Lehigh County Health & Medicine Spring 2023

Reduces the risk of HIV infection by up to 99% but not enough people know about it

DIALYSIS: ANSWERS TO COMMONLY ASKED QUESTIONS

FENTANYL: UPPING THE ANTE PLUS

POCUS: AN UNCOMMON TECHNOLOGY THAT ENHANCES CARE

As I write this, it’s time for our Spring edition, but it seems we haven’t even had winter yet. I recently heard someone refer to the last few months as “sprinter.”

We are pleased to bring you this magazine, and hope you enjoy reading it. We look forward to your response, ideas, and contributions. Thank you to all who have contributed to this and every edition.

March includes campaigns for nutrition, colorectal cancer and National Women and Girls HIV/AIDS Awareness Day and National Native HIV/AIDS Awareness Day. Please see the piece “PrEP reduces the risk of HIV infection by up to 99%. Many of you may have heard the term PrEP, but not enough people know about the facts.

Another article, “POCUS – An Uncommon Technology That Enhances Care,” explains this ultrasound technique thoroughly. If you have heard about the technology and wanted more information, this is a great article. I found the cases discussed to be quite interesting.

We have an interesting story about “My Friend Bob.” While the Beatles sang “I get by with a little help from my friends,” this friendship story is a bit different. Read about “Rock Steady Boxing,” a non-profit organization that works to benefit patients with Parkinson’s Disease. According to its Mission Statement, “Rock Steady Boxing equips affiliates and coaches with tools to improve the quality of life through a non-contact boxing curriculum.” For more information, go to www. rocksteadyboxing.org.

Hopefully you will 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.

If you have ideas or suggestions for upcoming issues, please consider contacting us; see our website https://lcmedsoc.org/.

Thank you for reading!

LEHIGH COUNTY MEDICAL SOCIETY

P.O. Box 8, East Texas, PA 18046

610-437-2288 | lcmedsoc.org

2022-23 LCMS BOARD OF DIRECTORS

Rajender S. Totlani, MD President

Oscar A. Morffi, MD Treasurer

Charles J. Scagliotti, MD, FACS Secretary

William Tuffiash

Immediate Past President

CENSORS

Howard E. Hudson, Jr., MD

Edward F. Guarino, MD

TRUSTEES

Wayne E. Dubov, MD

Kenneth J. Toff, DO

EDITOR

David Griffiths Executive Officer

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. 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.

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

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

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Bucks County / Lehigh Valley, PA

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www.doreyrealestate.com / 610-346-8800

O ld W o r ld Villa

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A rare blend of 19th century touches and outstanding modern luxuries make this sophisticated home a country retreat. Upgrades both indoors and out range from fresh interior and exterior paint to an updated pool and appcontrolled heating and cooling systems. 6bd. 5.5bths. 7,440 sqft. $2,500,000

W hite Ac r e

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W hite Ac r e

Tucked away in the lovely neighborhood of White Acre, this property has generous frontage on a notable private road, in a remarkable setting of lush lawn, gardens and specimen landscaping. There are bucolic vistas from every window. Channel your creativity ... an investment for your family and your lifestyle. 4bd. 3.5bath. 3,177 sqft. $925,000

Bethlehem Luxe

This single story home is the ultimate in mid century modern design. A sunken living room with a picture window opens via arched French doors to the sunroom with vaulted ceiling, walls of windows, and access to the shaded backyard. 3 BDs, 3.5 baths. $899,000

Bethlehem Luxe

This single story home is the ultimate in mid century modern design. A sunken living room with a picture window opens via arched French doors to the sunroom with vaulted ceiling, walls of windows, and access to the shaded backyard. 3 BDs, 3.5 baths. $899,000

M o on View Farm

Moon View Farm is ideal for anyone looking for a country retreat. The classic colonial home offers more than 3,000 square feet of living space, with arm hardwood floors runing throughout most of the home. There is a gambrel barn, which was fully renovated in 2018: includes four stalls, two haylofts, tack and feed rooms, and 1-bay garage. 4.5 Acres. 5 bds, 3.5 baths. 3,035sqft. $975,000

M o on View Farm

Moon View Farm is ideal for anyone looking for a country retreat. The classic colonial home offers more than 3,000 square feet of living space, with arm hardwood floors runing throughout most of the home. There is a gambrel barn, which was fully renovated in 2018: includes four stalls, two haylofts, tack and feed rooms, and 1-bay garage. 4.5 Acres. 5 bds, 3.5 baths. 3,035sqft. $975,000

POCUS

An Uncommon Technology That Enhances Care

KEVIN ROTH, DO, FACOEP DIRECTOR, POINT OF CARE ULTRASOUND PROGRAM DIRECTOR, EMERGENCY ULTRASOUND FELLOWSHIP

Point of care ultrasound (POCUS) is not new but, with enhancements in ultrasound technology, it is expanding rapidly. These improvements include image quality, instrument portability, image archiving, and the introduction of artificial intelligence. Many years ago, 20 to be exact, I was finishing my Emergency Medicine Residency. I was fortunate to train under a program director who was one of the pioneers of Emergency Ultrasound. This director was willing to teach, and I became deeply interested. In my mind this was a strategy to care for patients with better accuracy in diagnosis than by physical exam alone. Throughout my residency I learned to perform and interpret bedside ultrasound but, the POCUS educational experience is quite variable for many other physician learners. Let’s jump ahead to today’s world. The leaders of our residency have deemed this such an important skill for practicing physicians that it has become a graduation requirement for all our residents.

