Lehigh County Health & Medicine Winter 2023-2024

WINTER 2023-2024

Official Publication of The Lehigh County Medical Society

What You Need to Know

Winter Skincare

for Eczema-Prone Individuals

Did You Get Your Flu Vaccine?

Don’t let joint pain slow you down Surgery Center of Allentown is now offering Robotic Joint Replacement Surgery SAME DAY SURGERY



LOWER COSTS THAN HOSPITAL



HIGHER PATIENT SATISFACTION

Meet our Joint Health Team

Kenneth Brislin, M.D.

Gregor Hawk, M.D.

Paul Pollice, M.D.

Specialties: Knee, Shoulder

Specialties: Hip, Knee, Shoulder

Specialties: Hip, Knee

Our physicians utilize MAKO robotic-arm technology to perform their outpatient robotic-assisted surgeries.

Contact us today to schedule an appointment and discuss your joint replacement options.

484.268.5232 www.scoallentown.com

contents

WINTER 2023-2024

LEHIGH COUNTY MEDICAL SOCIETY P.O. Box 8, East Texas, PA 18046

610-437-2288 | lcmedsoc.org

2023 LCMS BOARD OF DIRECTORS Rajender S. Totlani, MD President Rajender S. Totlani, MD Vice President Oscar A. Morffi, MD Treasurer

20

Charles J. Scagliotti, MD, FACS Secretary William Tuffiash Immediate Past President Elect

5 IN THIS ISSUE

CENSORS Howard E. Hudson, Jr., MD Edward F. Guarino, MD

TRUSTEES Wayne E. Dubov, MD Kenneth J. Toff, DO

EDITOR David Griffiths Executive Officer

FEATURES 6 LONG COVID; THE PCP’S APPROACH

By Yvonne Kingon, MPH, MSN, RN, CPNP Allentown Health Bureau

By Diana E. Farrell, DO, FACOI

MANAGING LONG COVID IN OLDER ADULTS 16 ENCOURAGE YOUR PATIENTS TO GET THE FLU VACCINE IN THE PULMONARY CLINIC

By Madalyn Schaefgen, MD, FAAFP

By Christopher Lenivy, DO

10 BETTER COMMUNICATION 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 Lehigh County Medical Society.

12 CONGENITAL SYPHILIS RATES ARE AT 30-YEAR HIGH IN PENNSYLVANIA; HERE’S HOW TO BRING THEM DOWN

By Bruce M. Kaufmann, MD Asst. Prof. U. of Arizona, College of Medicine Phoenix

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

Lehigh County Health & Medicine is published by Hoffmann Publishing Group, Inc. Reading, PA | HoffmannPublishing.com | (610) 685.0914

SEE PAST ISSUES AT LH.HoffmannPublishing.com FOR ADVERTISING INFO CONTACT:

Tracy Hoffmann, Tracy@hoffmannpublishing.com, 610.685.0914 x201

LVPG Ambulatory Immunization Clinical Lead, Pennsylvania Medical Society Primary Care Trustee

19 PENNSYLVANIA MEDICAL SOCIETY ADDRESSES EMERGENCY DEPARTMENT (ED) OVERCROWDING 20 WINTER SKINCARE FOR ECZEMA-PRONE INDIVIDUALS

By Stacey Blannett, DO; Dominique Jacobs, DO; Kevin Liu, DO; and Shane Swink, DO

RECEIVE THE LATEST UPDATES BY FOLLOWING US ON SOCIAL MEDIA

Carol C. Dorey Real Estate, Inc. Specialists in High-Value Property

Bucks County / Lehigh Valley, PA www.doreyrealestate.com / (610) 346-8800

BELLE TERRE... A gated entrance & long drive is introduction to the

PREMIERE BUILDING LOTS... Custom home builder Myron

OVERBROOK MANOR... It’s love at first sight when you turn down

the gravel driveway, cross the wooden bridge over Rapp creek, and peek around the corner at a fairy tale come to life. 5 beds, 4 full baths, guest cottage, 7.55 acres.

Offered for $1,125,000

WEYHILL COTTAGE... Part of a world-class neighborhood; a lovely six home enclave within walking distance to the Weyhill Golf Course of the Saucon Valley Country Club. This luxury detached condo has an exterior of stone and cedar.

Offered for $1,050,000

VIOLA LANE... In a quiet mature neighborhood in Lower Saucon rests this traditional colonial. With 9’ ceilings throughout, Viola Lane’s spacious floor plan offers many recent upgrades including a generator, new HVAC & 50-year roof.

Offered for $850,000

THE MANOR ON APOLLO... An enticing glimpse of an earlier age of elegance, this all brick manor home built in 1992 is an amazing reproduction of the best in period architecture and craftsmanship. 4 bedrooms, 4 full baths.

Offered for $799,000

13,000 sqft stone manor house on 22 acres. 5 bedrooms, 10 garages, stone pool house, caretaker’s apartment, barn, tennis court, pool, waterfall, spa & greenhouse are just a few luxuries.

Offered for $6,950,000

Haydt works with homeowners who will settle for nothing less than extraordinary to create their dream home. Protective covenants include 4,500 sqft minimum.

Building packages starting at $2,899,500

SYCAMORE HOLLOW... Exposed beams, deep silled windows & HOPE ROAD... Pride of ownership is evident in this well-maintained random width wood floors meet modern amenities for the ultimate in luxury country living. Surrounded by acres of tall trees & bordered by farmland, Sycamore Hollow is a rural retreat.

Offered for $730,000

residence in the Bethlehem Area school district, a stone’s throw to St. Luke’s Anderson campus, bustling shopping centers, and essential Lehigh Valley thoroughfares.

Offered for $449,000

IN THIS ISSUE

A

s the calendar changes to another page, we move from all things pumpkin into hot chocolates and peppermint, and we bring you the winter edition of Lehigh Valley Health and Medicine.

