chester county medicine | winter 2016

“The Tiger” by Sandra Sabin Luciano FEATURED ON PAGE 18PROTECTING PATIentS

SODIUM RESTRICTION: A TIME-HONORED DOGMA OR AN EVIDENCE-BASED PURSUIT?

IN CHESTER COUNTY FROM ONE-SIZE-FITS-ALL HEALTHCARE

THE ART

of

Chester County

Your Community Resource for What’s Happening in Health Care

Winter 2016

Chester CountyThe Art of

ANTIBIOTIC RESISTANCE

a Serious Health Threat: CDC

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Chester County Medicine is a publication of the Chester County Medical Society (CCMS). The Chester County Medical Society’s mission has evolved to represent and serve all physicians of Chester County and their patients in order to preserve the doctor-patient relationship, maintain safe and quality care, advance the practice of medicine and enhance the role of

medicine and health care within the community, Chester County and Pennsylvania.

The opinions expressed in these pages are those of the individual authors and not necessarily those of the Chester County

Medical Society. The ad material is for the information and consideration of the reader. It

does not necessarily represent an endorsement or recommendation by the Chester County

Medical Society.

Chester County Medicine ispublished by

Hoffmann Publishing Group, Inc.,Reading PA 19608

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contact Karen Zach610.685.0914

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2013-2016CCMS OFFICERS

PresidentWinslow W. Murdoch, MD

President-ElectMian A. Jan, MD, FACC

Vice PresidentBruce A. Colley, DO

SecretaryDavid E. Bobman, MD

TreasurerLiza P. Jodry, MD

Board MembersMahmoud K. Effat, MD

Heidar K. Jahromi, MD

John P. Maher, MD

Charles P. McClure, MD

Susan B. Ward, MD

David A. McKeighan

Executive Director Rosemary McNeal

Administrative Assistant CCMS Headquarters

(610) 827-1543

[email protected]

Chester County Medicine is published by Hoffmann Publishing Group, Inc. Reading, PA I HoffmannPublishing.com I 610.685.0914 I for advertising information: [email protected]

WINTER 2016Contents

w w w . c h e s t e r c m s . o r g

8

In Every Issue6 President’s Message18 The Art of Chester County31 Membership News & Announcements

8

Features

Antibiotic Resistance a Serious Health Threat: CDC 12 Vitamin D

...to Supplement ornot to Supplement?

16

10 Breast Cancer Update

20 Due Diligence is Essential When Responding to Subpoenas for PHI

24 TB: The “White Plague” is Still With Us

26 Fighting Opioid Abuse

in Pennsylvania

28 CCMS Membership:

Resources You Need

30 CCMS Annual Clam Bake

Insuring Every Child in Pennsylvania

Dream Care – Why it Matters• 24,000 very poor children are barred from enrolling

in Pennsylvania’s Child Health Insurance Program (CHIP) because they are undocumented.

• Eight out of ten of these children haven’t been able to go to a health care provider or are receiving significantly delayed care.

• Nearly half of these children haven’t seen a dentist in more than year.

• Three quarters of these children cannot get the medications they need.

Dream Care – The Answer• Remove the 13 words from the PA CHIP statute

that currently deny undocumented children access to health care.

• The number of children who are not eligible for CHIP is less than 1% of children in Pennsylvania.

• PA can cover these kids for $15.4 million, or less than 1/20th of 1% of the state budget.

• The state cost for the CHIP program is now $90

million less because the federal government has picked up more of the program costs in the last year.

• It costs 50% less to insure a child through the CHIP program than the average uncompensated care costs for children currently being covered by hospitals and the state.

C H E S T E R C O U N T Y 6 M E D I C I N E


A s I prepare for my second to last president’s message, winding down three years of volunteer service, I am

reminded of how much organized medicine has done for our communities and profession, but also, how much more still needs to be done. Some of our ongoing community related activities include: Working with Delaware County Medical Society and the Chester County Department of Health on a collaborative prescription medication/opiate safety program to reduce intentional and unintentional overdoses in our communities. Bringing awareness and ready access to intranasal naloxone, and creating information kits for our practices and local pharmacies. In addition, the PA controlled medication database which we championed at PAMED and was passed into law should be coming on line early this year, once we get a budget passed. Working collaboratively with Dream Care Coalition and legislators to expand health insurance coverage for ALL children in Chester County. Meeting regularly on weekends with a tri state regional group of committed physicians, business people, and concerned community members, collectively “visioneering” a health care system centered on patients and caregivers, not insurers and middlemen. This working group is constructing a business plan to reengineer our fragmented and wasteful current payment and convoluted care process and may be of interest in the coming year as it develops. Expanding our outreach to all practices by hosting a local quarterly Practice Managers meeting, sharing best practices, and networking in a fun and interactive manner. On a state and federal level, we at CCMS and PAMED have been actively involved in: Working with PAMED on arranging support materials on Direct Primary Care in PA, as an alternative payment model for sustainable, independent primary care practice.

President’s Message

Are We Focused or Fuzzy?

Getting vaccinations made available at regional pharmacies, and covered by most local commercial insurers, wherein they were only covered incident to an office visit, and many of us did not have enough volume to stock the numerous newer or more expensive vaccines. Getting pull back by the American Board of Internal Medicine on their rapidly increased Maintenance of Board Certification (MOC) costs and requirements, with plenty more work that still needs to be done in this area, and other NBMS

MOC organizations. And PAMED is doing so much more. Through all this, we are all navigating a very tumultuous medical practice environment. Insurers continue to restrict care via progressively more complex and proprietary rules, regulations, and seemingly random restrictions on coverage of necessary care, diagnostics, and pharmaceuticals. We have all personally spent hundreds of hours transitioning first to a government certified EMR, and then on implementation of mandated ICD 10 codes for all we see and do, in order to access care for our patients, or get paid for our work. We have seen a huge migration of independent primary care and specialty physician practices into hospital employment, and as a result, additional facility fees added to all basic care. Specialty practices have horizontally integrated into mega groups to have more leverage with the monopsony of market dominant commercial insurers and hospital systems for payment and resources. One dominant local not for profit commercial insurer joined with a for profit national entity to contractually tie the large majority of the remaining independent primary care offices into a mega practice. Hospital systems are rapidly consolidating into mega regional enterprises, with attendant increase in cost, without obvious benefits (so far) in quality, access of services to our communities, or improved working conditions for the majority of the healthcare workforce. Many practicing physicians thankfully continue paying


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dues to the Chester County and PAMED Societies. We appreciate the perspective, voice, volunteerism, and the early warning response that all of you in the community bring. Collectively, we strive to research legislation and act on behalf of physician autonomy and our patients’ best interests. With massive government, hospital, and insurer mandates, however, we confront an inherent conflict. Where should our society utilize dues, manpower, and resources? Should we be sponsoring compliance courses, “helping” members assimilate, or, preserving the profession and the patient doctor relationship, and if both, in what balance? I encourage anyone to communicate or help in any fashion, to direct the mission of CCMS and PAMED towards a better future. To further this aim, I am excited to announce that we have a new executive director at CCMS, David McKeighan. David shares his time synergistically with Delaware County Medical Society, where he has and continues to be a valuable resource for the past 30 years. David lives just down the street from The Chester County Hospital. He has a master’s in social work from Penn. Over the decades, he has led or participated in numerous community coalitions; work groups, task forces, and

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organizational leadership roles, all to promote better community health and safety; pandemic and emergency public planning; mental health parity; suicide prevention; child welfare; physician and health policy leadership; advocacy for medically underserved and elderly at risk; political advocacy; chamber of commerce leadership; and health literacy. David has the creative thinking, experience, personal contacts, and bandwidth to prioritize and individualize volunteerism activities that engage our members. He will facilitate starting, finding, and catalyzing projects and collaboration, where your efforts, however small, or expansive, can be focused on something you are interested in. Your passion will then direct how limited or invested you care to become. We all need to come together in whatever way we can to navigate toward a better future; for our communities, our practices, and our own personal destinies, fueled by our shared passion for excellence.

Winslow W. Murdoch, MD, practices family medicine in West Chester. He is president of the Chester County Medical Society. Contact Dr. Murdoch at [email protected].



