Central PA Medicine Spring 2022

Your Community Resource For What’s Happening In Healthcare

SPRING 2022

Official Publication of the Dauphin County Medical Society

The Silent Epidemic in the United States PAGE 6

PLUS PAMED Awards Top Physicians Under 40 PAGE 14

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(833) 770-1541 • dauphincms.org 2022 DCMS BOARD OF DIRECTORS Shyam Sabat, MD President Jaan E. Sidorov, MD Immediate Past President Joseph Answine, MD President-Elect Andrew Lutzkanin, III, MD Vice President Everett C. Hills, MD Secretary/Treasurer

MEMBERS-AT-LARGE Mukul Parikh, MD Michael D. Bosak, MD John Forney, MD

SPRING 2022

Contents Features 6

The Silent Epidemic in the United States

10

Remembering Frank W. Jackson, MD

Virginia E. Hall, MD FACOG FACP Andrew J. Richards, MD, FACS, FASCRS Andrew R. Walker, MD Saketram Komanduri, MD

12

John C. Mantione, MD

EDITORIAL BOARD Joseph F. Answine, MD, Editor in Chief Kaela Luchs, County Executive

Discrepancies Between Clinical Prescribing Patterns Versus Literature Recommendations for Antibiotic Usage in Facial Fractures

14

PAMED Awards Top Physicians Under 40

16

Covid, The Aftermath

In Every Issue

Robert A. Ettlinger, MD Gloria Hwang, MD Puneet Jairath, MD Heath B. Mackley, MD

Editor's Message. . . . . . . . . . . . . . . . . . . 4

Restaurant Review. . . . . . . . . . . . . . . . . 18

Legislative Updates. . . . . . . . . . . . . . . . 17

DCMS News. . . . . . . . . . . . . . . . . . . . . . 20

Mukul L. Parikh, MD Meghan Robbins, MS2 Shyam Sabat, MD The opinions expressed in this publication are for general information only and are not intended to provide specific legal, medical or other advice or recommendations for any individuals. The placement of editorial opinions and paid advertising does not imply endorsement by the Dauphin County Medical Society.

All rights reserved. No portion of this publication may be reproduced electronically or in print without the expressed written consent of the editor.

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EDITOR’s Message

By JOSEPH F. ANSWINE, MD, FASA

A Feeling of Confusion A Lack of Residency Positions for Young Physicians

an update

4

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From my editorial in the Spring 2020 issue: “Take what I say with a grain of salt as a father with one child successfully matching for a residency position and one not. But, as I watch my child walk through the process of not matching, not finding a position through the supplemental match and coming away with a future uncertain,I have become confused with the disassociation between a need, no, a cry for more providers to the point that we are expanding the abilities of mid-levels in order to care for our patients and an inability of thousands of young physicians to practice due to a lack of residency training. As I write this, we are at the peak of the concern over the COVID-19 pandemic which has led to a cry for more physicians to care for the infected.

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In states such as Missouri and Kansas, suit on daily, hoping an open program they are using the young physicians in any specialty would see his application without residency training as so called and give him a call. A few did, and the Assistant Physicians (not to be confused Thursday of match week at noon, the with Physician Assistants) who practice unthinkable it seemed happened; he was with a collaborative agreement with a offered a position as a categorical Internal residency trained physician similar to Medicine resident in central Florida. After what we do in Pennsylvania with NPs four years of rejections, he will enter and PAs. This may be something for us medical residency training. to consider in our state.

Many of these physicians, as is very true for my child, would love to practice in underserved areas and with the indigent population. In my child’s case, he would prefer it as he sees his greatest benefit to the world in such a position.

I think it is time to expand the practice of physicians that have passed numerous steps of the board certification process after receiving an in-depth knowledge of the human body, its physiology and pathology in an accredited medical school, whether by providing more residency positions or allowing them to practice temporarily until residency positions open as Assistant Physicians to care for our growing population of individuals in need of medical care.”

Now, it is March 2022 as I am writing this, and the 2022 Match season is behind us. My son is in the process of finishing a Master of Biomedical Science (MBS) degree in Florida which is a combination of six months of second year medical school classes and six months of fourth year acting internships in primary care specialties. My son loves the patient interaction and enrolled in the program looking for another chance to be a medical resident. Over the last few years, along with his current master’s program, he has also been a medical simulation fellow and performed COVID-19 research. He, however, received his fourth “We regret to inform you that you did not match” email at 9 am on the Monday of match week 2022. He took time off from his rotations as he did with his simulation fellowship and COVID-19 research to undergo the Supplemental Offer and Acceptance Program (SOAP), or less fondly called the scramble. He put his

Doctors must be more proactive in putting our young into practice In Pennsylvania and nationally.

with graduate medical education (residency training) unchanged in positions available since 1997, despite a growing population that requires more doctors to meet their needs. This incomprehensible situation that has been allowed to develop means that we now have a current estimated shortage of between 20,000 and 60,000 physicians in the United States, according to Unmatched and Unemployed Doctors of America. That number, the group reports, is expected to increase to 140,000 in less than a decade. Yet, in 2021 alone, 7,400 medical school graduates who are U.S. citizens and lawful permanent residents did not match to a residency.”

During the 2022 Residency Match, 42,549 applicants applied for the match, 34,075 applicants matched, leaving 8,474 unmatched. Statistically, 19.9% did not match. To say it a different way, 1/5 of graduating or graduated doctors are without a place to train after this year’s match alone.

We are in a time where patients must wait months to see a physician and not infrequently progress with their illness and die because of the delay in care, while 1000s of physicians are on the sidelines not even able to give COVID-19 vaccinations because of a lack of training and licensing.