We have many different articles in this issue, including a discussion on Long-COVID, cold weather skin issues, the influenza vaccine and the worrisome rise in Syphilis in Pennsylvania. We initially brought you an article back in the spring 2022 edition. We include a follow up here that discusses more about what’s driving the congenital Syphilis rates to a 30-year high.

For many people who have contracted COVID, they suffer long after the quarantine period ends.

In this edition we have an interesting article on Long-COVID. The authors discuss what LongCOVID is, how your primary care physician goes about your care, along with older patients being treated by their pulmonologist.

As the weather gets colder, many of us will suffer from dry skin or more severe skin conditions.

Read on for information about “Winter Skincare for Eczema-Prone Individuals.”

Finally, better communication is a topic we all may be able to improve on. There are some great examples highlighted in this article on “Better Communication.” Please read on.

Thank you to all who helped with this edition, as well as those who have supported previous editions. We hope you enjoy this and past issues as we add to the conversation about how medicine and wellness can help us form strong communities in Lehigh County. If you are interested in back issues, or just want to read Lehigh County Health and Medicine online, please visit our website at https://lcmedsoc.org/our-publication.

WINTER 2023-2024 | Lehigh County Health & Medicine 5

FEATURE

The Status of Long COVID Three Years Post-Pandemic; Perspectives from the primary care physician and the pulmonary clinic

I

nvestigators from the Patient-Led Research Collaborative and Scripps Research Translational Institute report that 65 million people across the world are suffering from Long COVID.1 If we look at the United States, a Centers for Disease Control and Prevention survey found that more than 6% of all adults were experiencing at least one symptom of Long COVID as of mid-March 2023.

That jumps to nearly 15% when considering adults who have experienced the condition at any point in the pandemic.2 Even though the numbers vary from source to source, experts agree that the condition will remain a challenge in the public health sector and for the U.S. and world economies.

What causes Long COVID?

There are a couple of leading theories. One is that the virus lingers post-infection, hiding in “viral reservoirs” in body tissue and later causing problems. Another theory is that COVID-19 could reactivate other viruses that were dormant, bringing new symptoms with it. Additionally, the coronavirus triggers inflammation in the body that for some reason persists in certain people, causing an array of health problems.

There is also a question surrounding the tiny blood clots that have been found in people after COVID-19 infection. It’s been proven that those who have had COVID-19 are at higher risk of developing blood clots, but the persistence of these “microclots” could be complicating the passage of oxygen through the body.

Ultimately, there are probably multiple mechanisms for Long COVID, making the condition a confluence of factors that manifest in the same person at the same time.

As health care providers continue to see and treat patients for Long COVID, we look at the condition from the perspective of both the primary care provider and the pulmonologist treating older patients. This provides insight into how the condition is being managed and considerations for the practicing physician in the months and years ahead.

1 2

6 Lehigh County Health & Medicine | SUMMER WINTER 2023-24 2020

https://www.cidrap.umn.edu/covid-19/more-65-million-people-around-world-may-have-long-covid https://www.usnews.com/news/health-news/articles/2023-04-14/long-covid-19-is-sticking-around-whats-causing-it

LC M E D S O C . O R G

The PCP’s Approach

BY DIANA E. FARRELL, DO, FACOI

As we continue to study COVID-19, there is growing evidence to support that the effects of COVID do not end at the discontinuation of self-quarantine. While many patients will recover from their COVID-19 infection within two weeks of onset, there are patients who experience persistent symptoms long after their initial illness has resolved. According to the CDC and WHO, patients who continue to experience new or worsening symptoms four weeks after their initial COVID-19 infection are considered to have “Long COVID.” Also known as “Post-Acute COVID” or “COVID Long Haulers,” Long COVID is now associated with its own ICD 10 code and is an approved disability under the Americans with Disabilities Act.

Most studies now estimate that one in five individuals over the age of 18 have Long COVID. Those same studies show an increased incidence of Long COVID in patients over the age of 65, reporting that one in four individuals over 65 have developed Long COVID.

In patients over the age of 65, the three most commonly reported symptoms of Long COVID are persistent fatigue, persistent respiratory symptoms, and cognitive decline.

I started taking care of COVID-19 patients, in the first days of the pandemic, through a virtual program that was established in conjunction with Remote Patient Monitoring in March of 2020. The goal of the program was to care for COVID positive patients who were acutely ill and at risk for developing advanced disease but did not quite meet criteria for hospital admission. Our work with this program proved that by effectively coordinating services in the extra acute space, we were truly able to leverage telemedicine to deliver care to these patients in a way that was both safe and effective. The COVID telemedicine work continued to evolve throughout the pandemic.

As monoclonal antibodies were delivered under the FDA’s Emergency Use Authorization, we used our telemedicine platform to check in with patients and monitor them for response to, and side effects from, the infusions. Today, many of these COVID positive patients have developed Long COVID and have established care with me at my Internal Medicine Practice in Bethlehem. As a result, I am seeing the effects of Long COVID in my practice as a PCP on a nearly daily basis.

Many of these patients have complaints of persistent fatigue, dyspnea on exertion, cognitive decline and new or worsening anxiety and depression.

CONTINUED ON NEXT PAGE

WINTER 2023-24 | Lehigh County Health & Medicine 7

FEATURE

Because of this, I have found that when it comes to treating them, a multidisciplinary approach is essential. Many of my patients with persistent respiratory symptoms, or new onset cardiac symptoms, are followed closely by their pulmonary or cardiac specialists. The use of therapy services has also been instrumental in my care of these patients. Physical therapy has played a crucial role in helping deconditioned patients return to their activities of daily living with limited impairment. Occupational therapy teams have worked closely with my patients who have suffered from brain fog and other forms of cognitive decline from Long COVID by providing intensive cognitive therapy. And finally, as we recognize that a significant number of Long COVID patients develop new or worsening symptoms of mental illness, behavioral therapy has been invaluable in their delivery of mental health services.

