Summer 2019 (July-September)

FP MISSOURI FAMILY PHYSICIAN SUMMER ISSUE

VOLUME 38, ISSUE 3

D e rm a to l o g y In sig hts o n d ise a ses a n d tre atm e nts

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MISSOURI FAMILY PHYSICIAN SUMMER ISSUE 2019

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FP MISSOURI FAMILY PHYSICIAN

EXECUTIVE COMMISSION

BOARD CHAIR Sarah Cole, DO, FAAFP (St. Louis) PRESIDENT Jamie Ulbrich, MD, FAAFP (Marshall) PRESIDENT-ELECT John Paulson, DO, PhD, FAAFP (Joplin) VICE PRESIDENT John Burroughs, MD (Liberty) SECRETARY/TREASURER Lisa Mayes, DO (Macon)

BOARD OF DIRECTORS DISTRICT 1 DIRECTOR Arihant Jain, MD (Cameron)

ALTERNATE Jared Dirks, MD (Kansas City) DISTRICT 2 DIRECTOR Brooks Beal, DO (Kirksville)

ALTERNATE Vacant DISTRICT 3 DIRECTOR Emily Doucette, MD, FAAFP (St. Louis)

DIRECTOR Kara Mayes, MD (St. Louis)

ALTERNATE Dawn Davis, MD (St. Louis) DISTRICT 4 DIRECTOR Jennifer Scheer, MD, FAAFP (Gerald)

ALTERNATE Kristin Weidle, MD (Washington) DISTRICT 5 DIRECTOR Natalie Long, MD (Columbia)

ALTERNATE Vacant DISTRICT 6 DIRECTOR David Pulliam, DO, FAAFP (Higginsville)

ALTERNATE Carrie Peecher, DO (Marshall) DISTRICT 7 DIRECTOR Wael Mourad, MD, FAAFP (Kansas City)

DIRECTOR Afsheen Patel, MD (Kansas City)

ALTERNATE Beth Rosemergey, DO, FAAFP (Kansas City) DISTRICT 8 DIRECTOR Kurt Bravata, MD (Buffalo)

ALTERNATE Vacant DISTRICT 9 DIRECTOR Patricia Benoist, MD, FAAFP (Houston)

ALTERNATE Vacant DISTRICT 10 DIRECTOR Vicki Roberts, MD, FAAFP (Cape Girardeau)

ALTERNATE Gordon Jones, MD (Sikeston) DIRECTOR AT LARGE Jacob Shepherd, MD (Grain Valley)

RESIDENT DIRECTORS Ann Lottes, MD, SLU Misty Todd, MD, UMC (Alternate)

STUDENT DIRECTORS Mimi Liu, SLU Morgan Dresvyannikov, UMKC (Alternate)

AAFP DELEGATES Todd Shaffer, MD, MBA, FAAFP, Delegate Keith Ratcliff, MD, FAAFP, Alternate Delegate Kate Lichtenberg, DO, MPH, FAAFP, Alternate Delegate Peter Koopman, MD, FAAFP, Alternate Delegate

MAFP STAFF EXECUTIVE DIRECTOR Kathy Pabst, MBA, CAE COMMUNICATIONS & EDUCATION MANAGER Sarah Mengwasser MEMBERSHIP & PROGRAMS COORDINATOR Becki Hughes The information contained in Missouri Family Physician is for informational purposes only. The Missouri Academy of Family Physicians assumes no liability or responsibility for any inaccurate, delayed, or incomplete information, nor for any actions taken in reliance thereon.

The information contained has been provided by the individual/ organization stated. The opinions expressed in each article are the opinions of its author(s) and do not necessarily reflect the opinion of MAFP. Therefore, Missouri Family Physician carries no responsibility for the opinion expressed thereon.

Missouri Academy of Family Physicians, 722 West High Street Jefferson City, MO 65101 p. 573.635.0830 • f. 573.635.0148 Website: mo-afp.org • Email: office@mo-afp.org

CONTENTS 12 DERMATOLOGY: INSIGHTS ON DISEASES AND TREATMENTS

4 2018-19 Annual Board Reports 37 Members in the News 38 Show Me Family Medicine Conference Recap 40 A Celebration of Membership 42 End of 2019 Session Governmental Consultant Report 44 Ulbrich Assumes Helm of MAFP 49 2019 Transition Conference Recap 50 2019 MAFP Family Physician of the Year 52 MAFP Heads to Washington, DC 54 ACLF/NCCL Draws Leadership to KC 55 PRIME Registry: Building the Future of Primary Care 56 Middle School Medical Explorers

MARK YOUR CALENDAR AAFP Congress of Delegates September 23-25, 2019 Philadelphia Marriott Downtown Hotel, Philadelphia, PA

Annual Fall Conference & KSA November 8-10, 2019 Big Cedar Lodge Ridgedale, Missouri

AAFP Family Medicine Experience (FMX) September 25-28, 2019 Philadelphia Marriott Downtown Hotel, Philadelphia, PA MO-AFP.ORG 3

2018-19 Annual Reports Board Chair Report

b Sarah Cole, DO, FAAFP Board Chair

efore my Annual Report, I would like to introduce the focus of this issue: Dermatology can be a complex and challenging topic. During my first year as a teaching physician, I cringed when senior residents said to me, “Hey, Dr. Cole, I have a patient experiencing a weird rash. I don’t know what it is. Can you come look at it?”

There was a good chance that if one of my excellent senior residents didn’t already know what it was, then neither would I! Since then, thank goodness, I’ve developed more confidence in my diagnostic and therapeutic capacity when it comes to skin conditions. I suspect, however, I’m not the only family doctor to ever scratch her own head when looking at someone else’s unusual rash. This issue of the MAFP journal attempts to broaden your own skills in diagnosis and management of skin conditions and is a timely subject as we enter summer months. I appreciate the contributing authors’ energy and expertise.

The staff at MAFP have worked hard at solicitation and layout of the MAFP journals recently. In fact, they’ve "upped" the journal’s appearance and readership to such a degree that MAFP’s education commission and I will be discussing the best ways to “up” it’s content as well. We want to assure the quality and evidence-basis of the journal’s articles moving forward. Many thanks to our members and readers who provide feedback for our state chapter journal. Keep it coming!

Annual Report I thought I knew my state. I thought I knew my specialty. I know both better now.

Many of you know that, upon taking office, I reflected upon the diversity of our membership -- MDs and DOs, graduates of U.S. and international medical schools, students and residents, physicians in direct practice or FQHCs, physicians who are selfemployed, clinic- or hospital-employed, those who work part-time or full-time, in clinical or non-clinical roles, those who are military or veteran, those who serve patients in urban areas, rural areas or both, those who teach the next generations of physicians,

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MISSOURI FAMILY PHYSICIAN SUMMER ISSUE 2019

those who practice a range of traditional clinical skills, and those who focus on a necessary niche -- and then I pledged to visit all 10 MAFP districts to listen to members in their home districts.

After driving 2,011 miles, tuning in for marathon sessions of AFP podcasts, and changing one flat tire on the side of Interstate 44, I did! Along the way, I became a blogger (which still only semiimpresses my kids). Some of you may have followed these reports of my visits in real time on the MAFP website.

In all, I visited 14 clinics and hospitals, meeting with you, hearing about your daily work in clinics, hospitals, nursing homes, labor and delivery units, patient homes, and academic centers. I am indebted to Executive Director, Kathy Pabst, who both facilitated and accompanied these visits, and to the MAFP staff for their ongoing support. Together, we gleaned some common themes from our members.

Here’s what makes you happy during the day: 1) Being a local expert. Some of you are the partner in your practice who does procedures or point of care ultrasound. Some of you are the director of your medical group’s weight loss, wound care, or substance recovery clinic. Others of you maintain inpatient or maternity care privileges.

Whatever clinical niche that brings you passion, feeling supported in your ability to do “it” is what makes you happy.

2) Being a leader. Some of you are CEOs or on the medical boards of hospitals. Others are innovators in practice design. Still others don’t describe themselves as ‘leaders’; though their roles in the community (on school boards, church boards, chambers of commerce or simply as one of only a handful of doctors in a county) make them so inherently.

3) Feeling like you are making a difference in the lives of your patients. Every single one of you had a story about a time a patient’s life improved as a result of some action you were able to take. And every single one of you ended your story with, “and that’s why I went into family medicine”.

Here’s what keeps you awake at night: 1) Wondering who’s going to replace you when you are ready to retire. You have genuine concern for whether the pipeline of students and residents training in family medicine is sufficient and geographically appropriate to the primary care needs in Missouri.

2) Electronic health record. Literally. You’re still working on it when you should be sleeping.

3) Health equity. Some of you referenced Medicaid expansion, others mentioned health outcomes based on zip code, while still others mourned the lack of a prescription drug monitoring program, or closure of critical services in your area.

But all of you expressed concern about your capacity to care for all the patients in your community in an equitable way.

These are my own observations. These aren’t evidence-based or quantified. They are simply my own opinion. I don’t have the answers to these thorny issues in health care today. I do have some initial thoughts: • MAFP continues to be part of a state-wide coalition targeting an increase the primary care workforce in Missouri.

• At AAFP’s chapter leadership forum in April, 2019, MAFP officers learned how artificial intelligence and proposed changes in Centers for Medicare Services may ease some of the burdens associated with EHRs; this gave me hope that policy and product makers are finally responding to physician frustration with EHRs. • We also heard about grassroots efforts in other states to expand Medicaid, and will continue to explore efforts that increase access to health care for Missourians.

If any of these efforts resonate with you, please email MAFP at office@mo-afp.org. We, in turn, will strive to keep you appraised of developments in these areas. I also reported on my district visits to MAFP’s Board of Directors at its June meeting.

Together, we’ll use your feedback to align MAFP’s strategic goals to best support Missouri’s family physicians and the patients they serve.

In closing, I am humbled by the quantity, quality, and variety of the work, volunteerism, advocacy and education my colleagues in family medicine across Missouri perform on a daily basis. I was honored to serve as your MAFP president and wish your incoming president, Dr. Jamie Ulbrich, the very best as he assumes the role.

President Report t has been a privilege to serve the Missouri Academy of Family Physicians as President-Elect.

I am incredibly grateful to the Academy for affording me with the opportunities to attend and participate in so many activities this last year.

My adventure began last summer with our board retreat in Camdenton, Missouri, where, after two days of guided discussions, the board developed a strategic plan for greater advocacy efforts, improving awareness of family physicians, and improving our pipeline to recruit the brightest Missouri students to become Missouri family physicians. A new vision statement was created, and a mission statement reaffirmed. This may sound trivial to some, but realistically, we need clear direction as an academy as to determine where we will focus our efforts over the next several years. Leadership is guided by this vision and mission to know how to efficiently use our resources, both financially and in terms of time and energy.

i

Next, I was able to attend the MAFP Advocacy Day at the capitol in February. The night before, MAFP members met for Advocacy 101 to catch everyone up to speed on the legislative process.

We went to the capitol the next day to promote and educate the governing body of Missouri on the most pressing issues concerning family physicians. It is always interesting to me just how little legislatures know about what we do for a living and how different family practice is compared to other specialties. Specifically, there is a lack of understanding around the differences between our training compared to mid-level providers, pharmacists, physical therapists, athletic trainers, etc. The assumption we make at home, "that everyone understands what we do every day," is not reality when it comes to Jefferson City. If you have never had the opportunity to make the trip to Jefferson City for Advocacy Day, it would be worth it for you both personally and professionally.

I was then able to attend the Multi-State Forum in Dallas, Texas. We heard from Dr. John Cullen,

Jamie Ulbrich, MD, FAAFP President

MO-AFP.ORG 5

AAFP President. He spoke on advocacy efforts at the national level, payment reform with Medicare, and changes that have occurred with the ABFM through direct discussions with the AAFP. Issues of burnout were discussed as well as primary care spend (investment) bills that are starting to be introduced across the country to try to increase payment percentages to primary care as a whole.

This has been shown to improve population health with decreased morbidity and mortality rates.

Shawn Martin from the AAFP also gave a “State of Healthcare” seminar in which he presented a bird’s eye view of the national political scene as best as any one can at this time. One of the most enjoyable aspects of the Multi-State Forum was the ability of the thirteen represented states to present shared successes and failures with each other. As a result, a lot of networking occurred and we all gave and took away something helpful for each of our state chapters.

Finally, this spring, I was able to attend a leadership conference in Kansas City, Missouri.

Topics discussed included how to build a better board, advocacy efforts with primary care spend bills, workforce issues, and leadership development. One of the most interesting topics I heard centered around the relationship that the AAFP has developed with an artificial intelligence company to build a better EHR system to help expand our capabilities and capacities as family physicians.

We just held the Show Me Family Medicine Conference at Lake of the Ozarks. It was a great conference with many educational and networking opportunities.

I would like to take this opportunity to share with you my vision for the MAFP for the upcoming year.

1) I plan to follow the strategic plan laid out by the MAFP last summer. Doing anything else would not be in keeping with what we, as a board, have collectively agreed are our top priorities.

2) Try to continue to strengthen our Board by improving our efficiency to allow us to be more forward-thinking.

3) I want to meet as many physician members as possible this year. Through various means such as social media, blogs, interactive media, emails and phone calls, I want to hear your story and how you feel about various topics.

4) Rural family physician recruitment and retention has been a priority for the AAFP. I heard a lot of discussion at our leadership conference this spring regarding strategies to increase and improve upon this, like payment reform or increasing taxes; in other words, put more money into it. Going forward, I am most interested to see if a simple “small business” design plan in practice formation may be a feasible way to draw physicians to small towns in Missouri. It takes a person who wants to run a small business to go out today and start a practice. I have not heard of or been impressed by the willingness to invest in this venture or the training provided to help achieve this goal.

Again, thank you to the MAFP for helping in my formation in leadership to help forward the strategic plan of this academy. It looks to be an exciting, challenging, and rewarding year.

President - Elect Report

h

ello MAFP members! I am the newest MAFP executive board member and excited to start my four-year term. I have been a part of the MAFP board since 2007 when I was appointed alternate resident board member while attending Cox Family Medicine Residency in Springfield, Missouri.