Nurses are taking online courses to My son sounds terribly unlucky, but be CRNPs, and PAs are being trained in all honesty, he is truly one of the because we do not have enough doctors lucky ones. From a website entitled Docsince many feel midlevels are the answer. tors Without Jobs from June 2021: “For I stress that I am not belittling the further too long, too many American medical education of nurses or the value of PAs, school graduates have been sidelined in but how far behind we are as physicians their careers. Students first enter a highly in putting our talented docs in the field competitive process to be accepted into helping patients. medical school. Then they commit years to studying to become doctors. Most I am so tired of being the stupid one in students also take out significant student the room with idealistic thoughts of giving loan debt – $250,000 on average – for their young physicians an opportunity to work education. After all that, thousands of U.S. under a residency trained physician until doctors are stopped in their career track that time when the federal government when they can’t obtain taxpayer-funded catches up with the need for physicians medical residencies. Without a residency and allows entry of these great minds into at a teaching hospital, a doctor cannot be an ACGME accredited residency. licensed and thus cannot practice medicine.

Doctors must be more proactive in This has been the widely unreported putting our young into practice in Pennand unaddressed issue for many years now, sylvania and nationally.

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Features FEATURES

The Silent Epidemic in the United States

By VIRGINIA HALL, MD, FACOG, FACP, FCPP 6

Spring 2022 Central PA Medicine

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MATERNAL MORTALITY RATIO (maternal deaths per 100,000 live births)

Did you know there is a rarely talked about epidemic in the United States? No, I do not mean the COVID-19 pandemic. The epidemic is that the United States of America is the only developed country where maternal mortality is rising. We see 26.4 maternal deaths per 100,000 live deliveries in the United States, per the World Health Organization; whereas in the other 13 developed countries the international agencies note falling maternal mortality.

Worldwide we see a 37% decline in maternal mortality except here in the USA. CDC data gives the USA 17.4 maternal deaths in 2018, 20.1 in 2019, and 23.8 in 2020. In 2020, I was privileged to give a Gallery Talk at the College of Physicians of Philadelphia, the oldest US medical organization. There are new laws and policies that may allow improvement if we adopt them fully.

What is maternal mortality? The simplest definition is the death of a woman while she is pregnant or within 42 days of delivery of infant or infants. That definition used by our Center for Disease Control and Prevention (CDC) and the World Health Organization (WHO) misses late maternal deaths that can occur up to one year after a liveborn infant’s birth. Stillborn deliveries are not factored into this; certainly, psychological and physical support are keys for these ladies. Maternal deaths include those women with ruptured ectopic pregnancy and its associated life-threatening hemorrhage, infections and excessive bleeding associated with miscarriage, and both medically supervised and unsupervised pregnancy termination although infection and excessive bleeding is uncommon with medically supervised pregnancy termination.

Some deaths are directly attributable to pregnancy such as postpartum hemorrhage, pregnancy associated hypertension, infection, and blood clots. Pre-existing heart disease, hypertension, diabetes, and obesity often impact pregnancy negatively if not appropriately cared for. It is estimated 60% of maternal deaths are preventable and yet in the USA maternal mortality is rising when worldwide maternal mortality has declined 37%. Suicide, homicide, substance use disorder and motor vehicle accidents also contribute indirectly to maternal mortality. We need to remember that intimate partner violence begins in pregnancy 25% of the time.

Maternal Mortality Review Committees (MMRC) are present in 49 states (Wyoming has Utah review its data), New York City, Philadelphia, the District of Columbia, and Puerto Rico but are widely different in scope and requirements and frequency of reports and to whom they report. Pennsylvania established its MMRC through Act 24 in 2018 with anesthesiologist, Department of Health member, emergency medical service provider, epidemiologist, medical examiner or coroner, mental health expert, midwife, pathologist, substance use expert, social worker or public health professional, and my favorite, other. Pennsylvania only requires a report every three years. There are no recommendations to correct racial disparities. Only California, Louisiana, Maryland, New Jersey, New York, West Virginia, and New York City require recommendations aimed at racial disparity corrections. Nevada and Continued on page 8

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Features

MATERNAL MORTALITY is rising in the u.s. as it declines elsewhere (deaths per 100,000 live births)

Texas do not conform to standardized CDC system in which to review deaths. If the woman is a non-Hispanic black, she has a 55.3/100,000 maternal mortality rate, 2.9 times her non-Hispanic white counterpart.

as Planned Parenthood and subsequent lack of access to contraceptive services as cause of further increase of maternal mortality and severe morbidity or illness. Ethical practitioners who provide health care to women encourage pregnancy prevention before pregnancy occurs. Religious beliefs regarding an unplanned pregnancy dictate counsel and/or referral to a practitioner whose beliefs respect the patient’s autonomy.

As concerned professionals and citizens, we must change these statistics. Why are American women dying? The usual culprits of hemorrhage, hypertension, and infection persist but noncommunicable diseases (NCD) Philadelphia recently overtook Chicago now contribute greatly to this unwelcome trend. These diseases include heart disease, but not in a good way. Philadelphia now hypertension, obesity, thromboembolism has the highest maternal death rate of any (clots in lungs or brain from legs or pelvis), major US city. Late postpartum deaths in diabetes mellitus, thyroid disorders, mental Philadelphia (more than 42 days postparillness, substance use disorders, stroke, mul- tum) occur in more than 50% of women tiple sclerosis, autoimmune disorders, and exceeding the 33% observed in most other epilepsy. Pregnancy planning occurs in about regions. If you are black or African-American, 50% of all US pregnancies so chronic or you are 10 times more likely to die; black sometimes undiagnosed medical conditions women constitute 75% of maternal deaths are not addressed, preventing optimization in Philadelphia. Educational achievement of maternal health preconception. A recent does not protect black women from death; Reuters article cited the decreasing access to a black woman with a college education health services for women by facilities such or higher is still 5.2 times more likely to 8

Spring 2022 Central PA Medicine

die in the pregnancy or in that first year postpartum. Nationally the highest risk group for death is a black woman age 40 or more. Overall, women age 40 or more in 2020 had a death rate of 107.9 with white women still having the lowest death rate in the white, Hispanic, Asian/Pacific Islander, Native American, and black races in each age group. Older women tend to have more chronic medical conditions in part accounting for their higher mortality and morbidity. In US our mothers are older than most other countries.