I have also worked very closely with COVID patients, both in the acute phase of their illness as well as those suffering from Long COVID, through my work as a home care program Medical Director. I began this work six months into the pandemic. At that time, our nurses were routinely providing care to acutely ill COVID-19 patients. Following the approval of vaccination, our nurses were then instrumental in the delivery of vaccines to our homebound patients and now continue to care for Long COVID patients.

8 Lehigh County Health & Medicine | WINTER 2023-24

We have found that when it comes to treating this patient population in the home care setting, especially older adults with Long COVID, we typically front-load visits to provide the most intensive care immediately after patients come onto our service. We have also found that this population may require a longer length of stay with our services given the slow improvement that is typically observed in this Long COVID population. Finally, since leaving the home can be quite taxing for these patients, we have once again leveraged telemedicine to coordinate virtual visits between the provider and our Home Care nurses at the bedside. This enables providers to obtain real time vitals, have access to the nurse’s physical exam findings, and visualize the patient, all without the patient even needing to leave their home.

Through all my Long COVID work, I recognize that when it comes to caring for these patients, one constant theme prevails. These patients are tired, frustrated, and simply want to be heard.

Validation that their symptoms are real, that they are not alone, and reassurance that they will, in time and with the proper treatment improve, may just be our single, most valuable tool when it comes to caring for them.

LC M E D S O C . O R G

Managing Long COVID in Older Adults in the Pulmonary Clinic

BY CHRISTOPHER LENIVY, DO

The effects of long COVID on the pulmonary system can be derived from a variety of factors. Many patients suffer with longstanding dyspnea on exertion, persistent limitations in exercise tolerance, and can even develop new lung pathologies as a result of the body’s response to the virus.

While asthma and COPD patients do share similar flow obstruction on PFTs and inhaler options, they differ in that asthma has not proven to be a major risk factor for severe COVID infection or worse outcomes. Again, the controller regimen should not affect the outcomes from COVID infection.

All aspects of the respiratory system can be affected, including the conducting airways, the alveoli and pulmonary interstitium, the arterioles and vasculature, and even the respiratory muscles themselves. Our main goal in evaluating a new patient in the pulmonary clinic for Long COVID symptoms is to tease out which of the above factors seems to be driving the individual’s symptoms. Long-term effects tend to be unique to each patient; as an example, postCOVID fibrosis of the lungs can be seen in both patients who are recovering from ICU-level critical illness and those with mild outpatient infections alike. There is no one rule to how the body responds as it heals from the insult.

Certain patients without prior underlying lung disease that exhibit a persistently low SpO2 despite adequate recovery time may be suffering with some of the more unique diseases that we see in the outpatient setting. Post-COVID organizing pneumonia is an inflammatory condition where the airways and interstitium are filled with myxoid plugs of connective tissue as a part of the immune system’s handling of the virus. Historically this has been a very steroidresponsive entity when associated with other viruses, and on early observational data it seems to hold true with COVID. Capillaritis and endothelial dysfunction have been proven to play a major role in the pathogenesis of COVID, and unsurprisingly the rates of thromboembolism are high in patients with COVID. In those with ongoing hypoxia despite radiographic clearance, attention must be brought to the potential for VTE and in certain cases chronic thromboembolic pulmonary hypertension (CTEPH).

A large portion of our outpatient volume is suffering with COPD. Multiple meta-analyses have suggested that patients with COVID infection and underlying COPD do not just have higher lung-related morbidity, but also a higher allcause mortality. Unfortunately, there is a considerable overlap between poorly controlled COPD and Long COVID symptoms, so it's generally advised to keep a low threshold for further testing. Thus far, there has not been any data to support the idea that any controller inhalers (notably inhaled corticosteroids) are either linked to more severe disease, or longer times to recovery from COVID infections. What has been known for years in our COPD population is that each insult to the lung that causes an exacerbation oftentimes results in an inability to return to prior baseline functional status. Optimal baseline control with LAMA, LABA, and ICS is therefore paramount.

Overall, there is a vast array of pulmonary manifestations with Long COVID. Clinicians must have a low threshold to investigate further with PFTs, high resolution CT scans, and other modalities to determine if there is a measurable abnormality that can be acted on to help the patient’s symptoms.

WINTER 2023-24 | Lehigh County Health & Medicine 9

FEATURE

BETTER COMMUNICATION

BY BRUCE M. KAUFMANN, MD ASST. PROF. U. OF ARIZONA, COLLEGE OF MEDICINE PHOENIX

We regard effective, accurate communication as one of the most important tools of medical care.

H

owever, we do not always utilize this tool properly. As the Captain said to Paul Newman in “Cool Hand Luke,” “What we have here is a failure to communicate.” I wish to examine our communication efforts in several different ways.

10 Lehigh County Health & Medicine | WINTER 2023-24

First, it does not necessarily follow that a measurement below which obviates the need for intervention, then a measurement above that amount requires intervention. An example is endometrial thickness on ultrasound. Endometrial thickness of 4mm or less on ultrasound in a woman with postmenopausal bleeding has a very small risk of uterine cancer. The converse of 5mm or more does not necessarily cause the need for biopsy, especially if it is an incidental finding on imaging in the absence of postmenopausal bleeding. ACOG Committee Opinion, May 2018, Vol. 131, Issue 5, pp 124 – 129. Dare I say, we must be somewhat more like our attorney colleagues and pay attention to every word in each sentence.

LC M E D S O C . O R G

Second, I wish to explore what I call medical aphorisms. William Mayo said, “We think of truths as ponderables capable of being measured and weighed, but introduce a new fact and a new truth is developed.”

We did not understand what we were saying until new facts were introduced. Specifically, as residents in OB-GYN in the seventies, we flippantly said that (in the pre-tattoo era) if a woman had one tattoo, she probably had gonorrhea. If she had two tattoos, she probably had syphilis in addition.

If she had three tattoos, she probably had cervical cancer.

I now apologize to my colleagues with tattoos, and gladly have rejected that cruel line of thought. However, we did not realize what we were saying—cervical cancer is an STD and at that time we equated tattoos with a wanton lifestyle.