Currently, I am the Department Chair of Primary Care Medicine at Kansas City University of Medicine and Biosciences (KCUMB) in Joplin, Missouri. I am John Paulson, DO, PhD, FAAFP one of the founding faculty members who opened President-Elect the new extension campus of KCUMB in July 2018.

It is very exciting to be a part of the first new medical school in the state of Missouri in nearly

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MISSOURI FAMILY PHYSICIAN SUMMER ISSUE 2019

50 years. I have practiced in rural Missouri where I practiced in-patient, ICU, ER, and ambulatory medicine including endoscopy. I also practiced in Tulsa, Oklahoma in an ambulatory only practice.

However, most of my career, I have been in Joplin, Missouri where I have practiced ambulatory medicine, served as the Associate Chief Medical Informatics Officer at Freeman Health Systems, and now have returned to pass on my knowledge and experience to the medical students at KCUMB. I am blessed to be loved and supported by my amazing wife, Crissy, and my eight-year-old daughter, Ella.

I had the opportunity to attend the 2019 MultiState Forum held in Dallas last February. Shawn

Martin, from the AAFP presented discussion on the most recent political issues and how the most recent election and changes in the House and Senate seats may alter the political climate over the next few years. About 11 other state chapters came together that weekend to discuss current issues, with a healthy discussion on what’s working and what’s not across the country in our state chapters.

The MAFP continues to advocate for the family physicians in Missouri at the state level by monitoring legislation and providing testimony to support efforts that protect the livelihood and sustainability of family medicine physicians across Missouri. I also had the opportunity to testify in several house and senate hearings in regards to primary care investment, assistant physicians, and radiologic safety issues.

We have been very happy with the hiring of RJ Scherr and Associates as our lobbying group; but we will always be thankful to Pat Strader and her many years of service to the MAFP and family medicine physicians.

The MAFP strives to represent the members of the MAFP both at the state and national level in

all aspects of family medicine. We continue polling our members to make sure that the issues we are advocating for are aligning with the members and their opinions. So, please understand and do your best to respond to the member survey that we send out which determines the MAFP’s position and advocacy focus based on what our members feel is important.

The MAFP Board hired an outside agency to assist us in strategic planning last Summer and I am very excited to share that plan with our members and put it into place. We recognize the need to push ourselves to grow and strengthen this organization and this specialty.

I am proud to be a family medicine physician and I want to foster that feeling in students and practicing physicians alike. It is time to think strategically, communicate persuasively, and act decisively so that family medicine continues to be seen as the most innovative, value-based, compassionate care of all medical specialties.

Secretary/Treasurer Report

t

he last 12 months have been financially secure for the Missouri Academy of Family Physicians. We continue to be financially sound with adequate reserves to sustain the academy and future endeavors. As of March 31, 2019, our assets were over three times our operational budget. Our investments are diversified to withstand some of the fluctuations in the market.

The board approved the 2019-2021 Strategic Plan which includes new initiatives in advocacy, public awareness, and pipeline efforts. MAFP reserves may be used to fund these future goals identified in the 2019-2021 Strategic Plan.

In November, 2018, the Board of Directors reviewed and approved a comprehensive Policies

and Procedures Manual to guide the decisions and actions of the board and MAFP team. The policies and procedures are based on association management and state chapter best practices.

A recommendation from the 2017 audit was increased fiscal oversight. We have implemented a new process whereby the Secretary/Treasurer reviews the monthly bank reconciliation statements and investment reports.

Looking ahead, the MAFP leadership continues to make sound financial decisions to further the mission of the academy, as well as fund the strategic initiatives to further Missouri family medicine.

Lisa Mayes, DO Secretary/Treasurer

MO-AFP.ORG 7

Resident Report

O Ann Lottes, MD, Mercy FMR Resident Director

Misty Todd, MD, UMC FMR Alternate Resident Director

ur Missouri residency programs were very effective in training physicians for Missouri – of the 55 residents graduating in spring 2019:

• 32 will be staying in Missouri • Three will be going to Kansas • Three will be going to Arkansas • Two will be going to Illinois • One will be going to Iowa, one will be going to Oklahoma, one will be going to Kentucky, one will be going to Wisconsin, one will be going to New Mexico, one will be going to Texas, one will be going to South Dakota, three will be going to California, one will be going to Canada. (Four unknown) Within Missouri, many will be serving in rural or semi-rural areas, including Warrensburg/ Clinton, Harrisonville, Butler, Fayette, Oak Grove

First Name Jennifer Matthew Whitney Alyssa Jenny Cliff Evan John

First Name Ann Eric Kathryn James Brittanie Rebecca

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MISSOURI FAMILY PHYSICIAN SUMMER ISSUE 2019

MD MD DO MD MD MD MD MD

Future Employer Family Care Clinic unknown Cox Health Cox Health Cox Health Indian Health Cox Health Unknown

Location Jackson, MO Rural, AR Springfield, MO Branson, MO Springfield, MO Ada, OK Springfield, MO Garnett, KS

Type of Practice Outpatient Hospitalist/Outpatient Outpatient Hospitalist Hospitalist/Outpatient Hospitalist/OB/Outpatient OB Fellowship Hospitalist/Outpatient

Mercy Family Medicine - St. Louis

Last Name Lottes Martin Rampon Starrett Weinhaus Winchester

First Name Priscilla Gaurav Sourab Gewel Manveer Brittney Joseph Will Varsha Hazen Maureen Max

Cox Health - Springfield

Last Name Bulcock Dalke Davis Easter Eichhorn Ganus Johnson Long

and Clinton, Missouri and Jackson, Cape Girardeau (two), Jefferson City and Branson. A majority of the rest will be in the St. Louis area (seven), the Springfield area (four) or the Kansas City area (10).

We have trained many physicians to practice outpatient medicine (33), inpatient medicine (12), and a mix of both (five). Four will be going on for further training in fellowship programs, including three in OB fellowships and one in a sports medicine fellowship. Only one resident will practice OB outside of a fellowship or faculty position in Ada, Oklahoma. One will be working in urgent care and two will be serving in the military.

Two residents will be teaching - one at University of Kansas Family Medicine, one at St. Louis University Family Medicine. At least two residents will be going on to work in FQHCs, one in Missouri, one in Wisconsin.

MD DO MD DO DO DO

Future Employer Mercy Southeast Health University of Kan. Mercy BJC Mercy

Location Type of Practice St. Charles, MO Outpatient Cape Girardeau, MO Outpatient Kansas City, KS Faculty St. Louis, MO Outpatient St. Charles Co, MO Outpatient St. Charles Co, MO Outpatient

Research Medical - Kansas City

Last Name Borden Chaturvedi Chopra

de los Santos Flora

Frisby

Meier

Patton

Pawate Short

Weber

Zollicker

MD MD MD MD MD MD MD DO MD MD MD MD

Future Employer Location Type of Practice Hospitalist Harrisonville MO Hospitalist Hospitalist Warrensburg/Clinton, MO Hospitalist St. Luke's Kansas City, MO Hospitalist Unknown Blue Springs, MO Hospitalist HCA Kansas City, MO Hospitalist Unknown AK Outpatient Unknown Rural KS Hospitalist Unknown Urgent Care Unknown Unknown Kansas City, MO Hospitalist Unknown Unknown SD Hospitalist

Saint Louis University - St. Louis

First Name Last Name

Brittany Goodrich-Braun MD

Ashley Meyr

MD Deanna Bajala

MD Ritesh Gandhi

MD Yibing LI

MD Alison Matsunaga MD

First Name Nicholas Ben Geoffrey Brady John Kristen Parker Kaci Stephanie Kaitlin Calvin Aaron

Last Name Bratten Crary Dankle Fleshman Jayroe Killen Kohlfeld Larsen Lersch Saucier Tai Wood

First Name Hannah Karina Joshua Megan Josh Chelsie Ryan Robbie Helen Benson Adam Andrew

Last Name Anderson Belino Booth Buri Buschling Cain Carey Harriford Hill Lan Legg Wherley

Future Employer Location Rural WI Health Sauk City, WI Cooperative (FQHC) SLU St. Louis, MO SSM St. Charles, MO Mercy St. Louis, MO Presbyterian Medical Group Albuquerque, NM US Naval Base San Diego, CA

Type of Practice Outpatient Faculty Outpatient Outpatient unknown Military

University of Missouri - Columbia

MD DO MD MD MD MD MD MD MD MD MD MD

Future Employer Cox South Bates Co. Mem. Hosp.

Mercy One FM Clinic University of KY Little Rock Family Practice Ferrell-Duncan Clinic (Cox) SouthEast Health University Physicians (MU) Golden Valley Memorial Hosp.

JCMG Family Practice Christus Medical Group

Location Springfield, MO Butler, MO Indianola, IA Lexington, KY Little Rock, AR Ozark, MO Cape Girardeau, MO Fayette, MO Clinton, MO Jefferson City, MO Toronto, CAN New Braunfels, TX

Type of Practice Hospitalist Hospitalist/Outpatient Outpatient Sports Medicine Fellowship Outpatient Outpatient Outpatient Outpatient Hospitalist Outpatient Outpatient Outpatient

University of Missouri - Kansas City

MD DO MD MD DO DO DO MD DO MD DO MD

Future Employer Location Truman Med Center Kansas City, MO Delayed - December Camp Pendleton San Diego, CA KC Care (FQHC) Kansas City, MO Unknown Truman Med Center Kansas City, MO Unknown Sonora, CA North KC Hospital Kansas City, MO Truman Med Center Kansas City, MO Unknown IL St. Mary's Hospital Oak Grove, MO OSF St. James Hospital Pontiac, IL

Type of Practice OB Fellowship Military Outpatient Outpatient Outpatient Hospitalist OB Fellowship Hospitalist/Outpatient Outpatient Outpatient

MO-AFP.ORG 9

Student Report

Mimi Liu, SLU Student Director

A. T. Still University of Health Sciences: Osteopathic Medical School • 170 graduates • # of students who matched into family medicine: 40 • # of students who matched into Missouri family medicine: 11 • FMIG members: 177 • FMIG officers • President: Kade Kinney • VP: Lei Alena Dagat • Secretary: Mallory Dameron • Treasurer: Karina Timmerman • Faculty Advisors: Dr. Margaret Wilson and Dr. Joseph Novinger

Kansas City University of Medicine and Biosciences • 235 graduates • # of students who matched into family medicine: 36 Morgan Dresvyannikov, UMKC • # of students who matched into Missouri family medicine: 6 Alternate Student Director Joplin Campus • FMIG members: 147 • Primary care officers (includes family medicine) • President: Charles Foust: cfoust@kcumb.edu • VP: Bridget Tesher: btesher@kcumb.edu • Secretary: Olivia Jang: Ojang@kcumb.edu • Treasurer: Tina Langley: tlangley@kcumb.edu • FMIG representative: Devon Wright, DO: dwright@kcumb.edu • Faculty Advisor: John Paulson, DO, PhD: jpaulson@kcumb.edu Kansas City Campus • FMIG members: 104 • Primary Care Officers (includes family medicine) • President: Joe Li, joeli@kcumb.edu • VP: Mitchel Lau, mnlau@kcumb.edu • Secretary: Karen Lai, klai@kcumb.edu • Treasurer: Jonathan Hendrzak, jehendrzak@ kcumb.edu St. Louis University School of Medicine • Mission/goals: Increase awareness/interest in family medicine and primary care by serving the students, the institution, the community, and anyone in need.

• FMIG members: 84 • # of students who matched into family medicine: 16 • # of students who matched into Missouri family ' medicine: 1

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MISSOURI FAMILY PHYSICIAN SUMMER ISSUE 2019

• Officers • Co-president: Joanna Dembek: joanna. dembek@health.slu.edu • Co-president: Nicolas Andrade: nicolas. andrade@health.slu.edu • Other Board Members • Kristen Woody: kristen.woody@health.slu.edu • Kanav Gupta: kanav.gupta@health.slu.edu • Daphne Cheng: daphne.cheng@health.slu.edu • Daniel Sprehe: daniel.sprehe@health.slu.edu • Faculty Advisor: Matthew Breeden, MD: matthew.breeden@health.slu.edu University of Missouri - Columbia School of Medicine • Mission/Goals: Engaging M1 students and finding ways to make them active in FMIG. • FMIG members: 15-20 active members • # of students who matched into family medicine: 13 • # of students who matched into Missouri family medicine: 5 • FMIG Leadership • Kane Laks: kmlfdc@health.missouri.edu • Lindsay Koerperich: lmkmt9@health. missouri.edu • Liga Blyholder: labgf8@health.missouri.edu • Tori Dahmer: dahmert@health.missouri.edu • Advisor: Amelia Frank, MD; frankae@health. missouri.edu University of Missouri-Kansas City School of Medicine • Mission/Goals: To introduce students to family medicine and the opportunities available within the field. To provide contacts and resources to those interested in family medicine. To educate students in the community about healthy living through sports physical events.

• FMIG Members: 115 • # of students who matched into family medicine: 7 • # of students who matched into Missouri family medicine: 3 • FMIG Leadership • Co-President: Morgan Dresvyannikov: mam5xc@mail.umkc.edu • Co-President: Kyla Mahone: km824@mail. umkc.edu • Co-Vice President: Michele Sun: mhs4z7@ mail.umkc.edu • Co-Vice President: Andrea Pelate: aepcp2@ mail.umkc.edu

• Other Board Members: • Secretary: Paige Charboneau: prc3p6@ mail.umkc.edu • Treasurer: Noah Brown: npbdw7@mail. umkc.edu • PR Chair: Claire Wolber: cewgg7@mail. umkc.edu • Year 1 & 2 Rep: Allison Green: aeghyv@ mail.umkc.edu • Advocacy chair: Amudha Porchezhian: ayphzc@mail.umkc.edu • Community Service Chair: Conner Sutton: jsdb9@mail.umkc.edu • Photographer: Haley Kertz: hmk8tc@mail. umkc.edu • Advisor: Dr. Aniesa Slack aniesa.slack@ tmcmed.org

Washington University School of Medicine • Mission/Goals: To increase exposure to primary care related fields at a center that is very tertiary/ quaternary care driven and to provide students interested in primary care fields or in family medicine with community mentors at nearby institutions such as Mercy and SLU who have family medicine residencies. Since Wash U does not have a family medicine program, SLU and Mercy provide essential support in helping students match into family medicine and gain exposure to the field.

