Lancaster Physician, Spring 2016

Contents

SPRING 2016

2016 BOARD OF DIRECTORS COVER STORY

Memory Care Options in Lancaster County

OFFICERS James M. Kelly, MD President

(p. 24)

Lincoln Family Medicine

David J. Simons, DO President Elect

Best Practices

Community Anesthesia Associates

Robert K. Aichele, DO Vice President

Aichele & Frey Family Practice Associates

6 In Sinus Surgery, The Balloons

Have It: The Success of

Balloon Sinuplasty

Laura H. Fisher, MD Secretary

Lancaster Family Allergy

Stephen T. Olin, MD Treasurer

Lancaster General Hospital

8 Familial Hypercholesterolemia:

A Global Health Crisis With

Local Ties

DIRECTORS Stacey Denlinger, DO Robin Hicks, DO

14 Meeting the Health Needs

of the Plain Community

in Lancaster County

John A. King, MD Venkatchalam Mangeshkumar, MD Kathryn McKenna, MD Ashley Morrison, MD Lora S. Regan, MD Karen A. Rizzo, MD, FACS

Editors: Dawn Mentzer Beth E. Gerber Lancaster City & County Medical Society James Kelly, MD Lincoln Family Medicine

Graphic Designer: Brittany Fry Lancaster Physician is a publication of the Lancaster City & County Medical Society (LCCMS). The Lancaster City & County Medical Society’s mission statement: To promote and protect the practice of medicine for the physicians of Lancaster County so they may provide the highest quality of patient-centered care in an increasingly complex environment.

In Every Issue 4 President’s Message

32 Medical Society Updates

16 Healthy Communities

36 Restaurant Review

23 Passion Outside of Practice

38 News & Announcements

24 Patient Advocacy

46 Foundation Updates

30 Legislative & Regulatory Updates

Content Submission The Lancaster Physician magazine welcomes recommendations for editorial content focusing on medical practice and management issues, and health and wellness topics that impact our community. However, we only accept articles from members of the Lancaster City & County Medical Society. For more information or submission suggestions, please email bgerber@lancastermedicalsociety.org.

Lancaster Physician is published by Hoffmann Publishing Group, Inc. Reading PA HoffmannPublishing.com 610.685.0914

For Advertising Info Contact: Kay Shuey, Kay@hoffpubs.com, 717.454.9179

L A N C A S T E R M E D I C A L S O C I E T Y.O R G

President’s Message

James Kelly, MD President

he spring of 2016 has proven to be an exciting yet controversial time for organized medicine.

The PA House of Representatives recently voted in favor of medical marijuana, and in a timely coincidence our long delayed controlled substance database is expected to be up and running this fall. CRNP freedom from restrictive covenants continues to be a hot topic, and legislative reform of the insurance prior authorization process has recently gained traction. Alternative care models are here with telemedicine being the latest entry into the insurance reimbursement world. Finally, unexpected balance billing for out of network care and Highmark’s affordable care act physician reimbursement cuts were two surprising but important developments that placed hospital systems and insurances on the opposite ends of the playing field.

With legislative activity regarding health care issues at an all time high (there are approximately 340 health care related bills currently under consideration at the state legislature), a major goal during my term as LCCMS president has been to revitalize our grassroots local advocacy efforts.

I often hear two divergent comments from physicians: “There isn’t much I can do.” or “What can I do?” I’d therefore like to address a few simple but effective advocacy options available to our membership.

Visit lancastermedicalsociety.org



Developing relationships through regular meetings with local legislators to inform, educate, and provide a personal story is important and effective. Our county society hosts legislative breakfast meetings two to three times yearly to discuss pertinent health care issues with our state representatives. We target physicians living in the district of the respective politician in attendance, and we have had several well-attended and productive events since changing to this new format last year.



Directly contacting your legislator through one of the several active PAMED advocacy campaigns via this website link: www.votervoice.net/PAMED/Campaigns



Current web page opportunities awaiting your support address efforts in provider insurance credentialing, prior authorizations, and team-based care. These are all hot topics, and our legislators are hearing opinions from their constituents. Physicians need to be involved in the conversation as well.



As your county society, we are your representation at the state level with the purpose of taking emerging issues directly to PAMED in Harrisburg. Our board is now actively considering topics for resolutions to present at the annual PAMED House of Delegates this October. This is a chance to have your voice heard and hardship addressed at a meaningful venue. Whether it be practice specific, specialty specific, or a more global health care concern (such as insurance reimbursement, access to care, or public health), resolutions approved at the House of Delegates are taken to PAMED leadership for lobbying and consideration at the state level.

This is a true outlet to effect change.

I invite anyone interested in local advocacy efforts to attend the next legislative breakfast at the Cork Factory Hotel on May 12, 2015. To RSVP or for questions regarding society membership, please contact the Lancaster City & County Medical Society main office at 717-393-9588.

LANCASTER

4

PHYSICIAN

L A N C A S T E R M E D I C A L S O C I E T Y.O R G

best

pr  ctices The Success of Balloon Sinuplasty Familial Hypercholesterolemia

In Sinus Surgery, The Balloons Have It:

Meeting the Health Needs of the Plain Community in Lancaster County

RICHARD A. POLLOCK, M.D.

he central upper face is a meeting place, at the intersection of the cranium (skull) and face, and it may be conveniently divided into four compartments: naso-septal, naso-maxillary, orbito-ethmoid, and basilar-sphenoid. The compartmentalization is arbitrary but clinically useful, substantiated by a host of embryologic, anatomic, and physiologic studies.1-6 Sinuses are best illustrated as stacked, in domino-like fashion, beginning at the forehead and proceeding posteriorly beneath the skull base.6 (Fig. 1) XprESS™ Pro, Entellus Medical, Inc., Plymouth, MN

The sinuses originate from the nasal chambers in fetal life and early adulthood, so it comes as no surprise, the nose and sinuses remain in close proximity and, among other things, have similar mucosal lining. Strategically, each compartment contains landmarks and spaces apparent on high resolution CT

LANCASTER

6

PHYSICIAN

Figure 1: Illustration of compartmentalization at the junction of the cranium and upper face, courtesy Bill Winn/ Pollock, RA/ Thieme Medical Publishing

SPRING 2016

The Success of Balloon Sinuplasty

Figure 2: Illustration of balloon catheters in place, in the frontal, sphenoid, and maxillary sinuses, courtesy of Entellus Medical, Inc., Plymouth, MN

that favor minimally invasive sinus surgery (MISS),7 spurred on by introduction of the intranasal endoscope (Kennedy, 1985) and by powered nose-and-sinus instrumentation initiated by Setliff, in 1994.8,9 In more recent years, industry has done its part, by introducing video-chip camera-tipped endoscopes (to allow real-time surgical intervention) and image-guidance systems and balloon catheters, collectively favoring patient safety and together reducing the postoperative “healing burden.” What a difference they have made, notably in recovery, measured outcomes, and outpatient safety.

Technique:

Local anesthetics are applied topically and by local injection. The operative sequence

varies in the presence of septal deviation.

Sometimes septoplasty is first, particularly when the deviation is marked; in others, the septum is addressed secondarily, after the sinuplasty. Reduction of hypertrophied turbinates (to normal anatomic size) is almost always third.

The endoscope is inserted into the upper nasal vault. The balloon catheter follows and is advanced to the offending sinus opening (“ostium”). The catheter has a battery-activated safety device that illuminates the sinus, to confirm location and proper position of the balloon. (Fig. 2) A spring-loaded, sterile-saline filled plunger inflates the balloon to a standard diameter and desired length, at 12 atmospheres. Delicate “egg-shell” bone

obstructing the outflow of mucus (and the inflow of air) is pushed aside (“remodeled”) to facilitate proper nose-and-sinus function.

Results:

Modern meta-analysis and other clinical studies10-13 have nicely shown an equivalence between minimally invasive techniques and conventional methods in the carefully selected patient. Thus we are able to advise less invasive surgery, in as many patients as not—nice choices, particularly when nasal obstruction and sinus pathology are caught early enough. We undertake balloon sinuplasty at Lancaster Regional Medical Center on an outpatient basis and will soon offer the procedure at Heart of Lancaster and in our office facility.

BIBLIOGRAPHY 1. Sicher,H, Tandler, J. Anatomie fur Zahnartze.

Wien, Verlag von Springer, 1928 2. Gray, WS. Embryology for Surgeons.

Philadelphia, WB Saunders Company, 1972 3. Ritter, FN. The Paranasal Sinuses: Anatomy and Surgical Technique. St. Louis, CV Mosby, 1973 4. Le Pesteur, J, Firmin, F. Considerations on the cartilage pent-roof of the nose. Annals Chir Plast 22: 1-9, 1977 1977 5. Sheen, JH. Aesthetic Rhinoplasty.

St. Louis, CV Mosby, 1978 6. Pollock, RA. Craniomaxillofacial Buttresses: Anatomy and Operative Repair. New York, Thieme Publishing, 2012

7. Setliff, RC. Minimally invasive sinus surgery: the rationale and the technique. Otolaryngol Clin North Amer 29: 115-129, 1996 8. Kennedy, DW. Functional endoscopic sinus surgery technique. Arch Otolaryngol 111: 643-649, 1985 9. Setliff, RC III. Parson, DS. New concepts and the use of powered instrumentation (The “Hummer”) for functional endoscopic sinus surgery. Amer J Rhinolo 8: 275-278, 1994 10. Vaughn, WC. Current Opin Otolaryngol Head Neck Surg 16: 2-9, 2008 11. Gould, J, Alexander, I, Tomkin, E, Brodner, D. In-office, multisinus balloon dilation: 1-year outcomes from a prospecetive, multicenter, open label trial. Amer J Rhinol Allergy 28: 4043, 2014

LANCASTER

7

PHYSICIAN

12. Bikhazi, N, Light, J, Schwartz, M, Truitt, T, Cutler, J. Standalone balloon dilation versus sinus surgery for chronic sinusitis: a prospective, multicenter, randomized, controlled trial with 1-year follow-up. Amer J Rhinol Allergy 13. Chandra, RK, Kern, RC, Cutler, JL, Welch, KC, Russell, PT. REMODEL larger cohort with long-term outcomes and meta-analysis of standalone balloon dilation studies. Laryngoscope 10; 1002, 2015

L A N C A S T E R M E D I C A L S O C I E T Y.O R G

Best Practices

FAMILIAL HYPERCHOLESTEROLEMIA:

A Global Health Crisis With Local Ties

LARS H. ANDERSEN, BA

ROLF L. ANDERSON, MD, FACC

Lancaster General Health/Penn Medicine Research Institute

The Heart Group of Lancaster

amilial hypercholesterolemia (FH) is an inherited disorder of lipoprotein metabolism characterized by severe elevation of plasma low-density lipoprotein (LDL) particle concentration.1 Pathogenic mutations in three identified genes, LDLR, APOB, PCSK9, are recognized as confirmed causes of FH; however, in some cases of “definite” phenotypic FH, a mutation in one of these genes cannot be found and the disease is of unknown genetic origin.2-5

receptors; thus, an increase in cytoplasmic PCSK9 decreases the expression of LDL receptors and increases plasma LDL concentration.3,15-19 Interestingly, individuals with loss-of-function mutations in PCSK9 display very low circulating LDL concentrations, as well as low risk for atherosclerosis.20,21 Recently approved monoclonal antibody inhibitors of PCSK9 evolocumab and alirocumab lower LDL through pharmacological, rather than endogenous, reduction of cytoplasmic PCSK9 concentration in hepatocytes.16,17

The first-discovered, and most frequently encountered, genetic cause of FH is a mutation in LDLR leading to dysfunctional LDL receptors expressed in hepatocytes.2 The subsequently reduced uptake and degradation of LDL particles causes significant accumulation of LDL in the bloodstream, thereby accelerating the atherosclerotic process. The severity of the observed lipid elevation is proportional to the loss of functionality in the LDL receptor; mutations resulting in a completely defective LDL receptor lead to higher plasma LDL concentrations and more extensive atherosclerosis than mutations resulting in partial defectiveness.6-8

Each of the three genetic defects described above presents with an autosomal codominant inheritance pattern, leading “familial hypercholesterolemia” to be described as such; however, as noted above, in a significant number of cases, the affected genetic locus, and thus the inheritance pattern, remains unclear. While genetic testing for FH is a Tier 1 genomic recommendation from the Centers for Disease Control and Prevention, the vast majority of phenotypically diagnosed FH patients in the US do not receive genetic testing to confirm the diagnosis despite the rapidly decreasing cost of genetic sequencing.22 The cost of sequencing has indeed fallen faster than the famous Moore’s Law predicting increases in computing power over time. According to the National Institutes of Health (NIH), a full genome sequence cost $95 million dollars in 2001 compared to $1,245 in 2015.23 For scale, if consumer prices fell as fast as genome sequencing costs within the same period, a $76,000 luxury car model produced in 2001 would cost one dollar if manufactured fourteen years later.