Feature

ANTIBIOTIC RESISTANCEa Serious Health Threat: CDC

BY JOHN P. MAHER, MD, MPH

According to a Centers for Disease Control and Prevention (CDC) report, “Antibiotic Resistance Threats in the United States” (2013), more than two

million people in the U.S. get infections which are resistant to antibiotics every year, and at least 23,000 of them die as a result. The landmark report published “the first snapshot of the burden and threats posed by antibiotic resistant organisms having the most impact on human health.” The report ranks the threats according to whether they are considered “urgent,” “serious,” or “concerning.” This ranking of importance of the threats was assessed using seven factors associated with resistant infections, including: health impact, economic impact, prevalence (how common an infection is), transmissibility (how easily it spreads), availability of effective antibiotics, barriers to prevention, and a 10-year projection of how common it could become.

Table IBiggest Threats

Urgent Threats (a) Clostridium difficile (CDIFF) (b) Carbapenem-resistant Enterobacteriaceae (CRE) (c) Neisseria gonorrhoeae

Table IIBiggest Threats

Serious Threats (d) MDR Acinetobacter (e) Drug-resistant Campylobacter (f ) Fluconazole-resistant candida (g) Extended spectrum beta-lactamase producing Enterobacteriaceae (ESBL) (h) Vancomycin-resistant Enterococcus (VRE) (i) MDR Pseudomonas aeruginosa (j) Drug-resistant non-typhoidal Salmonella (k) Drug-resistant Salmonella typhi (l) Drug-resistant Shigella (m) Methicillin-resistant staphylococcus (MRSA) (n) Drug-resistant Strep pneumoniae (o) Drug-resistant Mycobacterium tuberculosis

Table IIIBiggest Threats

Concerning Threats (p) Vancomycin-resistant Staph aureus (q) Erythromycin-resistant Group A Streptococcus (r) Clindamycin-resistant Group B Streptococcus


Maher

CDC Director Dr. Tom Friedman, MD, MPH, notes that “antibiotic resistance (AR) is rising for many different pathogens which are threats to health,” and “if we don’t act now, our medicine cabinet will be empty and we won’t have the antibiotics we need to save lives.” Practicing physicians have long been aware of the problems of new and emerging diseases, the potential threat of biological WMDs, the rapidity of international spread of diseases (due to international travel and commerce, military deployments, legal and illegal immigration, etc., etc.). In addition to these factors there is the ongoing issue of clinical overuse and misuse of antibiotics, as well as the use of antibiotics in agriculture and agronomy. CDC now estimates that up to 50% of all antibiotics prescribed for people are not needed or are not prescribed appropriately! Over the past couple of decades we have encountered resistant staphylococcus, gonorrhea, pneumococcus, a variety of resistant enteric organisms, and the steady growth of Mycobacterium tuberculosis resistant to one or more antibiotics. Carbapenem-resistant Enterobacteriaceae (CRE) are often resistant to most classes of antibiotics, and cause heath care associated infections with high mortality rates. CRE strains, first reported from south Asian countries, have spread internationally, often through health care facilities where infected travelers are seen. Those strains which carry plasmid-encoded carbapenemase enzymes, which inactivate carbapenem antibiotics, are of greatest public health concern because of their potential for rapid global dissemination; e.g., the increasing distribution of CREs which produce the Klebsiella pneumoniae carbapenemase [KPC], and the New Delhi metallo-beta-lactamase [NDM]. Resistance to the last-line antimicrobial, colistin, was recently reported from China, as has been resistance to the newly approved drug ceftazidime-avibactam found in a KPC strain in the US. It took a dozen years for the OXA-48 carbapenemase organism to work its way from Turkey in 2001 to the US in 2013 (mostly via patients infected overseas during travel) and cause case clusters here. A few patients have also been found to have combined infections with NDM and OXA-48 organisms. Most commonly, the organisms are isolated from urine and/or respiratory specimens. Another major concern for clinicians is the increasing incidence of resistant tuberculosis, with some health officials worrying about a possible return to the major TB problems of the early 20th century. Much has been published in recent years about multi-drug-resistant tuberculosis (MDR-

TB) and extensively drug-resistant tuberculosis (XDR-TB). Such cases have in fact been identified here in Chester County. A number of them have been extra-pulmonary cases requiring long-term, expensive, parenteral/infusion treatment with multiple third-line drugs. It should be noted that many of our TB cases now come via high risk patients from high risk third world nations. [Ed.—At this author’s last look, the Chester County Health Department’s Chest Clinic was seeing patients from 13 different nations, as well as from the US.] In addition to the toll on human life, the CDC notes that antibiotic resistant infections (ARIs) add considerable and avoidable costs to the already overburdened US health care system. In the US, ARIs add an estimated $20 billion in excess direct health care costs, with additional indirect costs to society for lost productivity of as much as $35 billion yearly. To combat these threats the CDC has created a Public Health Action Plan to Combat Antimicrobial Resistance (PHAP-CAR). This is a blueprint for specific, coordinated federal actions to address the growing threat. The plan sets up an Interagency Task Force on Antimicrobial Resistance (ITFAR) to address three areas for federal action: (1.) Surveillance, Prevention & Control; (2.) Research; and (3.) Regulatory Pathways for new products, and then outlines goals and actions which the participating federal agencies and departments are pursuing or preparing to pursue in the effort to respond to the complex and growing public health risk posed by ARIs. The new national strategy identifies five core actions:

• Slow the development of resistant bacteria and prevent the spread of resistant infections.

• Strengthen national One Health surveillance efforts to combat resistance.

• Advance the development and use of rapid and innovative diagnostic tests for identification and characterization of resistant bacteria.

• Accelerate basic and applied research and development for new antibiotics, other therapeutics, and vaccines.

• Improve international collaboration and capacities for antibiotic resistance prevention, surveillance, control, and antibiotic research and development.

For further details and developments on this topic, clinicians should visit www.cdc.gov/drugresistance/itfar/introduction_overview.html.

Dr. Maher is a long-term member of the CCMS Board, and former Director of the Chester County Health Department.

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2015 was a very good year for evidenced based medicine to dominate the breast cancer screening communities. This summer, the United States Preventive Services Task Force reaffirmed their

2009 recommendations for normal risk women to limit mammogram screenings to the ages of 50-74 yrs. of age.1 The International Agency for Research on Cancer, a World Health Organization consortium of experts from 16 countries (including the US), concluded that mammography be offered to women between 50 and 69 years of age.2 The American Cancer Society now recommends normal risk women begin mammograms at 45 years of age and at 55 years of age reduce screening to every 2 years.1 These recommendations took into account a large study from Canada that showed no improvement in breast cancer mortality resulting from mammogram screenings in women observed for 25 years. Also, the Bleyer et al study which spanned 30 years from the United States found that there was very little improvement as a result of mammogram screenings. This study showed a very large increase in prevalence of DCIS as a result of mammography and yet this did not result in improvement in the occurrence of advanced (potentially lethal) breast cancer.3 In direct alignment with these data, this past year, we learned that DCIS serves as a risk factor for developing breast cancer but treating DCIS vigorously does not improve breast cancer survival.4 This concept that less is best is further strengthened by a study I co-authored in which we found that the true risk of breast cancer for a woman who has not previously been diagnosed with breast cancer is significantly less than the 1 in 8 that our medical experts have been quoting. Our systematic review of 2,305,427 asymptomatic peri/

Feature

postmenopausal women demonstrated that approximately 95% would not be diagnosed with an invasive breast cancer during 25 years of follow-up. The CDC figure of a 1 in 8 (12.5%) lifetime risk of breast cancer may be misleading when applied to peri- and postmenopausal women without a prior diagnosis of breast cancer. The CDC developed its predictive models based only on studies of women with breast cancer obtained from cancer registries and attempted to work backward to predict outcome in all women. The newest published study worked forward using only screening reports of 2,305,427 women who were screened and followed but who did not have a prior diagnosis of breast cancer. Analysis of cancer free women at enrollment yielded a dramatically lower 25-year subsequent risk estimate. The widely promoted rationale for more frequent mammogram screenings appears to apply mostly to those patients with a prior personal history of breast cancer.5 Indeed, any screening test should take into account the frequency of that condition when developing a screening program. We have been learning that one of the principle harms of excess mammography is over-diagnosis that results in overtreatment of innocuous breast cancers, which never would become clinically significant if left undetected. This overtreatment increases the risk for other cancers developing in the future6,7 as well as a significant increase in cardiac mortality8, emotional turmoil9; complications from diagnostic and therapeutic surgical procedures; long-term aftereffects from medical treatments such as osteoporosis, cardiovascular damage; and disrupted sexual lives. Furthermore, this past year excess mammography has been shown to cost our country over $4 B yearly10. Much of this cost is not completely covered by health insurance programs and can become an economic burden for many women.