• # of students who matched into family medicine: 1 • # of students who matched into Missouri family medicine: 0 • Contacts: • Amisha Parikh: aparikh@wustl.edu • Sean Terada: seanterada@wustl.edu • Shariq Khan: skhan29@wustl.edu • Advisor: Dr. Phillip Asaro: asarop@wustl.edu

MO-AFP.ORG 11

SKIN

is more than a fleshy surface for pimples, tattoos, and wrinkles.

Your skin is the body's largest organ.

Inside, you will find an overview of symptoms and types of skin conditions, skin care tips, dermatologic emergent issues, and more...

12

The information contained in Missouri Family Physician is for informational purposes only.

The Missouri Academy of Family Physicians assumes no liability or responsibility for any inaccurate, delayed, or incomplete information, nor for any actions taken in reliance thereon.

The information contained has been provided by the individual/organization stated.

The opinions expressed in each article are the opinions of its author(s) and do not necessarily reflect the opinion of MAFP. Therefore, Missouri Family Physician carries MISSOURI FAMILY PHYSICIAN SUMMER ISSUE 2019 no responsibility for the opinion expressed thereon.

Member Opinion

My Top Three Rashes This Summer

e

arly in my training, a sage preceptor taught me to have a “things I don’t want to miss list”.

Every time I presented a patient to him and reviewed my differential diagnoses, he’d say, “Did you consider the ones you don’t want to miss?” That basic way of organizing my diagnostic rankings has saved my bacon more than once! In residency, we had a patient with influenza and ehrlichiosis- a terrible combination of infections that could have gone very badly if it weren’t for that little mantra in my head. It comes in very handy for the analysis of rashes. We’ve all had those days where the urgent telephone complaint was for a “rash, getting worse”- only to have the patient come in to the office for evaluation and, after careful scrutiny, the voice inside your head says, “what rash?”

This always reminds me of the fabled story, The Emperor’s New Clothes, in which the Emperor is tricked into believing he has an amazing new suit and the confused crowd goes along with the ruse, when in fact, he is naked! Until the bright child in the crowd stands up and yells, “what clothes?”, but I digress... In practice, I’d take 1,000 of these mystery rash visits over even one with an acute petechial rash associated with fever in an unvaccinated child any day. This brings me to my top three rashes I don’t want to miss:

“Did you consider the ones [rashes] you don’t want to miss?”

That basic way of organizing my diagnostic rankings has saved my bacon more than once!"

Meningococcemia Defined as dissemination of Neisseria meningitides in the blood, it may present with or without meningitis. The first vaccine, MPSV4, was approved in 1978. Since the 1990’s the incidence of infection has declined steadily. However children ages 0-59 months are most likely to be infected with serogroup B, which is not prevented by currently licensed vaccines. Serogroup B continues to cause sporadic outbreaks on college campuses.

Serogroups C, Y, and W are vaccine preventable and cause 73% of the cases of meningococcal disease in people 11 years and older. Despite the success of the vaccines and historically low incidence of cases, the case-fatality ratio is still 10-15%. Many people who do survive the infection suffer neurologic sequelae, deafness, and loss of limbs. Due to the high rates of vaccination in adolescents and collegeaged people with the quadrivalent meningococcal conjugate vaccine, outbreaks of C and Y type are rare. For this reason, many younger physicians have never seen the characteristic palpable petechiae that may worsen to form purpura fulminans.

Some cases start with a prodrome of fever, malaise and muscle aches, perhaps mild, for several days. During this early phase there may be a transient maculopapular rash that resolves quickly and may be unnoticed or be attributed to a viral exanthem. The initial petechiae are palpable and

Jennifer Allen, MD Dr. Jennifer Allen owns New Freedom Family Medicine, LLC in Hermann, Missouri.

She completed her residency training at Mercy Family Medicine, St. Louis, in 2015.

Figure 1 MO-AFP.ORG 13

often start on the trunk or lower limbs. Petechiae may develop in the conjunctiva, the palms of hands and soles of feet, clues that this isn’t a common rash. Once disseminated infection begins, sepsis develops quickly with dramatic hypotension and the potential for multiple organ failure. Purpura fulminans develops from wide-spread capillary bleeding with necrosis of tissue and often results in amputation of limbs or death. Treatment is initiated emergently with antibiotics, typically ceftriaxone. (www.cdc.gov has an extensive section on meningococcemia transmission, presentation, treatment and prevention).

who do not have natural immunity (i.e. had the disease) to have their IgG titers checked to ensure immunity. The classic symptoms of cough, coryza, and conjunctivitis are often associated with Koplik spots ­­- bluish white lesions on a red base in the oral cavity, usually on the buccal surface opposite the molar teeth. If these are present, they are pathognomonic for measles.

Figure 3

Figure 2

Measles Currently making headlines all over the U.S. and the world, this vaccine-preventable rash and illness has made a notorious comeback. Measles typically starts about 8-12 days after exposure and begins with a high fever, cough, runny nose (coryza), and red watery eyes (conjunctivitis) (the 3 C’s from board review). Again, due to prior successful vaccination of large populations, the virus was reported eliminated in the U.S. in 2000.

While there were sporadic cases and cases in foreign travelers, measles was no longer a constant threat, and many younger physicians have never seen this characteristic presentation. But this spring, the U.S. is having the worst outbreak in 25 years with 880 cases documented in 25 states.

(Reuters.com, May 22, 2019). 72% of cases are in unvaccinated children, 10% reportedly had one of the two recommended vaccine doses, and 18% were undetermined. For those of us who haven’t seen an actual clinical case, the history and physical is vital for early recognition and quarantine. First, identify a patient’s vaccine status. The 2 dose series of MMR is considered 97-98% effective, one dose is 93% effective. People born before 1957 are generally considered immune after having had the illness. However, people born between 1957-1988 may be at risk according to the CDC’s website.

It is recommended for all healthcare providers

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High fever and photophobia are present for two to four days. After that time, the rash appears. It typically starts on the head, and spreads distally to the trunk and limbs over the next three days.

It is very red, usually maculopapular (the classic description is morbilliform which means measleslike) and raised. The rash may become confluent on the face and trunk. It goes away in the same head to toe pattern. People are contagious from the onset of the 3 C’s until 48 hours after the rash appears.

Figure 4

Confirmatory testing is best done with PCR with samples taken from the throat and nasopharynx.

However, commercial labs typically do not do PCR so serology is done to detect antibodies. IgM may be negative through the first five to seven days and repeat testing should be done if there is a high suspicion of infection. This is not usually clinically useful however, due to lab turn-around time and the highly contagious nature of the infection. The virus spreads by aerosol and patients suspected of having the infection should be quarantined to prevent further spread. People at high risk of contracting measles should be vaccinated. Infants aged 6-11 months can be vaccinated during outbreaks and older children can have their second

dose of MMR vaccine 28 days after the first. During non-outbreak times the first dose is given at 12-15 months and the second dose at four to six years.

The most vulnerable populations include infants and children younger than age five; adults older than 20 years; pregnant women and immune compromised people. The potential complications of measles are devastating and include a full range of otitis media or croup to fatal diarrhea, pneumonia, blindness, fetal loss, and sclerosing panencephalitis which may appear years after the infection and cause brain damage or death. Treatment is supportive and prevention of spread is crucial.

Ehrlichiosis Human Monocyte Ehrlichiosis (HME) is a tickborne bacterial infection caused by bacteria in the Anaplasmataceae family. These are obligate intracellular bacteria that kill white blood cells, specifically monocytes. While there are reportedly five species that cause human infection, the most common in Missouri is Ehrlichia chaffeensis. First described in 1987, it is a gram-negative rickettsial bacterium transmitted to humans through the bite of the lone-star tick which are commonly associated with white-tailed deer. Active surveillance for cases has established a rate of 138 cases per 100,000 people in southeastern Missouri in 2002. The majority of cases occur in May-August.

Symptoms of illness present one to two weeks after being bitten. Most people do not recall the bite. Early symptoms are mild to moderate in severity and may include headache, fever, chills and muscle aches - like a typical viral prodrome, so a high degree of suspicion is needed to catch this potentially life threatening infection. Tick borne illnesses should always be considered during the spring and summer when tick activity is high. Late symptoms may involve meningitis, encephalitis, Coagulopathy, renal and liver failure, ARDS, and toxic shock.

The rash is admittedly more common in children, with up to 60% of cases associated with a rash. In adults, the rash may only be present in 10% -30% of people infected. The rash presents five days after the fever starts and may be maculopapular or petechial. The distribution of the rash may be widespread or local. It usually spares the face but may be on the scalp and often includes the palms and soles - similar to Rocky Mountain spotted fever.

It is distinctly different than the erythema migrans rash of Lyme disease.

Figure 5

A full review of the presentation, epidemiology, and management of Rickettsial illness is available in PDF format from the CDC in the May 13, 2016 edition of the Morbidity and Mortality Weekly Report, MMWR. If Ehrlichia infection is suspected then early treatment with doxycycline should be initiated.

Treatment initiated in the first week of symptom onset can prevent worsening and poor outcomes.

However prophylaxis is not recommended in an asymptomatic patient, even with a tick bite.

An adult dose is 100 mg every 12 hours; and in children under 45 kg, 2.2 mg/kg every 12 hours.

The duration of treatment should continue at least three days past when the fever subsides and there is clinical improvement, usually 7-10 days.

Longer duration of treatment has been reported depending on severity. Treatment should not be delayed for confirmation. Whole blood PCR or IFA immunoglobulin testing should be performed.

Acute and convalescent IFA samples may be needed to ensure the correct diagnosis due to the delay in antibody production.

As a final reminder, each of these diseases are reportable to the local health department and/or CDC. References: • Figure 1: https://img.medscapestatic.com/pi/ meds/ckb/08/37308tn.jpg • Figure 2: https://img.medscapestatic.com/pi/ meds/ckb/16/37316tn.jpg • Figure 3: https://encrypted-tbn0.gstatic.com/ images?q=tbn:ANd9GcRUlUbLSeqdXPAQDxhxI7 2zI_1pHo8-7qmhjjutc0MR32EAw1kA • Figure 4: https://encrypted-tbn0.gstatic.com/ images?q=tbn:ANd9GcRALMhG6jNsnjwAb1id6 bRP6rqSIrnvN-PVZxGDSjSRpy4dl_D2Ug • Figure5: http://www.ijcasereportsandimages. com/archive/2018-images/2018100046Z01XQqiu/figure1.gif • https://www.cdc.gov/mmwr/volumes/65/rr/ pdfs/rr6502.pdf MMWR, May 13, 2016 • https://Rarediseases.org/rare-diseases/HME • www.cdc.gov • Up to Date: May 18, 2019 Measles: Clinical manifestations, diagnosis MO-AFP.ORG 15

Non-Member Opinion

Suspect, Detect, and Correct Deficiency States in Skin Disorders

t Dave McCarthy, MD Dr. David McCarthy is a graduate of Bowdoin College in Maine, with a degree in chemistry. He trained at both the University of Connecticut Schools of Pharmacy and Medicine. He has been a speaker at the national Uniformed Services Academy of Family Practice scientific assemblies talking about vitamins C and D as well as essential minerals, including magnesium and iodine. He is a retired career U.S. Air Force family physician, including a tour where he was an assistant clinical professor of family medicine at Creighton University School of Medicine.

Dr. McCarthy lives in O’Fallon, Illinois.

here is a mismatch between what medical researchers know and what clinicians know. Some of this gap involves the impact that co-existing deficiency states have on disease outcomes. A deficiency state is a condition where the body does not have enough of a substance to autoregulate. The body has more options to handle excesses than deficiencies. It is very difficult to regulate something you need, yet do not have.

All authors have preferences. These emerge in training and get modified by experiences. My clinical bias is to search for and detect deficiency states when good, standard care, falls short.

Skin disorders give us real opportunities to test this approach. Skin is the easiest organ to observe.

Changes in the skin occur in many disorders. Biopsy is easier than most organs. The skin can also be treated with different options in different places at the same time, as skin areas can serve as its own control. There are dozens of deficiency states; so let’s cull that list by focusing on two hormones which are usually deficient in patients with treatment resistant diseases: Vitamin D (cholecalciferol) is a hormone made by the skin. D regulates about 10% of our genome.

Each year, more genes get analyzed in detail so that about a third of the regulated genes are understood at the molecular level. It is fascinating that about half of those genes are up regulated while the other half are suppressed. There is also a pattern to this activation/suppression by D. In many cases, D upregulates beneficial genes while suppressing harmful genes. For this reason, my bias is to describe D as our “guardian hormone.” The list of skin diseases affected by low 25-OH vitamin D levels is lengthy; but includes: melanoma, acne, viral warts, eczema, psoriasis, alopecia, and the rashes of infectious diseases.

Question: Do you need to have a very low D level in order to benefit by raising D status?

Answer: No.

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Question: Does the laboratory reference range for 25-OH(D) overlap with the toxicity range?

Answer: It does not overlap.

Question: Is vitamin D an active compound?

Answer: No, it is inert until it undergoes a two-step activation (both hydroxylations).

The activated 1,25 di OH vitamin D is created and then almost immediately deactivated locally, again by hydroxylation. Activated vitamin D doesn’t persist very long. It took many years of research at the molecular level to unravel D’s metabolic pathway and elimination. The clue is to look at the units of measure for the circulating 25-OH(D) and the activated 1,25 di-OH(D).

Vitamin D3 dosing is in micrograms (mcg) if you’re European. It’s in International Units in the U.S. 25-OH(D) level is reported in nanograms/ml (one thousandth of a mcg).

1-25 di-OH(D) is given in picograms (one thousandth of a ng).

So, a picogram is one trillionth of a gram. I benefit from a background in chemistry and pharmacology. But, in truth, it was a long, productive meeting over lunch with a retired Israeli gynecologist that put these pieces of information into perspective. He developed the technology to assay human steroid hormones in the blood.

Vitamin D is a steroid hormone that is made from cholesterol. He [Guy Abraham] said that the units of measure at this ultra-small scale indicate potency, and reflect the need for rapid metabolic elimination.