Some NCDs related to pregnancy are not always evident in the first 6 weeks postpartum. Fatigue and shortness of breath can be normal but may signal cardiomyopathy, thromboembolism, depression, postpartum thyroiditis, autoimmune disease flare or even the unusually delayed postpartum multiple sclerosis flare or onset. In many states Medicaid is terminated 45-60 days postpartum.

Pennsylvania has taken steps to prevent this barrier to care (no insurance) by extending Medicaid coverage for the entire first year postpartum as of April 1, 2022 for the next five years. These funds come from monies in the American Rescue Plan Act. It covers women and their infants who live at 138% poverty level or lower. Medicaid covers 30% of Pennsylvania deliveries, somewhat lower than the 40% nationwide. This will prevent maternal deaths due to substance use disorder who have the medication assisted treatment (MAT) abruptly withdrawn at no later than 60 days. Given the stressors of caring for a newborn (they don’t come with instruction manuals, folks!), her own recovery from delivery, and a now unsatiated craving for the substance, she will often return to her drug dealer seeking relief. What she does not realize is her tolerance has been lowered and using that dose will result in her death.

In 2022, the US Congress passed the Maternal Health Quality Improvement Act as part of the omnibus spending bill.

Provision of funds to teach evidence based best practices, approaches that address racial and social disparities in care (yes, it is social drivers of health rather than social determinants of health), and improved access to care in rural areas are achievable goals.

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So what are the ways we can decrease maternal mortality? It will be one woman at a time. Optimizing her health preconception is important. We need to empower women to take control of their health by getting an adequate history and education.

This includes achieving an ideal body weight months before pregnancy begins, having a healthy diet with fresh fruits and vegetables and adequate intake of iron and vitamin B12. Pure vegan diets often lack iron and B12 in sufficient amounts. Adequate exercise and sleep and being part of a supportive and caring community are important pillars of self care. Work environment and hobbies should be discussed. Tobacco, alcohol and recreational drug usage should be strongly discouraged.

A complete review of medical and surgical history is needed in addition to prior pregnancy history. Postpartum hemorrhage in a prior pregnancy is an indicator of increased risk of repeat bleed. Prior postpartum cardiomyopathy is an ultra-high risk setting.

Medications and supplements should be reviewed as some need to be eliminated or changed to an alternative class. Think angiotensin converting enzyme inhibitors (ACE) and angiotensin receptor blockers (ARB), valproic acid, and chemotherapeutics to name some agents you should not expose a developing pregnancy to. Some herbals have been contaminated with heavy metals as there is no regulation of what are deemed supplements and herbals.

Too often the woman gains excessive weight and yet as practitioners, we do not inform her of her increased risks for elevated blood pressure, blood clots, and diabetes where glucose intolerance develops in one out of six pregnancies. Testing for resolution of gestational diabetes at 6 weeks is not done often enough. It sometimes persists. Some practitioners do not discuss weight for fear of patient or family backlash. Some cultures really believe the woman needs to eat for two when caloric increases are 340 calories a day in first trimester and 452 calories a day in second and third trimesters.

If you are caring for a woman in labor, be alert to hemorrhage occurring more frequently in those with prolonged or extremely rapid labor, at emergency Cesarean delivery, in multiple gestation pregnancy or excess amniotic fluid. The hospital or birthing center must be prepared for postpartum

hemorrhage with this best done by simulation drills. Since 80% of postpartum hemorrhage is related to uterine atony, familiarity with medications that contract the flabby uterus after vigorous massage and uterine exploration fail, is imperative.

There are safety and contraindications to be considered as well as surgical remedies that should be reviewed with all professional staff. Hypertensive emergencies deserve the same careful attention and should be part of drills. Many hospitals now have crash carts where fluids and medications are readily available. Important but subtle signs of excessive blood loss that are often neglected or trivialized are air hunger and restlessness or agitation.

Reducing maternal mortality is a team effort beginning with education and resources. We need to engage women in care before and early on during pregnancy.

Providing adequate access to care is both local and national. The social drivers of health include adequate practitioners in the area, transportation to and from care, education of the patient and community, adequate housing and nutrition, and safe environments. We need to act as if lives depended on it because they do.

Family history is important. Did you know a woman whose mother had preeclampsia has a 25% incidence of the same disorder whereas her partner’s mother having preeclampsia gives her only a 5% risk?

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Features

Remembering

Frank W. Jackson, MD

By F. WILSON JACKSON, MD

F

rank W. Jackson, MD, passed away September 29, 2021, at the age of 88. Born June 23, 1933, in Pittsburgh, PA he was the middle of three boys in the family. He was a career-long member of PAMED.