U P DAT EBY JAMES KOLTER, M.D., FACOG

C H E S T E R C O U N T Y 10 M E D I C I N E C H E S T E R C O U N T Y 11 M E D I C I N E

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Kolter

When a patient having a routine check-up asks what to make of all the conflicting information about early detection and mammography, she must learn that the chance that this cancer will affect her is much lower than she may have been taught. We clinicians had been cautioned of the over-use of mammography since the late 1970s by John C. Bailar III, MD, PhD, former Editor-in-Chief of the Journal of the National Cancer Institute.11 We have learned that the benefits of mammography are significantly less than we had hoped, and the harms of mammography are significant. This should be discussed with every patient so that she may make a truly informed decision about the screening process. I believe most asymptomatic women who learn what is behind the new screening recommendations would reject the annual mammograms of yesterday and sleep better knowing of the reduced threat to her from breast cancer. Moreover, if we teach our patients some lifestyle pointers they can do to help promote health, we would be making a real health contribution. For example, we can promote longevity if we all fight against weight gain with proper nutritional habits and include a daily portion of nuts and olive oil, engage in daily exercise, and treat the symptoms of menopause with appropriate hormonal therapy.

James Kolter, MD, FACOG, is a Clinical Associate Professor at Philadelphia College of Osteopathic Medicine and Senior Attending Physician, Department of OBGYN at Paoli Hospital.

1.Breast Cancer Screening Guidelines in the United States, Jill Jin, MD, MPH,JAMA. 2015;314(15):1-2. doi:10.1001/jama.2015.11766.2. Breast-Cancer Screening — Viewpoint of the IARC Working Group, N Engl J Med 2015; 373:1478-1479October 8, 2015DOI: 10.1056/NEJMc15087333. Bleyer A, Welch HG. Effect of three decades of screening mammography on breast-cancer incidence. N Engl J Med 2012;367:1998–20054. Breast Cancer Mortality After a Diagnosis of Ductal Carcinoma In Situ, Steven A. Narod, MD, FRCPC; Javaid Iqbal, MD; Vasily Giannakeas, MPH; Victoria Sopik, MSc; Ping Sun, PhD, JAMA Oncol. 2015;1(7):888-896. doi:10.1001/jamaoncol.2015.25105. Invasive Breast Cancer Incidence in 2,305,427 Screened Asymptomatic Women: Estimated Long Term Outcomes during Menopause Using a Systematic Review, Cutler W, Bürki R, Kolter J, Chambliss C, Friedmann E, Hart K (2015). PLoS ONE 10(6): e0128895. doi:10.1371/journal.pone.01288956. Risk of marrow neoplasms after adjuvant breast cancer therapy: the national comprehensive cancer network experience,Wolff AC1, Blackford AL2, Visvanathan K2, Rugo HS2, Moy B2, Goldstein LJ2, Stockerl-Goldstein K2, Neumayer L2,Langbaum TS2, Theriault RL2, Hughes ME2, Weeks JC2, Karp JE2J Clin Oncol. 2015 Feb 1;33(4):340-8. doi: 10.1200/JCO.2013.54.6119. Epub 2014 Dec 22.7. Second nonbreast malignancies after conservative surgery and radiation therapy for early-stage breast cancer. Galper S, Gelman R, Recht A, Silver B, Kohli A, Wong JS, Van Buren T, Baldini EH, Harris JR.,Int J Radiat Oncol Biol Phys. 2002 Feb 1;52(2):406-14.8. Risk of Ischemic Heart Disease in Women after Radiotherapy for Breast Cancer, Sarah C. Darby, Ph.D.et al, NEJM March 14, 2013 vol. 368 no. 11 p987-9989. Long-term psychosocial consequences of false-positive screening mammography. Brodersen J, Siersma V.D Ann Fam Med 2013;11:106-11510. National Expenditure For False-Positive Mammograms And Breast Cancer Overdiagnoses Estimated At $4 Billion A Year,Mei-Sing Ong and Kenneth D. Mandl,Health Aff April 2015 34:4576-583; doi:10.1377/hlthaff.2014.108711. Mammography: a contrary view, Bailar JC 3rd, Ann Intern Med. 1976 Jan;84(1):77-84

Current Advances in Cardiovascular Care 2016

Saturday, March 5, 2016The Wyndham Garden Exton Valley Forge815 North Pottstown PikeExton, PA 19341

ACCREDITATION Physicians: The Perelman School of Medicine at the University of Pennsylvania is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. Nurses: The Hospital of the University of Pennsylvania, Department of Nursing Education, Innovation and Professional Development is an approved provider of continuing nursing education by the PA State Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. DESIGNATION OF CREDIT Physicians: The Perelman School of Medicine at the University of Pennsylvania designates this live activity for a maximum of 7.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Nurses: The program will award 7.25 contact hours.

COURSE DIRECTORSTimothy Boyek, MDMian Jan, MDNicholas Vaganos, MDSteven Weiss, MD, MBA

The purpose of this educational activity is to provide information on recent advances in the field of cardiovascular medicine and how they impact the management of patients. The emphasis will be on evidence-based, best practice standards of care and on practical and clinical issues faced on a daily basis by the health care team. This activity has been designed for primary care physicians, interventional cardiologists, clinical cardiologists, cardiac surgeons, vascular surgeons, hospitalists, emergency medicine specialists, interventional radiologists, nurses, technologists and other members of the health care team who want to enhance their knowledge of current advances in the management of patients with heart and vascular disease.

For more information: 215-898-6400 or [email protected] • penncmeonline.com



Feature

Vitamin D ...to Supplement or not to Supplement?

BY ZARSHAWN & MIAN JAN, MD

Although Rickets, Osteomalacia (Figure 1) and other such diseases have been known to mankind for centuries it was not until 1922 that professor McCollum at Johns Hopkins linked the diseases to the new vitamin called Vitamin D. Although the benefits of Vitamin D in rickets and bone health is established, the role of Vitamin D in other maladies in modern medicine is uncertain. This makes Vitamin D one of the most confusing mysteries of medicine despite being around for decades. We are still uncertain of its need, dose, benefits, or side effects and to compound confusion the National Health and Nutrition Examination Survey from 2005 to 2006 revealed 41.6 percent of adult participants had levels below 20 ng/ml indicating deficiency. The situation is worse in many countries of the world (Figure 2); this level of deficiency makes it a very important issue. We in this article intend to give an overview of Vitamin D for health care personnel. We will concentrate more on practical matters based on scientific data rather than anecdotal evidence.

Introduction

“In case of religion we put our faith in Gods, and in nutrition we have vitamins.” Catherine Price in Vitamania

(Figure 1)

(Figure 2)


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Jan & Jan

Chemistry and Homeostasis

Vitamin D is a fat soluble vitamin secosteroid and there are not many foods that contain Vitamin D; fish livers, eggs, cheese, and mushrooms are an exception (Figure 3). Dermal synthesis from ultra violet light is the main source of Vitamin D, and occurs with sun exposure. Vitamin D from diet or dermal synthesis is inactive and requires enzymatic conversion in the liver (Figure 4) to 25-hydroxyvitamin D (25[OH]D) which is a major circulating form of Vitamin D which is then converted in the kidney to 1,25-dihydroxyvitamin D, the active form of Vitamin D. To simplify, circulating Vitamin D3(cholecalciferol) is converted in the liver to calcidiol and then calcidiol is converted in the kidney to calcitriol, the biologically active form. Similarly, circulating Vitamin D2 or ergocalciferol is converted in the liver to 25-hydroxyvitamin D3. It’s Calcitriol which circulates as a hormone and regulates Calcium and Phosphorus metabolism and bone health but also affects the immune and neuromuscular function. Although there are Vitamin D1 through D5 designated, Vitamin D2 and D3 are the important ones. (Figure 3)

Continued on page 14



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(Figure 4)

Serum measurement and requirement The first question is whether universal screening is needed. Many organizations including... • US preventive task force• American Endocrine Society• American Geriatric Society• American Academy of Pediatrics• American College of Gynecology and Obstetrics Do not recommend routine screening for individuals without risk. Routine screening increases the cost which has resulted in the increase in cost of Vitamin D supplements from around $100 million in 2007 to over $700 million in 2013. Our recommendation is to measure it in population at risk.Serum 25-hydroxyvitamin D[25(OH)D] reflects the total supply of Vitamin D from all sources. There is no agreement on what is the optimum level; we have listed recommendations from governing bodies.