Now we can freely sport tattoos and also discuss HPV vaccination with our patients.

Lastly, we must clearly understand and properly utilize statistics in communicating with our colleagues, patients, and (shudder) attornies. Relative risk increase or reduction have very different meanings. These were used inappropriately to communicate breast cancer risk with hormone replacement therapy or estrogen replacement therapy. Please note that these are very different therapies and not interchangeable words. In addition, relative and absolute risk differ in the denominator in statistical analysis.

Another example is statins and cardiovascular risk. The relative risk reduction of ASCVD mortality is 1.2% whereby the relative risk reduction is 19%. Lancet, 2005,366:126778. We must talk to ourselves and our patients accurately and completely to satisfy our oaths.

BETHLEHEM MEDICAL ARTS CENTER 5325 NORTHGATE DRIVE BETHLEHEM

PREMIER MEDICAL OFFICE SUITES AVAILABLE SCHEDULE A TOUR!

(610) 264-0200 Leasing Agents: Sarah Finney Miller Jennifer Kennedy

LISTING INFO

Spacious, first-floor office suite that occupies 8,550 sq. ft. (divisible) offers excellent visibility and convenience for patients. Support your growing patient base by establishing an office location in Bethlehem Medical Arts Center. This independently owned and professionally managed two-story medical office building is located near Route 512. Lease the well-appointed 2,309 sq. ft. secondfloor corner suite. Benefit from generous tenant improvement options and explore the possibility of free rent.

Commercial Real Estate Services www.naisummit.com

WINTER 2023-24 | Lehigh County Health & Medicine 11

FEATURE

Congenital Syphilis Rates are at 30-Year High in Pennsylvania

Here’s How to Bring Them Down

BY YVONNE KINGON, MPH, MSN, RN, CPNP ALLENTOWN HEALTH BUREAU

I

n the Spring 2022 issue of this journal, we presented an article on the alarming rise in syphilis rates across the Commonwealth. Now, a year and a half later, according to the Pennsylvania Department of Health (DOH) Sexually Transmitted Disease (STD) Program, primary and secondary syphilis rates are at a 30-year high.

Even more concerning, congenital syphilis (CS) rates, also at a 30-year high, are on track to outpace even the numbers seen in 2022.

12 Lehigh County Health & Medicine | WINTER 2023-24

LC M E D S O C . O R G

That year, 13 CS cases were reported in Pennsylvania (exclusive of Philadelphia). However, in the first six months of 2023 alone, a total of 10 cases were reported.

Based on current data, PA DOH projects total cases for 2023 will be 18, exceeding the previous high in 1990.

Because of this, PA DOH considers pregnant individuals a priority population for public health prevention efforts.

The surge in CS reflects the disconcerting rise in early syphilis (encompassing primary, secondary, and early latent syphilis) among women in PA. From 29 cases of early syphilis in 2010, the number of cases began rising in 2014 and climbed to 309 in 2022. Most early syphilis cases in women in PA occur in the prime reproductive years of 2044. In Lehigh County, the number of early syphilis cases in females in 2021 was five; in 2022, it was 18.

These high rates are not exclusive to Pennsylvania. In its early release Morbidity and Mortality Weekly Report “Vital Signs” published on November 7th of this year, the Centers for Disease Control (CDC) reported a greater than 10-fold increase in CS nationwide, from 334 cases in 2012 to 3,761 in 2022. During the same period, rates of early syphilis in women of reproductive age increased 676%.

The consequences of CS could not be more dire. As many as 40% of infants born to women with untreated syphilis will be stillborn or die in infancy. In the November 7 MMWR report, the CDC identified 231 stillbirths and 51 infant deaths related to CS.

Ongoing negative sequelae for infants born with syphilis include hepatomegaly, jaundice, severe anemia, neurological insults such as blindness and deafness, developmental delays and intellectual disabilities, abnormal tooth development, and deformities in the long bones (most frequently the femur, humerus, and tibia).

It is not unusual for infants to be asymptomatic at birth; 60 to 90% of infants born with syphilis will not initially show symptoms. However, 40% of infants born to mothers with untreated syphilis will ultimately become symptomatic.

Of all the CS cases in Pennsylvania in 2023 thus far, 53% occurred in women who had no prenatal care. Another 17% were immigration-related, meaning that there was no reliable history of treatment elsewhere and a high probability of no prenatal care, bringing the number of cases due to no prenatal care closer to 70%. More troubling is the steady increase in the number of cases in which there was inadequate maternal treatment despite timely diagnosis.

In the CDC’s recent report, among 2,179 cases of CS for which timely testing and no late identification of syphilis had occurred, more than two-thirds of all cases had documentation of inadequate treatment during pregnancy.

Beyond the consequences to the infant, each case of CS is a sentinel event, defined by the CDC as a preventable disease, disability, or untimely death whose occurrence serves as a warning signal that the quality of preventive and/or therapeutic medical care may need to be improved in a jurisdiction. The rise in cases points us to two essential challenges: engaging all pregnant women in prenatal care as early as possible, and ensuring that all prenatal providers are following treatment recommendations.

CONTINUED ON NEXT PAGE WINTER 2023-24 | Lehigh County Health & Medicine 13

FEATURE

For individuals who are un- or under-insured, free and confidential testing is available at the Allentown Health Bureau, the Bethlehem Bureau of Health, and the Lehigh County State Health Office.

Treatment Recommendations:

If there is any good news to report, it is that the tools to prevent CS are at hand: adequate testing with accurate interpretation; identification of cases in pregnant women; and timely and appropriate treatment. Yet there are challenges to be overcome if we are to correct this course.

Testing Recommendations: PA DOH recommends that all sexually active individuals be routinely screened for HIV, syphilis, gonorrhea, and chlamydia, and that all pregnant individuals should be tested for syphilis and HIV at the first prenatal visit.