After graduating from Peabody High School in Pittsburgh, he matriculated to Princeton University where he majored in biology. Medical school was completed at Johns Hopkins University. While a medical

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student, he and his recently wedded wife Center) that focused on patient-centric, comspent a summer providing medical care, puter educational program around diabetes, jettisoning by boat, mule, foot, or vehicle, congestive heart failure, hypertension and to the townspeople of a remote town in the obesity. Also, in the 1980s, he established northern reaches of Newfoundland named Chek-Med Systems, a company that focused Twillingate. He completed a one-year on patient education material for patient internship year at the old Bellevue Hospital medications. Passionate about patient eduin New York City where he contracted and cation, he broadened the company’s portfolio recovered from tuberculosis, before returning on a wide range of diets and GI diseases, to Pennsylvania where he completed training creating a subsidiary company, Meducate. in internal medicine and then gastroenterol- With the advent of the internet, this patient ogy at the University of Pennsylvania. educational material became the foundation In 1965, he moved from Chester, PA to of what became at that time, one of the most Harrisburg, PA joining the Cowley Medical widely and globally read patient resource for Group, a prominent, multi-specialty medical GI diseases, medications, and diets.

practice in the community. He established his career in gastroenterology while also maintaining a small, primary care, internal medical practice – patient relationships of which became lifelong. He founded his own gastroenterology practice in 1974 and maintained a private GI practice, Jackson Gastroenterology, until he retired from the practice of Medicine in 2003. His son, F. Wilson Jackson, MD, joined the practice in 1999.

Ever an advocate for patients yet health care efficiency, he was an early advocate to move routine endoscopy out of the hospital and into ambulatory surgical centers, becoming the first in the state of Pennsylvania to build a free-standing ASC. Given that many of the rules and regulations of ASCs had not yet been established, he helped the Pennsylvania State DOH to create these standards. He was an early proponent of Propoful sedation in endoscopy, champiHis career paralleled the growth and oning its use and safety dating back to the impact of the endoscope and pharmaceutical mid 1990s. Somewhat unapologetically, innovation on gastroenterology. He was end- he found hospital-based patient care inlessly fascinated to bring endoscopic findings efficient and unnecessarily costly not only into the clinical arena of office-based patient for routine endoscopy but also ambulatory care. A restless intellect, he made numerous and acute patient care. He created one of contributions to medicine beyond that of the first dedicated, office-based infusion direct, clinical patient management. He was centers shortly after the FDA approval of a founding medical director of a Cardiac infliximab. He spent the later part of his Rehab program in the mid and late 1970s, a career managing and exploring how a wide first of a kind in the nation and well before range of acute GI patient disorders could be cardiac rehab became a mainstay of patient managed within the office and designed his management. Around the same time and practice to enable ambulatory care for many before the use of computer-generated EKGs, acute GI symptoms, effectively creating a he designed a handheld device to facilitate GI specific, UrgiCare clinic within his office interpretation of EKGs with measurements for his patients to use. of PR and QT intervals. He sold the device Maintaining a focus on the field of gasto a pharmaceutical company and promptly troenterology, he expanded the Chek-Med took his wife and five kids on a memorable Systems patient educational material into the ski trip to Switzerland. He later pioneered field of endoscopy as the company became and patented a compact, benchtop device rebranded as GI Supply. The originator of that enabled rapid, efficient, and consistent over a dozen patents that focused primarily quality H&E stains (Neat Stain). In the on the field of gastroenterology, he innovated early 1980s and recognizing the potential of or improved on endoscopic bite blocks (Bite computer assisted learning, he founded an Blocks), H pylori rapid urease test (HP Fast outpatient rehab center (American Rehab and hpOne), rapid peristaltic paracentesis

pump for ascites (RP Pump), carbon dioxide based endoscopically delivered cryotherapy (Polar Wand) for treatment of dysplastic Barrett’s, GAVE and radiation proctitis, biliary and pancreatic stents (Winged Stent), post-procedure endoscopic cleaning kits (GI Tote) and even designed an endoscopy cart to hold endoscopic instruments with a dedicated work space. He created the Spot tattoo after collaborating with a local tattoo shop. He had an uncanny ability to partner with creative, like-minded people to develop medical device products and in doing so, established lifelong friendships.

In the early 2000s, he became curious in the microbiome, its not yet fully explored potential and its role in health and disease.

His research let him to believe that prebiotics had much greater potential than the more popular probiotics. He founded Jackson GI Medical and developed a series of prebiotic products under the tradename Prebiotin and went on to pen a book on prebiotics, Prebiotics not Probiotics.

He was an active member of PAMED throughout his professional and retirement years. He was also president of the Pennsylvania Society of Gastroenterology from 1998 – 1999. As president, he organized an educational, “how-to” session on building ambulatory endoscopy centers which was attended by numerous PSG members, nearly all of whom went on to build their own ASCs throughout our commonwealth. He was a well-regarded voice to the Pennsylvania General Assembly where he successfully testified on behalf of PAMED and PSG members on a range of legislative bills under review at that time.

He was predeceased by his first wife, Joaquine Ireland Jackson, in 1998. He remarried and is survived by her as well as his five children. Importantly, he greatly valued the friendships forged amongst his colleagues within PAMED and its leadership. They became not only fast friends but also trusted colleagues whose council and camaraderie he valued.

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Features

Discrepancies Between Clinical Prescribing Patterns Versus Literature Recommendations for Antibiotic Usage in Facial Fractures

By JACQUELINE TUCKER, BS1, MADISON OXFORD, BA1, JESSYKA G. LIGHTHALL, MD, FACS2

T

he first antibiotic, penicillin, was discovered in the 1920s.

Throughout the next several decades antibiotic discovery was exponential. This led to an overall reduction in worldwide morbidity and mortality due to bacterial infections.