• The Institute of Medicine concluded that 20 ng/ml is the top end requirement in 97.5% of the population. To add to the confusion, the rest of the world uses nmol/L, rather than ng/ml. The Institute of Medicine also suggests that most individuals do not need more than 600 to 800 IU of Vitamin D per day.

• The American Endocrine Society agrees with the Institute of Medicine for the general population but recommends 30 ng/ml and not 20 ng/ml for at risk populations like older adults, pregnant women, and dark skinned individuals. They also recommend the daily dose in such populations to 1000 to 2000 IU per day. Many labs report deficiency of Vitamin D on their interpretation of the literature. Moreover, different labs use different assays and sensitivity and specificity varies significantly and there is no consensus standard.

We have listed the Institute of Medicine’s guidelines in Figures 5 and 6.

(Figure 5) Age group RDA (IU/day)Infants 0–6 months 400*Infants 6–12 months 400*1–70 years 600 (15 μg/day)71+ years 800 (20 μg/day)Pregnant/lactating 600 (15 μg/day)

(Figure 6)Age group Tolerable upper intake levelInfants 0–6 months 1,000 IU/day (25 μg/day)Infants 6–12 months 1,500 IU/day (37.5 μg/day)1–3 years 2,500 IU/day (62.5 μg/day)4–8 years 3,000 IU/day (75 μg/day)9+ years 4,000 IU/day (100 μg/day)Pregnant/lactating 4,000 IU/day[7]:5(100 μg/day)

Our recommendation would be not to exceed the upper number on the recommendations and monitor levels if needed. One should also be concerned over supplementation and toxicity. Doses over 20000IU may be excessive and cause toxicity and hypercalcemia resulting in thirst, increased urination, vomiting, weakness, and insomnia, and if untreated, calcium deposits in various organs with consequences.

Benefits

We have left the most controversial discussion for last and will try to go over each potential benefit and evidence available. Unfortunately, most of the evidence is either anecdotal, observational or retrospective. There are very few double blind randomized trials available. The lack of evidence does not eliminate the potential advantages but also does not point towards benefits.

• Bone HealthThere is very little doubt about the benefits of Vitamin D for bone health, calcium metabolism and prevention of fractures and osteoporosis. In 3rd World countries it is a cure for rickets and osteomalacia. We have already established the dose required in the general population and in those at risk.

• Mortality There was one meta analysis that showed mortality benefits in elderly but another that showed no clear justification for supplements so the jury is still out.


Jan & Jan

Zarshawn Jan is a medical student at Drexel Medical School; he wrote this article under the guidance of Mian A Jan, MD, an interventional cardiologist practicing in Chester County.

• CancerTwo epidemiological studies at the Dana Farber Cancer Institute Center showed benefits in colorectal cancer. The first study showed in metastatic colorectal cancer that those with the highest plasma levels of Vitamin D decreased their risk of dying and lived 33 percent longer than those with the lowest levels. Kimmie Ng, one of the researchers, concluded some association with the delayed progression of the cancer. A second study suggested Vitamin D boosted auto-immune systems and thus anti-cancer effect. Epidemiological studies by Cedric Garland have also shown some benefit in breast cancer. The data and evidence still does not meet the high bar.

• Cardiovascular Disease A large observational study of 247,574 subjects, from Denmark, revealed low and high levels of 25(OH)D were associated with cardiovascular disease, stroke, and acute myocardial mortality in a nonlinear, reverse J-shaped manner, with the highest risk at lower levels. A 25(OH)D level of 70 nmol/L was associated with lowest cardiovascular mortality. Whether this was a causal or associational finding was not able to be determined. At this time there is no robust meaningful data available to prove the benefits of Vitamin D on cardiovascular health. There is a need for randomized clinical trials to confirm cardiac benefits.

• DepressionAgain, there is no clear evidence to support the benefits. Some subgroup analysis and less than adequate studies have shown benefits but the evidence bar remains low.

• Cognition and DementiaAlthough review of studies has shown an association between Vitamin D levels with Dementia and Alzheimer’s disease, causal relationship has not been established. These individuals were not maintaining multiple aspects of their nutrition and health.

• Immune systemDeficiency has been linked to increased infections including tuberculosis and influenza but beneficial effects of supplementation have not been established.

• PregnancyLow levels of Vitamin D are associated with preeclampsia, premature infants, and diabetes but benefits of supplementation have not been proven.

• Chronic Kidney DiseaseMeta analysis of twenty-two studies, seventeen observational, and five randomized control trials, suggests Vitamin D supplementation improved biochemical endpoints but whether such improvements translate into clinically significant outcomes is yet to be determined.

Summary From our discussion one can see that there are associations between the deficiency in Vitamin D and disease states, but proof of benefit of supplementation, except for a few instances, requires further data and research. At this time regulatory agencies are only allowing manufacturers the following health claims...

• The US Food and Drug Administrationo May reduce osteoporosis

• European Food Safety Authorityo Normal function of immune systemo Normal inflammatory responseo Normal muscle functiono Reduced risk of falls in people over age 60 years

There is a very large 26000-person study spearheaded by Professor JoAnn Manson called VITAL in progress which will not only assess benefits of taking 2,000IU of Vitamin D3 on cancer, heart attacks, and strokes but also effects on depression, diabetes, cognitive decline, and other health ailments. Until we have sufficient data, our recommendation is a combination of healthy diet with adequate Vitamin D intake along with an exercise program, with screening limited to individuals at risk. We must not let our enthusiasm outpace the available evidence.

As Vitamin D is fat-soluble, individuals with fat malabsorption issues or those who have had intestinal or bariatric surgery are often unable to absorb oral forms of Vitamin D. A new patented delivery system trademarked TransEpi® technology has been developed to deliver Vitamin D3 into the skin to avoid intestinal absorption. The patchless technology mimics the natural solar process of Vitamin D in the skin without needing UV exposure from the sun. TransEpi® technology was presented at the International Endocrine Society and has demonstrated 40-50% increases in Vitamin D levels in individuals with low Vitamin D.



Feature

Luis is a tall, beefy 12 year old with spiky brown hair and clear brown eyes.* His school attendance is spotty due to frequent bouts of asthma. His mother lives in fear of the kind of acute attack that would necessitate a rush to the ER, saddling her with an enormous bill she could never pay. If Luis had health insurance like his documented asthmatic baby sister, he’d have a maintenance inhaler on hand that he could use regularly to prevent an emergency – but it’s been months since his mother filled that prescription. Although she works six days a week from 6 am to 2 pm in the kitchen of a diner, it’s often a struggle just to pay the rent, let alone buy medication. The best she can offer Luis is an occasional nebulizer treatment using his sister’s medication. Hers is covered by insurance because she’s an American citizen. School used to be a refuge for Luis. That was before a gym teacher publicly humiliated him before practice by announcing he could no longer play on the basketball or football squad because he didn’t have health insurance. After that the bullying started—taunts, name-calling, threats on the way to school, beatings in the bathroom where there are no cameras—all because the kids say he is a Mexican, not a real American. Bullying turns its victims into bullies and Luis has begun to live out that prophecy. His grades have plummeted and he has angry outbursts in the classroom. “Luis is very depressed. He needs help,” his mother says desperately. She managed to find a counseling center that would treat him on a sliding scale and tried three times to make an appointment, only to be told repeatedly that there were no openings. With insurance there would have been alternative choices.