In addition, all pregnant individuals living in a high morbidity county, which includes Lehigh County, should have additional serologic testing for syphilis at the third trimester (28 weeks gestation) of pregnancy. The same applies for any pregnant individual with a concurrent STD or history of a prior STD. (In these cases, if testing is not done in the third trimester, testing should also be done at the delivery of a child or upon the delivery of a stillbirth.) The timing of the second test is crucial, as treatment for syphilis in pregnant women must be completed at least 30 days prior to delivery. (For detailed information about syphilis testing, refer to the 2021 Sexually Transmitted Infections Guidelines – see footnote at bottom of page 11) Whenever possible, women being treated for primary, secondary, and early latent syphilis who are at risk of pregnancy should have pregnancy testing done upon diagnosis.

14 Lehigh County Health & Medicine | WINTER 2023-24

The only therapy with documented efficacy for syphilis in pregnancy is parenteral benzathine penicillin G. Long-acting penicillin G (Bicillin® L-A) is the only acceptable formulation; other forms such as combination long- and short-acting benzathine-procaine penicillin (Bicillin® C-R) are not appropriate for treatment of syphilis. Treatment must be completed at least 30 days before delivery to be considered adequate. Women with a bona fide allergy to penicillin must be desensitized so that they can receive appropriate treatment. Primary, secondary, and early latent syphilis are treated with one dose; late latent syphilis and syphilis of unknown duration must be treated with three doses spaced 7-9 days apart. (For additional information on syphilis staging, refer to the treatment guidelines.) If a repeat dose is given more than 9 days after the prior dose, treatment is considered inadequate and must be restarted. Seven days between doses is considered ideal.

Complicating matters is the current shortage in injectable penicillin, with estimated recovery of stock not expected until mid-2024. While oral doxycycline is an acceptable alternative in some situations, only injectable penicillin is acceptable in the setting of pregnancy. Providers who are unable to obtain benzathine penicillin G are urged to contact PA DOH or their local health department for assistance.

LC M E D S O C . O R G

Because interpretation of test results can be complex, and because accurate staging of disease, essential to determine appropriate treatment, may depend upon the patient’s prior test history, all providers who encounter a case of prenatal syphilis are encouraged to reach out to their local health department for support. Often, prior test results are not available in a patient’s electronic medical record, but if the patient was tested previously anywhere in the Commonwealth, local health departments can often locate and interpret prior test results. Local health departments will also provide partner services, including testing and treatment for exposed partners of pregnant women, and will be able to identify resources for obtaining injectable penicillin during the current shortage.

Syphilis is a reportable condition for good reason: test interpretation is complex, information essential to accurate staging may be difficult to find, and treatment, challenging in regular times, can be confounding during a shortage. But CS is ultimately preventable, and local health departments are ready, willing, and eager to partner with providers to ensure adequate treatment and follow-up, and to work collaboratively to bend the curve of this troubling trend.

For further information about syphilis testing and treatment, refer to the Sexually Transmitted Infections Treatment Guidelines, 2021 (MMWR Vol. 70 No. 4): https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf

WINTER 2023-24 | Lehigh County Health & Medicine 15

FEATURE

ENCOURAGE YOUR PATIENTS TO GET THE

FLU VACCINE

BY MADALYN SCHAEFGEN, MD, FAAFP LVPG AMBULATORY IMMUNIZATION CLINICAL LEAD, PENNSYLVANIA MEDICAL SOCIETY PRIMARY CARE TRUSTEE

National Influenza Vaccination Week (NIVW) is December 4-8.1 CDC recommends that everyone 6 months and older get an annual flu vaccine.

The season has started, but it’s not too late to get vaccinated. Please encourage your patients and loved ones to get vaccinated.

What can you do to address Vaccine Fatigue, Hesitancy, Misinformation and Disinformation?

Address Misinformation/Disinformation2 • Think critically about what you read and hear. Learn how to identify misinformation.

• Seek information through credible websites like CDC.gov, NIH.gov or MedlinePlus.gov.3 • Learn about the vaccines and share credible & accurate information with others.

• Address health misinformation in your community.

• Teach your friends common tactics used by those who spread misinformation online.

16 Lehigh County Health & Medicine | WINTER 2023-24

LC M E D S O C . O R G

Address Vaccine Fatigue4 • Tailor your message to the person – what are their concerns?

• Offer and communicate about new vaccines available to them.

Address Vaccine Hesitancy • Utilize Motivational Interviewing (MI). See Voices for Vaccines toolkit5 or CDC’s Vaccinate with Confidence.6 • See CDC’s Talking with Patients about COVID-19 Vaccination7 or Canada’s Canvax site8 or the World Health Organization’s Conversations to Build Trust in Vaccination (A training module for healthcare workers).9 • Amplify positive aspects, accurate information regarding vaccines.

• Know where they can go to get the vaccine and assist them in getting there.

• Present vaccination as a social norm – “most people…”

Vaccinations save lives, and vaccination requires teamwork.

Help us to protect others!

Why get a flu vaccine?

Influenza each year causes 9 million to 41 million illnesses, 140,000 to 710,000 hospitalizations and 12,000 to 52,000 deaths in the U.S. As of Nov 25, CDC estimates that there have been at least 1.8 million illnesses, 17,000 hospitalizations, and 1,100 deaths (8 pediatric) from flu so far this season.10 Adults ≥65 years should preferentially receive high-dose inactivated influenza vaccine (HD-IIV4), quadrivalent recombinant influenza vaccine (RIV4), or quadrivalent adjuvanted inactivated influenza vaccine (aIIV4). If not available, any other age-appropriate standard dose influenza vaccine is better than none. These vaccines provide a greater immune response in elderly patients who generally have a less competent immune system. RIV4 (Flublok) is licensed for 18 years and older and is a good choice for younger adults with immunodeficiency.

I got the flu after vaccination!

How effective is the flu vaccine?