Question: Why did the national laboratory reference range increase at both the lower limit and/or upper limit annually from 2007 through 2010 (four times in four years)?

Answer: Because the older range was based on suppressing rickets. The new ranges are based on multiple non-osteal benefits of vitamin D.

Another bias is the recognition that recent information on genetic polymorphisms has not yet been factored into the treatments of deficiency states. There are several gene variants for the vitamin D binding protein and hundreds of polymorphisms for the vitamin D receptor.

This is important because it means that two people with the same 25-OH(D) level (ie- 50 ng/ ml) may not have the same clinical outcome. The current reference range is 30–80 ng/ml. A clinical pharmacologist may note that if a good therapy for a disease is falling short at a D level of 50 ng/ ml, there is “wiggle room” to edge the level up an additional 30 ng/ml without increasing risk.

There is an excellent graphic chart on the website of Grassrootshealth.org. It is entitled “Disease Incidence Prevention by Serum 25(OH)D level.” It demonstrates that for many disorders there is an increasing response to higher D levels. Researchers also note that levels in excess of 60 ng/ml are only just now being tested for enhanced efficacy.

Let’s look at another hormone. Vitamin C is a stress hormone in mammals. Cats, dogs, horses, cows, pigs, sheep, and goats can make thousands of milligrams per day. They can double or triple that when stressed. Humans are one of four mammals with a gene defect preventing the production of any vitamin C from blood sugar. Vitamin C is a hard requirement for the repair and replacement of cells, all cells. The human organ with the highest concentration of vitamin C is the placenta. After all, babies are nothing but new cells. Any disease that affects skin and requires cellular repair or replacement will need vitamin C. Another bias is the observation that clinicians do not suspect vitamin C deficiency even in seriously stressed patients. It is easy to quickly and inexpensively evaluate a person’s vitamin C status. There is a urine dipstick which quantifies the concentration of vitamin C. It costs $0.30 and takes 30 seconds.

It could be used at the bedside of every intensive care unit patient in America.

The skin manifestations of sepsis are known by many names including ecthyma gangrenosum (pseudomonas), scalded skin syndrome (s. aureus) and purpura fulminosis. Necrotizing fasiculitis and toxic shock syndrome are particularly troublesome. The approach to serious sepsis highlights another bias. Research studies focus on single variable causes. This underestimates the impact of deficiency states in multi-factorial diseases. Vitamin C alone did not reduce mortality from severe sepsis; neither did thiamine alone, nor hydrocortisone by itself. When all three were

"A deteriorating patient situation should increase the suspicion of coexisting deficiencies.

Clinicians usually test for conditions they suspect.

We can become more suspicious, become better detectives, and act as the corrections officer for our patient’s deficiencies." used together as an intravenous drip, the mortality went from 40% to less than 8.5%. This shows that treating sepsis is a team sport.

The easiest way to assess the adequacy of vitamin C deficiency SUSPICION is to ask the hospital pharmacist how many physicians routinely order vitamin C for sick or post-operative patients.

Also ask the nurses if vitamin C deficiency is being considered in each patient in the intensive care unit. Some hospitals do not have oral vitamin C on the formulary. Very few have intravenous vitamin C. Another bias is that the prevalence of deficiency states in the general population underestimates the likelihood of finding a deficiency in a specific disease. Articles on thiamine deficiency usually begin by noting this is uncommon in the U.S. In a diabetic with a HgbA1C > 8, it is nearly universal.

While most healthy people have a few deficiency states, individuals who are ill have many. People who are malnourished have many more. People on a lot of prescription drugs may have the most.

A deteriorating patient situation should increase the suspicion of co-existing deficiencies. Clinicians usually test for conditions they suspect. We can become more suspicious, become better detectives, and act as the corrections officer for our patient’s deficiencies.

“Half of what you will learn in the next four years is incorrect. If we knew which half, we wouldn’t teach it.”

-Welcoming Address from the Dean of Students, University of Connecticut School of Medicine, 1974.

(See references on page 49) MO-AFP.ORG 17

Non-Member Opinion

Skin Cancer: The Three Most Common Types

s

Introduction Skin cancer is the most common cancer with over three million cases detected every year in the United States. Early detection is key in treatment and prognosis. This article will cover an overview of the most common types of skin cancer: basal cell carcinoma, squamous cell carcinoma, and malignant melanoma, and review clinical manifestations, prognosis and treatment.

Helen Tergin, MD Dr. Helen Tergin is a board certified Dermatologist at Central Missouri Dermatology, practicing in the mid Missouri area in Columbia and Jefferson City. She is a member of the American Academy of Dermatology and the Missouri Dermatology Society.

Basal cell carcinoma Basal cell carcinoma (BCC) is the most common cancer and the most common skin cancer. One in five people will develop a non-melanoma skin cancer. Three million Americans will be affected by non-melanoma skin cancer every year. Basal cell carcinoma grows locally and destructs surrounding tissue. Risk factors include intermittent intense sun exposure, radiation therapy, skin types I or II, blistering sunburns in childhood, and indoor tanning. Common treatments include surgical excision, electrodessication and curettage, cutaneous micrographic surgery or Mohs, and topical Imiquimod and radiation therapy. Mohs surgery has the highest cure rate for skin cancer and is indicated for non melanoma skin cancers in certain locations such as the nose, eyelids, ears, and for more aggressive histology where margin control is critical.

Nodular BCC is the most common type of basal cell carcinoma at 50-80% with the characteristic rolled border and telangiectasias throughout. They are most commonly found on the head and neck, especially the nose. Superficial BCC comprises 15% of the total and favors the trunk and extremities.

Clinically this appears as a dry scaly lesion that can mimic eczema or psoriasis. Other less common types of BCC include Morpheaform BCC, which can present as a white sclerotic plaque on the head and neck, and Infiltrative BCC, a more locally aggressive form of basal cell carcinoma.

Squamous cell carcinoma Squamous cell carcinoma (SCC) is the second most common form of skin cancer. Most cases of SCC are due to chronic, long-term sun exposure.

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Immunosuppression greatly increases the risk for SCC by 65-fold to 250-fold among organ transplant recipients, especially those on Azathioprine. SCC begins at sites of actinic damage, such as the face and hands, and are three times more frequent than BCC on the back of the hands. SCC can occur on the lip, and lower lip SCC lesions far outnumber upper lip. SCC on the lip occurs in men over women in a 12:1 ration, and a history of smoking is a significant risk factor. Given the various clinical presentations of SCC, there should be a low threshold for skin biopsy of a suspicious keratotic, ulcerated, or nodular lesion.

The rate of SCC metastasis is 0.5%-5.2%. Risk factors for metastasis include the following: those on the lip, ear, anogenital skin; those at sites of scar or radiation; those 2cm or more in diameter; those more than 4mm thick; those that are recurrent; those with perineurial invasion, and those in setting of a organ transplantation. These lesions should be treated aggressively, surgically, and with possible adjuvant radiotherapy. Regional lymph nodes should be part of the physical exam at initial appointment and follow up.

Bowen Disease, or Squamous Cell Carcinoma in situ, is an intraepidermal form of SCC. Bowen’s can be caused by HPV, arsenic, and sun exposure.

It is often scaly and crusted and misdiagnosed for eczema or psoriasis. These lesions are treated with excision, destruction (curettage and desiccation), Mohs microsurgery, topical therapies (Imiquimod, 5-FU).

Malignant melanoma The vast majority of skin cancer deaths are from melanoma, and nearly 20 Americans die from melanoma every day. Melanoma can arise about 50% of the time from a preexisting nevus and the other 50% on previously normal appearing skin.

Common risk factors include light complexion and eye color, blond or red hair, history of childhood blistering sunburns, heavy freckling, family history of melanoma, history of more than 50 benign nevi, history of dysplastic nevi, tanning bed use, and immunosuppression. Melanoma is the second most common form of cancer in females age 1529. Types of melanoma include lentigo maligna,

"1 in 5 people will develop skin cancer." superficial spreading, acral lentiginous, mucosal, nodular, desmoplastic, ocular, and amelanotic.

Staging of melanoma is outlined by the American Joint Committee on Cancer (AJCC) based on primary tumors, lymph node involvement, and distant metastases. The single greatest risk factor is the depth of invasion of the melanoma, or Breslow depth. Early detection is key to prognosis, with Stage 1 showing 80% survival and Stage 4 less than 10%. Early excision remains the most important determinant of outcome. A melanoma in situ is typically excised with a 0.5 cm margin, while a 1.0 cm margin is taken for a 1.0 mm or less melanoma, a 1.0-2.0 cm wide local excision for those under 2 mm depth, and a 2cm margin for those greater than 2 mm depth. When a melanoma is 0.8mm-1.0mm or greater in thickness, a sentinel lymph node biopsy should be discussed and the patient sent to a center having experience in this technique.

Newer therapies for advanced disease include immunotherapy treatments that target immune checkpoint inhibitors of programmed cell death pathway (PD-1) such as Nivolumab (Opdivo) and Pembrolizumab (Keytruda).

Impact of Primary Care One in five people will develop skin cancer. The overall incidence of melanoma is increasing, and surgical excision can be curative if melanoma is detected early. Encourage patients at an annual exam to wear sunscreen SPF 30 or greater, avoid 10am-2pm sunlight, and wear protective clothing including a hat and sunscreen. If a patient has a concerning lesion that bleeds, itches or has

changed, or if an unusual mole is noted on physical exam, a skin biopsy may be indicated for histology and pathology, or referral to a board certified dermatologist for evaluation.

In general for a pigmented lesion, especially if there is a concern for melanoma, complete removal, excisional biopsy, or punch biopsy are good options for technique of skin biopsy. It is important to obtain a depth for a melanoma for staging purposes, and sometimes a shave biopsy will result in a lesion extending to the base, making staging of the melanoma more difficult.

Caucasian individuals who have had more than one melanoma have an increased risk of developing both subsequent melanomas and other cancers, including those of the breast, prostate and thyroid, so these patients need to be watched more closely and kept up to date on routine health maintenance exams. Skin cancers in the immunosuppressed setting of organ transplantation, can demonstrate aggressive behavior and lesions need to be diagnosed and treated early. These patients should see a dermatologist regularly, even up to every three months.

Skin cancer can affect all ages and races, and is the most common type of cancer. It is important to recognize the signs and symptoms of skin cancer because early detection can be key for treatment and prognosis.

References • Andrews’ Diseases of the Skin, William James and Dirk Elston 2020 • American Academy of Dermatology

MO-AFP.ORG 19

Member Opinion

Frontal Fibrosing Alopecia: From Rare to Common

Scott Darling, DO, RPVI, RVT Dr. Scott Darling has been in private practice in the Liberty, Missouri area for 20 years. He is Board Certified in Venous & Lymphatic Medicine, Sports Medicine/ Family Medicine and has additional training in Dermatology. He has been a dermatology provider for commercial insurance for 20 years.

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ew conditions are as challenging as the chief complaint of “hair loss�. Although infrequently a result of a serious medical condition, hair loss can cause profound psychosocial distress for the patient.

Patients usually present after trying several supplements or home remedies themselves, and may also have spent a significant amount of money on various over the counter products which may or may not grant them any improvement. The etiology of hair loss varies, and treatment options are limited.

Primary cicatricial alopecias refer to a group of dermatologic diseases that result in scarring, permanent hair loss due to destruction of the hair follicle. Although some familial cases have been

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described, most cases of PCA are acquired.

A working classification for PCA was proposed by the North American Hair Research Society(1).

PCAs account for approximately 5% of cases in specialized hair clinics,(2-4) and the ratio of lymphocytic to neutrophilic or mixed PCA is 4:1(2,3).

Cicatricial alopecias have been traditionally divided into four categories based on the predominant inflammatory infiltrate: lymphocytic, neutrophilic, mixed, and nonspecific. Both frontal fibrosing alopecia (FFA) and lichen planopilaris (LPP) fall in the group of lymphocytic primary cicatricial alopecias and are considered variants of the same disease process. LPP presents with multifocal lesions on the scalp with mild to moderate perifollicular erythema and scaling. It may be

"Be compassionate in dealing with patients with hair loss as your patients know what is normal for them.

Although the management of frontal fibrosing alopecia can be challenging, promising new therapeutics which are available, offer hope and encouragement to patients with this challenging disease." accompanied by lichen-planus lesions on the skin, mucosa, and nails. In contrast, FFA occurs primarily on the anterior hairline, with erythema and perifollicular scaling noted at the fronto-temporal region of the scalp. This is accompanied by loss of eyebrow hair and facial papules. When these findings are noted in associated with nonscarring alopecia of the axillae and pubic areas, and when the follicular papules are additionally noted on the trunk and extremities, the patient may have a variant called Graham – Little Syndrome. While both FFA and LPP commonly affect females in their 50s, FFA can also present in pre-menopause and in men. In men, FFA can present at unique sites such as facial hair or sideburns. While an increased prevalence of hypothyroidism has been reported in FFA patients, this association has not been found in studies looking specifically at FFA in male patients.

Hair loss may progress subclinically and scalp biopsy specimens obtained from clinically ‘‘normal’’ areas may have evidence of disease(5,6). A significant amount of hair is usually lost before the alopecia is apparent, making it difficult to precisely determine its onset(7,8). Patients are often aware of their alopecia for >1 year before consulting a physician(9,10).

Inflammation frequently extends well beyond the alopecia area(s). Assessment is done by parting the hair over the entire scalp and looking for signs of alopecia and inflammation. Hair-bearing areas, the skin, mucosa, and nails should be examined.

Subtle clues to PCA may be easily overlooked.

Discrete, millimeter-wide alopecia patches and perifollicular accentuation may be the only signs present. Patients may present without obvious areas of hair loss but rather diffuse hair thinning and discrete perifollicular erythema and scaling.

They are often misdiagnosed with pattern hair loss and seborrheic dermatitis.

Longstanding plaques without a history of regrowth and the presence of isolated hair(s) within the plaques should raise suspicion for PCA. Female pattern hair loss (FPHL) or male pattern hair loss (MPHL) may be present concomitantly.