Mutations in APOB similarly limit LDL receptor-mediated endocytosis by reducing the affinity of apolipoprotein B-100 ligand-binding domain for the LDL receptor. Discovered in 1990, genetic defects in APOB were initially termed “familial defective apolipoprotein B-100,” or FDB, causing a phenotype that is often milder and more variable than that associated with FH due to LDL receptor dysfunction.9-12 Despite the frequently milder lipid elevation observed in FDB subjects, mutations in APOB have been independently associated with increased atherosclerotic disease even at lipid levels equivalent with non-FDB subjects.13,14

Internationally, three diagnostic systems are commonly accepted as standard tools for phenotypic FH identification. The most common system, the Dutch Lipid Clinic Network Criteria, include point values for various categories such as lipid levels, family history, and physical findings.24,25 The Dutch criteria, originally developed for the successful Dutch national FH screening program, are modified from the Simon Broome Criteria, another system for FH

The most recently discovered cause of monogenic FH is endogenous overproduction of proprotein convertase subtilisin/kexin type 9, or PCSK9, stemming from a gain-of-function mutation in the PCSK9 gene. PCSK9 positively regulates the catabolism of LDL

LANCASTER

8

PHYSICIAN

SPRING 2016

Familial Hypercholesterolemia Table 1.

Make Early Diagnosis to Prevent Early Death (MEDPED) Criteria Age (years)

Table 2.

Dutch Lipid Clinic Network Criteria scoring system Family History

Total Cholesterol (LDL) in mg/dL General Population

1st Degree 2nd Degree 3rd Degree relative

Less than 18

270 (200)

220 (155)

230 (165)

240 (170)

18 to 29

290 (220)

240 (170)

230 (165)

260 (185)

30 to 39

340 (240)

270 (190)

280 (200)

290 (185)

40 or greater

360 (260)

290 (205)

300 (215)

310 (225)

1st degree relative with premature coronary/vascular disease OR 1st degree relative with LDL-C > 95th percentile for age and gender

1

1st degree relative with xanthomata or arcus OR Children less than 18 years old with LDL-C > 95th percentile for age and gender

2

Clinical History

Score

Patient with premature CHD

2

Patient with premature cerebral or peripheral vascular disease

1

Physical Examination

OR pathogenic mutation in LDLR, PCSK9, or APOB.

Score

Xanthomata

6

Arcus prior to age 45 years

4

LDL-C (mg/dL)

diagnosis.26 Finally, the US Make Early Diagnosis to Prevent Early Death (MEDPED) criteria provide a definitive diagnosis based on lipid levels, age range, and degree of relatedness to an FH index case, disregarding family history and physical findings.27 All three diagnostic criteria are shown in Tables 1–3. As shown by the CASCADE-FH registry of US FH patients, however, most patients in the US are not diagnosed using one of the above systems, instead receiving a diagnosis based on a provider’s clinical impression.28 A recent consensus scientific statement from the American Heart Association recommended that a diagnosis be based on an LDL-C greater than 190 mg/dL with a family history of dyslipidemia and/ or a family history of early atherosclerotic disease.29

Score

LDC-C > 330

8

LDL-C 250-329

5

LDL-C 190-249

3

LDL-C 155-189

1

Pathogenic mutation in LDLR, APOB, or PCSK9

8

Results: Definite FH: >= 8 points Probably FH: 6-7 points Possible FH: 3-5 points Unlikely FH: <3 points

Appearing at a rate of 1/200 to 1/500 in the general population, FH is the world’s most common potentially deadly genetic disease by a significant margin, affecting every racial and demographic group.30,31 Worldwide, approximately 10.5 to 20 million people have FH, far more than the 8.4 million current residents of New York City and likely more than the 13 million residents of the state of Pennsylvania. Furthermore, certain ethnic groups display higher rates of FH inheritance due to genetic “founder effects” increasing the frequency of the deleterious allele over generations; these groups include French Canadians, Lebanese Christians, Afrikaners, and the Old Order Amish. In addition to the more commonly observed heterozygous FH, approximately 1/300,000 individuals worldwide has a homozygous form of FH, presenting with a much more severe phenotype and often suffering acute coronary syndrome in childhood and early adulthood.31 The high frequency, dominant inheritance pattern, and global scale of FH make it a unique population health issue compared with other genetic illnesses.

Table 3.

Simon Broome Criteria DEFINITE FH Children: Total cholesterol concentration above 259 mg/dL or LDL-C above 155 mg/dL AND tendon xanthomas, or tendon xanthomas in a first or second degree relative Adults: Total cholesterol concentration above 290 mg/dL or LDL-C above 190 mg/dL AND tendon xanthomas, or tendon xanthomas in a first or second degree relative OR Genetic diagnosis of a mutation in LDLR, APOB, or PCSK9

POSSIBLE FH At least the cholesterol concentrations above AND at least one of the following: Family history of MI before age 50 in second degree relative or before age 60 in first-degree relative Family history of raised total cholesterol greater than 290 in adult first or seconddegree relative or greater than 259 in child, brother, or sister aged younger than 16 years.

The most widely recommended strategy for diagnosing FH patients is cascade screening, as system in which all known relatives of an FH index case receive lipid and/or genetic testing to construct a functional inheritance pedigree. National cascade screening programs in countries such as the Netherlands, Norway, Spain, and the UK have shown the model to be highly cost-effective in terms of quality-adjusted life-years added even when the cost of genetic

LANCASTER

Score

Continued on page 10

9

PHYSICIAN

L A N C A S T E R M E D I C A L S O C I E T Y.O R G

Best Practices

testing is considered.25,32-37 In the US, two primary factors hinder the growth of cascade screening on the scale of that performed abroad. First, research and public health outlays for FH in the US are disproportionately low compared to the disease and cost burden posed by the disease. For example, NIH allocations for FH-related projects totaled just 0.85% of all grants for projects related to atherosclerosis, while FH has been found to cause approximately 14% of early coronary artery disease. Second, privacy laws and legal precedents in the United States limit physicians’ ability to contact the relatives of an FH index case, leaving the task of explaining the disease and encouraging treatment to the patients themselves.38 These factors, among others such as limited insurance coverage for genetic testing, have led to a state of severe under-diagnosis of FH in the US despite its centrality to worldwide clinical lipid research.

In fact, the true extent of under-diagnosis in the US is unknown, with current estimates placing the rate of correct identification between 1% and 10% of total patients.39

of simvastatin in pediatric FH patients found that 20% of children under age 16 diagnosed with FH had already lost a father to the effects of FH by the time of the study, a sobering reminder of the disease’s fatal effects if untreated.42 However, when effective lipid-lowering treatment is initiated at a young age, the risk of atherosclerosis related to FH can be sharply reduced.31 Treatments for heterozygous FH include high-dose, high-potency statins, adjunct therapies such as ezetimibe, PCSK9 inhibitors, and lipid apheresis.1,16,17,30,43 Specialty drugs are also available for homozygous FH, including mipomersen, an RNA antisense oligonucleotide that decreases apolipoprotein B production, and lomitapide, a microsomal transfer protein inhibitor that disrupts lipoprotein assembly.44,45 While PCSK9 inhibitors have been approved for patients requiring additional lipid-lowering therapy that may otherwise require lipid apheresis, an invasive, time-consuming procedure involving the mechanical removal and return of blood to circulation, outcome data on the effect of PCSK9 inhibitors on morbidity and mortality do not yet exist. Lipid apheresis, however, is supported by a strong body of outcome-based evidence.46 Both lipid apheresis and PCSK9 inhibitors currently remain effectively restricted to specialty clinics equipped to manage complex dyslipidemia.

Without treatment, individuals affected by FH face a significant risk of early morbidity and mortality. A male with untreated FH, on average, has a 50% chance of myocardial infarction before age 50, while a female has a 30% chance before age 60.40 The risk of cardiovascular disease is twenty times higher among FH patients in comparison with the general population.41 A study on the use

Lancaster County serves as a natural hotspot for FH research and public health outreach. As previously mentioned the Old Order Amish are affected by a genetic “founder effect” related to FH. A 2010 study by the Amish Research Clinic in Strasburg, PA, found that 12% of all members of the Old Order Amish community carry a mutation in APOB known as R3527Q. In addition to the many heterozygous carriers, the study found multiple R3527Q homozygotes.14 Furthermore, the founder effect among the Lancaster County Old Order Amish is significantly stronger than founder effects reported in other populations; whereas approximately one in fifty French Canadians is affected by FH, nearly one in eight Old Order Amish carries the R3527Q mutation in APOB. Interestingly, the APOB R3527Q mutation is known to be far more prevalent in Switzerland and the Rhein-Main area of Germany than in other regions and was carried to the Americas as part of a transatlantic migration.47,48 The effect of the R3527Q mutation on other Pennsylvania German, in addition to the wider Lancaster County community, is at present unknown.

FH presents a public health challenge on both a global and local scale. Due to the availability of effective treatments, lipid specialists consider FH a “winnable battle” hindered by a lack of awareness on behalf of medical providers and the general population and effective screening programs. Research into the genetics of inherited lipid abnormalities has already contributed to the development of new therapies such as PCSK9 inhibitors and RNA antisense oligonucleotide treatment. Increased understanding of FH among medical providers across specialties, particularly in Lancaster County, will undoubtedly profoundly impact the lives of the many people affected by FH.

LANCASTER

10

PHYSICIAN

SPRING 2016

Familial Hypercholesterolemia

Works Cited 1. Goldberg AC, Hopkins PN, Toth PP, et al. Familial hypercholesterolemia: screening, diagnosis and management of pediatric and adult patients: clinical guidance from the National Lipid Association Expert Panel on Familial Hypercholesterolemia. J Clin Lipidol. 2011;5(3 Suppl):S1-8.

8. Vilades Medel D, Leta Petracca R, Carreras Costa F, et al. Coronary computed tomographic angiographic findings in asymptomatic patients with heterozygous familial hypercholesterolemia and null allele low-density lipoprotein receptor mutations. Am J Cardiol. 2013;111(7):955-961.

2. Brown M, Goldstein, J. . Familial hypercholesterolemia: a genetic defect in the Low-Density Lipoprotein Receptor. The New England Journal of Medicine. 1976;294(25):1386-1390.

9. Hansen PS. Familial defective apolipoprotein B-100.

Dan Med Bull. 1998;45(4):370-382.