So, what is POCUS? POCUS is an ultrasound that is performed and interpreted by the same physician who is holding the ultrasound probe. They know the history, have performed a physical exam, and now are completing a preliminary evaluation. This evaluation is performed independent from our Radiology colleagues. Radiology-performed ultrasound is a comprehensive study performed within the radiology suite by a technologist and later is interpreted by a Radiologist. In contrast, POCUS is a limited, focused exam used to provide rapid answers to clinical questions or guide invasive procedures. It is available 24 hours a day, is at the bedside, and provides near immediate results. Some diagnoses become evident as soon as the probe touches the area of investigation.

So, why perform POCUS? POCUS has been extensively studied and has been found to enhance patient care. It specifically reduces time to diagnosis, boosts efficiency, and improves patient safety and satisfaction. A counterpart of mine, J. Christian Fox of UC Irvine, shares the following and I paraphrase, “there are many patients who would not have lived had they gone to another emergency department” when he speaks of a department that performs POCUS.

The list of POCUS applications is long but, is divided into two main categories – diagnostic and procedural guidance. Procedural guidance simply put makes us better in performing central lines, lumbar punctures, thoracentesis, etc. This has been found to be such a powerful tool in patient care we teach our nurses to perform ultrasound-guided peripheral IV placement on our most difficult access patients. We also perform ultrasound-guided nerve block in our hip and femur fracture patients which is widely known to reduce morbidity and mortality, especially in our elderly population.

Diagnostic POCUS categories can be broken down in several ways but, for quick reference there are three main types – resuscitative, emergent, and urgent. Resuscitative POCUS looks for causes of cardiac arrest or near arrest. POCUS answers questions such as, is there cardiac tamponade, severe right

heart strain seen with a massive pulmonary embolus, or left ventricular failure? Emergent uses include the evaluation of the aorta for aneurysm, renal to search for hydronephrosis, or pelvic which evaluates for the presence or absence of an intrauterine pregnancy when an ectopic pregnancy is considered. Finally, the urgent category is used frequently as it includes soft tissue to determine abscess versus cellulitis and musculoskeletal in the diagnosis of tendon, bone, or joint pathology. While the above list is incomplete it demonstrates the breadth of POCUS use in medicine.

To further highlight the use of POCUS I would like to introduce three cases to illustrate its use in practice. The first case takes us back to the beginning of the COVID pandemic. Before we had nasal swabs to diagnosis COVID, we had POCUS. Our group had found viral pneumonia with POCUS before the pandemic but, infrequently. POCUS became an invaluable tool with COVID’s migration to the United States. I vividly recall the early days of the pandemic when two patients presented almost simultaneously with profound hypoxia and respiratory distress. I was performing POCUS teaching rounds with my residents and discovered a pattern on lung ultrasound that made me stop and inform the attending physician in charge of those patients’ clinical care – “I think they have COVID pneumonia.” A CT scan verified those early cases but, we soon

abandoned CT scanning and performed both POCUS lung and ECHO exams on potential COVID patients to establish early diagnoses. Not only could we diagnose COVID with POCUS but, also determine the severity of lung injury as well as lung recovery. Views of both normal and COVID lung patterns are drastically different (Image 1). A normal lung will have an ultrasound artifact known as A lines. These A lines are evident in the horizontal plane and appear white or hyperechoic. The pleural line in the normal lung is smooth in appearance. In COVID lung the A lines are replaced with B lines. These vertical B lines are also white or hyperechoic. They signify interstitial thickening. COVID lung can also display pleural changes which generate an irregular pleural line appearance.

Case two involves a patient who presents with a visual field deficit. Eye complaints are common in medicine. A detailed exam includes an external exam with a slit lamp, an intraocular pressure reading, and an attempt to view the retina and optic disc with an ophthalmoscope. Often this exam leaves the physician with continued questions as to the patient’s diagnosis. While many types of pathology can be identified with Ocular POCUS, one of the mainstays is diagnosing a retinal detachment. The normally smooth and adherant retinal layer is replaced by an

Continued on page 8

IMAGE 1 PATIENT A NORMAL LUNG – SMOOTH PLEURA (STRAIGHT ARROWS) AND A LINES (DOTTED ARROWS). PATIENT B COVID LUNG – IRREGULAR PLEURAL LINE (STRAIGHT ARROWS) AND VERTICAL B LINES (DOTTED ARROWS).

elevated often “wormlike” projection into the center of the eye. The cause of the patient’s symptoms were indeed found to be a retinal detachement as displayed in this Ocular POCUS transverse view of the eye (Image 2).

The final case is of a young patient who presents with an extended history of worsening dyspnea on exertion. Initial testing was unremarkable. The patient then presented to the emergency department with worsening symptoms, which now occurred at rest. A POCUS ECHO was performed

revealing the cause of the patient’s symptoms, a left atrial myxoma (Image 3).