However, the eventual overuse of these newly discovered antibiotics gave birth to antibiotic resistance. With increasing resistance, medication options for resistant infections became limited. To counter the increase in antibiotic resistance, antibiotic stewardship programs began to emerge at different hospitals and treatment centers. Antibiotic stewardship is the effort to measure and improve how antibiotics are prescribed by physicians.1

1 The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, USA. 2 Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA. 12 Spring2022 Spring 2022Central Central PA PA Medicine Medicine

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In addition to antibiotic resistance, there are other downsides to antibiotic administration, including side effects such as nausea and vomiting, and even potentially fatal diarrhea. An additional downside is financial. Antibiotics can also be expensive, increasing patients’ hospital bills. The advantages and disadvantages must be considered before administering antibiotics. Physicians should constantly ask themselves whether prescribing an antibiotic is necessary in the context of these downsides.

Antibiotics are often used in trauma patients, especially in patients with open fractures or those being repaired to avoid surgical site infections. Surgical site infections may necessitate additional surgeries, prolong hospitalizations, and be expensive as well as painful for patients.

Facial trauma is relatively common with more than 3 million facial injuries occurring per year in the United States.2 Facial fractures can be managed in a variety of ways, depending on their location. Various locations can include, but are not limited to, the midface, mandible, orbit, frontal sinus, or nasal area.

Sometimes fractures are managed with closed reduction, which does not involve surgery, or with an open reduction, requiring surgery to reposition the fractured bones. In severe cases, more extensive reconstructive surgery may be required.

Facial fractures are a controversial topic when it comes to assessing appropriate antibiotic use, likely because of the complex nature and the variable presentation and management for facial fractures. In 2020, the Surgical Infection Society (SIS) Therapeutics and Guidelines Committee met to develop guidelines for antibiotic administration in the management of traumatic facial fractures.

They recommended avoiding antibiotic usage in non-operative upper face, midface, and mandibular fractures.3 In a study comparing non-operative facial fracture management, patients who were treated with no antibiotics were compared to those treated with short term antibiotics.

Neither group had any soft tissue infections after treatment.4 However, in a survey of otolaryngologists, plastic surgeons, and

oral and maxillofacial surgeons, it was The various presentations of facial fractures found that 66% prescribed prophylactic necessitate individualized management antibiotics for non-operative fractures. The and recommendations, adding additional most common fracture location that was challenge for physicians. Further prospective prescribed antibiotics was dentate segment clinical trials are necessary to determine the mandibles, followed by nasal bone fractures, ideal recommendations. and frontal sinus.5 When assessing operative management of facial fractures, several reports break down recommendations into preoperative, intraoperative, and postoperative antibiotic usage. The SIS also recommended avoiding preoperative and postoperative antibiotic prescriptions for mandibular or non-mandibular fractures.3 Contradictory to these recommendations, some previous articles show perioperative cefazolin can reduce the incidence of postoperative infections. In fact, one study demonstrated that in a cohort of patients with facial fractures, 42.2% of patients who did not receive antibiotics developed infections whereas only 8.9% of patients who did receive antibiotics had a postoperative infection.

Interestingly, 85% of surveyed physicians reported prescribing preoperative, intraoperative, or postoperative prophylactic antibiotics for surgically managed facial fractures.5 This demonstrates a large lack of consensus between recommendations and current practices of physicians. A research study investigating whether evidence-based recommendations aligned with evidence-based practice by assessing the literature and surveying physicians. In agreeance to what we have described here, they found prescriber practice differed markedly with literature recommendations.6

References: 1. Centers for Disease Control and Prevention. Core Elements of Antibiotic Stewardship. Published April 7, 2021.

Accessed March 28, 2022. https://www.cdc.gov 2. Gibson A, Boswell K. Facial Trauma: Challenges, Controversies, and Therapeutic Options. Trauma Reports. Published online April 2011.

3. Forrester JD, Wolff CJ, Choi J, Colling KP, Huston JM. Surgical Infection Society Guidelines for Antibiotic Use in Patients with Traumatic Facial Fractures.

Surgical Infections. 2021;22(3):274-282. doi:10.1089/sur.2020.107 4. Malekpour M, Bridgham K, Neuhaus N, et al. Utility of Prophylactic Antibiotics in Nonoperative Facial Fractures. Journal of Craniofacial Surgery.

2016;27(7):1677-1680. doi:10.1097/ SCS.0000000000002724 5. Brooke SM, Goyal N, Michelotti BF, et al. A Multidisciplinary Evaluation of Prescribing Practices for Prophylactic Antibiotics in Operative and Nonoperative Facial Fractures. Journal of Craniofacial Surgery. 2015;26(8):2299-2303. doi:10.1097/SCS.0000000000001976

6. Mundinger GS, Borsuk DE, Okhah Z, et al. Antibiotics and Facial Fractures: Knowing when and how to appropriately Evidence-Based Recommendations prescribe antibiotics is a vital skill in a Compared with Experience-Based physician’s toolbox. With so many conPractice. Craniomaxillofacial Trauma tradictory recommendations and findings, & Reconstruction. 2015;8(1):64-78. it is difficult for physicians to determine doi:10.1055/s-0034-1378187 the best course of action for individual patients. Additional research studies need to be conducted, and organizations should publish recommendations for their specialty or for specific surgeries. However, physicians must also take it upon themselves to stay up to date with current recommendations.

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Features

PAMED Awards

Top Physicians

Under 40

James Latronica, D.O.

Kevin Rakszawski, M.D.

Dauphin County congratulates Dr. James Latronica and Dr. Kevin Rakszawski on their recent awards!