Dermoscopy can help differentiate noncicatricial alopecia from cicatrical alopecia and can improve biopsy site selection. A scalp biopsy specimen helps confirm the diagnosis in clinically ambiguous cases and identifies the nature and density of the inflammatory infiltrate. One biopsy specimen usually suffices, and it should be processed with horizontal, transverse sections rather than vertical sections(3).

Although some biochemical or nutritional anomalies have been inconsistently reported, there is no blood test specifically recommended for PCA at this time. Laboratory studies should be dictated by the clinical context and to monitor potential side effects of treatment. Antinuclear antibody levels should be assessed in patients with LE. Syphilis should be ruled out if suspected.

Frontal fibrosing alopecia (FFA) was first described as a progressive recession of the frontal hairline in postmenopausal women. Since its initial description, recognition and understanding of FFA has expanded. The condition is now defined as a patterned, symmetric, frontotemporal scarring alopecia that is considered to be histopathologically indistinguishable from lichen planopilaris.

Numerous case reports and series have suggested clinical variants of and associations with FFA. In addition to reviewing the literature on FFA’s associations, women with skin of color (Hispanic and black) who presented with various cutaneous findings in association with FFA, including lichen planus pigmentosus (LPP), facial papules, and eyebrow loss. Recognition of these conditions that can occur in association with FFA in individuals with skin of color is important in further expanding our knowledge and understanding of FFA as a disease entity.

Managing Frontal Fibrosing Alopecia Frontal fibrosing alopecia is a very recent disease described in the last 20 years. The Spanish group, led by Dr. Vañó-Galván, the authors of this study, retrospectively evaluated the clinical presentations and evolution of frontal fibrosing alopecia in MO-AFP.ORG 21

242 female patients in an attempt to create a clinical and prognostic classification scheme. They identified three clinical patterns: 1) a linear pattern (48.8%), characterized by a uniform band of frontal hairline recession without hair thinning behind the band; 2) a diffuse pattern (45%), characterized by a diffuse band of alopecia affecting the frontal hairline with significant hair thinning behind the band; and 3) a pseudo-fringe pattern (6.2%), characterized by a pseudo-fringe sign at the frontal hairline, which resembles traction alopecia.

Patients presenting with the third pattern had less hairline recession and eyebrow involvement at the time of diagnosis and after treatment.

Using frontal hairline recession as the main distinguishing factor, there are three distinct clinical presentations of frontal fibrosing alopecia that can be identified. The least common presentation, or the pseudo-fringe pattern, has the best prognosis. The linear pattern is the most common presentation and has an intermediate prognosis, and the diffuse pattern has the worst prognosis.

There is an increased prevalence of autoimmune disease associated with FFA patients. However, thyroid disease is more prevalent.

Patients are often very afraid that they will lose almost all of their hair when they initially present to a physician. Using the classification into the three patterns is helpful to give the patient a better understanding on how they are going to lose their hair. But more importantly, it illustrates to the patient the urgency to start their treatment as soon as possible, since all hair loss is permanent. The goal with treatment is to slow down and stabilize the progression of their hair loss.

The pathophysiology of the disorder may have a genetic component, as HLA Typing reveals a HLAB 0702 association with autoimmune disease. There is also the potential for a hormonal component to this disease, as the Zip1B1 hormone processing enzyme has been identified, suggesting the disease may be responsive to Finasteride. Much is still to be discovered.

Therapy A combination therapy is the best approach to start treatment, including Tacrolimus ointment followed by Clobetasol ointment, Minoxidil and Doxycycline orally. The next level of therapy could include Pioglitazone, Isotretinoin, JAK inhibitors and Finasteride. If this is not successful, additional therapies could include the Excimer Laser 308nm, Plaquenil, Cyclosporine or Methotrexate.

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For the facial papules of FFA, the addition of 10mg isotretinoin every other day resulted in clinically observed improvement in facial papules after four months of use, potentially due to the role of sebaceous glands in the clinical course of these lesions. The facial papules of FFA are felt to initially demonstrate lichenoid inflammation involving vellus hairs, followed by hypertrophic sebaceous glands lacking associated vellus hairs, followed by skin atrophy without hair follicles.

Be compassionate in dealing with patients with hair loss as your patients know what is normal for them. Although the management of frontal fibrosing alopecia can be challenging, promising new therapeutics are available, which offer hope and encouragement to patients with this challenging disease.

References 1. Olsen EA, Bergfeld WF, Cotsarelis G, et al.

Summary of North American Hair Research Society (NAHRS)-sponsored Workshop on Cicatricial Alopecia, Duke University Medical Center, February 10 and 11, 2001. J Am Acad Dermatol. 2003; 48:103-110.

2. Tan E, Martinka M, Ball N, Shapiro J. Primary cicatricialalopecias: clinicopathology of 112 cases. J Am Acad Dermatol.2004;50:25-32.

3. Whiting DA. Cicatricial alopecia: clinicopathological findings and treatment. Clin Dermatol.

2001;19:211-225.

4. Rakowska A, Slowinska M, Kowalska-Oledzka E, et al. Trichoscopy of cicatricial alopecia. J Drugs Dermatol. 2012;11: 753-758.

5. Mirmirani P, Willey A, Headington JT, et al.

Primary cicatricial alopecia: histopathologic findings do not distinguish clinical variants. J Am Acad Dermatol. 2005; 52:637-643.

6. Sperling LC, Homoky C, Pratt L, Sau P. Acne keloidalis is a form of primary scarring alopecia.

Arch Dermatol. 2000; 136: 479-484.

7. Gathers RC, Jankowski M, Eide M, Lim HW. Hair grooming practices and central centrifugal cicatricial alopecia. J Am Acad Dermatol.

2009;60:574-578.

8. Rallis E, Gregoriou S, Christofidou E, Rigopoulos D. Frontal fibrosing alopecia: to treat or not to treat? J Cutan Med Surg. 2010; 14:161-166.

9. Moreno-Ramirez D, Camacho Martinez F. Frontal fibrosing alopecia: a survey in 16 patients. J Eur Acad Dermatol Venereol. 2005; 19:700-705.

10. Chieregato C, Zini A, Barba A, Magnanini M, Rosina P. Lichen planopilaris: report of 30 cases and review of the literature. Int J Dermatol. 2003; 42:342-345.

K C I QU

#1

6

SKI

s p i t

“Do not underestimate the importance of sunscreen.

Sunscreens helps to protect you from developing skin cancer, and is the most valuable addition you can make in your anti-aging skin care routine, as it helps to avoid wrinkles and sunspots.

Be sure to use a broad spectrum, water resistant sunscreen of SPF 30 or higher and reapply it every two hours.”

Meghan Feely, MD, FAAD

#3

E R A NC

“For hard to treat eczema, or dry, cracked skin on the hands and feet, I recommend pure white crisco (not butter flavored!) It’s 100% soy oil, so be aware of allergies, but it is much less expensive than olive oil or coconut oil and works great.”

#2

Dave McCarthy, MD, retired medical officer United States Air Force

#4

Jennifer Allen, MD

#5

“Perform regular self skin checks for new or changing moles. About half of all melanomas are self detected. For outdoor activities, avoid 10am -2pm. Seek shade, and wear protective clothing including a wide brimmed hat and sunglasses.

Reapply sunscreen every two hours or every hour after swimming or sweating.”

Helen Tergin, MD

“The skin is the largest organ in our body where many illnesses leave their clues. Deficiency states often alter our skin, right before our eyes.

Common deficiencies affecting the skin include vitamin C and D deficiencies and a lack of inorganic iodine intake.”

“Dry skin , chapped lips, and eczema can be a nuisance .

Using a thick ointment is more effective and often less irritating than traditional lotions. Applying a small Amount of petroleum jelly your skin , lips and eyelids while your skin is still damp (right out of the shower) will help to lock in moisture and provide protection .”

Miles Crowley, MD, MPH

#6

“Check your skin for skin cancer. Skin selfexams can help you find skin cancer early when it’s highly treatable. If you see a spot that differs from others, changes or bleedsthen see your physician. When it comes to your skin, Physicians are the experts and are able to diagnose and treat multiple skin conditions.”

Scott Darling, DO, RPVI, RVT

Case Report

A Peculiar Case of Tick-Borne Illness in a 6-year-old with Persistent Lymphadenopathy

Miles Crowley, MD, MPH University of Missouri Columbia

Zachary Treat, MD University of Missouri Columbia

Laura Morris, MD, MSPH, FAAFP University of Missouri Columbia

24

Introduction Tularemia is an uncommon zoonotic infection caused by Francisella tularensis, an extremely pathogenic intracellular Gram-negative coccobacillus. F. tularensis bacterium is easily aerosolized, and has a low infectious dose of <10 CFU(1,3). Transmission of the disease is usually through bite of an arthropod vector or by handling infected animals, however cat bites, contaminated drinking water or food, and aerosolized droplet transmission are also reported(2, 5). In the United States, ulceroglandular followed by glandular tularemia are the most common forms of the disease, however rarer reports of oculoglandular, oropharyngeal, intestinal, pneumonic, and thyphoidal presentations arise. Diagnosis of the disease is often delayed, as tularemia is uncommon, difficult to culture, and disease manifestations vary widely(1). In the U.S., 1,208 cases of tularemia were reported during 2001–2010, with approximately 40% of all cases occurring in Arkansas, Oklahoma, and Missouri. Missouri reported the most cases, with 231 (19%)(4). Due to the increased prevalence in Missouri, the pathogenicity, and the varying disease manifestations, it is important to consider tularemia in the differential diagnosis for illnesses that do not respond to conventional treatment, especially in those with potential exposure.

This case report highlights a delayed diagnosis of ulceroglandular tularemia from a tick bite in a pediatric patient, highlighting important considerations for the treatment of tick bites in Missouri.

Case Report

MISSOURI FAMILY PHYSICIAN SUMMER ISSUE 2019

In June of 2018, a 6-year-old female presented to clinic for new onset of malaise and one day of fever to 103.5. One day prior to onset of symptoms, the patient was found to have an engorged tick on the scalp that was removed intactly. Mother also noted that siblings were sick at home with strep throat. Physical exam was unremarkable. Despite benign exam the patient was treated empirically with Amoxicillin for potential strep exposure and Lyme prophylaxis. Two days after the initial visit, the patient was taken to the Emergency Department for sustained fever (105.0 F oral), fatigue, arthralgias, myalgias, and decreased oral intake. Laboratory evaluation showed thrombocytopenia (plt 86,000) with otherwise unremarkable cell counts and chemistry panel. Urinalysis was performed, revealing ketones, moderate leukocytes, 16-20 WBC/hpf, no nitrites, and no visualized bacteria. Due to inability to tolerate oral intake, she was admitted for dehydration and presumed urinary tract infection (UTI). Rocephin was administered for treatment of UTI and she was started on intravenous fluids. Rocky Mountain Spotted Fever antibodies and Ehrlichia PCR were obtained and negative. On day two of hospitalization, the patient had improved energy, was tolerating oral intake, and was well appearing. Thrombocytopenia and fever were attributed to viral illness and UTI. The patient was discharged home.

Three weeks later, the mother noticed the area of the tick bite continued to be open with drainage and she noticed an enlarged lymph node on the patient's neck. Then, one month after initial presentation, she returned to her Family Medicine physician for evaluation. On physical exam, the patient was well appearing with a 0.5 cm ulcerated lesion to the scalp at the area of previous tick bite and a 1.5cm right anterior cervical lymph node with mild overlying erythema. The patient was given topical bactroban ointment and started on Augmentin for possible secondary lymphadenitis. Tularemia and bartonella titers were sent. Five days later, the patient’s tularemia titers were positive (1:1,280); however, the patient was out of state on vacation with family. Oral doxycycline 2.2mg/kg twice daily was prescribed for 14 days of treatment.

One month after finishing doxycycline, the patient returned to clinic for follow up. The lymph node continued to be erythematous and swollen. The patient’s mother noted slight fatigue without any

Clinical Presentation

Route of Transmission

Exposure Risk

Ulceroglandular/ Glandular

Initial nonspecific febrile illness, enlarged regional lymph node, +/- non-healing skin wound

Skin inoculation

Hunting, fishing, farming, arthropod bites, handling contaminated animal products

Pneumonic

Fever, dyspnea, bronchopneumonia, dry cough, septicemia, diaphoresis

Inhalation

Hunting, farming, mowing over animal carcasses

Typhoidal

Fever, malaise, headache, lymph node enlargement

Unknown

Environmental exposures

Oculoglandular

Unilateral conjunctivitis, mucopurulent discharge regional lymphadenopathy, photophobia

Aerosolized particle/ contaminated finger

Hunting, farming, contact with infected animals

Oropharyngeal

Severe tonsillitis, pharyngitis, persistent fever, neck lymphadenitis

Ingestion

Contaminated drinking water or contaminated food products (rat feces)

other complaints. On physical exam, the patient was noted to have a 2x2cm erythematous, fluctuant right-sided neck mass with associated cervical lymphadenopathy. The patient was admitted to the hospital for intravenous antibiotics and incision and drainage (I&D). On admission, she was started on gentamicin, 2.5 mg/kg IV three times daily. An audiogram was obtained for baseline hearing, which was normal. Ultrasound of the neck showed a 4.7 x 2.5 x 2.0 cm abscess within the right side of neck, mostly solid in appearance. ENT was consulted and arranged I&D in a negative pressure operating room. Lab personnel was notified due to concern for the infectivity of tularemia. The abscess was aspirated, then opened and curettage performed to remove necrotic debris. The area was packed with iodoform gauze and fluid samples were sent to pathology. Tularemia titers were 1:640. AFB culture, anaerobic cultures, and blood cultures were negative. The patient tolerated the procedure well. A peripherally inserted central IV catheter was placed in the operating room so the patient could complete a 10-day course of IV gentamicin at home. Ten days later at outpatient Infectious Disease follow up, the packing was removed. Erythema had resolved and the wound was noted to be well healing without ongoing drainage. By one month after hospitalization, the patient had returned to baseline, the wound had completely healed, lymphadenopathy had resolved, and repeat audiogram was normal.

Discussion Tularemia, caused by Francisella tularensis, is a rare but potentially fatal zoonotic bacterial infection that has been reported in all of the continental United States, with the highest incidence in the Midwest.

Infection via F. tularensis can manifest as many clinical

syndromes depending on the route of exposure(5,3).