Remember that the flu vaccine works only against 4 strains of influenza, and not other viruses that can cause flu-like illness. It helps protect against severe illness, hospitalization and death. The effectiveness of the vaccine cannot be determined until the flu virus season is in full swing. Last year preliminary interim estimates of efficacy were 43% against adult hospitalizations,11 54% against medically attended influenza A in children and workingaged adults, and 71% against symptomatic influenza A in children.12 Interestingly, if you received a flu vaccine the prior season, the current vaccine is more effective.13 If you do get the flu after vaccination, you are much less likely to be hospitalized or die.

What are Other Benefits of the Flu Vaccine?14 • In pregnancy, giving mom a flu vaccination reduced risk of their newborn infants getting flu by 48%, and of infants being hospitalized for flu by 72%. This is important because infants < 6 months cannot be vaccinated and are much more likely to be severely ill or die if they get the flu.

• Flu vaccination lowers risk of hospitalization and death in those with chronic diseases: fewer COPD exacerbations in those with COPD, fewer heart attacks in those with heart disease, and fewer complications/ hospitalizations in those with diabetes.

What are the risks of the vaccine?

Anaphylaxis is rare (and safety measures are in place to handle it), and no new safety concerns for the flu vaccine have been seen.15 Guillain-Barré Syndrome (GBS) has been seen in some flu seasons (2009-2010 “swine flu”) but is very rare.16 A much greater risk for GBS was found in the 6 weeks following influenza illness.17 CONTINUED ON NEXT PAGE

WINTER 2023-24 | Lehigh County Health & Medicine 17

FEATURE

Vaccines Do Not Harm the Immune System, but Strengthen It People are exposed to 2000-10,000 antigens daily through eating, breathing and touching areas that have viruses and bacteria. There is no evidence that exposure to multiple vaccines is associated with an increased risk for infections not targeted by the vaccines18, meaning there is no evidence of weakening of the immune system. Although it is true that natural infection almost always causes better immunity than vaccines, it comes at a price that is much more severe than vaccination. Some viral illnesses (like measles) can cause increased risk for hospitalization and death for years after infection due to immune system suppression,19 but getting the measles, mumps, and rubella (MMR) vaccine did not show any decrease in the immune system.20

What is “immunity debt”?

There is recent discussion in the news of “immunity debt” since there were fewer infections in the first 2 years of the pandemic due to less exposure to viruses through use of masking and reduced socialization. The concern is that there are now more people who are susceptible to infection and that we need to “catch up.” Although measles has been shown to suppress the immune system, there is no evidence that COVID-19 illness nor vaccination does the same.

References 1

https://www.cdc.gov/flu/resource-center/nivw/index.htm

2

https://www.hhs.gov/sites/default/files/surgeon-general-misinformation-advisory.pdf

3

https://ahimafoundation.org/understanding-the-issues/spotting-health-misinformationonline/?utm_source=google_cpc&utm_medium=ad_grant&utm_campaign=Understanding%20The%20 Issues&gclid=Cj0KCQiAyKurBhD5ARIsALamXaGym5zE84dz7o4Bi29mZ4S3_BL_KkIOQFoVS3obbI955jerH6tLft4aAixpEALw_wcB 4

https://www.nature.com/articles/s41591-023-02282-y

5

https://www.voicesforvaccines.org/toolkits/vaccine-hesitancy/

6

https://www.cdc.gov/vaccines/partners/vaccinate-with-confidence.html

7

https://www.cdc.gov/vaccines/covid-19/hcp/engaging-patients.html

8

https://www.canada.ca/content/dam/phac-aspc/documents/services/reports-publications/canada-communicable-disease-report-ccdr/ monthly-issue/2020-46/issue-4-april-2-2020/ccdrv46i04a06-eng.pdf 9

https://view.officeapps.live.com/op/view.aspx?src=https%3A%2F%2Fcdn.who.int%2Fmedia%2Fdocs%2Fdefault-source%2Fimmunizati on%2Fdemand%2Ftrainingmodule-conversationguide-final.pptx%3Fsfvrsn%3D32a16425_2&wdOrigin=BROWSELINK 10

https://www.cdc.gov/flu/weekly/

11

https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2023-02/slides-02-22/influenza-03-Olson-Lewis-Tenforde-508.pdf

12

https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2023-02/slides-02-22/influenza-04-Mclean-508.pdf

13

Clinical Infectious Diseases, Volume 73, Issue 3, 1 August 2021, Pages 497–505, https://doi.org/10.1093/cid/ciaa706

14

https://www.cdc.gov/flu/prevent/vaccine-benefits.htm

15

https://pubmed.ncbi.nlm.nih.gov/31815089/

16

https://www.cdc.gov/vaccinesafety/concerns/guillain-barre-syndrome.html

17

https://academic.oup.com/cid/article/58/8/1149/355966

18

JAMA. 2018;319(9):906-913. doi:10.1001/jama.2018.0708

19

https://www.science.org/doi/10.1126/science.aay6485

20

Science 2019;366:599-606.

21

https://yourlocalepidemiologist.substack.com/p/has-covid-messed-with-our-immune

18 Lehigh County Health & Medicine | WINTER 2023-24

LC M E D S O C . O R G

ADVOCACY

Pennsylvania Medical Society Addresses Emergency Department (ED) Overcrowding

E

arlier this year, the Board of Trustees of the PA Medical Society created a task force to address the issue of emergency department (ED) overcrowding in Pennsylvania. Led by President-Elect, Kristen Sandel, MD, the task force issued a letter to Governor Shapiro, urging him to address this issue at a state level.

What is Emergency Department Overcrowding?

Emergency Department (ED) overcrowding is a dire problem facing rural and metropolitan communities across Pennsylvania. The issues leading to overcrowding are multifactorial and result in more patients presenting in the emergency department than the health care staff can accommodate.

Background

The primary cause of ED overcrowding is “boarding”, the practice of holding patients in the emergency department after they have been admitted to the hospital, because no inpatient beds are available.

Boarding is a decades long, unresolved problem that was only brought to its brink during the COVID-19 pandemic. It has become its own public health emergency which has negatively impacted healthcare systems, patients, and the community at large.