3. Abifadel MV, M. Rabes, J. Allard, D. Ouquerram, K. Devillers, M. Cruaud, C. Benjannet, S. Wickham, L. Erlich, D. Villeger, L. Farnier, M. Beucler, I. Bruckert, E. Chambaz, J. Chanu, B. Lecerf, J. Luc, G. Moulin, P. Weissenbach, J. Prat, A. Krempf, M. Junien, C. Seidah, N. Boileau, C. . Mutations in PCSK9 cause autosomal dominant hypercholesterolemia. Nature: Genetics. 2003;34(2):154-156.

4. Innerarity TL, Mahley RW, Weisgraber KH, et al. Familial defective apolipoprotein B-100: a mutation of apolipoprotein B that causes hypercholesterolemia. J Lipid Res. 1990;31(8):1337-1349.

5. Talmud PJ, Shah S, Whittall R, et al. Use of low-density lipoprotein cholesterol gene score to distinguish patients with polygenic and monogenic familial hypercholesterolaemia: a case-control study. Lancet. 2013;381(9874):1293-1301.

6. Koeijvoets KC, Wiegman A, Rodenburg J, Defesche JC, Kastelein JJ, Sijbrands EJ. Effect of low-density lipoprotein receptor mutation on lipoproteins and cardiovascular disease risk: a parent-offspring study. European Heart Journal. 2005;180(1):93-99.

7. Santos PC, Morgan AC, Jannes CE, et al. Presence and type of low density lipoprotein receptor (LDLR) mutation influences the lipid profile and response to lipid-lowering therapy in Brazilian patients with heterozygous familial hypercholesterolemia. European Heart Journal. 2014;233(1):206-210.

LANCASTER

10. Hansen PS, Defesche JC, Kastelein JJ, et al. Phenotypic variation in patients heterozygous for familial defective apolipoprotein B (FDB) in three European countries. Arterioscler Thromb Vasc Biol. 1997;17(4):741-747.

11. Pimstone SN, Defesche JC, Clee SM, Bakker HD, Hayden MR, Kastelein JJ. Differences in the phenotype between children with familial defective apolipoprotein B-100 and familial hypercholesterolemia. Arterioscler Thromb Vasc Biol. 1997;17(5):826-833.

12. Miserez AR, Keller U. Differences in the phenotypic characteristics of subjects with familial defective apolipoprotein B-100 and familial hypercholesterolemia. Arterioscler Thromb Vasc Biol. 1995;15(10):1719-1729.

13. Tybjaerg-Hansen A, Humphries SE. Familial defective apolipoprotein B-100: a single mutation that causes hypercholesterolemia and premature coronary artery disease. European Heart Journal. 1992;96(2-3):91-107.

14. Shen H, Damcott CM, Rampersaud E, et al. Familial defective apolipoprotein B-100 and increased low-density lipoprotein cholesterol and coronary artery calcification in the old order amish. Arch Intern Med. 2010;170(20):1850-1855.

15. Al-Waili K, Al-Zidi WA, Al-Abri AR, et al. Mutation in the PCSK9 Gene in Omani Arab Subjects with Autosomal Dominant Hypercholesterolemia and its Effect on PCSK9 Protein Structure. Oman Med J. 2013;28(1):48-52.

Continued on page 12

11

PHYSICIAN

L A N C A S T E R M E D I C A L S O C I E T Y.O R G

Best Practices

16. Raal FJ, Honarpour N, Blom DJ, et al. Inhibition of PCSK9 with evolocumab in homozygous familial hypercholesterolaemia (TESLA Part B): a randomised, double-blind, placebo-controlled trial. Lancet. 2015;385(9965):341-350.

17. Raal FJ, Stein EA, Dufour R, et al. PCSK9 inhibition with evolocumab (AMG 145) in heterozygous familial hypercholesterolaemia (RUTHERFORD-2): a randomised, double-blind, placebo-controlled trial. Lancet. 2015;385(9965):331-340.

18. Shioji K, Mannami T, Kokubo Y, et al. Genetic variants in PCSK9 affect the cholesterol level in Japanese. J Hum Genet. 2004;49(2):109-114.

19. Awan Z, Baass A, Genest J. Proprotein convertase subtilisin/ kexin type 9 (PCSK9): lessons learned from patients with hypercholesterolemia. Clin Chem. 2014;60(11):1380-1389.

20. Cohen J, Pertsemlidis A, Kotowski IK, Graham R, Garcia CK, Hobbs HH. Low LDL cholesterol in individuals of African descent resulting from frequent nonsense mutations in PCSK9. Nat Genet. 2005;37(2):161-165.

21. Fasano T, Cefalu AB, Di Leo E, et al. A novel loss of function mutation of PCSK9 gene in white subjects with low-plasma low-density lipoprotein cholesterol. Arterioscler Thromb Vasc Biol. 2007;27(3):677-681.

22. Prevention CfDCa. Public Health Genomics - Genomic Application Toolkit. 2014.

23. KA W. DNA Sequencing Costs: Data from the NHGRI Genome Sequencing Program (GSP). 2016.

24. Hopkins PD, J. Beiseigel, U. Betteridge, J. Dos Santos, J. Faergeman, O. Craig, I. Hayden, M. Kastelein, J. Ose, L. Familial Hypercholesterolemia: Report of a second WHO Consultation. In: Programme WHOHG, ed. Geneva: World Health Organization; 1998.

25. Umans-Eckenhausen M, Defesche, J., Sijbrands, E., Scheerder, R., Kastelein, J. . Review of the first 5 years of screening for familial hypercholesterolaemia in the Netherlands. The Lancet. 2001;357(9251):165-168.

26. Group SSCobotSBR. Risk of fatal coronary heart disease in familial hypercholesterolemia. British Journal of Medicine. 1991;303(6807):893-896.

27. Williams RR, Hunt SC, Schumacher MC, et al. Diagnosing heterozygous familial hypercholesterolemia using new practical criteria validated by molecular genetics. Am J Cardiol. 1993;72(2):171-176.

28. Ahmad Z, Newman CB, Oâ&#x20AC;&#x2122;Brien EC, et al. Diagnosing Familial Hypercholesterolemia (FH) in the United States: Results from the CASCADE FH Patient Registry*â&#x20AC; . Journal of Clinical Lipidology. 2015;9(3):451-452.

29. Gidding SC, M. de Ferranti, S. Defesche, J. Ito, M. Knowles, J. McCrindle, B. Raal, F. Rader, D. Santos, R. Lopes-Virella, M. Watts, G. Wierzbicki, A. . The Agenda for Familial Hypercholesterolemia: A Scientific Statement From the American Heart Association. Circulation. 2015.

30. Sniderman AD, Tsimikas S, Fazio S. The Severe Hypercholesterolemia Phenotype: Clinical Diagnosis, Management, and Emerging Therapies. Journal of the American College of Cardiology. 2014;63(19):1935-1947.

31. Nordestgaard BC, M. Humphries, S. Ginsberg, H. Masana, L. Descamps, Olivier. Wiklun, O. Hegele, R. Raal, F. Defesche, J. Wiegman, A. Santos, R. Watts, G. Parhofer, K. Hovingh, G. Kovanen, P. Boileau, C. Averna, M. Boren, J. Bruckert, E. Catapano, A. Kuivenhoven, J. Pajukanta, P. Ray, K. Stalenhoef, A. Stroes, E. Taskinen, M. Tybjaerg-Hansen, A. . Familial hypercholesterolaemia is underdiagnosed and undertreated in the general population: guidance for clinicians to prevent coronary heart disease. European Heart Journal. 2013;34(45):3478-3490.

32. Wonderling D, Umans-Eckenhausen, M., Marks, D., Defesche, J., Kastelein, J., Thorogood, M. . Cost-effectiveness analysis of the genetic screening program for familial hypercholesterolemia in The Netherlands. Seminars in Vascular Medicine. 2004;4(1):97-104.

33. Besseling J, Sjouke B, Kastelein JJ. Screening and treatment of familial hypercholesterolemia - Lessons from the past and opportunities for the future (based on the Anitschkow Lecture 2014). European Heart Journal. 2015;241(2):597-606.

LANCASTER

12

PHYSICIAN

SPRING 2016

Familial Hypercholesterolemia

34. Marks D, Wonderling D, Thorogood M, Lambert H, Humphries SE, Neil HA. Cost effectiveness analysis of different approaches of screening for familial hypercholesterolaemia. BMJ. 2002;324(7349):1303.

35. Ademi Z, Watts, G., Pang, J., Sjibrands, E., Bockxmeer, F., Oâ&#x20AC;&#x2122;Leary, P., Geelhoed., E. Liew, D. . Cascade screening based on genetic testing is cost-effective: Evidence for the implementation of models of care for familial hypercholesterolemia. Journal of Clinical Lipidology. 2014;8(4):390-400.

36. Mundal L, Sarancic M, Ose L, et al. Mortality among patients with familial hypercholesterolemia: a registry-based study in Norway, 1992-2010. J Am Heart Assoc. 2014;3(6):e001236.

37. Palacios L, Grandoso L, Cuevas N, et al. Molecular characterization of familial hypercholesterolemia in Spain. European Heart Journal. 2012;221(1):137-142.

38. Andersen R, Andersen L. Examining barriers to cascade screening for familial hypercholesterolemia in the U.S. Journal of Clinical Lipidology. 2016 (In Press).

39. Neil HA, Hammond T, Huxley R, Matthews DR, Humphries SE. Extent of underdiagnosis of familial hypercholesterolaemia in routine practice: prospective registry study. BMJ. 2000;321(7254):148.

40. Marks D, Thorogood M, Neil HA, Humphries SE. A review on the diagnosis, natural history, and treatment of familial hypercholesterolaemia. European Heart Journal. 2003;168(1):1-14.

41. Oâ&#x20AC;&#x2122;Brien ER, M. Fraulo, E. Peterson, E. Ballantyne, C. Genest, J. Gidding, S. Hammond, E. Hemphill, L. Hudgins, L. Kindt, I. Moriarty, P. Ross, J. Underberg, J. Watson, K. Pickhardt, D. Rader, D. Wilemon, K. Knowles, J. Rationale and design of the familial hypercholesterolemia foundation

LANCASTER

CAscade SCreening for Awareness and DEtection of Familial Hypercholesterolemia registry. American Heart Journal. 2014;167(3):342-349.

42. Versmissen J, Oosterveer DM, Yazdanpanah M, et al. Efficacy of statins in familial hypercholesterolaemia: a long term cohort study. BMJ. 2008;337:a2423.

43. Kastelein JJ, Robinson JG, Farnier M, et al. Efficacy and safety of alirocumab in patients with heterozygous familial hypercholesterolemia not adequately controlled with current lipid-lowering therapy: design and rationale of the ODYSSEY FH studies. Cardiovasc Drugs Ther. 2014;28(3):281-289.

44. deGoma EM. Lomitapide for the management of homozygous familial hypercholesterolemia. Rev Cardiovasc Med. 2014;15(2):109-118.

45. Bell DA, Hooper AJ, Watts GF, Burnett JR. Mipomersen and other therapies for the treatment of severe familial hypercholesterolemia.

Vasc Health Risk Manag. 2012;8:651-659.

46. Moriarty PM. Lipoprotein apheresis: present and future uses. Curr Opin Lipidol. 2015;26(6):544-552.

47. Miserez AR, Laager R, Chiodetti N, Keller U. High prevalence of familial defective apolipoprotein B-100 in Switzerland. J Lipid Res. 1994;35(4):574-583.