Inoculation of the skin through direct contact with infected animal tissue or by arthropod bite (ticks, flies, mosquitoes) typically results in ulceroglandular tularemia, identified as an ulcerated lesion at the site of inoculation with localized lymphadenopathy.

Less commonly, tularemia can develop as lymphadenopathy without cutaneous ulcer, known as glandular tularemia. Inhalation of the aerosolized bacterium can result in a primary pneumonia, whereas ingestion via contaminated meat or drinking water can manifest as oropharyngeal tularemia presenting as pharyngitis or tonsillitis. Other forms of tularemia include typhoidal, which is fever without localizing signs and oculoglandular which is infection of the eye associated with lymphadenopathy(5,6).

Ulceroglandular and glandular tularemia mainly affect lymph nodes in the head and neck region, whereas pulmonary tularemia usually affects hilar and mediastinal lymph nodes. Our patient had unilateral cervical lymphadenopathy with an ulcerated lesion at the site of her tick bite, consistent with the most common form of tularemia, ulceroglandular.

Although tick bite was the mode of transmission in this case, considering tularemia in patients with other epidemiological risk factors such as hunting, farming, and other arthropod bites is also important(7).

While our patient presented early in the disease process with systemic symptoms of fever and arthralgias following a tick bite, most cases of tularemia are identified in the setting of isolated lymphadenopathy without systemic symptoms, as seen in our case at the time of definitive diagnosis.

Tick exposures and prior febrile illness are easily forgotten by patients, leading to increased difficulty in establishing the diagnosis for some patients who do not present early with the prodromal illness(3).

MO-AFP.ORG 25

"Although tularemia is rare in the United States, Missouriâ&#x20AC;&#x2122;s increased incidence makes it an important disease to consider in cases of isolated lymphadenopathy, or in other illnesses that do not respond to conventional treatment."

26

The differential diagnosis for isolated cervical lymphadenopathy should include staphylococcal or streptococcal lymphadenitis, tuberculosis, nonmycobacterium tuberculosis, malignancy, tonsillitis/ pharyngitis, periodontal disease, cat scratch disease, and tularemia. Strongly consider tularemia when localized lymphadenopathy is present after initial treatment for lymphadenitis or when ulceration or conjunctivitis is present(8). Routine laboratory testing is generally within normal ranges, and is usually only helpful at excluding other diseases from the differential diagnosis. As seen our patient, mild thrombocytopenia and sterile pyuria may be present.

In half of patients, serum transaminase levels are mildly elevated, and hyponatremia is occasional observed(9).

F. tularensis is highly fastidious and culturing the bacteria is difficult. Definitive diagnosis is made through laboratory testing and physical exam findings. An antibody agglutination titre of 1:160 or greater is generally diagnostic of disease. Antibodies titers less than 1:20 are negative, however do not rule out disease during the acute presentation. If clinical suspicion is high, titers should be repeated in 2-4 weeks after initial presentation. A four fold increase in titers is diagnostic of tularemia. Titers between 1:20 and 1:80 are considered equivocal. In patients with equivocal titers, titers should also be repeated with continued clinical suspicion. Equivocal titers may be due to past infection, other infections with cross-reactive antibodies such as brucella, yersinia, salmonella, legionella, or proteus, or in patients that have an acute F. tularensis infection(10).

Presumptive diagnosis can also be made through PCR, ELISA, molecular, direct fluorescent antibody, or immunohistochemical staining testing. These test offer a more rapid diagnosis, however these tests are not as widely available or are more costly(5,12). In any specimen suspected to contain F. Tularensis, such as biopsy aspirates or wound cultures, it is important to contact laboratory personnel who may be handling the specimen due to pathogenicity of the bacterium(5).

In our patient, the final diagnosis was made by physical exam findings of localized lymphadenopathy and diagnostic antibody titers with tick bite exposure.

As demonstrated by our case, drugs that empirically cover lymphadenitis, including augmentin and cephalosporins, are not effective at treating tularemia.

The first line treatments for tularemia are aminoglycosides (streptomycin or gentamicin), despite the drawbacks of parenteral administration and the risk of toxicity(5,10). Treatment is considered successful when signs and symptoms resolve and if lymphadenopathy decreases in size without abscess formation or suppuration(12). Delay in diagnosis and treatment is an important risk factor in failing

MISSOURI FAMILY PHYSICIAN SUMMER ISSUE 2019

monotherapy with antibiotics. I&D and IV antibiotics were mandated due to the abscess formation from the lymph node necrosis. Fluoroquinolones (e.g., ciprofloxacin and levofloxacin) are increasing in popularity for the treatment of tularemia due to excellent bioavailability, oral administration, and decreased toxicity, although fluoroquinolone treatment is longer in duration(10,12). Treatment with fluoroquinolones in children under age 12 is relatively contraindicated due to an increase in cartilage toxicity observed in animal models and short term arthropathy in children(13). However, there are no long term adverse musculoskeletal effects associated with use and reports show that arthropathy resolves following cessation of antibiotics(13). Tendon rupture is not associated with use in children. Thus, after discussion of risks and benefits with family members, fluoroquinolone monotherapy may be a suitable treatment option prior to the development of an abscess(13).

Tetracyclines (i.e. doxycycline) are another potential treatment option for tularemia. Although seen as standard therapy for prophylaxis and treatment of tick-borne illness, doxycycline is often ineffective for treatment of tularemia in children due to a high rate of relapse and need for an extended treatment course(5,10). Our patient had no reduction in lymphadenopathy with doxycycline and required treatment with gentamicin and I&D. It is possible that failure of initial therapy may have been secondary to the prolonged time to diagnosis. In our case, doxycycline was not initially prescribed due to the historical concern for teeth discoloration. Several recent retrospective cohort studies have refuted the dogma that doxycycline stains teeth in children, owing to the fact that doxycycline has less affinity for calcium binding compared to other tetracyclines(14).

In hindsight, this patient, who presented with fever and systemic symptoms after a tick bite in Missouri, should have started doxycycline at initial presentation due to the potential high morbidity and mortality of rickettsial and other tick-borne disease in children(14,15).

Although tularemia is rare in the United States, Missouriâ&#x20AC;&#x2122;s increased incidence makes it an important disease to consider in cases of isolated lymphadenopathy, or in other illnesses that do not respond to conventional treatment. Tick exposure in Missouri is common and starting treatment with doxycycline early for symptomatic patients is prudent for treatment of potentially fatal infections, especially in children. Considering your patientsâ&#x20AC;&#x2122; epidemiological risk and potential exposures may lead you to earlier treatment and diagnosis of Tularemia.

Question 1) All of the following antibiotics are appropriate for treatment of tularemia in pediatric patients except for: A) Streptomycin IM B) Doxycycline PO C) Gentamicin IV D) Ciprofloxacin PO Answer B) Doxycycline PO Doxycycline PO can be an acceptable alternative choice in adults with mild to moderate tularemia.

However, in children doxycycline is not recommended as there have been higher rates of treatment failure and requires a prolonged course if used.

[American Academy of Pediatrics. Tularemia. In: Red Book: 2018 Report of the Committee on Infectious Diseases, 31st ed, Kimberlin DW, Brady MT, Jackson MA, Long SS (Eds), American Academy of Pediatrics, Itasca, IL 2018. P.861.] https://www.cdc.gov/media/dpk/diseases-andconditions/lyme-disease/index.html Question 2) All of the following tick-borne diseases are relatively common in Missouri except for: A) Ehrlichiosis B) Rocky Mountain Spotted Fever C) Tularemia D) Lyme Disease Answer D) Lyme Disease Lyme Disease, although overall a common tickborne disease in the U.S., is uncommon in Missouri.

Only two cases were reported in Missouri in 2017 with an overall incidence rate of 0 per 100,000 population.

Incidences for Ehrlichiosis, Rocky Mountain Spotted Fever, and Tularemia in Missouri were 36.3-, 94.5-, and 5.4-cases per million, respectively. The overwhelming majority of documented Lyme Disease occurs in the northeastern and upper midwestern United States. https://www.cdc.gov/lyme/resources/ TickborneDiseases.pdf; https://www.cdc.gov/lyme/ stats/tables.html; https://www.cdc.gov/ehrlichiosis/ stats/index.html#geography; https://www.cdc. gov/rmsf/stats/index.html; https://www.cdc.gov/ tularemia/statistics/index.html

Question 3) Which of the following results would be most helpful in confirming the diagnosis of Tularemia?

A) Tularemia antibody titer of 1:160 at time of presentation.

B) Tularemia antibody titer of 1:40 at time of presentation and 1:80 on follow up 8 weeks later.

C) Tularemia antibody titer of 1:80 at time of presentation and 1:40 on follow up 1 year later.

D) Tularemia antibody titer of 1:80 at time of presentation and 1:1,280 on follow up 4 weeks later.

Answer D) Tularemia antibody titer of 1:160 at time of presentation and 1:1,280 on follow up 6 weeks later.

Confirmation of the diagnosis is established by a four-fold increase in the antibody titer between the acute and convalescent stages, which occurs approximately four weeks after onset of illness. Titers of 1:160 or higher are generally considered positive.

However, a single positive titer is not diagnostic, as they can remain positive for years and may represent a past infection. https://www.cdc.gov/tularemia/clinicians/index. html Question 4) Which of the following statements regarding gentamicin administration is false?

A) Renal function should be measured at baseline and monitored during treatment due to concerns for

nephrotoxicity.

B) Dosing is dependent on body weight in both adult and pediatric patients.

C) Hearing loss associated with gentamicin use is generally reversible, and hearing can be expected to return with drug cessation.

D) Even when dosing by body weight, drug levels should be monitored at regular intervals.

Answer C) Hearing loss associated with gentamicin use is generally reversible, and hearing can be expected to return with drug cessation.

Due to toxicity to the eighth cranial nerve, especially with prolonged duration or high doses, patients may experience hearing loss or vertigo due to ototoxicity and vestibulotoxicity. These side effects are irreversible and signs or symptoms of such should prompt consideration for discontinuation of gentamicin and consideration of an alternative agent.

MO-AFP.ORG 27

https://www.pharmaceutical-journal.com/learning/ learning-article/gentamicin-dose-regimens-andmonitoring/20069096.fullarticle?firstPass=false Question 5) When considering infection control for patients diagnosed with Tularemia, it is recommended: A) Patients should be kept in isolation rooms while in the hospital due to risk of transmission.

B) Lab personnel should be alerted when handling specimen suspected to contain Francisella tularensis, such as biopsy specimen.

C) Procedure or surgical mask should be worn to prevent transmission through respiratory droplets for all patients with suspected Tularemia.

D) N95 respirator is required when examining patients due to concern for airborne transmission.

Answer B) Lab personnel should be alerted when handling specimen suspected to contain Francisella tularensis, such as biopsy specimen Laboratory staff should be notified if specimen are suspected to contain F. tularensis, as manipulation of the cultures may produce aerosols or droplets.

However, isolation is not recommended by CDC due to lack of person-to-person transmission. Standard precautions are sufficient. https://www.cdc.gov/tularemia/clinicians/index.html

Family Medicine Physicians The Department of Family Medicine at Mayo Clinic Health System invites board certified or board eligible Family Physicians to have a life-changing career. The Department of Family Medicine is dedicated to providing reliable, high value, patient-centered, evidence based medicine in an innovative clinical environment that is supported by education and research. Family Medicine physicians and allied health staff practice in a team environment and serve a large and diverse community at four practice sites.

Opportunities available at: • Waukon, IA • Mondovi, WI • Tomah, WI • Austin, MN • Albert Lea, MN • Mankato, MN • Red Wing, MN

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To learn more, please visit mayocareers.com/MOFP

Heal the sick, Advance the science, Share the knowledge. ©2019 Mayo Foundation for Medical Education and Research. Post offer/pre-employment drug screening is required. Mayo Clinic is an equal opportunity educator and employer (including veterans and persons with disabilities).

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MISSOURI FAMILY PHYSICIAN SUMMER ISSUE 2019

References 1) Ellis, J., Oyston P.C., Green M., Titball R.W. “Tularemia.” Clinical Microbiology Review. 2002;15:631646.

2) Capellan, J., Fong, I. W. “Tularemia from a cat bite: case report and review of feline-associated tularemia.”

Clinical Infectious Diseases. 1993;16(4) 472-475.

3) Dennis D.T., Inglesby T.V., Henderson D.A., et al.

“Tularemia as a biological weapon: medical and public health management.” JAMA, 2001; 285:2763–73.

4) “Tularemia - United States, 2001–2010.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 29 Nov. 2013; www.cdc. gov/mmwr/preview/mmwrhtml/mm6247a5.htm?s_ cid=mm6247a5_w.

5) "WHO Guidelines on Tularemia." Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 2007; https://www.cdc.gov/tularemia/ resources/whotularemiamanual.pdf 6) Eliasson H., Broman T., Forsman M., Bäck E. “Tularemia: current epidemiology and disease management.” Infect Dis Clin N Am. 2006;20:289–311.

7) Ellis J., Oyston P.C., Green M., Titball R.W. “Tularemia.” Clin Microbiol Rev. 2002;15(4):631–646.

8) Peters, T. R., K. M. Edwards. "Cervical Lymphadenopathy and Adenitis."Pediatr Rev. 2000; Dec; 21(12):399-405. https://pedsinreview. aappublications.org/content/pedsinreview/21/12/399. full.pdf.

9) Stevens D.L., Bisno A.L., Chambers H.F., Dellinger E.P., Goldstein E.J., Gorbach S.L., Hirschmann JV, Kaplan SL, Montoya JG, Wade JC. “Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections, 2014 Update by the Infectious Diseases Society of America,” Clinical Infectious Diseases. 15 July 2014; 59(2)10-52. https://doi.org/10.1093/cid/ciu296 10) Kimberlin D.W., Brady M.T., Jackson M.A., Long S.S. “Tularemia. Red Book: 2018 Report of the Committee on Infectious Diseases.” American Academy of Pediatrics. 2018; 31:861, 11) Peterson J.M., Schriefer M.E., Jorgensen J., Pfaller M., Carroll K., et al. “Francisella.” Manual of Clinical Microbiology, 2015; 11:851.