Those three cases highlight the use of POCUS. In our emergency departments we perform thousands of POCUS examinations and ultrasound-guided procedures yearly. We embed the images and interpretations into patients’charts at the completion of each exam. This allows for quality assurance procedures and provides our subspecialists with the ability to view and act on the findings in real time.

The final question is how do we train physicians to perform POCUS? As you can imagine it takes significant training. Our residents meet our POCUS Faculty on day one of their residency for an introductory course. They then receive didactic and practical training throughout their four years of residency.

One of our main educational strategies has recently been presented at a national emergency medicine conference. It has been cited as a comprehensive and efficient way for the practicing physician who has already completed residency training to gain competency. First, Rapid Educational Events are conducted and expose learners to virtual and in-person didactic education. This is coupled with hands-on sessions to reinforce probe positioning and scanning techniques on standardized patients. The final component is participation in Physician Ultrasound Rounds. During these sessions the learner meets one on one with an experienced proctor in the clinical arena. They scan real patients together, honing performance and interpretation skills until a stated number of exams are completed to the satisfaction of the proctor. The exam number to complete is determined by our professional organization, the American College of Emergency Physicians.

The success stories of POCUS in emergency medicine have permeated throughout medicine. Our department has acted as consultants to the military, medical missions, and other specialties both in and outside of our network. We provide education to medical schools, physician assistant programs, and other residencies both within emergency medicine and beyond.

In conclusion, we have found POCUS to be integral in providing state of the art care. When I train residents, I often challenge them with the words “be uncommon” when caring for patients. POCUS truly assists in providing patients with care that is just that, uncommon.

IMAGE 2 TRANSVERSE VIEW OF THE EYE. VH = VITREOUS HUMOR, ON = OPTIC NERVE, RD = RETINAL DETACHMENT

IMAGE 3 ECHO – APICAL 4 CHAMBER RA = RIGHT ATRIUM, RV = RIGHT VENTRICLE, LEFT VENTRICLE = LVH, LA = LEFT ATRIUM WHITE OVAL = LEFT ATRIAL MYXOMA

PAIN AND ADDICTION SUMMIT

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For too many years, the mainstay of HIV prevention counseling consisted of advising patients to use condoms consistently, maintain a mutually monogamous sexual relationship with one partner, or avoid sex entirely. Condoms have been recommended for STI prevention for decades, but they are not without their drawbacks: they break, expire, limit pleasure, and aren’t always there when you need them. There is also data that suggests that, among heterosexual and same-gender-loving people alike, condoms signify a lack of trust and can be a barrier to intimacy. It’s no wonder, then, that the United States saw nearly 35,000 new HIV infections in 2019. (That number trended slightly lower in 2020, but the dip may reflect decreased access to testing and case surveillance during the SARS-CoV-2 pandemic.)

While it is certainly worth celebrating that we have come a long way from the peak of 100,000 new HIV infections annually in the mid-1980s, HIV incidence remains unacceptably high. In 2019 the United States launched Ending the HIV Epidemic in the U.S. with the goal of reducing new HIV infections by 90% by 2030, with an interim goal of 75%, or 10,000 new infections, by 2025. We are not currently on track, but we could be, thanks to a revolution in HIV prevention. In the same way that the birth control pill fundamentally changed contraception, PrEP has been a game-changer for reducing the spread of HIV. PrEP has the potential to dramatically change the landscape of the HIV epidemic – but only if people take it.

What is PrEP? In essence, PrEP – or Pre-Exposure Prophylaxis, also known as biomedical HIV prevention – refers to the use of antiviral medication to reduce the risk of HIV infection before exposure by preventing the virus from entering cells and establishing an infection. We might also consider PrEP as “proactive, responsible, empowered pleasure,” suggests PrEP activist Damon Jacobs, founder

Reduces the risk of HIV infection by up to 99% but not enough people know about it

YVONNE

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

of the evidence-informed volunteer-run Facebook page PrEP Facts. Being on PrEP means not having to worry about becoming infected with HIV if a condom breaks or slips off, or if a partner refuses to wear one. It puts the control in the hands of anyone who wants to take charge of their own HIV protection, without having to depend on their partner.

PrEP should be considered for anyone who is concerned about exposure to HIV through sex or shared injection drug equipment. Despite popular misconceptions, PrEP is not exclusively for men who are gay, bisexual, or have sex with men. While most efforts to publicize PrEP have been focused on the populations most vulnerable to HIV – primarily young gay and bisexual men of color – 22% of new HIV diagnoses in 2020 – over 6,000 cases – were in people who reported heterosexual contact. Of that 22%, the majority of cases – over 4,500 – were in women.

Proxies for HIV risk such as a recent STI should always prompt an offer of HIV testing and a conversation about HIV prevention. However, because patients may not always reveal every detail about their sexual lives to their primary care providers, providers should feel comfortable discussing and offering PrEP to anyone who is sexually active or using injection drugs, regardless of the number or frequency of sex or drug-using partners they report. One option for opening the conversation: “I’d like to talk to you about PrEP, because I want to make sure you know about all your options for preventing HIV and keeping yourself healthy.”