Have you cared for a child like Luis or tried to help a child without insurance secure critical follow up care without success? It’s a plight that unfortunately many of us have faced. There are an estimated 1,000 Chester County children who are undocumented and uninsured and an estimated 24,000 children statewide. They do not qualify for CHIP or Medicaid (with limited exceptions for Emergency Medicaid) or ACA Marketplace coverage. As a nurse, I worked in a federally qualified health center for nearly a decade, so I had the good fortune of being able to provide care to every child and adult who walked through our doors regardless of their citizenship status. But if a child who was undocumented and uninsured needed an x-ray, physical therapy or a dermatologist, I had no place to refer her for affordable care. We can’t afford NOT to cover all children. At CHOP alone, they spend $4,600 per child in uncompensated care, yet CHIP coverage costs just half of that amount – about $2,500. PA is losing its national standing for children. While we are the birthplace of CHIP, we are still not among the five states and District of Columbia that cover all kids. But we have the ability to change that. Because of an ACA requirement, starting last October, the federal government is paying 89% of the state’s CHIP costs – up from 66% previously. This provides an extra $591 per child per year or a total of $92 million more available for the 150,000 kids PA anticipates enrolling in CHIP this year. Federal funds cannot be used to pay for undocumented kids’ coverage, so the state could use a portion of the savings and expand CHIP to cover ALL kids. Based on other states’ experience, PCCY estimates that about 25% of the newly eligible children would enroll in year one at a cost of about $15.4 million for the first year – which is less than 1/20th of 1% of the state budget.














BY COLLEEN MCCAULEY, RN, BSN, MPH


W I N T E R 2 0 1 6

Public Citizens for Children and Youth (PCCY) interviewed 53 parents across southeastern PA, 10 of them Chester County parents, to better understand the health and financial impact of having a child who is undocumented and uninsured. Here are our findings:

It’s important to remember that these families contribute to public coffers. In fact, undocumented immigrants pay sales, wage and other taxes, contributing to revenues that back public health care programs. A 2007 Congressional Budget Office study found that 75% of undocumented immigrants had taxes withheld from their paychecks, filed individual tax returns or both. In PA, undocumented immigrants paid an estimated $135 million in combined income, property and sales taxes in 2010 but are ineligible to receive most services. Public support is building for efforts to help cover PA children who cannot receive the health care that they so badly need and deserve. PCCY created the “Dream Care” initiative with a 41 member strong “Dream Care Coalition” working towards expanding CHIP for all PA children. Visit www.pccy.org/fulfillingthepromise for coalition members, to join the coalition, for our report and much more information. *Luis is not his real name. His family lives in Chester County.

Colleen McCauley, RN, BSN, MPH, is Health Policy Director at Public Citizens for Children and Youth.














McCauley


The Art of Chester County

BY BRUCE A. COLLEY, DO

Chester County is of course known for its home grown, “Brandywine School of Art,” from George Cope, Howard Pyle, and the Wyeths to Jamison,

Bollinger, Sculthorpe and the many other home grown artists such as those already featured in our journal. Chester County has also become the adopted home of many artists, some who seek it, and are attracted by the vigorous and dynamic art community here. Others artists arrive by serendipity, such as Sandra Sabin Luciano who moved to Chester County about 25 years ago. Sandra has been creating art from the age of two when she would hide behind the living room furniture and produce masterpieces of crayons scribble and stick figures on the wall. Fortunately, that encouraged Sandy’s parents to purchase her some art supplies along with cleaning supplies. Growing up amidst the coal miners in the small upstate Pennsylvania town of Shamokin, it offered very little in artistic exposure and advantages. Sandra first attended Bloomsburg State College for two years studying Art Education, which opened the door of possibilities in the world of art for her. Sandra then transferred to the Moore College of Art. After testing the waters of fashion design and fashion illustration she finally chose illustration as her major, which we find intimations of in most of her work. Sandy lives in Downingtown with her husband Tim (also an accomplished artist) and daughter Quinn. Living in Chester County has offered opportunities and inspired Sandy in many expressions of creativity. Sandra is accomplished in many mediums as demonstrated in this sampling. Along with painting, drawing and photography, Sandy has created wedding and special occasion flowers along with gift baskets. She has also designed and sewn numerous wedding and bridesmaids gowns, and costumes for the Diane Matthews School of Dance Arts depicting the plight of slaves and the Underground Railroad in Chester County. I invite you to admire and enjoy these few works of art by Sandra that we are lucky to be able to share with our readers.

Bruce A. Colley, DO, is vice president of the Chester County Medical Society.

Chester County


The Art of

Holiday Party Watercolor and colored pencil on illustration board. 20”x 26”. This is a self-portrait of my husband and me celebrating the holiday season. I tend to be drawn to details and people-oriented art.

Winter Sunset Acrylic on canvas. 24” x 36”.A few years ago, I took an acrylic painting class at the Chester County Night School. My goal was to break away from the structure detail I had been drawn to. I found creating abstract art to be the perfect way to free myself from the mental confines I placed upon myself.


Colley

W I N T E R 2 0 1 6

Tiger Oil on canvas. 4ft high x 8 ft wide. A few years ago, my in-laws found this picture of a tiger in a magazine and asked me to paint it to fit a designated space following the roofline of the ceiling in their family room. Soon after completing the art, they moved to another house and brought the painting along. The canvas with squared-off at the top and re-mounted on their living room wall. The angled sides still depict the original roofline. Although not an original painting of mine, it was done with love for two of the most inspirational and wonderful people in the world.

Holiday Card Computer generated. Adobe Illustrator and Photoshop.These were created for the company where I worked as a graphic artist.

Day and Night Acrylic with modeling paste on canvases. 11” x 14” each. This was simply an attempt to cover a few mistakes and brush strokes that eventually took on a life of its own.

Wine with Grapes Acrylic on canvas. 16” x 20”.This painting was a product of the acrylic painting class that I attended. Though it’s a little more detailed than abstract painting, it was still an exercise in self-control from overworking the painting.

Faerie Bride Acrylic on canvas. 16” x 20”.I always dream I can fly and the best way to have wings would be to become a faerie. With my love of whimsical illustration, this is my most recent piece. I also like to give paintings of faeries as gifts for baby girls to those near and dear to my heart.


Healthcare providers are charged with protecting a patient’s right to privacy when disclosing protected health information (PHI), but how is that

accomplished when the provider is faced with responding to a federal subpoena for medical records without a patient authorization? The answer is simple if the provider understands its obligations and liabilities under the law and exercises due diligence when answering such legal requests.

Where Does the Subpoena Power Come From?

Subpoenas are routinely used by attorneys to obtain medical records from third parties for a variety of civil lawsuits; from personal injury to employment law to medical malpractice claims. The subpoena power comes from Rule 45 of the Federal Rules of Civil Procedure. Rule 45 allows a subpoena to command a provider to give oral testimony for deposition or trial purposes (known as a subpoena ad testificandum), command the production or inspection of documents and information (known as a subpoena duces tecum), or both. In

the alternative, a subpoena may command the production or inspection of documents by a specified date in lieu of providing oral testimony. This article only addresses third party subpoenas for the production of documents. If you are subpoenaed to provide oral testimony or if you are subpoenaed as a party to a lawsuit you should immediately contact an attorney. Rule 45 requires a subpoena to specify the documents sought, the name of the issuing court, the title of the lawsuit and the civil action number, and the time and place for production or inspection of documents. Before the subpoena can be served on a provider, the issuing attorney is obligated to provide advance notice of the subpoena to all other parties to the lawsuit. The purpose of this rule is to allow time for the parties to work out any objections regarding the validity or scope of the subpoena. Once a subpoena is served on a provider, the provider is required to produce the requested medial records on the specified date. However, the provider must be aware of its requirements under HIPAA since automatic compliance with a subpoena may constitute an unlawful disclosure of protected health information (PHI), placing the provider at risk for hefty fines and litigation.

The Interplay Between HIPAA and Subpoenas

The disclosure of PHI without a written authorization from the patient is generally prohibited under HIPAA, with a few limited exceptions. One of those exceptions applies to the disclosure of PHI pursuant to a valid subpoena. Specifically, HIPAA permits disclosure in response to a subpoena if one of the following conditions is satisfied:

1. The provider must receive a written statement and accompanying documentation from the attorney issuing the subpoena demonstrating that:

a. A good faith attempt was made to provide written notice of the subpoena to the patient or his or her attorney;

b. The written notice included sufficient information to allow the patient to raise an objection to the subpoena;

c. The time for objecting to the subpoena has passed; and

d. The patient did not object to the subpoena or that any objections by the patient were adequately resolved by the court.


a. All parties to the lawsuit have agreed to a qualified protective order and have presented it to the court or that the attorney issuing the subpoena has filed for a protective order. A qualified protective order limits the use of the requested PHI to the lawsuit and requires the PHI to be returned or destroyed when the lawsuit ends.