12) Karlı A., Şensoy G., Paksu Ş., Korkmaz M.F., Ertuğrul Ö., Karlı R.. “Treatment-failure tularemia in children.”

Korean J Pediatr. 2018;61(2):49–52.

13) Jackson, M. A., Goldman, J. “AAP report details use of fluoroquinolones in children.” American Academy of Pediatrics,Oct 2016; https://www.aappublications.org/ news/2016/10/31/Fluoroquinolones103116 14) Lochary, Margaret E., Peter B. Lockhart, and William T. Williams Jr. "Doxycycline and staining of permanent teeth. "The Pediatric infectious disease journal, 1998; 17(5), 429-431.

15) “Rocky Mountain spotted fever.” Centers for Disease Control and Prevention, 2018; http://www.cdc. gov/ncidod/dvrd/rmsf/index.htm.

Skin Deep: How to Properly Code for Biopsies and Lesion Removal

© AAFP

Learn about the new skin biopsy codes, and follow these tips to make sure you get full credit for the skin procedures you perform.

i

t is often easier for family physicians to perform skin procedures than it is to correctly code for them. The codes are complicated, and many electronic health record systems and even the CPT manual use different terms than physicians use to describe these services. Incomplete or unclear documentation can lead to submitting lower-valued codes, which not only reduces practice revenue but also lowers physicians’ work relative value units (wRVUs), affecting their productivity-based compensation.

Correct coding for skin procedures is not impossible. This article will detail how to code for two types of common skin procedures — biopsies and destruction of lesions — as well as how to code when multiple skin procedures are performed on the same day. The “Skin care encounter form” (https://www.aafp.org/journals/fpm.html) features codes for the skin procedures most commonly performed by family physicians.

Performing Biopsies Using the 2019 Codes CPT deleted skin biopsy code 11100 and add-on code 11101 this year and introduced three base codes and three add-on codes that are defined by the method of biopsy — tangential, punch, or incisional — rather than size or anatomic location Simple closure, when needed, is included in the payment for all three biopsy types and should not be billed separately. If you need to manipulate the wound to get the edges to align, that is also not separately billable.

Betsy Nicoletti Betsy Nicoletti is a speaker and consultant in coding education, billing, and accounts receivable. She holds a Master of Science in Organization and Management from Antioch University, New England, and has worked in and around physician offices since mid-80s. Betsy is a member of the Medical Group Management Association and the AAPC. She lives in Northampton, Massachusettes.

MO-AFP.ORG 29

Tangential biopsies (codes 11102–11103), which include shave, scoop, saucerization, or curette techniques, are performed with a sharp blade and remove a sample of epidermal tissue, with or without a portion of the underlying dermis. These are not considered excisional biopsies, which remove the entire lesion with margins.

Punch biopsies (codes 11104–11105) use a punch tool to remove a full-thickness cylindrical sample of the skin.

Incisional biopsies (codes 11106–11107) use a sharp blade to remove a full-thickness sample of tissue via a vertical incision or wedge, penetrating deep to the dermis and into the subcutaneous space. This method may sample subcutaneous fat.

When multiple biopsies are performed for the same patient on the same date, only one primary biopsy code may be reported, depending on the following: • If multiple biopsies are performed using the same technique, report the primary code with the highest RVUs, then use the corresponding add-on code for the other biopsies.

• If multiple biopsies are performed using different techniques, report the primary code with the highest RVUs, then use the add-on code that is specific to the other biopsies performed.

When billing for these services, record the method and the number of units in your documentation. Although the location of the biopsy is not required to select a code, you should document it as well. An example of coding for multiple biopsies is shown below.

CPT left unchanged the codes for shave biopsies and excisional biopsies of benign or malignant lesions. Here are some reminders for those codes.

Shave biopsies (codes 11300–11313) use a sharp instrument to remove epidermal or dermal lesions without a full-thickness excision. They are used for therapeutic removal when the lesion is symptomatic, such as rubbing on a waist band or bra line. Shave biopsy codes are selected based on the location and size of the lesion. Simple closure, if needed, is included in the procedure and is not separately billable. Be sure to document the location and size of each lesion.

Excisional biopsies include two sets of codes, for excision of benign lesions (codes 11400–11471) or malignant lesions (codes 11600–11646). These codes are for full-thickness removal and should be selected based on the lesion type, the location, and the size of the excision, not the size of the lesion itself. The excision size is the largest diameter of the lesion plus twice the narrowest margin required to remove the lesion. Because excision code selection depends in part on lesion type, 30

MISSOURI FAMILY PHYSICIAN SUMMER ISSUE 2019

you must wait to submit the claim until after you receive the pathology report. For all other biopsies, you may submit the claim at the time of service.

Excision codes include simple wound repair, so this should not be reported separately. Layered closures may be billed separately, although the Centers for Medicare & Medicaid Services (CMS) does not pay for it in these cases. Again, be sure to document the size and location of each lesion, as well as the type.

Destruction of Benign, Premalignant, and Malignant Lesions There are three sets of CPT codes for destruction of benign and premalignant lesions, as well as a fourth for treating malignant lesions.

Destruction of premalignant lesions (actinic keratoses) should be billed based on the number of lesions. The first should be billed with code 17000, and each additional lesion, up to 14, should be billed with add-on code 17003. The destruction of 15 or more lesions should be billed with a single unit of code 17004.

CPT introduced three base codes and three add-on codes this year that are defined by the method of biopsy.

For the destruction of benign lesions (seborrheic keratoses and warts), bill a single unit of code 17110 to treat up to 14 lesions and a single unit of code 17111 for 15 or more.

Removing skin tags can be tricky as payers may consider the procedure cosmetic and not cover it.

Explain this to the patient, and document whether the skin tags are irritated or bleeding. Use a single unit of code 11200 for removing up to 15 lesions, and use add-on code 11201 for each additional block of up to 10 more.

The coding for destruction of malignant lesions is different than for benign lesions. Use a code from the 17260–17286 range for each lesion, and select the code based on the location and size of the lesion, not the defect. These codes include local anesthesia and are used for all destruction

methods, including electrosurgery, cryosurgery, laser treatment, and chemical treatment.

Note that more specific codes exist for destruction of benign and premalignant lesions on the mouth (40820), eyelid (67850), conjunctiva (68135), anus (46900–46924), penis (54050– 54060), vulva (56501–56515), and vagina (57061– 57065), and these codes should be used instead of codes in the integumentary system section of CPT. Destruction of lesions in the genital area may be coded according to whether it is considered simple or extensive, although CPT does not define these terms. Destruction of some genital lesions also are coded based on the method used.

Performing Multiple Procedures on the Same Day Multiple skin procedures are often performed at the same patient visit. This leads to questions about bundling and how to use modifiers when billing for more than one procedure on the same day. To bill these correctly and avoid denials, follow three steps: • Check the total RVUs for each code to determine which is valued highest (CMS provides this information at https://www.cms.gov/apps/ physician-fee-schedule/search/search-criteria.aspx).

• Check the National Correct Coding Initiative (NCCI) edits (https://go.cms.gov/2yLPjKp).

• Report the highest-valued code on the claim form without a modifier. If the second procedure is the same as the first or is bundled into the first based on NCCI edits, submit that code too, with modifier 59, “Distinct procedural service.” If the second procedure is not bundled into the first, use modifier 51, “Multiple procedures” (although Medicare contractors may not require modifier 51).

Note that payment amounts may vary when multiple procedures are performed on the same calendar day. The highest valued procedure may be paid at 100 percent, and procedures two through five may be paid at 50 percent. Billing more than five procedures may trigger a manual review by the payer.

Finally, remember to submit a wound repair code if allowed by CPT and, if you addressed an issue in addition to the skin procedures (hypertension, for example), include the appropriate E/M office visit code with modifier 25, “Significant, separately identifiable evaluation and management service.”

Most payers will pay for the E/M code, but some have additional edits for skin procedures, making it a challenge to get both the office visit and the skin procedures paid.

Here are some common procedure combinations and how to code for them:

Of course, this is only a handful of the possible procedures that could be done on the same day.

Access to up-to-date RVU and NCCI edit information is essential to correctly bill these procedures.

Documenting and coding skin procedures carefully will result in accurate payment and wRVU assignment.

To find more practice resources, visit https:// www.aafp.org/fpm/toolbox. AAFP News, Fam Pract Manag. 2019 Mar-Apr;26(2):15-19. © American Academy of Family Physicians Author disclosure: no relevant financial affiliations disclosed.

MO-AFP.ORG 31

Member Opinion

Urticarial Management

u Scott Darling, DO, RPVI, RVT Dr. Scott Darling has been in private practice in the Liberty, Missouri area for 20 years. He is Board Certified in Venous & Lymphatic Medicine, Sports Medicine/ Family Medicine and has additional training in Dermatology. He has been a dermatology provider for commercial insurance for 20 years.

32

rticaria is a commonly encountered dermatologic diagnosis that can be challenging to manage. Recently, a joint initiative of the Dermatology Section of the European Academy of Allergy and Clinical Immunology, the Global Allergy and Asthma European Network, the European Dermatology Forum, and the World Allergy Organization (EAACI/GA2LEN/EDF/ WAO) published guidelines for the diagnosis and management of urticaria in the journal Allergy, creating an important and highly valuable resource regarding the diagnosis and management of urticaria.

By definition, urticaria is divided into acute (lasting less than six weeks), or chronic (lasting more than six weeks) forms. Additionally, chronic urticaria can be classified as either spontaneous (previously known as idiopathic urticaria), where no specific etiology is identified (however 40-50% of these cases also have an autoimmune etiology); or inducible urticaria (previously known as physical urticaria), where a specific precipitating factor is identified. A third group, known as other inducible urticaria, which includes cholinergic urticaria/ exercise induced urticaria and aquagenic urticaria.1 Acute Urticaria is usually due to more obvious reasons. Looking for triggers or potential exposures such as allergy, infections, drug reactions or any systemic symptoms is helpful. In Acute Urticaria it is important to rule out anaphylaxis in the presence of respiratory, gastrointestinal, or neurological symptoms or hemodynamic instability, as angioedema can be a component in addition to spontaneous wheals < 6 weeks. Precipitating factors have been found in <50% of cases, with upper respiratory infections being the most common trigger (40%), followed by drug reactions (9.2%) and suspected food intolerance (0.9%).8 Infectious causes in the pediatric population could include, upper respiratory infections, Mycoplasma pneumonia and parasitic infections. In adults viral hepatitis and infectious mono-nucleosis are potential causes.9-11 Chronic Urticaria is almost never allergy related.

In the Chronic form of Urticaria, 30%-40% have hives only, 30% have hives plus angioedema and 10%-20% have only angioedema. Angioedema should be referred to the Allergist as these patients may have Hereditary Angioedema which

MISSOURI FAMILY PHYSICIAN SUMMER ISSUE 2019

is Bradykinin mediated not Histamine mediated urticaria, and they may have complement abnormalities that include inhibition of C1 or low C4.

Hives are more common in women. However, this is less true when we talk about children and elderly, where there is a 1:1 male to female ratio.

Inducible forms of urticaria have a longer disease process than other forms of urticaria.

"Acute Urticaria is usually due to more obvious reasons.

Looking for triggers or potential exposures such as allergy, infections, drug reactions or any systemic symptoms is helpful.

Chronic Urticaria is almost never allergy related."

The Dermatology Section of the European Academy of Allergy and Clinical Immunology, the Global Allergy and Asthma European Network, the European Dermatology Forum, and the World Allergy Organization (EAACI/GALEN/EDF/WAO) recommend against any laboratory testing in the diagnosis of most cases of acute urticaria, as the diagnosis can be made based on a thorough history and physical examination alone.1 For chronic urticaria, the recommendations are similar, with a strong focus on the history and physical examination. If one is suspecting an inducible form of urticaria, there are additional physical exam maneuvers to consider, such as a cold provocation test in cold induced urticaria; however, laboratory testing with sinus x-rays, dental x-rays and RAST tests are not recommended.

In the approach of Chronic Urticaria, it is important to confirm they truly have urticaria. Cell phone pictures can help document hives. A detailed history & physical exam are the cornerstones

of every work up for Chronic Urticaria. Labs for Chronic urticaria can include CBC with diff for evidence of infection, or an Eosinophilic cause, such as a drug or parasitic etiology. Additional labs should include ESR and TSH. If the ESR is positive, consideration must be given to urticarial vasculitis, where patients have purpura discoloration, hives that hurt more than itch and last for >24hours. TSH screens for the possibility of Hashimoto’s disease, acute Thyroiditis and Chronic urticaria. NSAID’s should be avoided as 40% of people with Chronic urticaria will have their hives worsen with their use.

Knowing how long the hives have been there and documenting when they occur is important.

Furthermore, asking patients if they have noticed any physical stimulus during the course of a day can be helpful. A thorough review of the patient medication list (with duration) is necessary; including a summary of the patient’s response to previous treatment attempts (i.e. have they already taken anti-histamines and did they work?).

Management Due to the potential of anaphylaxis in acute urticaria, consider Epinephrine. First line treatment for urticaria, in particular chronic urticaria, are H-1 2nd generation anti-histamine in FDA approved doses, such as Ceterizine 10 mg q D. In treating someone with Chronic urticarial it is necessary to

keep them on the anti-histamine on a continuous basis and not just when they have symptoms.

Anti-histamines work as what are called inverse agonists. They keep the anti-histamine receptor in the “off” position. It is naturally in the “on” position. Explaining this to the patient is helpful for understanding why they should stay on the anti-histamines at all times. If this one anti-histamine does not work, then the recommendation is to gradually increase the dose of the anti-histamine up to 4 times the FDA approved dose.1 Evidence shows that up to 40% of the patient’s that do not respond to the approved dose will respond to this increased dosing of antihistamine that was initially tried.