The FDA has approved three PrEP regimens: two are oral daily tablets and the third is an intramuscular injection given every two months. Both oral medications are pills that contain a combination of two known HIV medications. The first regimen to receive approval was the fixed-dose combination tablet of emtricitabine 200 mg and tenofovir disoproxil fumarate 300 mg (TDF-FTC, brand name: Truvada®). The second was emtricitabine 200 mg and

tenofovir alafenamide 25 mg (TAF-FTC, brand name: Descovy®). Both are meant to be taken by mouth once daily. The third regimen, cabotegravir 200 mg (brand name: Apretude) is given via intramuscular injection every two months. Of the three, TAF-FTC is not approved for people at risk from vaginal receptive sex due to those populations having been excluded from the initial clinical trials, although additional studies are ongoing.

The evidence for PrEP has been accumulating for years, resulting in an “A” rating from the U.S. Preventive Services Task Force in 2019. From as far back as 2010, clinical trials of TDF-FTC have consistently shown that the key to PrEP’s power is adherence. The better the adherence, the stronger the protection, with daily dosing (i.e., 7 doses weekly) resulting in 99% risk reduction for HIV acquisition from sex and 74% from injection drug use. TDF-FTC has been FDA-approved since 2012 for men who have sex with men, for women including transgender women, and for men who have sex with women. TAF-FTC was approved for PrEP in 2019 and injectable cabotegravir was approved in December of 2021. Oral PrEP is recommended for adolescents at risk of HIV infection, as long as they weigh at least 77 pounds. (Studies of injectable cabotegravir in adolescents are underway.) The latest CDC guidelines for the use of PrEP are available for download; see the resources list following this article.

As a preventive health strategy, PrEP sits comfortably within the purview of primary care. A referral is not required because patients trust and prefer their primary care providers and may be put off or unnecessarily delayed by having to wait for a specialty appointment. Initiating PrEP requires labbased HIV testing to establish that there is no current HIV infection, STI screening, and, depending on the formulation under consideration, completing basic lab studies such as creatinine clearance and hepatitis B status. There are a few considerations of which prescribers need to be aware, including potential medication interactions and medical contraindications, but these

are no more complex than managing other chronic conditions frequently encountered in primary care. For clinicians interested in building PrEP into their practice, the National Clinician Consultation Center offers free guidance and advice on all aspects of PrEP initiation and maintenance. Phone consultations are available at 855-448-7737 (1-855-HIV-PrEP) or clinicians can submit a case online (see Resources, below).

Under federal law, almost all insurers, including Medicare and Medicaid, are required to cover all the costs of oral PrEP (TDF-FTC and TAF-FTC), including quarterly office visits and lab tests, with no charge for copayments, coinsurance or annual deductibles. The federal government’s Ready, Set, PrEP program makes oral PrEP medication available for those without insurance. TDF-FTC is available as a generic formulation for as low as $30 per month. In addition, the manufacturers of the brand-name medications, Gilead (Descovy®) and Viiv (Apretude), have patient assistance programs for the uninsured and for those whose insurance has high out-of-pocket costs.

PrEP has the potential to radically retool HIV prevention and bend the curve of the HIV epidemic, but it will require a concerted effort on the part of health care providers across the spectrum of care to make sure all our patients know about it and can access it. For more information, and to get started, see the resource list below, or contact your local health department.

ADDITIONAL RESOURCES:

CDC Clinical Practice Guideline (December, 2021): https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prepguidelines-2021.pdf

CDC Clinician Resources: https://www.cdc.gov/hiv/ clinicians/prevention/prep.html

National Clinician Consultation Center: https://nccc.ucsf.edu/clinician-consultation/ prep-pre-exposure-prophylaxis/

Ready, Set, PrEP (federal patient assistance program): https://www.hiv.gov/federal-response/ ending-the-hiv-epidemic/prep-program

ViiV Connect (patient assistance program for A pretude): https://www.viivconnect.com/

Advancing Access (patient assistance program for Descovy®): https://www.gileadadvancingaccess.com/

fentanyl UPPING THE ANTE

WILLIAM SANTORO, MD

CHIEF, SECTION OF ADDICTION MEDICINE, READING HOSPITAL TOWER HEALTH

alcohol and marijuana have always played a significant role in drug use and have often been called gateway drugs. However, the true gateway drug is nicotine from tobacco. All of that said, the popularity of different drugs differed from one decade to another.

In the 1960s, the drug of the day was marijuana. In the 1970s, cocaine was king. In the 1980s, crack took over from cocaine. In the 1990s, methamphetamine stimulated everyone. In the 2000s, prescription opioids made their debut and continued to surge in the 2010s. In a manner of upping the ante, the 2020s saw the influx of fentanyl.

What is most notable and scary, however, is that during the past 20 years the drug of choice has been some form of opioid with increasing potency. From 2020 to the present time, those of us in Addiction Medicine have seen a decrease in urine drug screens being positive for heroin and an increase in urine drug screens being positive for fentanyl. Today, fentanyl is the predominate drug of choice. With approximately 100,000 overdose deaths in the United States each year, two-thirds of them are the result of an opioid and most of them are secondary to fentanyl.