3. The provider makes reasonable efforts to provide notice of the subpoena to the patient and the patient does not make any objections to the release of his or her PHI.

4. The provider obtains a signed HIPAA authorization from the patient for the release of the subpoenaed medical records.


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Due Diligence is Essential When Responding to Subpoenas for PHI

BY SHEBA E. VINE, ESQ.


W I N T E R 2 0 1 6

Vine

The Interplay Between HIPAA and Subpoenas

The disclosure of PHI without a written authorization from the patient is generally prohibited under HIPAA, with a few limited exceptions. One of those exceptions applies to the disclosure of PHI pursuant to a valid subpoena. Specifically, HIPAA permits disclosure in response to a subpoena if one of the following conditions is satisfied:


a. A good faith attempt was made to provide written notice of the subpoena to the patient or his or her attorney;

b. The written notice included sufficient information to allow the patient to raise an objection to the subpoena;

c. The time for objecting to the subpoena has passed; and

d. The patient did not object to the subpoena or that any objections by the patient were adequately resolved by the court.


a. All parties to the lawsuit have agreed to a qualified protective order and have presented it to the court or that the attorney issuing the subpoena has filed for a protective order. A qualified protective order limits the use of the requested PHI to the lawsuit and requires the PHI to be returned or destroyed when the lawsuit ends.

3. The provider makes reasonable efforts to provide notice of the subpoena to the patient and the patient does not make any objections to the release of his or her PHI.

4. The provider obtains a signed HIPAA authorization from the patient for the release of the subpoenaed medical records.

These conditions can be found in Title 45 of the Code of Federal Regulations, Section 164.512(c)(1)(ii), (e)(1)(iii)-(vi). Accordingly, a provider must take specific measures to protect a patient’s right to privacy when responding to subpoenas for medical records. Upon receiving a subpoena, a provider should:

1. Immediately calendar the date on which the documents must be produced or inspected;

2. If the amount of time to respond is not adequate then request an extension of time from the issuing attorney, making sure to document the request and approval in writing for your records;

3. Evaluate the subpoena against the HIPAA required documentation. If the information contained in the subpoena does not meet one of the listed HIPAA conditions then it is incumbent upon the provider to obtain the necessary written documentation from the issuing attorney in a timely manner. In the alternative, the provider may contact the patient directly to obtain authorization.

4. The subpoena, accompanying documentation, and any written correspondences between the provider and the issuing attorney should be retained in case of an investigation or audit.

Once a provider obtains the necessary written assurances, it must release the medical records on the date specified in the subpoena. In the event that the issuing attorney cannot produce the necessary documentation or if the patient does not allow the provider to make the disclosure then the provider is simply not authorized to disclose the subpoenaed medical records. In this case, the provider should immediately contact an attorney, as it will need to object to the subpoena in writing, detailing the reasons for its objections, including the documentation needed to comply with HIPAA. In addition to HIPAA, providers must be aware of and comply with their respective federal and state laws that provide heightened confidentiality for certain types of medical records before making any disclosures. For example, Title 42 of the Code of Federal Regulations § Part 2 limits the disclosure of drug and alcohol treatment records. And certain state laws may limit the disclosure of records relating to HIV/AIDS records, mental health records and other sensitive records. Accordingly, a careful review of the medical records must be conducted to redact any such sensitive information prior to disclosure.

Continued on page 22


BY SHEBA E. VINE, ESQ.

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Don’t Confuse a Subpoena with a Court Order

Despite its legal language, a subpoena signed by an attorney or a court clerk differs from a court order or subpoena that is signed by a judicial officer such as a judge or magistrate. The distinction is important because of the exceptions carved out by HIPAA. If a provider receives a court order or subpoena signed by a judge or magistrate, a court-ordered warrant, or grand jury subpoena, it must disclose the requested documents. Of course the provider must pay careful attention not to disclose more than what is expressly authorized by the document to maintain compliance with HIPAA.

Steps to Mitigate a Provider’s Risk

In order to minimize the risk of unlawful disclosures and to foster a culture of compliance a provider should have policies and procedures in place that address disclosures pursuant to a subpoena. In addition, employees that are responsible for handling and responding to subpoenas must be trained on such policies and procedures. Protecting your reputation as a provider by mitigating the risk of a government investigation initiated by a patient complaint that alleges his or her PHI was improperly disclosed

is avoidable by having the proper policies and procedures in place, and ensuring they are followed.

This article does not address subpoenas issued by state courts. And to the extent state law is more restrictive than HIPAA, state law controls, which may require additional steps to be taken before disclosing such information.

Sheba E. Vine is the Senior Director of Regulatory Compliance at First Healthcare Compliance (www.1sthcc.com). In this role, Ms. Vine serves as an expert and resource for clients concerning regulatory compliance. Prior to joining First Healthcare Compliance, Ms. Vine was an attorney in private practice in the areas of litigation and employment law. Ms. Vine also held positions in the medical device industry with Hoffman La-Roche and Siemens. Ms. Vine received her Juris Doctorate from Widener University School of Law and her Bachelor of Science in Biomedical Engineering from Drexel University.

First Healthcare Compliance offers a comprehensive “turnkey” compliance program management solution to healthcare providers and others involved in managing healthcare compliance. The company also provides compliance management resources and CME online compliance courses. Find out more at www.1sthcc.com or

888.54.FIRST or [email protected].


Feature Vine

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o Primary Care Physician Volunteers Needed! The Clinic is in need of Volunteer Primary (Family Practice or Internal Medicine) physicians to provide direct care to our patients at our medical facility in Phoenixville, PA. Licensed and Board Certified or Board Eligible required. We are looking for a time commitment of one-half day (3 hours) on a weekly basis, with room for flexibility. Volunteers are needed for Monday afternoons (1:00 p.m. to 4:00 p.m.) and morning and afternoon shifts on Tuesdays and Thurs-days (9:00 a.m. to 12:00 p.m. and 1:00 p.m. to 4:00 p.m.).

The Clinic’s Mission The Clinic provides quality health care to the uninsured, in an atmosphere which fosters dignity and respect for our patients. It is our privilege to do so. Our Services The Clinic is a community-based, non-profit organization that provides free quality medical care to our patients, including diagnosis, treatment, laboratory tests, medications, and follow-up care. We provide all of the types of care that a busy family physician’s office would offer including specialty services at no cost to people in the geographical area that surrounds Phoenixville, PA.

Interested Volunteers . . . For more information, please email George Spyropoulos, DO at [email protected] or call our Volunteer Coordinator at 610-935-1134 ext. 33.

143 Church Street, Phoenixville, PA 19460 610-935-1134

PRIMARY CARE PHYSICIAN VOLUNTEERS NEEDED!

24

BY JOHN P. MAHER, MD, MPH



Feature

Most Americans living today, including some physicians, have little or no idea about the global size, scope, and impact of tuberculosis.

Tuberculosis (TB) is one of the world’s deadliest diseases. It currently infects one third of the world’s population: over 9 million new cases a year, and is a leading killer (est. 1.7 million deaths globally a year) especially of people who are co-infected with the human immune-deficiency virus (HIV), and in the developing nations. TB is an ancient enemy, with evidence of the infection having been found in pre-historic skeletal remains and in Egyptian mummies. The causative organism was not known, however, until Koch identified it in 1882. And the first drug treatment wasn’t available until 1946 (streptomycin). Still, even before the advent of effective antimicrobials, public health data graphs showed an ongoing decline in the incidence of TB in the US for many years, presumably due to the better hygiene, housing, nutrition and general medical care here. Consequently, many people concluded that TB was no longer a threat to concern Americans, and the US CDC had actually prepared a national plan for the eradication of TB in the US by the year 2000. Such optimism, however, fell victim to real world events, as the new disease HIV/AIDS affected both the incidence, morbidity and mortality of TB while, at the same time, the speed of international travel, military deployments, refugee movements, and immigration (both legal and illegal) made

shambles of international borders. In developed countries such as the United States, we are all accustomed to be aware of those diseases of modern life which account for most of society’s morbidity and mortality: cardio- and cerebro-vascular disease, common forms of cancer (lung, colo-rectal, breast, prostate, etc.), drugs (including tobacco) and alcohol abuse. However, most Americans have but a dim recollection that TB was one of the major killers back in the early 20th century. Nor do Americans remember “The White Plague.” consumption, sanatoriums, Christmas Seal campaigns, infectious disease hospitals with whole buildings specified for the isolation of TB patients, pneumonectomies, throracoplasties, fines for spitting on sidewalks or in the subway, and immigrants sent back to their homelands from Ellis Island because of TB, etc. Now, in the second decade of the 21st century, we must be aware that “out of sight, must no longer be out of mind.” TB is still with us! Despite the comforting knowledge that reported TB cases continue to “trend downward,” it is essential for every clinician to “Think TB” since if you don’t think about the diagnosis you may very well miss it. This is true when confronted with new (or even old) patients whose signs and symptoms could conceivably be due to the Mycobacterium tuberculosis.