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Pennsylvania Medical Society announces recipients of its annual Top Physicians Under 40 Awards. This is an annual award given out to the best of the best early career physicians, nominated by their peers, and selected by a committee of PAMED members.

“With their ambition and innovative ideas, these candidates are more than qualified to be recognized with the top physicians’ award,” said F. Wilson Jackson, M.D., PAMED President-Elect and Chair of the award committee. “They will shape and shine bright in the future of medicine.”

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James Latronica, D.O.

Kevin Rakszawski, M.D.

Dr. Latronica specializes in addiction medicine and family medicine. He has been integral in developing a novel mentorship program medical students called the Addiction Medicine Mentorship Program as part of his involvement with American Osteopathic Academy of Addiction Medicine. The program matches medical students with practicing addiction medicine physicians for one year with the goal of the medical students publishing a case report or literature review with a practicing physician by the end of the year.

Dr. Rakszawski is a hematologist with the Penn State Cancer Institute at the Penn State Health Milton S. Hershey Medical Center. He specializes in multiple myeloma and other plasma cell cancers. As an academic physician, he is also involved in the training and education of fellows, residents, and medical students to learn medicine and the art of taking care of cancer patients.

His nominator said, “Dr. Latronica is a superb addiction medicine physician. He works tirelessly to improve the care of people with substance use disorders through his clinical care, teaching, and advocacy work in Pennsylvania.”

His nominator said, “His high competence is only outmatched by how much he cares for his patients and how helpful he is to his colleagues.”

WE ARE currently accepting nominations for the 2023 Top Physicians Under 40 list at www.pamedsoc.org/awards.

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Features

Covid, the Aftermath Wha t We a s Ph y s i ci a ns Wi l l Be Lef t Wi th

By JOSEPH F. ANSWINE MD FASA

A

t this time, our EMR has a red “+” present on the record of many if not most of the patients that come to the operating room. That signifies a previous Covid infection. Thankfully, the majority of patients had a distant past positive Covid test, suffered minimal or no symptoms, and are now at baseline health. But for a small but definitely present few, it means residual problems. These are the individuals suffering from secondary organ damage, or have “long Covid”.

According to the CDC, lingering effects from a Covid infection are due to obvious organ damage from the initial infection or less obvious etiologies especially in those with minimal or no initial symptoms. For those with organ damage; whether the heart, liver, lungs, kidneys, brain and so on; direct damage from the virus, autoimmune attack or extended hospitalizations are the culprits. These will likely now be life-long problems, and pose future difficulty as we care for them. As for those experiencing symptoms after mild or no obvious initial symptoms, the etiology is not well understood.

With the Covid pandemic continuously evolving, the data too are evolving, therefore, much is incomplete, or the data are conflicting. Any data in this editorial came from the CDC, Pubmed searches, or from a major institution’s website.

According to the CDC, those with long Covid with less understood etiologies experience shortness of breath (SOB), fatigue, post-exertional malaise, difficulty concentrating, cough, chronic pain, palpitations, diarrhea, sleep disorder, and many other vague but life-altering symptoms. SOB, fatigue, and cognitive changes are the three most commonly described of the actually hundreds of documented conditions. Long Covid can last weeks or months after first being infected or can appear weeks after infection. It can occur in anyone who has had Covid, even if the illness was mild, or if they had no symptoms. Since the definition of long Covid varies, consistent statistics prove difficult but data have

16 Spring 2022 Central PA Medicine

been published stating that 50% of unvaccinated Covid sufferers experience the syndrome and 19% of those vaccinated with Covid do. Patients may or may not have abnormal laboratory values consistent with lingering infection or inflammation.

There are at least three theories of the etiology of long Covid.

One is that the virus is still present in the body and becomes intermittently reactivated. Two is that left over inflammatory cells continue to produce an inflammatory response. Lastly, the Covid infection has led to an autoimmune process therefore our own immune system is creating ongoing symptoms. It’s probable that a combination of two or all the theories are correct.

A process described with Covid is Multisystem inflammatory syndrome (MIS), a continuing process seen in post-Covid patients.

It has been seen in adults and children. MIS is not common but if present, is a serious condition in which different body parts become inflamed, including the heart, lungs, kidneys, brain, skin, eyes, or gastrointestinal organs.

As for mental health, literature describes a one in three likelihood of having generalized anxiety disorder post-Covid. Furthermore, one in four have disorganized sleep, one in five have depression, and one in eight have PTSD. As for treatment of all these processes, they are supportive and minimally defined.

What this all means is lingering problems after surviving the acute infection, as if that was not enough, will be with us for years to come; and we will be treating them with a myriad of therapies that are as yet probably unknown.