The historic drug cartels have all but abandoned heroin in favor of fentanyl. In the past, heroin was smuggled into the country and dubbed “bricks” because it was packaged in sizes that resembled bricks. One “brick” of heroin can equate to the size of a small deck of cards of fentanyl, so the small size and increased potency make it more favorable to smuggle.

Because of its potency, even a small amount of fentanyl contamination can cause an overdose in a patient who believes they were using one drug and ended up using fentanyl. Drug dealers supply a multitude of drug options from marijuana to cocaine and methamphetamines. I often sarcastically complain that the drug dealers need a Vice President of Quality Assurance because we have seen all these substances contaminated with fentanyl.

Fentanyl has a stronger affinity to the mu opioid receptor than either methadone or buprenorphine, the two opioids used for treating opioid use disorder. This has caused a major change in the management of opioid use disorder.

When heroin and prescription opioids were popular, methadone could be titrated to a dose that took away a patient’s cravings. It could also be titrated to a dose that blocked the effects of heroin by attaching to all the available mu opioid receptor sites. But methadone, at any dose, may not block the effects of fentanyl.

In the past, a trough plasma level of methadone could be monitored to see if there was sufficient methadone to be considered a therapeutic or a blocking dose, knowing that the peak level would be even higher. But with the shift to fentanyl, it is now necessary to check a peak level of methadone to ensure that the patient is not nearing a toxic dose. Adding to this is the difficulty in obtaining a peak plasma level of methadone compared to the ease of obtaining a trough level.

A trough level can be drawn immediately before the patient receives their methadone, but a peak plasma level needs to be drawn 2 hours after the dose is given. Logistically, having a patient receive a dose of medication and then return later for a blood test can often be problematic. Furthermore, higher dosing of methadone also requires monitoring for possible QT-prolongation, a dangerous potential side effect of methadone.

The increased use of fentanyl has also caused a change in the use of buprenorphine for opioid use disorder. When heroin and other opioids were predominant, inducting to buprenorphine only required 8 to 18 hours of abstinence to avoid precipitated withdrawal.

With fentanyl, precipitated withdrawal has been known to occur up to 48 hours of abstinence before inducting with buprenorphine. Although the central effects of withdrawal from fentanyl begin in 8 to 12 hours, the peripheral effects of

withdrawal may not start before 24 to 48 hours. This may be because with chronic abuse of fentanyl it is known to become stored in fatty tissue. The patient may feel withdrawal in the way of anxiety 8 to 12 hours after the last use, but the peripheral symptoms of withdrawal (nausea, vomiting, diarrhea, perspiration) may take 24 hours or longer to appear. If buprenorphine is given when only central symptoms are present, precipitated withdrawal can result.

When working with a schedule filled with so many patients, each needing our undivided attention for individual care, it is sometimes easy to miss the big picture. We need to remember that addiction is one disease, not multiple diseases. A person suffers from addiction, but the disease of addiction can be fed by multiple substances. Each substance feeding the disease of addiction may require a slightly, or massively, different approach.

As we adjust our efforts to care for patients using fentanyl, cocaine, or alcohol, we need to remind ourselves that we are not treating fentanyl addiction, cocaine addiction, or alcohol addiction. We are simply treating addiction that is being fed by different substances.

FTC Proposes Rule to Ban Noncompete Clauses

WHICH HURT WORKERS AND HARM COMPETITION

PETER KAPLAN OFFICE OF PUBLIC AFFAIRS, FEDERAL TRADE COMMISSION

Agency estimates new rule could increase workers’ earnings by nearly $300 billion per year

The Federal Trade Commission proposed a new rule that would ban employers from imposing noncompetes on their workers, a widespread and often exploitative practice that suppresses wages, hampers innovation, and blocks entrepreneurs from starting new businesses. By stopping this practice, the agency estimates that the new proposed rule could increase wages by nearly $300 billion per year and expand career opportunities for about 30 million Americans.

The FTC is seeking public comment on the proposed rule, which is based on a preliminary finding that noncompetes constitute an unfair method of competition and therefore violate Section 5 of the Federal Trade Commission Act.

“The freedom to change jobs is core to economic liberty and to a competitive, thriving economy,” said Chair Lina M. Khan. “Noncompetes block workers from freely switching jobs, depriving them of higher wages and better working conditions, and depriving businesses of a talent pool that they need to build and expand. By ending this practice, the FTC’s proposed rule would promote greater dynamism, innovation, and healthy competition.”

Companies use noncompetes for workers across industries and job levels, from hairstylists and warehouse workers to doctors and business executives. In many cases, employers use their outsized bargaining power to coerce workers into signing these contracts. Noncompetes harm competition in U.S. labor markets by blocking workers from pursuing better opportunities and by preventing employers from hiring the best available talent.