48. Fisher E, Scharnagl H, Hoffmann MM, et al. Mutations in the apolipoprotein (apo) B-100 receptor-binding region: detection of apo B-100 (Arg3500-->Trp) associated with two new haplotypes and evidence that apo B-100 (Glu3405-->Gln) diminishes receptor-mediated uptake of LDL. Clin Chem. 1999;45(7):1026-1038.

13

PHYSICIAN

L A N C A S T E R M E D I C A L S O C I E T Y.O R G

Best Practices

Meeting the Health Needs of the

P l ai n C o m mun i t y

In Lancaster County

KEITH WRIGHT, MD

WellSpan Ephrata Program Centers on Awareness, Transparency, & Packaged Pricing

“O

WellSpan Family Health – Georgetown

ne more thing,” said Amos, as he reached into his black vest with a hand stained and weathered by years of dairy farm work. Pulling out an envelope for his father’s recent hospitalization, he asked, “Can you help us understand this bill?”

In order to aid this kind of discussion, a list of charges for commonly ordered tests needs to be available. WellSpan Health has an established program that publishes and distributes prices for commonly performed tests and procedures. A folder with these prices is available in every one of my exam rooms.

Discussing bills is something I do every day, along with practicing medicine at my southern Lancaster County office where I treat many Plain community patients—Amish, Mennonite, and other people who dress plainly.

“Package pricing” for procedures such as a total hip replacement are given, in which all of the usual charges for a procedure are bundled into one price that includes the fees for the surgeon, anesthesiologist, and facility fees so that the patient knows the total price, unless there is an unusual complication. Though the program began here in Lancaster County, our Plain community patients now can get these package-priced services at any of the WellSpan hospitals in Ephrata, York, Gettysburg, and soon in Lebanon as well.

Most of these Plain patients are not insured. They believe that God will provide for them by enabling them to pay their own bills, or they get help from “mutual aid” funds set up by their church to help pay for the largest bills. So when I treat these patients, I include the cost of services in the discussion of tests and procedures.

We talk about the usefulness and limitations of each procedure, so everyone can agree on a treatment plan. Sometimes patients want to think about their options, even going home to discuss them with other family members, who often are actively involved in these decisions.

In the case of Amos, after we talked about his father’s bill, we discussed his cancer treatment. The father, Elam, was trying to decide if he should go with the recommended medical treatment or “natural treatments” that had been suggested by others in the Amish community. We looked at the benefits and costs of both and found a treatment plan that allowed him to continue the traditional treatments but included some evidence-based natural remedies. He opted for that route. His treatment is continuing and his family has been able to manage the bills for it.

This model of cultural awareness, price transparency, and true informed consent discussions is one that should be broadened to the “English” (the term the Plain community uses for people outside their culture). Perhaps our meeting the Plain community’s health needs may be the key to unraveling some of the complexity within the health care “system” as a whole.

One more thing, indeed.

LANCASTER

14

PHYSICIAN

L A N C A S T E R M E D I C A L S O C I E T Y.O R G

Healthy Communities

The Dangers of

How to Prevent Lead Poisoning in Children JENNIFER BRUBAKER, MD, FAAP

SouthEast Lancaster Health Services

L

ead has been in the news lately, especially with the recent situation in Flint, Michigan. Many of my patients here in Lancaster have also been wondering if they should be concerned. In Lancaster, we thankfully do not have the same concerns over lead in our water supply. However, lead paint was used in many older homes (those built before 1978). Even though the city water supply as a whole has not been shown to have high lead levels, individual homes may have lead pipes or lead solder on pipes, and this can affect lead levels in the water.

In children who are exposed to lead, lead levels often increase rapidly from 6–12 months of age and are highest at age 18–24 months. For that reason, the Department of Health and American Academy of Pediatrics recommend that children should be screened for lead at 9–12 months of age and again at two years of age. In lower risk areas with newer home construction, this screening can be done via questionnaire to help identify children who are at risk and in need of blood testing. At SouthEast Lancaster Health Services, we work with a more at risk population, so we screen all children with a blood test to look for elevated lead levels at 9–12 months of age. Children are then rescreened via a blood test or questionnaire at two years of age.

LANCASTER

16

PHYSICIAN

SPRING 2016

The Dangers of Lead

Lead is a heavy metal that accumulates in our bodies over time.

If levels are high enough, lead can affect almost every organ system.

Children under the age of six years are most at risk from lead toxicity, due to their developing nervous system. Also, as children grow, their bodies are more likely to absorb lead, and this is worsened by poor nutritional status. If children are deficient in iron and calcium, lead can be absorbed more easily into the body. Lead is also a danger to pregnant women since the fetus can be exposed to lead through the placenta. Lead poisoning has been shown to decrease IQ and can cause long-term developmental delays. It can affect balance, and cause anemia, kidney damage, hearing loss, and weakened bones. Some of these changes are reversible, but high lead levels have been shown to cause long-term damage in some individuals.

If your child does have an elevated lead value, you can contact your state or local health department to see about testing paint and dust from your home. If you rent, you should notify your landlord about your child’s elevated lead level and report any peeling or chipping paint. To permanently remove lead from your home, it is recommended that you hire a certified lead “abatement” contractor. You can temporarily reduce lead hazards by repairing damaged painted surfaces and wiping any surface where dust can collect weekly. Clean up any paint chips immediately, and keep your child away from peeling paint and chewable surfaces painted with lead-based paint. Other tips include removing shoes before entering your home to avoid tracking soil containing lead into the house and washing children’s hands, toys, bottles, and pacifiers often.

If your child does receive a blood test for lead, levels under 5(µg/ dL) are generally considered typical of most American children and further evaluation is not required. For children with lead levels 5 and over, it is important to try to identify the source of lead, so it can be removed from the environment. If one child in your family tests positive for lead, all the children in the family should be tested. Children will also need follow-up testing for levels of 5(µg/dL) and over.

Since children with poor nutrition are also more susceptible to lead poisoning, feeding healthy, low-fat meals high in iron, calcium, and vitamin C can also be protective. Foods with iron include lean red meat, beans, dried fruit, chicken, and fish. Foods high in calcium include milk, yogurt, and green leafy vegetables. Foods high in vitamin C include oranges, broccoli, strawberries, and tomatoes.

If you have further questions please talk to your child’s provider or call the lead information line at 1-800-440-LEAD (5323).

In Lancaster City homes, lead paint is most commonly found on window and door frames and on porches, but it can also be found on walls and floors. Other potential sources of lead include older pottery made with lead based glazes or ceramics imported from other countries. Soil can also contain lead, and children playing outside can be exposed. Painted toys that children put in their mouths, especially those imported from China and Mexico, can also be a concern. Certain traditional or folk remedies may also contain high levels of lead. The following folk remedies have been shown to have high lead levels and should not be used, especially in children:

Sources for the above information include the Department of Health, the Center for Disease Control and Prevention, and the American Academy of Pediatrics.

 Greta, a yellow powder that is a Hispanic remedy used to treat upset stomach.  Azarcon, a bright orange powder also known as Alarcon, Coral, Rueda, and Maria Luisa, that is a Hispanic remedy used to treat upset stomach.  Kandu, a red powder that is an Asian remedy used to treat upset stomach.  Ghasard, a brown powder that is an Indian remedy used to treat upset stomach.  Kohl, a dark powder that is used as a cosmetic and sometimes applied to a newborn’s navel.  Ba-baw-san, a Chinese remedy that is used for colic in children.  Daw Tway, used in Thailand and Burma for digestion problems. Can also be dangerous to children.

LANCASTER

17

PHYSICIAN

SPRING 2016

Healthy Communities

Zika Virus PAMED Holds Call-in to Provide a Pennsylvania Update

he World Health Organization anticipates that the Zika virus will spread to all but two countries in South, Central, and North America. Aedes albopictus mosquitoes, which are found throughout the U.S. and are known for transmitting dengue fever and chikungunya, may also transmit the virus. What is Pennsylvania doing about this virus? How concerned should Pennsylvanians be?

The Pennsylvania Medical Society (PAMED) held a media call-in on Jan. 29, 2016, to help answer these questions.

The panelists for the call-in included several state and health care leaders: Loren Robinson, MD, deputy secretary for health promotion and disease prevention at the Pennsylvania Department of Health (DOH); Stephen Colodny, MD, and Ray Pontzer MD, both infectious disease specialists; and Kurt Barnhart, MD, chair of the Pennsylvania Section of the American Congress of Obstetricians and Gynecologists and a practicing OB/ GYN in Philadelphia.

She also said that DOH will work with health care providers and facilities to ensure that patients with appropriate risk factors (primarily travel to the above-mentioned areas) be properly evaluated and screened, if necessary, for the Zika virus.

Dr. Robinson confirmed that the state will look to monitor mosquito activity as the weather warms up.

Drs. Colodny and Pontzer talked about the virus and how it spreads. The virus is not transmitted through casual contact.

Dr. Colodny said that symptoms include fever, rash, and body aches, but also noted that most people who get infected with Zika virus have no symptoms. Dr. Pontzer added that the symptoms of the virus, when present, are mild.

As there’s an increased risk for pregnant women, Dr. Barnhart talked about what is known and unknown about the chance of transmitting the virus from mother to baby. If a pregnant woman is infected with the virus, ultrasound is recommended to assess the fetus.

PAMED President Scott Shapiro, MD, and Michael Fraser, PAMED’s executive vice president, also participated in the call.

Dr. Robinson talked about alerts DOH has recently issued, including a Jan. 28 alert that has information on the process for diagnostic testing in the state. She also discussed Pennsylvania’s status and DOH’s preparations.

Though there have been no Zika virus infections identified among Pennsylvania residents at this time, she said that DOH is closely following the surveillance and advisory information coming out of the Centers for Disease Control and Prevention (CDC), as well as guidance issued from national physician organizations, to ensure that we keep Pennsylvanians and their families healthy. She said that, at this time, DOH fully supports the travel advisories issued, especially with regard to pregnant women and travel to affected countries.

LANCASTER

“It’s reassuring to me to know that we have experts and state officials aware of the possibility of Zika arriving in Pennsylvania, and that we’re all working towards a common goal to be ready just in case,” said Dr. Shapiro.

“And, for the Pennsylvania Medical Society, our role is primarily educational—keeping our members up-to-date through our communication channels but also working with our media partners to keep the public informed. We are in regular touch with the Pennsylvania Department of Health and the Centers for Disease Control and Prevention. And we will continue to do so as part of the team working to keep Pennsylvania healthy and safe.”

For the most current status, visit PAMEDSOC.org

19

PHYSICIAN

L A N C A S T E R M E D I C A L S O C I E T Y.O R G

Healthy Communities

PENNSYLVANIA COLLEGE OF HEALTH

New Campus Brings More Than Five Football Fields Worth of Learning Space To Lancaster

Offering 24 simulation spaces, PA College guarantees hands-on experiences for all clinical programs, beginning in the first semester.

LANCASTER

20

PHYSICIAN

SPRING 2016

SCIENCES

ennsylvania College of Health Sciences, an exclusively health-sciences-focused college in Lancaster, will open its doors to students this fall at a brand new, state-of-the-art campus located on Greenfield Road. The new campus includes an administrative office building and a former warehouse currently undergoing major renovations, which will convert the entire campus to more than 300,000 square feet of learning space...roughly the size of five and a half football fields! At present, PA College occupies five different locations throughout the downtown region, including its main building on Lime Street and its additional instructional site at BURLE Business Park. With the creation of the new campus, PA College can bring all of its educational services under one roof, fostering a sense of college unity and community.

But, PA College is building far more than walls at this new campus. “Our learners, faculty and staff, and eventually employers and patients, will all benefit from the strategic architectural design, enhanced technology, leading-edge pedagogy, and learner-centric patterns built into the new campus,” said College President Dr. Mary Grace Simcox.