How does this affect Pennsylvania physicians?

Emergency physicians, care teams and staff continue to do all they can to treat and stabilize every patient that needs care in Pennsylvania. ED overcrowding has led to high rates of clinician and nurse turnover and high rates of burnout. Physicians should be able to focus on what they do best, which is giving every patient in Pennsylvania quality health care.

Support efforts to encourage more activity to less burdens of overcrowded ED by contacting PAMED.

LEHIGH COUNTY MEDICAL SOCIETY New Members

David Patrick Adams – Medical Student Sam Baird, MD – Radiology Raul Davaro, MD – Internal Medicine Aaron Bond Deutsch, DO Emergency Medicine – Resident Daniel Adrian Fernandez Felix , MD Pulmonary Disease – Resident Sarah Kohn Finnerty, MD – Emergency Medicine Ursula M Hoffmann, MD – Family Practice Emilee E Kurtz, DO – Internal Medicine – Resident Kristina Maureen Lim, DO – Dermatology Kumar Seelam, MD – Anesthesiology Mark Thomas Shephard, DO – Psychiatry, Resident Chris Sielski, DO - Psychiatry – Resident Shane M. Swink, DO – Dermatology Kateryna Yevdokimova, MD Pulmonary Disease – Resident Adnan Yousaf, MD – Internal Medicine – Resident

Reinstatement

Travis Craig Dayon, MD – Obstetrics/Gynecology Meghana Ganapathiraju – Medical Student Danny Le, DO – Emergency Medicine – Resident Puja Dinesh Patel, DO – General Surgery – Resident Alissa Eileen Romano, DO – Neurology

WINTER 2023-24 | Lehigh County Health & Medicine 19

FEATURE

Winter Skincare

for Eczema-Prone Individuals

BY STACEY BLANNETT, DO; DOMINIQUE JACOBS, DO; KEVIN LIU, DO; AND SHANE SWINK, DO

A

s we transition from our warmer months into fall and winter, we become accustomed to cold, dry outdoor air and indoor heating. The change of seasons not only welcomes the excitement of the holidays, but also brings dry, rashy, and itchy skin, called eczema. This is partially due to the loss of the skin’s natural moisture during the colder months, but genetic and other environmental factors can play a role as well.

In this article, we aim to provide recommendations for winter skin care in eczema-prone individuals.

What is Eczema?

Atopic dermatitis (AD), more commonly known as eczema, is a chronic inflammatory skin condition that affects 2-3% of adults and up to 25% of children. AD starts with itchy red areas that may ooze or form a crust. Most individuals with AD have symptoms early in life, before 5 years of age. The most common time of onset is between 3 and 6 months of age. It is important to note that many individuals affected by AD have resolution of their skin disease, but some continue to have symptoms into adulthood.

Many variables contribute to the development of AD including environmental, genetic, and immunologic factors.

The result is a compromised skin barrier and dysregulated immune system response that manifests as itching and 20 Lehigh County Health & Medicine | WINTER 2023-24

rash. AD can have a significant effect on the day-to-day life of affected children and adults, sometimes being accompanied by unbearable itch, making it difficult to concentrate in school and complete other tasks. Due to their dysfunctional skin barrier, these individuals are also at an increased risk for skin infections.

Treatment

The goals for treating AD are to reduce itching and skin irritation and to prevent infection. Preventative skin care is of the utmost importance to keep AD flares at bay throughout the year. The foundation of this is gentle skin care and regular moisturization to restore the natural skin barrier. This is done by applying bland moisturizers, such as CeraVe, Cetaphil, or Vanicream lotions and creams. As a general rule, creams are thicker than lotions. Although lotions may rub in more easily, creams can provide more hydration and should be your moisturizer of choice if you are prone to dry skin or AD. Ointments, such as Vaseline or Aquaphor, are the most effective emollients and should

LC M E D S O C . O R G

be considered for active rashes or frequently inflamed skin.

Moisturizers should be used at least daily, and the best time for application is after bathing, while the skin is still moist.

Fragrances and other additives can further irritate the skin, so it is best to avoid these extraneous components in our skin care products.

Reduce Dryness and Irritation

You also want to keep your skin healthy by avoiding practices that may lead to dryness and irritation. Ironically, one of the main ways our skin can dry out faster is with repeated exposures to water. This is because our skin produces natural oils that create a barrier to help keep it hydrated, and water and soap work to erode that barrier.

Therefore, we recommend bathing no more than once a day and limiting hand-washing to certain circumstances, such as before and after eating, after using the restroom, and when visibly soiled.

It can also be helpful to keep a bottle of lotion or cream by the sink for use after hand-washing, as hands are one of the most common areas to get AD, particularly in the winter. We also suggest taking lukewarm showers or baths, as hot water will remove more of the natural oils in our skin. Using gentle cleansers, such as Dove Sensitive bar soap, will reduce the risk of skin irritation. Try to limit the use of soap to the armpits and groin. After showering, pat dry (preferably leaving some water on the skin surface) and apply moisturizer. For particularly red and itchy areas, you may use an over-the-counter hydrocortisone ointment, or any other topical steroid prescribed by your health-care provider. This may be done once daily for up to two weeks.

Soak and Smear Method

Another effective, yet time intensive treatment option, is called the “soak and smear” method. If done correctly, this treatment can lead to marked improvement of AD in a few days. It involves soaking in a bath in plain water for 20 minutes before bedtime followed by immediately applying ointment to wet skin. The ointment or moisturizer can be decided between you and your provider, but often involves a prescription topical steroid. Over-the-counter ointment or cream, such as Vaseline or CeraVe, can also be used.

The soaking allows water to go into the skin and hydrate it. The subsequent ointment or cream locks in the water, moisturizes the skin, and allows the anti-inflammatory ingredients to get deep into the skin.

