motivation on Facebook and Instagram @mygutinstinct and @gutsyandmini.

About My Gut Instinct, Inc. Our mission at My Gut Instinct, a non-profit organization, is to collaboratively inspire and empower our community to embrace health and eat and live better for longevity. Our organization aims to increase awareness of preventable diseases that impact community health. We focus on preventing these avoidable diseases through motivating the community to make healthy choices, promoting cancer screenings, and raising awareness for various health concerns.

www.mygutinstinct.org SUMMER 2022 | 35

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