There is a shift from educating at the front of the classroom with lecture-style instruction and memorization to active exploration and inquiry throughout the campus. With that in mind, classrooms are being designed differently to reflect an atmosphere of collaboration and research, rather than a “sage on a stage” approach, and there is a significant increase in the amount of technology and simulation space available to learners for ample hands-on experiences to begin their first semester on campus.

At the existing location on Lime Street, students can make use of four simulation spaces that are shared among the associate degree programs. However, in the new campus, students in every clinical program will have access to 24 simulation rooms, including 40 patient beds, 15 real-life manikins, a full size operating room, intensive care units, a home health care suite and more. The design of these spaces aligns with what students will be seeing in the health care setting upon graduation and allows them to combine didactic and hands-on learning in a safe environment.

Joe Corvino, Director of Simulation Learning at PA College, is very excited about what the new space will offer students as well as the community. “We are able to provide an experience like no other in this controlled environment. We can simulate various high-risk scenarios that allow participants to practice what they know without the fear of failure. They are able to make mistakes and learn from them, so that when the time comes in their careers, they are ready.”

What started out in 1903 as a nursing school to meet the staffing needs of Lancaster General Hospital has since grown into a premier health care college offering a variety of associate, bachelor’s and master’s degrees, as well as certificate programs, to more than 1,400 students from across Lancaster County and the Central PA region. The landscape of health care is constantly changing and PA College keeps its finger on the pulse of education to ensure that students are being prepared to meet the demands of the industry and their future employers. As a result, new landmark programs are being created, such as a three-year Bachelor of Science in Nursing program—the first in the Commonwealth of Pennsylvania to move students from pre-licensure to registered nurse in less than four years.

Aware of the potential for growth in these new programs, along with the predicted increase in job outlook for health care, Pennsylvania College of Health Sciences has positioned itself for expansion by allocating shelled space at the new campus to build out at a later date.

Scott Lokey, Director of Facilities at PA College and the project manager for the new campus construction said, “While we’re meeting an immediate need of facility space for our existing students, we’re setting the stage for what’s to come—more students in our programs, which means more graduates working in health care in our community and better patient outcomes because of the high quality education they received. I, for one, am excited to be a part of that.”

Background Photo: PA College’s new campus at Greenfield Road will offer 320,000 sq. ft. of learning space for more than 1,300 health care students.

SPRING 2016

Passion Outside of Practice It’s our pleasure to highlight a Lancaster City & County Medical Society member’s “passion outside of practice” in each issue of Lancaster Physician. Beyond their commitment to health care, LCCMS members have many other talents, skills, and interests that might surprise you. In this issue, we’re thrilled to feature Matthew D. Bacharach, MD and his passion outside of practice.

Matthew D. Bacharach, MD

5. What else would you like readers to know about this?

I have a few good cooking stories!

My favorite one is when I was fixing Thanksgiving Dinner for my eldest daughter and her fellow Peace Corp volunteers in Madagascar when we went to visit them that year. We brought most of the dinner over with us, including ingredients for both apple and pumpkin pies. Our biggest challenge was finding a rolling pin, but we found out wine bottles work just as well!

I also spent a summer in my teenage years as a cook in my hometown Holiday Inn—the head chef took a liking to me and showed me how to make the dinner specials each night.

In college one spring, the cook in my fraternity needed surgery. My fraternity brothers knew I could cook, and I was “elected” substitute cook.

(They all lived!)

And finally, in a biochemistry lab in college, we were doing an experiment with egg yolks. But I couldn’t stand wasting all the egg whites, so I collected them and made an angel food cake for the lab. (I felt a smidge guilty copying the recipe out of a cookbook from the school bookstore, but this was during pre-internet days!)

Bacharach (right) with his daughter and her fiancé while baking Christmas cookies.

Passion Outside of Practice: Cooking & Baking 1.

Would you briefly describe your passion outside of practice for those who might be unfamiliar with it?

Since childhood I have enjoyed cooking…and especially baking treats! I’m the youngest of three boys and we all “helped” our mother in the kitchen—especially around the holidays, baking Christmas cookies.

2. How did you develop an interest in your passion outside of practice?

My mother had no daughters onto which to pass her baking skills, so my brothers and I had the great opportunity to learn. But because we were all involved in wrestling through junior and senior high school, we always needed to watch

our diets to make certain wrestling weights. We often couldn’t enjoy our Christmas treats while they were fresh, so we would each pack and freeze one tin of cookies to enjoy after the wrestling season was over.

3. How long have you been

participating in this activity?

I started baking with my mother when I was very young…and I continue to this day.

4. Why is this pursuit special to you?

I especially enjoy making recipes that are handed down through my family. One of my favorites is Ginger Snaps from my Great-Great-Grandmother.

She brought the recipe with her from Scotland.

LANCASTER

23

PHYSICIAN

Making Thanksgiving pies in Madagascar…rolling the dough with a wine bottle!

Ginger Snaps

1904 recipe from the kitchen of Mrs. Alice Cowen Matt Bacharach’s Great-great Grandmother.

1 c. Crisco or oleo

2 tsp. Vinegar

1 c. sugar

2 tsp. soda dissolved in 2 Tbsp. HOT water

1 c. New Orleans Molasses 2 tsp. Ginger

Flour to make a stiff dough (~4cups)

Mix all together. Roll very thin & cut out with cookie cutters. Sprinkle with sugar.

Bake at 325� for ~8 minutes. Yield ~ 10 doz .

L A N C A S T E R M E D I C A L S O C I E T Y.O R G

Patient Advocacy

Memory Care

OPTIONS in Lancaster County

SUSAN SHELLY

B

etween 4 and 6 million people in the United States suffer from Alzheimer’s disease and other forms of dementia. Two-thirds of them are women, and most are over 65 years old. They are our grandparents, our mothers, our fathers, our sisters and brothers and our friends, and more than 15 million of us are providing unpaid care for them. As our population continues to age, more and more people will be affected by these potentially devastating conditions. Some estimates predict that by 2050, between 15 and 20 million Americans will be living with dementia.

Right now, we spend $226 billion a year to care for Americans 65 years or older who suffer from dementia, but treatments have not kept up with those for some other diseases. While pharmacologic treatments for Alzheimer’s disease are available, none of them stop damage to neurons that result in symptoms of Alzheimer’s and eventually cause the disease to be fatal. Alzheimer’s disease, which accounts for 60 to 80 percent of all dementias, is the sixth-leading cause of death in the United States.

While this information from the Alzheimer’s Association is grim, advances are being made as the medical community learns more about dementia and how to treat it, according to Dr. Jon E. Bentz, a neuropsychologist with Lancaster General Health’s Alzheimer’s and Memory Care program.

There is even some evidence that the rate of dementia is slowing down, perhaps related to healthier lifestyles among older adults.

“The evidence is kind of speculative, but the thought is that keeping active, or having a healthy diet, or staying mentally active and engaged might delay the onset of dementia,” Bentz said.

LANCASTER

24

PHYSICIAN

SPRING 2016

Memory Care Options in Lancaster County

“Once a patient

Common symptoms include:

is diagnosed, we

 Memory loss that disrupts daily life

can put a plan into

 Confusion regarding time or place

place for dealing with the situation— having a plan can

 Difficulty completing familiar tasks  Misplacing things and losing the ability to retrace steps to find them  Trouble understanding visual images and spatial relationships

provide relief for

 Decreased or poor judgment

both the patient

 Changes in mood and personality

and caregivers.”

– Dr. Jon E. Bentz Dementia, which Bentz described as “an umbrella term that indicates the presence of impairment beyond normal age-related changes,” has many causes. The biggest risk factor of getting dementia is aging.

“The older you get, the higher your risk is of getting dementia,”Bentz said.

While we often think of Alzheimer’s disease as a type of dementia, Bentz and the Alzheimer’s Association refer to it as a cause of dementia. Other causes for dementia—commonly referred to as types of dementia—include vascular dementia, which occurs when blood flow to the brain is decreased; dementia with Lewy bodies, which is associated with Parkinson’s disease; Parkinson’s dementia, which accompanies Parkinson’s disease; frontotemporal lobar dementia, which is characterized by personality changes and difficulty with language; and mixed dementia, in which brain abnormalities associated with more than one cause of dementia occur.

While a common condition, dementia is not always easily diagnosed. Fifty percent of individuals with dementia are not diagnosed at the time when they begin to show symptoms, according to Bentz.

 New problems with words in speaking or writing  Withdrawal from work or social activities

Lancaster General’s Alzheimer’s and Memory Care program has made great strides in diagnosing and treating dementia by employing a multi-disciplinary approach.

“We don’t just have physicians, we have a team that includes geriatricians, neurologists, neuropsychologists, nurse practitioners, occupational therapists, physical therapists, speech therapists and social workers,” Bentz explained. “That helps us to diagnose patients earlier so that treatment can begin earlier.”

Patients may be treated with medicines that can slow the progression of Alzheimer’s disease and provided guidance on how to manage other physical conditions, such as anxiety, chronic pain, sleep disorders or depression. An important part of treating dementia is managing a patient’s medications, as some drugs can have a negative effect on brain function.

A patient or caregiver who is concerned about dementia should start by consulting a family doctor or the Lancaster General Health Alzheimer’s and Memory Care program at 717-544-3539. While there is no Continued on page 27

SPRING 2016

Patient Advocacy

single test to diagnose Alzheimer’s disease or other forms of dementia, doctors use a range of tools including:  Obtaining a patient’s medical and family history  Assessing cognitive and behavioral changes  Conducting cognitive tests and physical and neurological exams  Using magnetic resonance imaging scans to identify changes to the brain  Referring the patient to a neurologist or neuropsychologist  Obtaining input from family members or other caregivers

According to Bentz, if a patient is diagnosed with Alzheimer’s or another form of dementia, the patient and caregivers will be guided on how to manage and cope with the condition. Often, changes can be made at home to make it easier for someone affected by dementia, and methods can be used to optimize memory and awareness.

“Once a patient is diagnosed, we can put a plan into place for dealing with the situation,” said Bentz. “That actually provides a solution, and that can lessen the stress associated with the diagnosis. Having a plan can provide relief for both the patient and caregivers.”

Memory Care Options in Lancaster County

“We are not treating the memory issue per se, we’re treating the associated symptoms,” she explained. “We can provide medications that work to slow memory loss, but memory loss alone can often be assessed in an outpatient setting.”

People living with late stage dementia may experience psychotic-like symptoms that result in a state of intense anxiety for them and that are exhibited as behavioral disturbances, Scheidt explained.

“Most likely, a patient with dementia would have some type of acute crisis or an exacerbation of symptoms to be admitted here,” she said.

ALZHEIMER’S CAREGIVER

Resources Alzheimers.gov

For the people helping people with Alzheimer’s: www.alzheimers.gov

Alzheimer’s Association www.alz.org

1-800-272-3900 24/7 hotline

Conditions in which symptoms can mimic those of dementia include side effects from medications, depression or delirium, thyroid problems, excessive use of alcohol and certain vitamin deficiencies.

Alzheimer’s Disease Education & Referral Center

Experts in Lancaster Regional’s geriatric unit, which include psychiatrists, psychiatric nurses, social workers, therapists, counselors and a recreational therapist, work to teach caregivers how to access a patient’s residual skills. Residual skills are those that remain once dementia has taken hold, such as the ability to fold towels, remember one’s wedding day, or simply walk.