TB: The “White Plague” is Still With Us


W I N T E R 2 0 1 6

Maher

Table I. High Risk Patient Categories

** Close contacts (of all ages, especially very young children) with known or suspect active cases; ** Patients with HIV/AIDS; ** Injecting drug users or users of other illicit drugs; ** Patients with other medical risk factors, diabetes, any immune suppressive condition; ** Residents and employees of risk institutions (correctional, mental, nursing homes, long-term care, homeless shelters, etc.); ** Health care workers serving high risk clients; ** Foreign born persons from high risk countries, especially within 5 years of arrival; ** Other high risk groups as determined by local health authorities.

In 2006, the WHO reported an estimated 9.15 million new cases worldwide 95% occurring in developing countries. The highest rates per capita are in Africa, especially eastern and sub-Saharan Africa; but the highest numbers of cases are in Asia (nearly 60% of all cases). By the early 1990s, over 25,000 new cases of TB were reported in the US. At that time, the case rate for US-born persons was 7.4/100,000 population, but the rate for foreign-born persons was nearly 5 times higher, at 34 to 38/100,000 population. Twenty years later, in 2012, the comparable respective rates were 1.2 (US-born) versus 15.9/100,000 (foreign- born)! A year later (2013) some (politically motivated?) officials were advertising that the numbers and rates of TB had declined by 1.2 to 2.2%, but to the experienced phthisiologist those changes did not appear statistically significant and may have simply represented the annual variations in reported numbers — time will tell. Meanwhile, foreign-born case rates remain about 15 times that of US-born rates, and account for two-thirds (66%) of reported TB cases in the US in 2014. Of further concern, there were 555 TB deaths in the US in 2013 (the most recent year TB mortality data were available). That was a worrisome 8% increase over the 510 TB deaths reported in 2012. Despite this, the longer trend was more positive, showing that TB deaths have declined 67% since 1992 — a tribute to the public health system’s activism as well as the diagnostic and therapeutic acumen of those physicians and clinic staff who actually wind up caring for patients with TB disease and prophylaxing those screened persons found to have latent TB infections (LTBI cases). The effectiveness of our TB control programs here in the US is particularly dependent upon strong efforts to prevent

actual TB disease by screening, early identification, treatment of open cases and prophylaxis of LTBI patients according to the CDC/ALA/WHO current guidelines, rather than having them go untreated and eventually have a higher risk of developing clinical tuberculosis. It is important, then, for all concerned to be aware of those nations which have the highest risk of TB (Mexico, Philippines, India, Vietnam, China, Africa, et al.). In Chester County the TB rate is a bit less than half that of the state. However, at last look by this author, the Chester County Health Department’s Chest Clinic records showed patients from all socio-economic levels, from 13 different countries, and from five continents. A handful of these patients had extra-pulmonary (cervical, axillary, bone) &/or resistant TB, requiring long term, expensive, infusion therapy with third line drugs, — a clear indication that the world has gotten much smaller, that TB is always with us, and that every physician must stay up-to-date about TB.

Table II. Important Take-away Points 1. All TB-related diagnoses (latent as well as active cases) should be reported to the Health Department. Whenever possible, sputum should be obtained for microscopy, culture and sensitivity testing.2. Two of the highest priorities must be (a) the prompt and proper treatment of contagious open cases, and (b) appropriate contact tracing, screening and preventive treatment to stop transmission. Lab and radiology facilities should be accessible.3. Learn and follow the CDC/ALA-ATS (American Lung Association- American Thoracic Society) current criteria for screening, diagnosis and treatment of either type and stage, as well as for pregnant, lactating or other complicated situations. Visit http://www,cdc.gov/ 4. Drug resistance tends to develop: (a) when patients do not complete the full course of treatment; (b) physicians prescribe the wrong treatment, wrong dosages, or wrong duration of time for treatment; (c) when the supply of drugs is not always available; (d) when the drugs are of poor quality; (e) when patients develop TB disease again after past treatment for TB disease; (f ) when patients come from nations where drug-resistant TB is common; (g) when patients spend time with someone known to have resistant TB.


Fighting Opioid Abuse in Pennsylvania

To help prescribers combat this problem, PAMED, in collaboration with the Pennsylvania Department of Health and 11 other health care associations, is

creating a comprehensive online educational resource for prescribers. “Addressing Pennsylvania’s Opioid Crisis: What Health Care Teams Need to Know” is a four-part course that examines all the tools prescribers can use to identify patients with addiction issues and get them help. The first session of the course addresses how prescribers can use the statewide voluntary opioid prescribing guidelines, and the second session takes a deeper dive into the state’s naloxone law. Both are available at www.pamedsoc.org/opioidresources. Upcoming sessions (Parts 3 and 4) will address the controlled substances database and the warm hand-off. This educational series features: • Videos and interviews with physicians, other prescribers, and state officials working on the front lines of the crisis • The latest statistics and data • Details on how to use opioid prescribing guidelines for physicians, emergency departments, and other providers • Scenario-based learning to help implement the lessons into daily practice


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INTRODUCING PAMED’S INNOVATIVE EDUCATIONAL SERIES AND OTHER

RESOURCES HEALTH CARE TEAMS CAN USE TO ADDRESS THE OPIOID CRISIS

THE PROBLEM: Opioid abuse, misuse,

and overdoses are increasing, both in

Pennsylvania and nationally.

While some requests for pain

medication are legitimate, others are

likely to be from pill scammers who

have become addicted to opioids.

THE SOLUTION: A multi-pronged

approach that includes physicians,

patients, and health care organizations

like the Pennsylvania Medical Society

(PAMED) working collaboratively to

address this growing epidemic.


This crisis spans nearly every state in the U.S., but has hit Pennsylvania particularly hard. Nearly 2,500 deaths were reported in Pennsylvania as a result of drug overdoses in 2014, and more people die from drug overdoses than in car accidents. No one disputes the magnitude of the prescription drug abuse crisis in Pennsylvania and the nation at large. The question is, how do we combat the problem? “I think that we have to understand this is a public health crisis and we all have a role to play in terms of solving this,” said PAMED member and Pennsylvania Physician General Rachel Levine, MD.

“We need to get past the idea that these are somehow just drug abusers that are miscreants and throwaway members of our society,” says Dr. Levine. “The substance use problem and opioid problem touches all of the families in our state and in the country.” PAMED’s education seeks to address the many layers and complexities of the crisis. Learn more and get CME credit by visiting www.pamedsoc.org/opioidresources.

W I N T E R 2 0 1 6

FOUR WAYS TO INCREASE YOUR CONFIDENCE IN MANAGING

OPIOID THERAPY

Familiarize yourself with these state-endorsed, voluntary

guidelines for opioid prescribers in Pennsylvania:

• Guidelines on the Use of Opioids to Treat Chronic

Non-Cancer Pain

• Emergency Department Pain Treatment Guidelines

• Prescribing Guidelines for Dentists

Get involved with grassroots advocacy and initiatives by

having a discussion with the physicians in your county or

region. Call PAMED’s Speakers Bureau at (800) 228-

7823, ext. 2620 for details.

Have a conversation with your chronic pain patients using

PAMED’s Opioid Prescription Checklist to help facilitate

the pain-management discussion.

Access even more PAMED opioid education and receive

patient safety and risk management CME credits. Take

PAMED’s six-part, online course designed to educate

physicians and other health care providers on the

appropriate use of long-acting and extended-release

opioids.

Visit www.pamedsoc.org/opioidresources to access these resources and more.