The number of nights of soaking and smearing depends on the severity of your rash and how long it takes to get under control, ranging from 1 night to 2 weeks. Use an old pair of pajamas and do this at night, so the ointment stays on your skin for several hours while you sleep. After the rash is under control, you may stop the soaking and continue the smears with the ointment or moisturizer. If any red or scaly areas persist after this home treatment, we recommend making an appointment with your dermatologist to discuss other treatments.

WINTER 2023-24 | Lehigh County Health & Medicine 21

FEATURE

Humidifiers

You may find your AD worsens during the winter months and this is partly due to the dry, cold environment.

Humidifiers can help put this moisture back into the air, making your skin less dry and itchy. Humidifiers are generally safe for all skin types, however, remember to clean it daily to get rid of debris and prevent build-up of mold. Additionally, avoid using essential oils or fragrances with humidifiers, as these can worsen AD. You also want to be careful with warm-mist humidifiers since the tanks can be hot and risk a child to get burned.

Protect Your Skin

Most people with eczema are also affected by heat and sun.

For this reason, it is important to protect your skin from the sun year-round. The sun’s rays continue to penetrate your skin in the winter, resulting in skin cancer, facial wrinkles, and potential exacerbation of rash.

Don’t forget to protect your skin when you are enjoying winter sports such as skiing, since the sun’s rays are very strong in high altitude and can reflect off of snow.

Remember that if you are closer to the equator, the UV radiation is higher, so it is easier to burn even when there are clouds. Try to find a sunscreen that doesn’t irritate your

22 Lehigh County Health & Medicine | WINTER 2023-24

skin. Use a broad-spectrum sunscreen of at least SPF30 and make sure you apply it generously and frequently when in the sun, as it can be removed unintentionally with sweating or getting wet. This is why we recommend regular application with all sunscreens, including those marketed as needed less frequently. You can also protect your skin with clothing, including a wide-brimmed hat and sunglasses. Try to spend time in the shade from 11 a.m. to 3 p.m.

It is time to prepare for the transition into the colder, winter months. This change of season is an exciting time spent with family and friends, but welcomes dry, rashy, itchy skin. We hope this article helps to prevent those flares and provides recommendations to keep your skin barrier feeling moist and protective. See your local dermatologist if you are dry and itchy, and remember to protect yourself from the sun, even on a cloudy day.

1. Eichenfield LF, Tom WL, Berger TG, et al. Guidelines of care for the management of atopic dermatitis: section 2. Management and treatment of atopic dermatitis with topical therapies. J Am Acad Dermatol.

2014;71(1):116-132. doi:10.1016/j.jaad.2014.03.023 2. Assarian Z, O'Brien TJ, Nixon R. Soak and smear: an effective treatment for eczematous dermatoses. Australasian Journal of Dermatology. 2015 Aug;56(3):215-7.

BETHLEHEM ROSEMONT MANSION BETHLEHEM CITY

BEAUTIFUL MOUNTAIN VIEWS LOWER SAUCON TWP

Many original features remain in this incredible 3-story Federal Style Georgian Colonial mansion, a reflection of the architectural brilliance of the 1920’s. An all-stone masterpiece set on a 1.25 acre corner lot. Stunning gourmet kitchen and sumptuous primary suite.

Outdoor private oasis with inground pool, meticulous landscaping & gardens. 2 attached + 4 car detached garage. 7 bedrooms, 4 full/ 1 half bath. $1,095,000

Spacious living and backyard sanctuary are sure to impress. An outside oasis features an inground pool and spa with a gorgeous waterfall, koi pond, outdoor kitchen with built-in grill, granite counter seating and extensive landscaping...just perfect for entertaining. Inside, a gourmet kitchen, luxurious primary suite with vaulted ceilings and an extensive lower level recreation and entertainment area. 4 bedrooms, 4 full/1 half bath. $975,000

ELEGANT HISTORIC FARMHOUSE BETHLEHEM CITY

PRESTIGIOUS ESTATE UPPER SAUCON TWP

Historic features meet modern amenities in this magnificent Georgian-style 19th century farmhouse. Perfectly located on almost 6 acres with stunning views of the Monocacy Creek.

Original Birch hardwood floors, three fireplaces, gourmet kitchen, formal living and dining rooms and elevator access to all levels. 5 bedrooms, 3 full/1 half bath. $1,350,000

This estate home in Weyhill Woods is well-designed and over 5200 sq ft! Features a magnificent enclosed front stonewall patio with sweeping views, grand foyer, expansive first floor primary suite, a 2-story great room with floor to ceiling stone fireplace, chef's gourmet kitchen and three large second level en suite bedrooms. Enchanting private backyard. 4 bedrooms, 4 full/3 half bath. $1,895,000

Specializing in the Lehigh Valley and Upper 3477 Corporate Parkway, Center Valley

Bucks County luxury 484.280.6212 home market, The direct • 610.282.4444 office Rebecca Francis Team delivers expert guidance, RebeccaFrancisTeamInfo@gmail.com professional marketing expertise, and unrivaled RebeccaFrancisRealtors.com

market knowledge of the region’s finest homes and neighborhoods. Recognized in the top half

© BHH Affiliates, LLC. And independently operated subsidiary of HomeSerivces of America, Inc., a Berkshire Hathaway affiliate, and a franchisee of BHH Affiliates, LLC. Berkshire Hathaway HomeServices and the Berkshire Hathaway HomeServices ® symbol are registered service marks of HomeServices of America, Inc. Equal Housing Opportunity. Information not verified or guaranteed. If your home is currently listed with a Broker, this is not intended as a solicitation.

Discover the Difference

We’re Here For You!

Sometimes care can’t wait. That’s why The Isaacman Family St. Luke’s Children’s ER is here! Ready to treat unexpected injuries like sprains and breaks. Late night high fevers that won’t quit. Any emergency that comes your way. Our new Children’s ER is just another way we’ve been caring for kids, and comforting parents, for 150 years.

sluhn.org/childrenshospital

Open & ready in Bethlehem! 24/7/365