Family Caregiving Alliance

“We teach families how to access those skills because we want to help them to be able to validate the patient where they are,” shared Scheidt.

www.thefamilycaregiver.org 1-(800)-896-3650

At Lancaster Regional Medical Center, a behavioral health services team works with older patients who are admitted to the hospital’s 10-bed, short-term geriatric unit, said Debra Scheidt, director of behavioral health services.

WellSpan Ephrata Community Hospital does not offer a memory care program in Lancaster County, but has a program called WellSpan Geriatrics in York that offers comprehensive evaluations for the diagnosis of dementia, as well as treatment plans for patients and their families.

Typically, patients are admitted due to issues resulting from depression, delirium, or dementia. The 3 Ds can have a similar presentation. Both depression and delirium can accompany dementia, and they can make an early stage of dementia look much more advanced until treated.

Anyone who is concerned about dementia for themself or a loved one is encouraged to learn more by accessing a resource such as the Alzheimer’s Association. Offices are available in Reading and Harrisburg, or you can contact the agency any time at 1-800272-3900 or at www.alz.org.

LANCASTER

27

PHYSICIAN

www.alzheimers.org 1-(800)-438-4380

www.caregiver.org 1-(800)-445-8106

Caregiver Stress

www.caregiverstress.com

National Family Caregivers Association

National Institute on Aging www.nia.nih.gov/ HealthInformation/Publications 1-(800)-222-2225

These are just a handful of resources. Dial 2-1-1 for quick and easy access to information about other related health and human services available to you.

L A N C A S T E R M E D I C A L S O C I E T Y.O R G

Patient Advocacy

Children, Teens, & the Hazards of Too Much Electronic Media Exposure How Can Health Providers Help?

PIA FENIMORE, MD, Lancaster Pediatric Associates

70% of children

and teenagers have a television in their bedroom.

The average 8 year old

7 hours a day

spends using a variety of media.

Each teenager sends an average of

3,364

texts per month.

20% of teens have sent or received sexually explicit material via cell phone or internet.

Two thirds

of all teens state that their parents have “no rules” about media usage.

T

he statistics prove that technologic media has become a very significant force in the lives of American youth.

There is no question that the influence of media on our young people is impactful and is growing. As the health care providers for these children and teens, we need to offer awareness and guidance to both our patients and their parents about technology and its proper use. In its 2013 statement on Children, Adolescents and the Media, the American Academy of Pediatrics (AAP) called on health care providers to become educated about media related topics, to take a “media history” for each patient, and to counsel parents and patients on appropriate media usage. Yet many of us struggle to fit this discussion in amid limited time and resources.

There are ways, however, to simplify this complex issue and to make yourself a mediaaware health care provider.

Starting with the education piece, there are a few key points about technology use that each health care provider should know. It is recommended that parents limit the amount of entertainment screen time to 1–2 hours per day. Media exposure under the age of

LANCASTER

28

PHYSICIAN

two should be avoided. Electronic devices such as computers and televisions in the bedroom have been shown to correlate with higher rates of sleep dysfunction, obesity, and mood disturbances. Parents should be careful to observe age recommendations for movies, video games, and television programs. Cell phones should be docked at night and during meals. Parents are encouraged to monitor their children’s media usage, especially text messages, internet sites, and social media pages. Research suggests that violent and sexually explicit media exposure correlates with similar real life behaviors in children and teens.

The next step is to become proficient at taking a “media history.” The AAP recommends that you start with two key questions for everyone.

1. How much time per day do you spend in total entertainment screen time?

2. Do you have a television in your bedroom?

SPRING 2016

The Hazards of Too Much Electronic Media Exposure

These two questions will likely alert you to children/teens who are at risk. A more detailed history, including media content and social media usage should be taken in the setting of mood disturbances, sleep dysfunction, or aggressive behaviors.

Finally, health care providers should become comfortable counseling parents on the risks of technology and media use and on useful ways to integrate this omnipresent force into their family safely. You and your office staff should become familiar with some websites that provide parents with information about technology, media, safety, and parental controls. Advise parents that they should have a media plan for their household to serve as a guide for safe and productive use of technology. The plan should include media curfews at bedtime and mealtimes, avoiding content that is not age appropriate, internet parental controls, and safe social media usage. Advise parents to use media to their children’s advantages

by watching television/movies together and integrating conversation time about media into their daily lives.

As a health care provider to children and teens, you should be media savvy because I guarantee your patients are! Consider placing your practice or yourself on Facebook, Instagram, and/or Twitter. It is an excellent forum to post things like flu vaccine reminders, safety advisories, and even new developments within your practice, such as new providers or EMR systems. Keep posts short and use photos that emphasize your point.

Finally, I believe that it is our duty as health care providers to advocate for responsible media production. This means limits on advertising tobacco and nicotine products; avoidance of glamorization of risky behaviors such as reckless driving, smoking, and drug use; and a continuation of current media and technology research.

LANCASTER

29

PHYSICIAN

The following websites may be useful resources: www.healthychildren.org

has a wonderful guide for parents about making a Media Use Plan for their family.

www.aap.org – Council on Communications and Media www.howtogeek.com provides

parents with step-by-step ways to place controls on their computers, regardless of operating software.

www.commonsensemedia.org is an organization dedicated to “media sanity not censorship” and advocating for parents.

L A N C A S T E R M E D I C A L S O C I E T Y.O R G

Legislative & Regulatory Updates

Pennsylvania Medical Society Quarterly Legislative Update March 2016

G

overnor Tom Wolf gave his second services in Pennsylvania. PAMED worked annual state budget address before a closely with Rep. Quinn in crafting this joint session of the General Assem- much-anticipated proposal and welcomed bly on Feb. 9, 2016. Instead of presenting her comments before PAMED’s Specialty details on his proposed budget and his policy Leadership Cabinet meeting on February 9, objectives for the coming fiscal year, however, 2016. In the coming months, PAMED will Gov. Wolf spoke mainly about the 2015- continue to build on a grassroots effort and 2016 state budget, which as of yet remains encourage physicians to engage with their unfinished. Items that were affected by the local legislators on this important legislation.

Governor’s partial veto of the spending PAMED will also be meeting with key House plan the legislature sent him in December members to inform them on the issue and continue to operate under the pressure of garner their support for the bill. insufficient funding, with no relief in sight.

expand its reach and, conversely, those who want to narrow it. Ultimately, if the House amends and successfully passes SB 3, the legislation will have to return to the Senate for that chamber’s concurrence with House amendments. At this time, it is uncertain as to how the Senate will receive the House amendments to SB 3, which they passed in May 2015. Gov. Wolf has already made his support and willingness to sign the bill clear, having identified medical marijuana legalization as a top policy priority of his for 2016.

Nevertheless, at the time of this writing, Medical Marijuana the House and Senate are in the process of Legalization completing their respective Appropriations The House of Representatives is slated to Committee budget hearings. At these budget vote on Senate Bill 3, medical marijuana hearings, representatives from the judicial legalization, when they return to session system, the attorney general’s office, and the week of March 14th. There are well over cabinet secretaries answer questions from 200 amendments filed to the bill, a factor legislators regarding their respective depart- which has contributed to the delay in its ment’s operations and funding needs, and consideration thus far. The amendments legislators delve into the Governor’s proposal are being offered by both supporters and for spending in the next fiscal year. opponents of SB 3—those who want to

PAMED has consistently opposed broadbased legalization of marijuana for medical use in Pennsylvania, citing marijuana’s ongoing status as a federal Schedule I controlled substance and the need for adequate and well-controlled studies of marijuana’s effects.

However, with public opinion overwhelmingly supportive of marijuana legalization and pressure building on legislature to act, we expect a final vote on the measure could take place in the near term.

The ongoing budget impasse has had the effect of slowing legislative action in recent months; however, there have been a number of developments of importance to Pennsylvania physicians and their patients.

Following are a few highlights.

Prior Authorization Reform House Bill 1657, recently introduced

by Rep. Marguerite Quinn (R-Bucks), would streamline and standardize the process of prior authorization of medical

LANCASTER

30

PHYSICIAN

SPRING 2016

PA Medical Society Quarterly Legislative Update

Mental Health Bed Tracking System Senator Camera Bartolotta (R-Greene) recently announced that she is introducing legislation to create a real-time, voluntary reporting system to identify available psychiatric beds across the commonwealth.

Sen. Bartolotta’s interest in the issue was

sparked after a recent Pittsburgh Post-Gazette article, which reported that beds in hospital psychiatric units in Pennsylvania regularly sit empty, even while emergency departments struggle to find available services for patients in need of inpatient mental health care. These patients may wait for hours or days to receive needed behavioral health evaluation and management, further exacerbating emergency department crowding.

PAMED, along with the Pennsylvania Setting aside the fact that ABC-MAP Psychiatric Society (PPS) and the Pennsyl- is not up and running yet, the legislature vania Chapter of the American College of appears eager to take further action to help Emergency Physicians (PAACEP), support combat the proliferation of misuse and the development of a shared bed tracking abuse of opioids. Legislation was recently system and have provided Sen. Bartolotta introduced in the state House of Represenwith draft legislation to address the issue. We tatives that would require physicians and anticipate a bill to be formally introduced other prescribers and dispensers to complete in the coming weeks. Similar legislation CME in the areas of addiction and opioid was introduced this session in the House prescribing as a condition of licensure (HB of Representatives by Rep. Dan Miller, 1805). A similar proposal is expected to soon but it has not received consideration be introduced in the Senate.

(HB 858).

Currently, physicians must complete 100 hours of CME for biennial licensure; twelve of those hours must be completed in the areas of patient safety and risk management.

PAMED’s position is that any new mandate for physicians to complete CME in pain management and opioid prescribing practices should satisfy a portion of these existing educational requirements for physicians to complete CME in the areas of patient safety and risk management.

Changes to the Child Protective Services Law

Mandatory CME Legislation The state’s opioid abuse epidemic has continued to intensify, with significantly higher rates for drug-poisoning deaths in Pennsylvania than the U.S. average. A recent study by the Pennsylvania Health Care Cost Containment Council (PHC4) revealed a 225 percent increase in the number of hospitalizations for overdose of pain medication and a 162 percent increase in the number of hospitalizations for overdose of heroin from 2000 to 2014. From 2013 to 2014, Pennsylvania’s drug overdose death rate increased significantly, by 12.9 percent.

The creation of a voluntary, shared bed tracking system would increase health care providers’ ability to ensure that proper mental health care is being delivered in an appropriate timeframe and in an appropriate setting. Specifically, the registry proposed

by Sen. Bartolotta would provide contact information and descriptive details for participating psychiatric facilities throughout Department of Health officials recently the state; provide real-time information announced that the administrative infraregarding the number of beds available at structure for the state’s new prescription each facility, the type of patient who may drug monitoring program—also known be admitted, and the level of security; and as ABC-MAP (Achieving Better Care by identify appropriate facilities for detention Monitoring All Prescriptions)—is in place and treatment of individuals who meet the and the system should be operational by criteria for temporary detention.

August 2016.

LANCASTER

31

PHYSICIAN

Between the 2013-2014 and 2015-2016 legislative sessions, the Pennsylvania General Assembly passed more than twenty bills to update the Child Protective Services Law (CPSL). The goal of the package of legislation was to implement recommendations from the Governor’s Task Force on Child Protection, which was formed in the wake of the Penn State Sandusky investigation.

Amendments made to the CPSL in 2013 and in 2014 altered the scope of the child abuse clearance requirement. Those changes have resulted in some confusion as to how the law should be interpreted and which medical personnel are required to have a clearance. As a result of this confusion, legislation will soon be introduced in the state Senate to clarify who is covered under the child abuse clearance requirement in the CPSL. PAMED has provided input on the draft bill and will be monitoring its movement closely in the coming weeks.