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PAMED and Chester County Medical Society (CCMS) membership supports you and your community in many ways. Membership in both Societies provides an indispensable resource for information, continuing education, distance learning, professional contact, and networking.

PAMED offers practice management courses and refreshers on patient care. As leadership development is hard to find, PAMED presents webinars, online courses, conferences, and seminars for the benefit of its physician members. PAMED advocacy has an inside track on legislative and executive proposals on need-to-know issues so we can keep members like you fully informed.

CCMS works collaboratively with PAMED, but its focus is on the local Chester County community. Some specific benefits of membership in CCMS include:• An opportunity to sign up for the PAMED “Find a Physician” program to promote your practice• Representation with local legislators• An annual meeting which provides you with the opportunity to impact your Society’s activities and goals• A legislative dinner, known as “The Clam Bake,” where you can meet with local legislators in an informal setting• An automatic subscription to Chester County Medicine magazine, the Society’s new twist on its longtime quarterly publication, and• Access to DocBookMD®, an exclusive HIPAA-secure messaging application for smart phone and tablet devices.

CCMS Membership: Resources You Need

Building

Better

Practices

and Stronger

Communities

One Member

at a Time

For additional information about becoming a PAMED and CCMS member, visit

http://www.pamedsoc.org/membership and click “Join PAMED,”

email [email protected], or call (610) 827-1543.

To renew your current membership, visit http://www.pamedsoc.org/membershipand click “Renew your membership.”

Membership is available only for physicians licensed to practice in Pennsylvania.

APPLICATION___________________________________ County Medical Society(You may choose to be a member of the county in which youeither live or work.)

777 East Park Drive, PO Box 8820, Harrisburg, PA 17105-8820 717-558-7750 (Phone) 717-558-7840 (Fax)

Full Name (Print): ___________________________________________________________________________________Last First Middle

Home Address:________________________________________________________ _________________________Area Code & Phone Number

Office Address:________________________________________________________ _________________________Area Code & Phone Number

Email Address: ____________________________________________ Office Fax _________________________Area Code & Phone Number

For mailing, please use: Office Address Home Address Preferred Communication: Email Fax Mail

BIOGRAPHICAL DATA

Gender: Male Female Date of Birth: ____________ Spouse’s Name:

EDUCATION INSTITUTION LOCATION DEGREE BEGIN DATE END DATE

Medical -

FOR RESIDENCY & FELLOWSHIP, YOU MUST GIVE ACTUAL OR PROJECTED ENDING MONTH & YEARBEGIN DATE END DATE

Residency__________________________________________________________________ __________ -_________Fellowships_________________________________________________________________ __________ -_________License: PA No. Date Issued

PROFESSIONAL DATAPresent Type of Practice (Check Appropriately): Owner of Physician Practice Group Name ___________________________________________________ Employed by Hospital/Health System Employed by Physician(s) Group Name ___________________________________________________ Employed by Industry or Government Independent Contractor Other (specify) _________________________________________________

Specialty:

Within the last 5 years, have you been convicted of a felony crime or is your license to practice medicine actively suspended or revoked? If yes, please provide full information._________________________________________________________________________________________________________________________________________________________________________________

Yes No

DATE SIGNATURE

RETURN TO: Pennsylvania Medical SocietyATTENTION: Member Services

QUESTIONS? Call (800) 228-7823

FAX: 717-558-7840MAIL: 777 East Park Drive

PO Box 8820Harrisburg, PA 17105-8820


W I N T E R 2 0 1 6

Feature

CCMS Annual Clam Bake

50 yrs of service recipient Heidar Jahromi, MD and Zahra Jahromi

Father of Rep Becky Corbin, Michael Corbin, Rep Becky Corbin and Ambereen Jan, MD

Sen Andy Dinniman, Mian A Jan, MD

District Attorney Thomas Hogan, Representative Becky Corbin, Mian A Jan, MD, Commissioner Michelle Kichline and Commissioner Terence Farrell

Audience with Bruce Colley, DO, David Bobman, MD, Kevin Sowti, MD and Kamron Salavitabar

Sen Andy Dinniman, Mian A Jan, MD, Kevin Sowti, MD

Commissioner Terence Farrell, Representative Dan Truitt, Mian A Jan, MD

Ambereen Jan, MD, Zahra Jahromi, wife of one of the 50 yr recipients Dr Heidar Jahromi

Mahmoud Effat, MD, Winslow Murdoch, MD and Marina Makous, MD

Audience Rep Warren Kampf

The 2015 Clam Bake was a great success but we did not have space for photographs of many guests, so we are publishing them in this issue of the Chester County Medical Society Medicine.


Frontline GroupsFrontline Groups with 100 percent membership in CCMS

are the backbone of the society. We are thankful for their

total commitment to CCMS. This list reflects the Frontline

Groups as of March 1, 2016.

Members in the News

To publish photos ofnew CCMS member physicians, please submit digital copies to

[email protected].

We would like your help in touting the accomplishments of Chester County physicians. If you receive an award

or certification or have other good news to share, please submit it to [email protected].

Cardiology Consultants of Phila - West Chester

Medical Inpatient Care Associates

Cardiology Consultants of Phila-Paoli

West Chester GI Associates PC

Chester County Eye Care Associates PC

Devon Family Practice LLP

Gateway Myers Squire & Limpert

Clinical Renal Associates-Exton

Gateway Internal Medicine Of West Chester

Academic Urology-West Chester

Cardiology Consultants of Phila-Main Line

Gateway Endocrinology Associates

Gateway Medical Colonial Family Practice

Main Line Dermatology

Chester County Otolaryngology & Allergy Associates

Great Valley Medical Associates PC

Brandywine Gastroenterology Assoc Ltd

Family Practice Associates of West Grove

Gateway Family Practice Downingtown

Levin Luminais Chronister Eye Assoc

Village Family Medicine

Membership News & Announcements


Chester County Medical Society Board Meeting

Date: Tuesday, March 1, 2016, 5:30 PM

Location: Chester County Hospital


Date: Tuesday, May 3, 2016, 5:30 PM



Date: Tuesday, September 6, 2016, 5:30 PM



Date: Tuesday, November 1, 2016, 5:30 PM


Ask a Physician: If you have any medical questions for a physician member of the Chester County Medical Society, please submit an inquiry to [email protected] with “Ask a Physician” as the subject. Your question will be forwarded to a physician and may be featured with an answer in a future issue of the magazine.

Important Dates

Sen Andy Dinniman, Mian A Jan, MD

www.westchestergi.com

For more information or toschedule an appointment,

please call610-431-3122

Eva E. Sum, MDDr. Sum joined West Chester Gastrointestinal Group in 2015after practicing in Chester County for 7 years. She is a graduateof the University of Kentucky and University of Louisville Schoolof Medicine, and completed residency training in internal medi-

cine and a fellowship in gas-troenterology and hepatologyat Temple University Hospital.She is board certified in gas-troenterology and was recentlynamed a "Top Doc" by MainLine Today Magazine. Dr. Sum'sclinical interests includewomen's gastrointestinal

health, irritable bowel syndrome (IBS), gastroesophageal refluxdisease (GERD), Inflammatory Bowel Disease (Crohn's and Ul-cerative Colitis), Hepatitis, and colon cancer screening.

Top row, left to right:Karen Yoder, PA-CAlex S. Kuryan, MDCarrie N. Miller, MDDavid R. Neiblum, MDMatthew M. Baichi,MDReina P Bender, MDAshish Chawla, MDLinda Camlin, NP

SeatedAlbert K Hahm, MDEva E. Sum, MDDavid E. Bobman, MD

Our team of boardcertified gastroen-

terologists is dedicated to workingclosely with you and

your family physicianto individualize your

treatment plan. Theyare committed tocompassion and

understanding eachpatient’s needs.

Welcomes Our New Doctor

Fern Hill Medical CampusBuilding B, Suite 300, 915 Old Fern Hill Road WestChester, PA 19380

Kennett Square Office127 W. Street Road, Bldg 100, Suite 102Kennett Square, PA 19348

Penn Medicine Southern Chester County455 Woodview Road, Suite 215West Grove, PA 19390

ExtonThe Commons at Oaklands736 West Lincoln HighwayExton, PA 19341

March is Colon Cancer Awareness MonthGet Screened!

chester county medicine | winter 2016

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