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LEGISLATIVE UPDATES

PENNSYLVANIA MEDICAL SOCIETY Quarterly Legislative Update

Prior Auth—SB 225—PAMED is part of a 40+ member to allow pharmacists to administer flu vaccines to children ages coalition pushing for the passage of SB 225. At present, a 9 and above. Pharmacists are prohibited from delegating their final omnibus amendment to SB 225 is being drafted after injectable authority but pharmacy interns under the direct, extensive meetings between stakeholders. Commitments from immediate and personal supervision of a pharmacist are also Senate republican leaders and the bill’s sponsor, Sen. Kristin allowed to administer injectables under the same conditions Phillips-Hill, has been the driving force to reach meaningful applicable to pharmacists. agreements with the health insurers. Although a “date certain” Restricted Covenants—HB 681—This bill was approved by for a senate floor vote remains somewhat elusive, all indications the House Health Committee last year and is currently awaiting point to late May. PAMED will begin a grassroots campaign final passage by the full House of Representatives. Opposition to get physicians engaged in calling their senators. (PAMED by the Hospital Association, in conjunction with a number of initiated this initiative nearly 6 years ago.) legislators, has dramatically slowed the consideration of this IMG Licensure Parity—HB 245—After several years of nav- proposal. PAMED continues to coordinate legislative strategy. igating the legislative process, this legislation won the approval EPT—SB 317—Expedited Partner Therapy (EPT) legislation of the General Assembly and was signed into law on April 19 has now cleared the Senate and the House Health Committee. as ACT 16 of 2022. The bill reduces the number of resident The bill provides liability protections to physicians who elect years, from 3 to 2, that IMGs must complete to qualify for a to treat the sexual partner of a patient who has contracted an medical license. This brings IMGs into parity with graduates STI. PAMED has joined with the OB/GYNs in supporting of American and Canadian medical schools. (HB 245 was this initiative. Final passage is expected in the near term. legislation sponsored on behalf of PAMED.) Test Records—HB 1280—Originally initiated by PAMED Pharmacy—HB 1535/SB 515—This bill proposes to, among after the passage of ACT 112 of 2018, this bill will significantly other things, grant pharmacists with the authority to provide change the requirements that currently exist under ACT 112. childhood immunizations for children ages 3 and above. It also The bill will require imaging facilities to provide a written grants the ability of pharmacists to provide flu and Covid-19 notice to patients undergoing an imaging study (excluding vaccines to children. PAMED has joined with our physician x-rays) reminding them to contact their referring physician coalition partners in opposing these bills. We are aware that for the test results if they have not heard from them within 21 Rep. David Hickernell will be introducing his own version of days. The bill has passed the House and is currently awaiting HB 1535 that will limit expanded services by pharmacists to Senate Health Committee consideration. flu and Covid-19 vaccines for individuals aged 9 and above.

Since 2002 the Pharmacy Act has authorized pharmacists to administer injectable medications, biologicals and immunizations to individuals ages 18 and above. The Act was amended in 2015

Stay up to date on PAMED’s legislative priorities at

www.pamedsoc.org/Advocacy Central PA Medicine Spring 2022 17

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RESTAURANT REVIEW

18 Spring 2022 Central PA Medicine

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EL SOL CANTINA

By ROBERT ETTLINGER, MD

A

comedian once joked about Mexican food having 100 recipes made out of 6 ingredients. If you take a look at the offerings at that fast-food restaurant featuring a chihuahua, it’s kinda true. Refried beans, salsa, cheese, and guacamole if you’re lucky. But there’s another kind of cuisine from our neighbors to the south.

Mexican food was introduced to the US in the 19th century when settlers entered Texas and encountered Mexicans who had the territory of San Antonio. Beans and spices were combined with the beef that was plentiful from the cattle supply, to make chili con carne. In the 1890’s, the term Tex-Mex came to be, as food ideas were shared by the different ethnicities, and these grew into what most of us think of as Mexican food. However, it differs from authentic Mexican. The Texas brand uses cheese more often, and is more likely yellow, as opposed to the usually milder white queso of Mexican cuisine. Cumin is much more common in the Tex-Mex version, and tortillas are commonly made of wheat, rather than the original ones of corn. So, if you›d like to experience the real deal, the recently opened El Sol Cantina is the place to try.

Located at the site of the old Federal Taphouse, the southwestern style dining area is decorated with arts brought from Mexico. The menu mirrors that of its city counterpart, El Sol in downtown Harrisburg, down the block from the Whitaker Center. The food is a step above the others.

The drink menu has just about anything, including wine and beer selections, variations of margaritas and sangrias, as well as dozens of tequilas. Apps include guacamoles (with crab, goat cheese, and a surprisingly mild grilled jalapeno), served with baked crisps and enough for a table to nibble on before the main course. The chefs use avocados grown on a farm in Mexico of ESC’s owner, Juan Garcia.

A wide selection of tacos, ceviches, quesadillas, burritos, fajitas, and queso fundidos (melted Mexican cheeses, gussied up) make it hard to choose. Carne and pollo entrees are unique, with rice and beans. Lobster Enchiladas had fresh chunks of meat, sauteed spinach, and portabella mushrooms, topped with a smoky pepper reduction and white queso. A big sizzler plate of Fajitas Mixtas had chicken, steak, and shrimp, with another plate of the fixins.

If you still have a little room at the end of the meal, Tres Leches Cakes (traditional or chocolate), flan, fried ice cream, and churros are destined to be shared.

By the way, I don’t care what anybody thinks...every so often, yo quiero Taco Bell!

EL SOL CANTINA 3721 Market Street, Camp Hill, 717-635-9800

Central PA Medicine Spring 2022 19

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DCMS NEwS

FRONTLINE GROUPS The Dauphin County Medical Society thanks the following for their 100 percent membership commitment and their unified support of our efforts in advocating on behalf of physicians and the patients they serve.

 Allergy Asthma & Immunology

 UPMC Heart and Vascular Institute-LCV

 Brownstone Dermatology Associates

 UPMC Pinnacle Colon & Rectal Surgery

 Conestoga Eye-Hershey

 UPMC Pinnacle Harrisburg Transplant Services

 Cummings Associates PC

 UPMC Pinnacle Harrisburg-Emergency Room

 Elena R Farrell DO

 UPMC Pinnacle PHCVI Cardiovascular & Thoracic Surgery

 Family Practice Center PC-Millersburg

 Woodward & Associates PC

 F orti & Consevage PC  Gastroenterology Associates of Central PA PC  Harrisburg Gastroenterology Ltd  Hershey Pediatric Ophthalmology Associates PC  Hershey Psychiatric Associates  Houcks Road Family Practice  James R Harty MD  Jatto Internal Medicine & Wellness Center PC  John E Muscalus DO  Morganstein De Falcis Rehabilitation Institute-Harrisburg  Patient First-Harrisburg  PinnacleHealth Express  PinnacleHealth Radiation Oncology

Your Choice.