For the most current status, visit PAMEDSOC.org

L A N C A S T E R M E D I C A L S O C I E T Y.O R G

Medical Society Updates

To Be, Or Not To Be— The Role of the County Medical Society

HEATH B. MACKLEY MD, FACRO

n October 25, 2015, the PAMED House of Delegates adopted Resolution 15-501, requiring the Board of Trustees to create a task force to examine the feasibility of forming larger regional medical societies built upon the existing structure of the county societies. The goal of these larger medical societies would be to increase member benefits through the pooling of resources, while continuing to provide appropriate representation of physicians’ local issues. Consequently, on February 9, 2016, the PAMED Board of Trustees approved the creation of a task force, to be chaired by Charles Cutler, MD, and the appropriation of funds to contract with a consultant who is highly regarded

for work in the association and membership fields. The focus of the consultant’s work will be to look at the issue of dues pricing, relative to value and willingness to pay, as that will directly impact the cost analysis of the feasibility of regionalization. The task force, with the help of the consultant, will deliver a report to the Board later this year, which will then be presented to the House of Delegates on October 22, 2016.

This is important work, and we look forward to reading the task force’s findings, but this begs a fundamental question and leads to others, as well: What is the purpose of the county medical society? What has worked in the past, and what didn’t? What

LANCASTER

32

PHYSICIAN

works now and what doesn’t? Where should we go from here?

These are healthy questions for any organization undergoing change, and although PAMED is an appropriate venue to discuss regionalization, it must be discussed locally, in each county, as well. Each county’s medical society is an independent professional association with its own history. County medical societies are not subsidiaries of PAMED, just as PAMED is not a subsidiary of the AMA. The relationships between the local societies and PAMED are best described as interdependent, as it is difficult to imagine a healthy state society without engaged county societies, or a vibrant

SPRING 2016

The Role of the County Medical Society

national society without strong state societies. Although independent in one sense, the success of one is dependent on the success of the others. In short, this is a partnership, and any fruitful discussion of regionalization requires the participation of the counties.

The Dauphin County Medical Society (DCMS), of whom I am privileged to serve as Vice President, has a rich history, being founded on February 20, 1866. Its original mission, speaking broadly, was to help maintain the AMA and PAMED, which were founded in 1847 and 1848, respectively. More specifically, DCMS’s mission was to extend medical knowledge, advance medical science, elevate and maintain the standards of medical education, uphold the ethics and dignity of

the medical profession, foster partnerships between physicians and the communities they serve, and promote public health and hygiene in the prevention and management of disease. Over time, a number of changes have occurred. As a county medical society, DCMS is no longer focused on advancing medical science or improving medical education standards because those missions, although important, are not best suited to a county medical society. Today, DCMS’s mission is to uphold the ethics and dignity of the medical profession, elevate and maintain the highest standards of healthcare, promote and disseminate medical information to members and the public, and promote collegial relations among our members.

I’m sure many of the other county medical societies have similar missions—and also have a history of their missions changing as the needs of their members changed. A thoughtful discussion of regionalization requires deciding on a clear mission for those societies.

LANCASTER

33

PHYSICIAN

Organizations have official mission statements to publicly communicate their ideals and what they hope to achieve. But it is also useful to look at the unwritten mission statement of an organization—What is it actually doing, what do its members want it to do, and how does that match the formal mission? Broadly speaking, the activities of DCMS are focused on maintaining a community for physicians that crosses health systems and employment statuses. DCMS advocates for patient and physician causes in the legislative and regulatory spheres, offers continuing medical education on select topics, gives to the community through outreach and philanthropy, and provides a conduit for Dauphin County members to become involved in the work of PAMED. I have had the good fortune of meeting and working with other county societies in the 5th district, including Berks, Lancaster, and York. These county societies are also Continued on page 35

SPRING 2016

Medical Society Updates

very active, making their communities and PAMED better in the process.

But not all county societies are active.

Even if they have an attractive mission statement, what message is that saying to the public, and what value are they providing to their members? Would physicians in nearby counties with non-active county societies be better served by being a member of a regional society with a foundation featuring the pooled strengths of the active county societies? Or would this dilute the community that the strong county societies are trying to foster and hurt membership by alienating members that appropriately cherish, and take pride in, the rich histories of their county medical society?

And then there is the elephant in the room, money. Within the group of inactive county societies, some collect dues, and some do not. For PAMED to continue to thrive, it has to consider adjusting its own dues

structure, yet it has no direct control over the dues set by county societies—and the price tag physicians see can influence their decision to join or to not join. PAMED requires its members to be a member of a county society, but this is a choice, not a mandate. In 1995, PAMED ceased to require AMA membership for its members.

It is possible for PAMED to do something similar with the counties, but it’s hard to see that as anything other than harmful to county membership. Would that be in PAMED’s best interest? “Softer” measures could include exerting influence over county dues rates by making PAMED’s collection of county dues on their behalf contingent on specific conditions. Given the likelihood that less than 100% of counties would be compliant, this would lead to a schism of sorts between the “cooperative” counties and the “uncooperative.” It is also worth noting that the majority of many county society’s budgets are for professional support staff, most of whom are PAMED employees, so

LANCASTER

35

PHYSICIAN

any effort that significantly decreases county income could lead to PAMED needing to either downsize or reassign those positions.

All of this underscores the interdependence of PAMED and its county societies, and their collective need to be partners in any process that considers major changes that affect both.

This article is not a sound of alarm about impending changes, nor is it a recommendation on adopting a specific policy. This is a call to open the lines of discussion as broadly as possible. I see the county medical societies and PAMED engaged in important work each and every day. But what do we need to do to thrive in the future? Let us know your thoughts! We need your involvement more than ever!

Dr. Mackley is a Radiation Oncologist the Penn State Hershey Cancer Institute and 5th District Trustee, representing physicians of this county.

L A N C A S T E R M E D I C A L S O C I E T Y.O R G

Restaurant Review

Reviewed by: KRISTY WHITMAN, MD

ZACHARY GEIDEL, MD

LGHP Family and Maternity Medicine OB/Gyn

nfortunately, Zach and I do not get the opportunity to go out for a nice dinner very often. It can be difficult to coordinate with our busy schedules and two young daughters.

We were excited to find a babysitter and a night to go out to dinner as a couple to an eatery other than Isaac’s, Chic-fil-A, or somewhere of the like.

(Although I do enjoy some pickles or waffle fries every now and again.) We always enjoy exploring new places as they open in Lancaster, which is why we chose to try Mulberry Social.

Mulberry Social is located at 300 West James St. on the corner Mulberry Street. It opened in August 2015 in the space that was formerly occupied

by Checkers Bistro. It is owned by the former managers of Gibraltar and also

Wellspan Family & Sports Medicine – Cocalico

shares the former executive chef from Gibraltar, Carl Vitale. Gibraltar is one of the first places where we dined in Lancaster when we were searching for jobs over six years ago. As a native Rhode Islander, I have a love for seafood, so I always enjoyed it there. I was hoping for the same when I made our reservation at Mulberry Social.

Our reservation was at 6:45 pm on a Saturday evening. We arrived at the location and were easily able to park in the lot located behind the restaurant.

We walked in and noticed the space looked very similar to when it was Checkers. It remains cozy and welcoming, but has not been renovated much. It was crowded and every table seemed to be occupied. The hostess was friendly, offered to take our coats,

LANCASTER

36

PHYSICIAN

and then seated us at our table up on the second level. This area opens to the first level, and we were seated at a table for two. After sitting at the table for several minutes, we immediately were drawn to the fact that the restaurant was very loud.

Our server, Anthony, arrived shortly after we sat and told us about the specials for the night, which included a mushroom bisque, frisée steak salad with a cherry vinaigrette and an over-easy egg, and a swordfish entrée.

First, we took the time to look at the drink menu. They have an exclusively American wine list and seasonally crafted cocktails. They also have 11 mainly locally brewed craft beers on tap. Zach was definitely pleased with their beer selection. I chose a glass of

SPRING 2016

sauvignon blanc from Napa Cellars, and Zach ordered a glass of Mad Elf beer.

We noted that the food menu had a good variety of choices and that the prices were quite reasonable. Besides appetizers, soups, salads and entrees, the menu also includes a couple of “hand-held bites” (sandwiches) and pizza. They also have several pasta entrees, featuring pasta that is handmade fresh daily. We decided to forego an appetizer to leave room for dessert.

(I have no willpower when it comes to dessert!) I had a hard time making a decision, but I finally decided to order a braised short rib dish served with creamy polenta and a red wine sauce.

Zach ordered the gnocchi and duck confit. Unfortunately, Anthony told me they were out of the short rib dish that evening. I was disappointed and would have appreciated knowing that prior to looking at the menu. I ultimately went with the fettuccine with lobster sauce.

While we waited for our food to be served, we were offered bread, which

is also homemade. I chose the focaccia and Zach chose the pizza bread. Both were very good and fresh. Our entrees arrived very quickly. My fettuccine was amazing. The homemade pasta was served with scallops, shrimp, mussels and crab, all in a sherry lobster sauce. It was very rich but not too heavy. It was almost as good as a very similar dish that I had once before at the famous Italian restaurant, Filomena, in Georgetown, Washington, D.C. Zach also enjoyed his dish. The gnocchi were shaped different than we had seen before as they looked like little boxes, but they were light and delicious, having soaked up some of the sauce from the duck confit. It also had the tender duck and was served with butternut squash and brussels sprouts.

Then it was time for my favorite—dessert. Selections that night included apple pie with ice cream and crème brulee. We chose the final option, which was a chocolate chip peanut butter cheesecake, along with two cups of

LANCASTER

37

PHYSICIAN

coffee. The cheesecake was presented beautifully, like an upside down scoop of ice cream. It also had fresh whipped cream and caramelized banana pieces surrounding it. It was so good that we had no trouble finishing every last bite.

We greatly enjoyed our dinner at Mulberry Social and will definitely head back there soon. The only drawback was the fact that it was loud, so it may not be a good choice if you are looking for a quiet, intimate dining experience.

But the food was delicious and exceeded our expectations!

Mulberry Social 300 W. James Street, Lancaster, PA (717) 947-7162 www.mulberrysocial.com

L A N C A S T E R M E D I C A L S O C I E T Y.O R G

News & Announcements

Member Spotlight

David Silbert, MD, FAAP

Q:

Where do you practice and why did you settle in your present location or community?

A:

I have been practicing in Lancaster for 21 years and recently left Family Eye Group to start my new practice, Conestoga Eye, at Campus Plaza near the Health Campus. I also have Mechanicsburg and Carlisle locations. Conestoga Eye is a smaller, more intimate environment where I can better focus on my patients and my staff. I want to not only offer excellent and more focused patient care in my specialties of pediatric ophthalmology and cosmetic and reconstructive eyelid surgery, but also to give back to this wonderful community where I have lived, worked, and raised my daughters.

I bring my team to see students throughout the School District of Lancaster. During these visits, patients receive a complete eye exam comparable to a regular visit in my office at no cost to the student’s family. Those who need glasses are fitted for them.

In addition, my team and I go on missions every year to different rural communities abroad. This has included Honduras, Columbia, and, most recently, Ecuador. Last year, we saw more than 500 children in three days in school and clinic settings as part of the Ecuador Pediatric Ophthalmology Project.

I am also involved in numerous professional organizations and recently completed the Leadership Development Program for the American Academy of Ophthalmology (AAO). I serve as a board member, am on the Executive Committee and am Secretary of Public Health for the Pennsylvania Academy of Ophthalmology.