“Research shows that employers’ use of noncompetes to restrict workers’ mobility significantly suppresses workers’ wages—even for those not subject to noncompetes, or subject to noncompetes that are unenforceable under state law,” said Elizabeth

Wilkins, Director of the Office of Policy Planning. “The proposed rule would ensure that employers can’t exploit their outsized bargaining power to limit workers’ opportunities and stifle competition.”

The evidence shows that noncompete clauses also hinder innovation and business dynamism in multiple ways—from preventing would-be entrepreneurs from forming competing businesses, to inhibiting workers from bringing innovative ideas to new companies. This ultimately harms consumers; in markets with fewer new entrants and greater concentration, consumers can face higher prices—as seen in the health care sector.

To address these problems, the FTC’s proposed rule would generally prohibit employers from using noncompete clauses. Specifically, the FTC’s new rule would make it illegal for an employer to:

• Enter into or attempt to enter into a noncompete with a worker;

• Maintain a noncompete with a worker; or

• Represent to a worker, under certain circumstances, that the worker is subject to a noncompete.

The proposed rule would apply to independent contractors and anyone who works for an employer, whether paid or unpaid. It would also require employers to rescind existing noncompetes and actively inform workers that they are no longer in effect.

The proposed rule would generally not apply to other types of employment restrictions, like non-disclosure agreements. However, other types of employment restrictions could be subject to the rule if they are so broad in scope that they function as noncompetes.

This NPRM aligns with the FTC’s recent statement to reinvigorate Section 5 of the FTC Act, which bans unfair methods of competition. The FTC recently used its Section 5 authority to ban companies from imposing onerous noncompetes on their workers. In

one complaint, the FTC took action against a Michigan-based security guard company and its key executives for using coercive noncompetes on low-wage employees. The Commission also ordered two of the largest U.S. glass container manufacturers to stop imposing noncompetes on their workers because they obstruct competition and impede new companies from hiring the talent needed to enter the market. This NPRM and recent enforcement actions make progress on the agency’s broader initiative to use all of its tools and authorities to promote fair competition in labor markets.

The Commission voted 3-1 to publish the Notice of Proposed Rulemaking, which is the first step in the FTC’s rulemaking process. Chair Khan, Commissioner Rebecca Kelly Slaughter and Commissioner Alvaro Bedoya issued a statement. Commissioner Slaughter, joined by Commissioner Bedoya, issued an

additional statement. Commissioner Christine S. Wilson voted no and also issued a statement.

The NPRM invites the public to submit comments on the proposed rule. The FTC will review the comments and may make changes, in a final rule, based on the comments and on the FTC’s further analysis of this issue. The comment period was open through Mar. 10, 2023.

The Federal Trade Commission works to promote competition, and protect and educate consumers. You can learn more about how competition benefits consumers or file an antitrust complaint. For the latest news and resources, follow the FTC on social media, subscribe to press releases and read our blog. Editor’s Note – for those reading this article in hard-print please go to the FTC website to view with hyperlinks: https://www.ftc.gov/

WITH COSMETIC THERAPY

KAREN L. CHANDLER

or women suffering from hair loss or the aftereffects of breast reconstruction surgery, cosmetics are not just meant for a black-tie event or a fun weekend getaway.

Alopecia affects almost seven million people in the United States. The National Alopecia Areata Foundation explains that alopecia is a common autoimmune disease that causes the loss of hair, most frequently on the scalp.

There is no cure today for alopecia and treatments vary, leaving desperate sufferers attempting to mask their hair loss by shaving the areas completely or applying scalp powders, and using fake eyelashes and stick on eyebrows.

Statistics reported by Pfizer note that the connection between hair and identity is more powerful in women than in men. They report that about 40 percent of women with alopecia complain of marital problems while 60 percent have had employment troubles due to their condition. And women who lose their hair due to chemotherapy, heredity, Covid, or medications experience similar suffering.

Carol Cheshire, a licensed esthetician with certifications in permanent makeup and extensive training in scalp repigmentation, explains that networking with other professionals in her field led her to understand the need to help anyone suffering from hair loss.

Cheshire, owner of Always Pretty Salon & Day Spa in Coopersburg, Lehigh County, tells of a client who never let her husband see her without the scalp powder she applied to disguise the upsetting loss of the hair on her head.

“It’s to that extent that they don’t want their mate to know. It’s a feeling of shame and embarrassment.”

After scalp repigmentation, clients look in the salon mirror and cry, Cheshire said. “It’s a feeling of relief, abandonment of shame, and then a feeling of liberation. It’s priceless.”

Scalp Micropigmentation (SMP) creates the illusion of a full head of hair by making the scalp a similar color to the hair by tattooing hundreds of dots in the scalp that simulate miniscule hair follicles.  A safe and non-invasive treatment with minimal discomfort, SMP costs much less than a hair transplant and is complete in several sessions.

Permanent Eyebrows and Eyeliner can help mask the loss of facial hair due to Alopecia or chemotherapy as a professional can create natural looking permanent brows and eyeliner for eyelids lacking hair. Permanent makeup can help sufferers both regain a feeling of normalcy and a release from constant makeup application.

A similar feeling of shame resonates among women who undergo breast reconstruction after unilateral or bilateral mastectomies. Cheshire explains that these women are frequently left with only a white mound marked by a scar like a featureless, blank canvas; the areola and nipple removed during the surgery.