Our privilege.

We believe the care a person receives makes a difference in his or her quality of life.

 Premier Eye Care Group  Saye Gette & Diamond Dermatology Assoc PC  Schein Ernst Mishra Eye  Stratis Gayner Plastic Surgery  Tan & Garcia Pediatrics PC  Todd R Fisher MD Family Medicine 20 Spring 2022 Central PA Medicine

717-857-7400 | HomelandatHome.org Hospice volunteers are always welcome.

MAY 15, 2022 ~ HOMELAND 155TH ANNIVERSARY CELEBRATION Honoring Betty Hungerford

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NEW MEMBERS Thomas Zacharia, MD Katie McHale, DO

Evida Mars-Holt, DO

Abdullah Osme, MD

Emily Nicole Milarachi, MD

Jennifer Mardini, MD

Qurat-ul-Ain Mansoora, MD

Sarah Whitney Kesterson, MD

James Eric Greensmith, MD

Robert B. Simpson, MD

Dominique Na’Shea Durante,MD

Samuel Thomas Arcieri, MD Sophia Yen, MD Ankit Jain, MD

Marc David Polanik, MD

Stephen Paul Polanski, MD

Nanyaly Milagros Santiago-Aponte, MD

Anish George Mammen, MD

Yi Wang, MD

Min Yao, MD

Kristin Lenore Shute, DO

Chikezie Ikechukwu Eseonu, MD

Angela Derobertis, MD

Stewart Craig McCarver, MD Edward Gilbert Kim, MD

Jonathon Kirk Maffie, MD

Joshua Ryan Dellinger, MD

Madison Oxford Nicole Fye Rafay Nasir

Ciara Marshall

Sandeep Jain, MD

Jonathan Toan Pham

Joshua David Etzel, DO

Amanda Dubbs

Fielding Richards, DO

Anna Ptasinski

Anthony Olumide Kamson, DO Alfred Schupp III, MD

Michael Kozak

Ashley Wong

Ellie McNulty

Jennifer Elizabeth Coles, MD

Steven Michael Riela, MD

Sarah Hershberger

Nancy Fisher

Priya Shivraj, MD

Amy Thompson

Nicholas George Abourizk, MD

Ahsan Farooq, MD

Haidn Foster

Benjamin Ravichander, MD

Jennifer Marie Jordan, MD

Elon Einav

Christian Cotton, MD

Harsimran Singh

David E. Wilmot, MD

Alexandra Chahwala Michelle Ashley Rizk, MD Siddharth Goel, MD

Mahaswi Sirangi, MD

Michael Stack, MD

Erik J. Simonson, MD Christopher Thomas Soriano, MD Caitlyn Holden Hodge, MD

Nicholas Italo Pilla, MD

Ramin Beheshti, MD

Scott Anthony Weismiller, DO

Benjamin Sisco

Kevin Justin Mills, MD

Melanie Shpigel

Martha Doxsey Devon Ackerman

Catherine Caldwell

Hannah Stein Mary Connolly Mara Trifoi

R E I N S TAT E D M E M B E R S Fabian Alcaraz-Angulo, MD Eric Alfred Walker, MD

Michael Taylor Faschan, MD

Mark Tulchinsky, MD

Chelsea Lynn Cambria, DO

Jeffrey J. Miller, MD

Daniel James McKeone, MD

Jessica Lynn Mann, MD

Catherine Bongka Baye Easton, MD

Claudia Jane Kasales, MD

Salim Baghli, MD

Farda Qayyum, MD

Michael P. Krall, DO

Margaret Mary Fitzsimons, MD Stephanie Anne Schultz Horst, MD Matthew Scott Redclift, MD

Serdar H. Ural, MD

Grace Zi-Yan Wang, MD

Kevin Louis Rakszawski, MD

Frederick Curtis Sudbury, MD Gregory Scott Mowrer, MD

Benjamin Pinto, MD

Central PA Medicine Spring 2022 21

SUMMER TOURS AVAILABLE AT LANCASTER COUNTRY DAY SCHOOL challenging academics are only the start of each student’s opportunities for personal discovery and growth. From preschool to 12th grade, LCDS students are able to develop established passions or try new activities in a supportive independent school environment. Schedule a tour today! www.Lancastercountryday.org | 717-392-2916

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The Latest Advances in Neurosurgery for Your Patients— Right Here, Close to Home

The Penn State Health Neurosurgery team provides comprehensive treatment for common to complex conditions of the brain, spine and nervous system.

Our world-class neurosurgeons have specialized expertise in many neurosurgical subspecialties to bring both children and adult patients lifesaving care tailored to their specific needs.

Patients also benefit from research conducted at Penn State College of Medicine, with access to innovative clinical trials – with the latest treatments and new hope.

Contact a Penn State Health neurosurgical expert near you: Penn State Health Neurosurgery Milton S. Hershey Medical Center 30 Hope Drive, Entrance B, Suite 1200 Hershey, PA 17033 717-531-3828 American Office Center (on the Holy Spirit Medical Center campus) 423 N. 21st Street, Suite 300 Camp Hill, PA 17011 717-763-2559 St. Joseph Medical Center Medical Office Building 2494 Bernville Road, Suite 201 Reading, PA 19605 610-378-2557

pennstatehealth.org/neurosurgery

NEU-16797-22 166047 040522 CPAM