I serve on the Carrier Advisor Committee (CAC) for Novitas, our Medicare carrier, and also serve on the Specialty Leadership Cabinet of the Pennsylvania Medical Society. I am Chairman of the Corporate Relations Committee of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) and am the RVU Chairman for the American Academy of Pediatrics, Division of Ophthalmology. I have served as a congressional advocate for the AAO and have endeavored to work with and support our elected federal, state, and local representatives, offering myself as a resource to them in their research and study.

Q: What do you like best about practicing medicine?

A:

Practicing medicine is about helping people. The best part of my job is seeing the work I do change people’s sight for the better. My hope is that Conestoga Eye is more than just a doctor’s office, but a community resource for children’s eye care and eyelid surgery.

Q: Are you involved in any community, non-profit, or professional organizations? If so, please list the groups.

A:

Q: What are your hobbies and interests when you’re not working?

In 2013, I launched KinderSee after receiving a $135,000 federal grant to outfit a school-based eye clinic. Kindersee opened at George Washington Elementary School that fall, serving patients one day each month since. That day every month continues to be one of my favorite days of the month. I strongly believe that if a child cannot see, they cannot learn, and this belief formed the impetus behind KinderSee. Every month during the school year,

LANCASTER

A:

38

I am a voracious reader of the New York Times, Wall Street Journal, and to a lesser degree the Washington Post. I love politics!

I exercise daily, enjoying cardio, HITT, biking, skiing, and water sports. To me, a day without exercise is a day without sunshine. In the winter, I love skiing in Utah, and in the summer, I spend my free time on Cape Cod, MA near my parents and siblings.

PHYSICIAN

SPRING 2016

News & Announcements

Frontline Group Spotlight

Dermatology Associates OF LANCASTER

Sara J. Heilig, MD, FAAD

Back Row (Standing) Left to Right: Jeanette L. Hebel, MD, FAAD, Jennifer A. Sceppa, MD, FAAD, Bruce A. Brod, MD, FAAD

Christina N. Lawson, MD, FAAD

Front Row (Seated) Left to Right: Patrick R. Feehan, MD, FAAD, Desiree A. Antonacci, MS, PA-C, Jennifer L. Mueller, MD, FAAD, Mark B. Gibbs, MD, FAAD, Mary F. Kegel, MD, FAAD

D

ermatology Associates of Lancaster Associates of Lancaster uses the latest has nine board-certified dermatologists has been serving the patient commu- technologies in dermatology to provide serving at its two locations: its main nity in Lancaster County and surrounding for the continued health and well-being office at 1650 Crooked Oak Drive, Lanareas for nearly four decades. The practice of its patients. In addition to leveraging caster and its satellite office located at strives to provide the highest level of advancements in medicine, the team also 212 Willow Valley Lakes Drive, Willow dermatologic care to patients of all ages, delivers care with the greatest level of Street. The services they provide include and it has approximately 83,600 patients integrity, compassion and respect. a range of comprehensive care: general in its database! With a physician-led team and pediatric dermatology, skin cancer comprised of highly trained and dedicated Founded by Dr. Patrick Feehan, Der- treatments, Mohs micrographic surgery, health care professionals, Dermatology matology Associates of Lancaster currently dermatopathology, and aesthetic care.

LANCASTER

41

PHYSICIAN

L A N C A S T E R M E D I C A L S O C I E T Y.O R G

News & Announcements

Community Events

Lancaster Regional Medical Center & Heart of Lancaster Regional Medical Center Events:

WellSpan Ephrata Community Hospital Events:

March of Dimes March for Babies walk

Like Mother, Not Entirely Like Daughter: Good Gynecological Practices

Heart of Lancaster Regional Medical Center is again the title sponsor for the March of Dimes March for Babies walk. We are currently recruiting volunteers to join and/or donate to the HLRMC team (go to: www.marchforbabies.org/team/heart).

The American College of Obstetricians and Gynecologists recommends a teenage girl first visits an obstetrician/gynecologist between the ages of 14 and 15. This free program covers questions that may arise before or after that visit, and good gynecological health practices for teenagers. To register, call (717) 738-3556. Press 1, then 2.

When: Sunday, May 1 Where: Long’s Park Time: beginning at noon

When: Tuesday, April 19 Where: Ephrata Public Library, 550 S. Reading Road, Ephrata Time: 6 – 7 pm

Ongoing free surgical and non-surgical weight loss seminars To RSVP call (717) 378-4402.

We cover a wide variety of topics, including:

Plant the Seed of Learning Class

• Medically supervised weight management options, with personalized nutritional guidance • In-depth information on different types of weight loss surgeries, including potential benefits and risks of each, and the physical and emotional aspects of the journey • How to know if you qualify for weight loss surgery, including the insurance process • What to expect, from pre-operative prep through ongoing follow-up care

“Plant the Seed of Science” will offer helpful tips on how to educate a young child in a playful environment. Supplies are provided. Designed for parents of children from birth to 2 years old, the free class is sponsored by WellSpan Ephrata Community Hospital, the Ephrata Area School District, Cocalico School District and the Conestoga Valley School District. Registration is required, by calling (717) 738-MOMS.

When: Thursday, May 5 Where: Keystone Villa, 100 N. State Street, Ephrata Time: 6 – 7 pm

When: First Wednesday of every other month (5/4, 7/6, 9/7, 11/2) Where: Heart of Lancaster Regional Medical Center, 1500 Highlands Drive, Lititz, Multi-Purpose Room Time: 7 – 8 pm

Healthy You

This program is for adults who want to lose weight, eat healthy and be active.

Cost is $15. To register, call (717) 721-8790.

Stroke Support Group Putting the Pieces Back Together

When: Tuesdays, April 12, 19, 26, May 3 and 31 Where: WellSpan Cocalico Health Center, 63 W. Church Street, Stevens Time: 6:30 – 8:30 pm

Offering stroke patients and caregivers the opportunity to openly and voluntarily discuss the frustrations, goals, experiences and obstacles often faced with a stroke diagnosis. The group’s offers coping skills and non-judgmental empathy and understanding with the sharing of personal experiences.

When: The first Wednesday of each month Where: Lancaster Regional Medical Center, 250 College Ave., Lancaster, 3rd floor Rehab Unit Sunroom Time: 11am – 12noon (Times may vary depending on the needs of the community) RSVP: Deana at (717) 358-7208 or Robyn at (717) 291-8015

I Can! Challenge

The 12-week program for people with diabetes or heart disease who want to eat healthy, manage stress and get fit. Cost is $25. To register, call (717) 721-8790.

When: Tuesdays, May 3 to July 26 Where: WellSpan Cocalico Health Center, 63 W. Church Street, Stevens Time: 6 – 7:30 pm

Joint Pain? Let’s Talk About Your Options

Get back to the active life you love with the help from fellowship-trained orthopaedic surgeon Thomas Ring, MD with Orthopaedic Specialists of Central Pennsylvania. Join him for a discussion on the many treatment options for joint pain, from physical therapy and injections to minimally invasive surgery and total joint replacement. Register today by calling 1-844-784-DOCS.

When: 4/19, 6/21, 8/16, 10/18 and 12/20 Where: CPRS Physical Therapy, Willow Street Office 3100 Willow Street Pike, Willow Street, PA 17584 Time: 5:30 – 6:30pm

LANCASTER

42

PHYSICIAN

SPRING 2016

News & Announcements

Welcome…New Members

Upcoming Events

Mark your calendar so you don’t miss these 2016 events!

Jonathan E. Benaknin, DO Community Services Group

Renee R. Mitzel Administrator, Manning & Rommel

Kathleen C. Dougherty, MD LGHP – Behavioral Health Specialists

Alireza Sadegh Nejad, MD Allergy & Asthma Center

Apr

Elizabeth Mary Fowler, DO Dale R. Lent DO & Associates

29 Young Physician Social

Bent Creek Country Club 6 - 9 pm • Childcare provided

M AY

11

Docs on Call WGAL • 5 - 6:30 pm Seeking Volunteers (5 – 5:45 pm & 5:45 – 6:30 pm)

Congratulations...Reinstated Members Gerald R. Baer, MD LGHP – Norlanco Family Medicine Leanne K. Beidler, MD LGHP – Willow Street Family Medicine Beth Irene Esterbrook, MD Wellspan Internal Medicine – Ephrata David W. Hartley, MD LGHP – County Line Family Medicine Francis J. Manning, MD Manning & Rommel

M ay

12

Legislative Breakfast Cork Factory Hotel • 7 – 8:15 am Senators Aument & Smucker

Jennifer Marie Payne, MD LGHP – East Petersburg Family Medicine

Jun

14 Annual Dinner

& Business Meeting

Rebecca M. Shepherd, MD LGHP – Arthritis & Rheumatology Specialists

Lancaster Country Club 6 – 9:30 pm

Michael T. Steelman, DO College Avenue Family Medicine

DEC Joyce A. Vafeas, MD Stephen G. Diamantoni MD & Associates

12

Silent Auction to benefit LCCMS Foundation Scholarship Fund

Neva Andrea Ouilikon, MD, Ephrata Hospitalist Group

In Remembrance...Deceased Members Fred R. Taylor, Jr., MD Dr. Fred R. Taylor, 65, of Leola, died unexpectedly on Saturday, September 19, 2015. His wife, Linda (Wright) Taylor, survives.

They had celebrated their 38th wedding anniversary on August 5th.

Born in West Chester, he was the son of the late Fred R. and Mary (Dillon) Taylor.

Dr. Taylor graduated from Villanova University, Hahnemann Medical College and the LGH Family Practice program. He practiced Family Medicine in Warren, PA and New Holland.

LANCASTER

Holiday Social Lancaster Country Club, Doors open at 6:30 pm

45

PHYSICIAN

L A N C A S T E R M E D I C A L S O C I E T Y.O R G

News & Announcements

FRONTLINE GROUPS The Lancaster City & County Medical Society thanks these groups for 100% membership in the Medical Society.

Allergy & Asthma Center Cardiac Consultants PC

Lancaster Cancer Center Ltd Lancaster Neuroscience & Spine Assoc

Community Anesthesia Associates Lancaster Physicians For Women Community Services Group LGHP – Lincoln Family Medicine Dermatology Associates of Lancaster Ltd Eye Associates of Lancaster Ltd Manning & Rommel Associates

LGHP – Manheim Family Medicine LGHP – New Holland Family Medicine LGHP – Susquehanna Family Medicine

Hospice & Community Care

OBGYN of Lancaster

Keyser & O’Connor Surgical Associates Ltd

Red Rose Cardiology Southeast Lancaster Health Services Inc Southeast Lancaster Health Services – Arch Street Southeast Lancaster Health Services – Hershey Aveue

The Heart Group of Lancaster General Health

Hypertension & Kidney Specialists

Pediatrix at Heart of Lancaster

Surgical Specialists of Lancaster WellSpan Family Medicine – Trout Run

Otolaryngology Physicians of Lancaster Patient First – Lancaster

LCCMS Foundation Updates The Lancaster Medical Society Scholarship FoundaAny Lancaster County resident fulfilling the criteria tion provides funding to Lancaster County residents listed above and accepted or continuing a medical attending medical school who exemplify good character, degree at an accredited medical school may apply for motivation, academic excellence, and demonstrate the Lancaster Medical Society Foundation scholarship. financial need.

Applications are due by July 1, 2016, for the 2016Since its establishment in 1991, the Foundation has 2017 academic year. awarded over $214,000 in scholarship funds. Each year, Lancaster City & County Medical Society holds a HolVisit our website, www.lancastermedicalsociety.org iday Social to raise funds for the scholarship program. for more information or to download an application.

LANCASTER

46

PHYSICIAN