Areola repigmentation simulates a real nipple and areola by a professional artistically tattooing the area, achieving a 3D effect through various pigments and shading.

For these women, “it’s more like feeling like a complete woman,” Cheshire said. “With the areola and nipple I can tattoo, it gives a realistic illusion of the real thing. It makes them feel complete, happy, and confident to see themselves in the mirror.”

While medical specialties and mental health professionals are key for people suffering from the effects of hair loss and breast reconstruction, a path to a new “normal” may be found with cosmetic therapies.

Carol Cheshire, Owner

Dialysis: answers to commonly asked questions

What is dialysis?

Dialysis is a procedure that supports kidneys when they have failed. It is considered life sustaining therapy. When kidneys fail, toxins can build up in the body that cannot be cleared with medications alone. Kidney failure can lead to complications such as hyperkalemia (high potassium), acidosis (acid build up in the body), and volume overload (fluid building up in the body that cannot be excreted in the form of urine). Dialysis comes in various forms and can help manage these complications as well as prolong life.

Who needs dialysis?

Patients may require dialysis to manage complications of progressive chronic kidney disease that can no longer be managed by medications and diet. A patient could require dialysis in the acute setting temporarily if the kidneys have a chance of recovering. Dialysis is most often provided chronically long-term, which would then be lifelong. Here, we discuss dialysis specifically for patients who have end stage renal disease (ESRD). There are 5 stages of kidney disease. The 5th stage most often precedes kidney failure when kidneys no longer work to manage electrolytes, blood pressure, acid base status and volume. The 5th stage is when complications of kidney disease can become more apparent and difficult to medically manage. When complications can no longer be managed medically, we say the patient has ESRD and would need to start life sustaining dialysis. Some symptoms of ESRD

HINA K. TRIVEDI, DO ST. LUKE’S NEPHROLOGY ASSOCIATES

include swelling in hands and feet due to volume overload, shortness of breath, loss of appetite and fatigue from toxin build up, acid accumulation in the body, high blood pressure, anemia, kidney-related bone disease and tremors. These symptoms would be managed by initiating dialysis. The kidney stage alone does not dictate when to initiate dialysis. The nephrologist, a board-certified physician trained in managing kidneys, reviews blood tests, blood pressure, the patient’s volume status and the patient informs their doctor of how they feel. Dialysis initiation is a conversation between a nephrologist and the patient. Prior to starting dialysis, the patient will typically have frequent office visits and discussions with their nephrologist to review labs and if needed, determine the best type of dialysis, as well as when and how to start.

What options currently exist to do dialysis and how does dialysis work?

There are generally two types of dialysis that can be performed in those with end stage kidney disease: hemodialysis and peritoneal dialysis.

Hemodialysis requires access to the bloodstream to clear toxins and remove fluid if needed. Access to the bloodstream comes in the form of a dialysis fistula or dialysis graft, usually placed by a vascular surgeon in the patient’s arm. Surgery is required for either method and involves communication and planning amongst the patient, nephrologist and vascular surgeon. A fistula connects the patient’s own artery and vein to each other to allow for needles to be inserted for dialysis. A dialysis graft connects the patient’s vein and artery but requires foreign material for the connection to take place. Once a patient has a functional fistula or graft, typically 6-16 weeks after fistula surgery and sooner for a graft, 2 needles are inserted into the arm access to perform dialysis. Blood is pumped out from one needle so that it may reach the dialysis filter in the dialysis machine to clean blood of toxins, correct electrolyte imbalances and pull out fluid if a patient is

volume overloaded. The cleaned blood then goes back into the patient’s body through the other needle. If a patient needs dialysis suddenly, or because a fistula or graft are not ready for use, a dialysis catheter is placed. The dialysis catheter is usually placed in a large vein in the neck or chest. Dialysis catheters are considered temporary as they can lead to infection, often clot, and lead to lower blood flows causing ineffective dialysis sessions. Fistulas or grafts are preferred for patients on chronic dialysis for end stage renal disease.

One type of hemodialysis is in-center hemodialysis. Patients receive 3-4 hour pre-scheduled dialysis sessions, typically three times per week. Dialysis is performed through a fistula, graft or dialysis catheter at a specialized center called a dialysis unit. Dialysis technicians, social workers, dieticians, dialysis nurses and nephrologists all work together to take care of patients while they are receiving dialysis at the dialysis unit.

Home hemodialysis is performed just as in-center hemodialysis, but the patient must learn to connect the dialysis machine to needles in the fistula or graft at home. This involves a period of training with a dialysis nurse at a dialysis center. The number of nights and number of hours can vary person to person as everyone’s needs for effective dialysis can vary. Patients on home hemodialysis must still come to monthly appointments at a dialysis center for monitoring of their dialysis efficacy and bloodwork. Sometimes, more frequent appointments are required if the patient needs help or dialysis is ineffective.

Peritoneal dialysis (PD) is another method of doing dialysis at home, but it does not require access to the bloodstream. Instead, a plastic tube called a peritoneal catheter is usually placed in the abdominal cavity to perform peritoneal dialysis. In some cases, peritoneal dialysis is initiated immediately or urgently after the catheter is placed in a hospital setting. Other times, the peritoneal dialysis catheter placement is scheduled with a surgeon or interventional

radiologist. Instead of performing dialysis through a filter outside the body as with hemodialysis, the lining inside the patient’s abdomen acts as a natural filter. Once a peritoneal dialysis catheter is ready for use, PD training can be initiated. This usually lasts 5-7 days until the patient has learned and demonstrated competency. After training is complete, PD is performed at home: Sterile fluid is put through the catheter into the abdominal cavity. It remains in the cavity for a period of time and is then drained back out. This process of dwelling and draining allows for toxins to be filtered and fluid to be removed from the patient’s body. PD can be performed with the help of a machine overnight or without a machine, with manual exchanges during the day while awake. The overnight PD machine allows patients to connect prior to bed, and the machine does the work of draining and dwelling the fluid. The best choice of overnight, daytime manual exchanges or combination of both is determined by a conversation amongst the nephrologist, dialysis nurse and the patient. Patients on PD must come to a dialysis unit for regular follow up monthly just like patients who perform home hemodialysis.

Conclusion

It is important to have regular kidney health monitoring by your primary care doctor. If kidney related abnormalities are noted by the patient or their physician, they should be addressed early and consideration for consultation with a nephrologist may be warranted. If a patient is already seeing a nephrologist, the patient will be updated on their kidney function at each visit. If a patient has late stage chronic kidney disease and/or nearing end stage renal disease, the nephrologist will educate the patient and ensure the patient is aware of the best choice for them if they should need dialysis through open communication. Primary care doctors and nephrologists can work together to promote kidney health in the community.

MY FRIEND BOB

Every week I look forward to seeing my friend, Bob. He is as reliable as an immovable rock. Even though he usually exhibits no expression — no elation , no watery eyes, no furrying of the eyebrows, I can depend on him to be there for me when I need him. I never really had a friend like that. He asks me no embarrassing questions, but is always willing to listen to me. I trust him so implicitly, that he would even take a punch for me. Some would say that he is so quiet that he might have some sort of personality disorder. From my medical training, one might call him a “borderline personality.” But that can’t be right; those people tend to exhaust their friends and family and are very dependent on them for attention. One might categorize him as an “antisocial,” but those people tend to exhibit damaging behavior. That’s not Bob. He’s just very, very….well…. quiet.

Okay, I will get it out in the open. I have had Parkinson’s Disease for almost 17 years. I have learned very well that exercise is just as important as medication to help slow down the inevitable progression of this neurologic disorder. One recent development is “Rock Steady Boxing.” No, we don’t box each other, Thank God! However, a well organized program will have several different available boxing bags, various other fitness equipment and a charismatic trainer. The object is to emphasize alternating movements, exaggerating movements, fine motor skills, loud speaking…..all in a supportive environment. We are literally “fighting back” at Parkinson’s…….and it’s a great workout..... and fun, too.

So who is Bob? He is a well endowed, muscular rubber mannequin, who we get to punch incessantly. He never falls over, never complains. As the expression says “He goes with the punches.” He’ll take it in the face, the eyes, the chest and abdomen — without flinching. A fierce uppercut will draw no blood; a jab-cross to the jaw never produces the slightest bruise. He just takes it, and will never give up.

Bob is somewhat of a symbol for me. Like many chronic diseases, it is important for the patient with Parkinson’s to forcibly adopt an attitude of positivity and action. Otherwise, the sedentary life will inexorably chew away at your body and yes, your very soul. Until a cure is found, you must keep moving. I see Bob standing there with his disapproving stare, challenging me to knock the blazes out of him, and I am only too happy to oblige. It might defy logical explanation, but he represents to me a rock steady man who refuses to be humiliated and refuses to give into whatever adversity comes his way. I approach him with a combination of anger, a bit of fear, but a feeling of release with a dose of determination.

Bob reflects a different way of looking at disability in general. It is not really pure optimism, but some genuine opposition to inevitable decline. I know it is not easy, or in fact, not possible to keep up such an attitude day after day. Yet, every week, Bob gives me hope that somehow, taking that boxing stance and giving him all I’ve got to give, will help ME to be that immovable rock as long as I can.

Thanks, Bob. See you soon in the ring.

For more information, go to www.rocksteadyboxing.org

GENE H. GINSBERG, MD

LCMS NEWS

NEW MEMBERS

Diane Patricia Begany, MD

Nicholas Michael Cardiges, MD

Philip Yue-Cheng Cheung, MD

Jaclyn M Davolos, MD

Amy Lynn Garner, MD

Julia Morrow Kerrigan, MD

Neha A Kothari, MD

Daniel Nathan Leonor, MD

Sohaib A Mohiuddin, MD

Pavan Patel, DO

Patricia Ann Quinlan, MD

Yecheskel Schneider, MD - Internal Medicine

RE-INSTATED MEMBERS

Kenneth James Brislin, MD

Radhika Chandramouli, MD

Denise Dicicco, DO

Francis Samuel Distefano, II, DO

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