One of the differences in the European 2017 guidelines vs. the 2014 guidelines is, that it is no longer recommended to add a sedating antihistamine to a non-sedating anti-histamine due to lack of sufficient evidence to support an H-2 antihistamine in addition to the H-1 anti-histamine (not to say it does not work sometimes). If patients are on an H-1 anti-histamine and an H-2 antihistamine and a leukotriene inhibitor and it is working there is no need for change. If the patient does not respond to 4X’s the anti-histamine dose, the next step is to move on to Omalizumab (Xolair, the brand name) or Cyclosprin. These are the two agents that have the most effectiveness with regard to the literature and expert opinion.1 U.S. practice parameters only differ from European guidelines after Step 1, which consist of second-generation anti-histamines and trigger avoidance. Step 2 in the U.S. practice parameters consists of one or more of the following: Advancing the dose of second- generation antihistamine used in Step 1, adding another second-generation antihistamine, adding an H-2 receptor antagonist, adding a leukotriene receptor antagonist and then adding a first-generation antihistamine to be taken at bedtime. Step 3 in the U.S. practice parameters is to gradually advance the dose of the sedating H-1 antihistamine at night. Only in Step 4 of the U.S. practice parameters is the use of Omalizumab or Cyclosporin recommended. Omalizumab is a biologic agent. It is an anti-IgE, originally approved for the treatment of asthma in 2003, that has been found effective in chronic urticaria. This has led to a whole new body of research, discovering the mechanism of how IgE works, and how it is related to chronic urticaria, contradicting previous theories.

As a result, new treatments have been found. It was approved for the treatment of chronic urticaria refractory to anti-histamines in 2014. Therefore, theoretically it should be available for all patients.

MO-AFP.ORG 33

However, like with other Biologicâ&#x20AC;&#x2122;s, there is a preauthorization process in place. The FDA approval in the United States is for children 12 and older for Omalizumab.3 The optimal dose of Omalizumab is 300 mg q 4 weeks.2 Results of treatment are: 1/3 of patients become hive free, in 1/3 the hives get better, and in 1/3 the hives do not show much improvement. The medication peaks at 10 weeks. Keeping patients on the medication for at least 6 months before ending treatment due to initial non response is important.

The guideline recommendations are to treat children similar to adults. In children, secondgeneration, rather than first-generation antihistamines should be used and corticosteroids should be avoided or used sparingly because of growth-related side effects.6,7 The management of urticaria in pregnant or lactating women is also largely the same as in adults.5 Furthermore, in pregnant or lactating women, anti-histamines should be used in the lowest effective dose for the shortest period of time possible.5 There are guidelines available regarding what dose should be used for children.5 Cyclosporin in the U.S. is used at a dose of 200mg-300mg /day. It can affect blood pressure, BUN, CR and lipids. Monitoring labs and executing caution with elderly patients for renal impairment is necessary. A Cyclosporin burst for three months can control disease severity and mitigate side effects of long term use. Steroids are a last resource only. No long term use should be administered.

(Only the smallest dose that can control the disease for the shortest period of time).1 Urticaria severely affects the quality of life. There can be a financial burden to patients from both the cost of medication and inability to function at work.

Furthermore, patients are often self-conscious about the appearance of their skin. There is a way clinically to evaluate your patientâ&#x20AC;&#x2122;s response to treatment that does not require much time.

It is strongly recommended that clinicians adopt and utilize a standardized scoring system such as the seven-day urticaria activity score (UAS7). In the seven-day urticaria activity score (UAS7), patients are asked to record their disease activity in terms of number and/or severity of wheals over the past seven days ranging from a score of 0 (none) to 3 (intense, >50 wheals in a 24-hour period).1,4 Similarly, patients are asked to record their perceived pruritus over the last seven days ranging from a score of 0 (none) to 3 (intense).

Documenting the seven-day urticaria activity score (UAS7) before and during treatment, can significantly help tailoring the treatment plan to 34

MISSOURI FAMILY PHYSICIAN SUMMER ISSUE 2019

ensure that patients are actually improving.

Managing expectations, counseling patients not to obsess about the cause of their urticaria, shifting the patients focus on to living their life and controlling their symptoms as much as possible can be instrumental. Hives can be stress related but we do not know the causality. Furthermore, there are a multitude of diseases that present with hives and angioedema that should be considered (such as cryopyrin-associated periodic syndromes; urticarial-vasculitis; serum sickness-like reactions; mastocytosis; bullous pemphigoid and arthropod bites).

References

1. Zuberbier T, Aberer W, Asero R, et al. The EAACI/ GA(2)LEN/EDF/WAO guideline for the definition, classification, diagnosis and management of urticaria.

Allergy. 2018; 73(7):1393-1414. URL: https://www. ncbi.nlm.nih.gov/pubmed/29336054.

2. Maurer M, Rosen K, Hsieh HJ, et al. Omalizumab for the treatment of chronic idiopathic or spontaneous urticaria. N Engl J Med. 2013; 368(10):924-935. URL: https://www.ncbi.nlm.nih.gov/pubmed/23432142.

3. Highlights of Prescribing Information: Xolair. In: Administration FD, ed2016. Available at: https:// www.accessdata.fda.gov/drugsatfda_docs/ label/2016/103976s5225lbl.pdf.

4. Weller K, Church MK, Metz M, et al. The response to treatment in chronic spontaneous urticaria depends on how it is measured. J Allergy Clin Immunol Pract. 2019 URL: https://www.ncbi.nlm.nih.gov/ pubmed/?term=30731179.

5. Deacock SJ. An approach to the patient with urticaria. Clin Exp Immunol. 2008; 153:151-161 6. Fine LM, Bernstein JA. Urticaria guidelines: consensus and controversies in the European and American Guidelines. Curr Allergy Asthma Rep. 2015; 15-30.

7. Pite H, Wedi B, Borrego LM, Kapp A, Raap U. Management of childhood urticaria: current knowledge and practical recommendations. Acta Derm Venereol. 2013;93:500-508.

8. Zuberbier T, Ifflander J, Semmler C, Henz BM. Acute urticaria: clinical aspects and therapeutic responsiveness. Acta Derm Venereol. 1996;76:295297.

9. Williams KW, Sharma HP. Anaphylaxis and urticaria.

Immunol Allergy Clin North Am. 2015:35:199-219.

10. Kulthanan K, Chiawsirikajom Y, Jiamton S. Acute urticaria: etiologies, clinical course and quality of life.

Asian Pac J Allergy Immunology. 2008; 26:1-9.

11. Zuberbier T Urticaria. Allergy. 2003; 58:1224-1234.

Š AAFP

Photo Quiz: Annular Skin Lesions on the Chest

Figure 1

and figure eight morphologies where plaques had coalesced. The rest of the skin, mucosae, and nails were normal. A punch biopsy was obtained from the skin lesions and submitted for histopathologic examination.

Question

Based on the patient's history and physical examination findings, which one of the following is the most likely diagnosis? (See answer on bottom of this page)

A. Annular atrophic lichen planus.

B. Annular psoriasis.

C. Discoid lupus erythematosus.

D. Fixed drug eruption.

Discussion

Histopathologic examination from the punch skin biopsy revealed epidermal hyperkeratosis, parakeratosis and atrophy, follicular plugging, few apoptotic keratinocytes, and basal cell vacuolization.

Dense lymphomononuclear infiltrate was present at the junction of epidermis and dermis (interface dermatitis) and in the perifollicular and perivascular distribution, suggesting discoid lupus erythematosus.

Findings on direct immunofluorescence were positive for speckled antinuclear antibody. A 24-hour urine protein test was normal. The patient was treated with daily hydroxychloroquine (Plaquenil).

Discoid lupus erythematosus is the most common subtype of cutaneous lupus, with lesions mostly localized above the neck. However, 20% to 40% of patients with discoid lupus erythematosus present with a generalized form, in which lesions develop both above and below the neck (similar to this patient).1 The lesions start as erythematous papules with a scaly surface and expand peripherally to form large discoid plaques that heal with central atrophic scarring and pigment changes.2 Scales are adherent and when deliberately removed, demonstrate carpet-tack sign (i.e., spiky hyperkeratosis on the undersurface of the scale).2 Annular atrophic lichen planus is a rare variant of lichen planus that presents as intensely pruritic, small, annular plaques with raised, thin, nonscaly, delicate, violaceous borders and central atrophy. It commonly occurs on the genitals but may be found on the trunk and extremities.3 Oral and nail lesions may be associated with the condition.

Annular psoriasis presents as erythematous, scaly plaques that undergo central clearing (especially observed after treatment with retinoids). The lesions do not have the central atrophy and severe, persistent scarring seen with discoid lupus.4 Nail changes and arthritis may be associated with the condition.

Fixed drug eruption presents as well-defined, erythematous to violaceous, edematous, nonscaly plaques in the acute stage. The plaques resolve, leaving typical coin-shaped, smooth, hyperpigmented patches. The lesions can involve the oral mucosa, genitalia, hands, feet, and trunk. They usually develop shortly after medication use and recur every time the causative medication is administered.5 The answer is C: discoid lupus erythematosus.

a

woman presented with a one-year history of mildly pruritic, annular lesions on her neck, ears, and chest. She had no history of drug or medication use prior to the onset of the plaques. The patient reported hair loss on the scalp. Results of routine blood tests and urine examination were unremarkable.

On examination, there were multiple scaly plaques of varying size on the anterior aspect of her neck and chest. The larger plaques had central atrophic scarring and hyperpigmentation, with a prominent peripheral rim of erythema (Figure 1). There were horseshoe

Anuradha Bishnoi, MD; Ankur Guliani, MD; and Davinder Parsad, MD, Postgraduate Institute of Medical Education and Research, Chandigarh, India

MO-AFP.ORG 35

References 1. Cardinali C, Caproni M, Bernacchi E, Amato L, Fabbri P. The spectrum of cutaneous manifestations in lupus erythematosus—the Italian experience. Lupus. 2000; 9(6):417–423.

2. Lee HJ, Sinha AA. Cutaneous lupus erythematosus: understanding of clinical features, genetic basis, and pathobiology of disease guides therapeutic strategies. Autoimmunity. 2006; 39(6):433–444.

3. Eyler JT, Garib G, Thompson KR, Dahiya M, Swan JW. Annular atrophic lichen planus responds to hydroxychloroquine and acitretin. Cutis. 2017;100(2):119–122.

4. Guill CL, Hoang MP, Carder KR. Primary annular plaque-type psoriasis. Pediatr Dermatol. 2005; 22(1):15–18.

5. Flowers H, Brodell R, Brents M, Wyatt JP. Fixed drug eruptions: presentation, diagnosis, and management. South Med J. 2014; 107(11):724–727.

52nd Annual Clinical Advances in Pediatrics September 18-20, 2019

Children’s Mercy Park | Kansas City, Kansas www.childrensmercy.org/caps

Up to 17.25 CME hours

36

MISSOURI FAMILY PHYSICIAN SUMMER ISSUE 2019

This series is coordinated by John E. Delzell Jr., MD, MSPH, Associate Medical Editor.

A collection of Photo Quiz published in AFP is available at https://www.aafp.org/afp/ photoquiz.

Previously published Photo Quizzes are now featured in a mobile app. Get more information at https://www.aafp.org/afp/ apps.

The editors of AFP welcome submissions for Photo Quiz. Guidelines for preparing and submitting a Photo Quiz manuscript can be found in the Authors' Guide at http://www. aafp.org/afp/photoquizinfo. To be considered for publication, submissions must meet these guidelines. E-mail submissions to afpphoto@ aafp.org.

Address correspondence to Davinder Parsad, MD, at parsad@me.com. Reprints are not available from the authors. Author disclosure: No relevant financial affiliations.

Copyright © 2019 by the American Academy of Family Physicians. Am Fam Physician. 2019 Apr 15;99(8):517-518.

MEMBERS IN THE NEWS Two FMIG's Receive the AAFP FMIG Program of Excellence Award The University of Missouri School of Medicine, Columbia, Family Medicine Interest Group, and the University of Missouri, Kansas City School of Medicine, Family Medicine Interest Group, both earned the 2019 Program of Excellence Award from the AAFP. From Columbia, Amelia Frank, MD and Kane Laks, Student; and from Kansas City, Aneisa Slack, MD, and Morgan Dresvyannikov, Student, were recognized at the AAFP National Conference of Family Medicine Residents and Medical Students, held July 25-27 in Kansas City, Missouri.

James DiRenna, DO, FAAFP, Elected MSMA President James A. DiRenna, DO, FAAFP, Diplomat of the American Board of Ambulatory Medicine, from Kansas City, Missouri, was installed as 2019-2020 President of the Missouri State Medical Association on April 6, 2019, during MSMA’s 161st Annual Convention. Under his tenure as Missouri State Medical Association President, Dr. DiRenna will focus on collegiality, collaboration, and communication among Missouri physicians and medical students. He will promote his belief that, "Medicine is a profession – not just a job."

Lottes, Awarded AFMRD Resident Award for Advocacy Family physicians are advocates for their patients, their communities, and their specialty.

The AFMRD Resident Award for Advocacy recognizes resident physicians who show an interest and aptitude for advocacy. Dr. Ann Lottes, a chief resident at Mercy in St. Louis, was honored with this award at her graduation on June 6.

Dr. Lottes poses with MAFP Board Chair, Dr. Sarah Cole.

NEWS TO SHARE?

E-mail photos and news you would like to see published in the Missouri Family Physician to office@mo-afp.org for review.

Top Graduating Medical Students The Missouri Academy awards $500 scholarships to the top graduating medical students who are entering a Missouri family medicine residency. This year's award recipients are: • • • • •

Adam Reinagel, MD, Saint Louis University Cynthia Breanne Lombardo, MD, University of Missouri - Columbia Monica Paulson, DO, Kansas City University of Medicine and Biosciences Taylor Reiman, MD, University of Missouri - Kansas City Katherine Field, DO, A.T. Still University - Kirksville

Pictured below are Katherine Field, DO, (left) receiving her award from Dr. William Sexton; and Adam Reinagel, MD, (right) receiving his award from Dr. Christine Jacobs and Dr. Kimberly Zoberi. Congratulations to all.

Rampon Receives Joseph A. Lauber Service Award Kate Rampon, MD, Kansas University Department of Family and Community Medicine Faculty, received the Joseph A. Lauber Service Award. This award, named for the Mercy Family Medicine founding department chair, is awarded annually by the residents, faculty, and staff to the graduating resident who most embodies the time, energy, love, and compassion that Dr. Lauber himself lavished upon patients and peers.

Dr. Rampon poses with MAFP Board Chair, Dr. Sarah Cole.

MO-AFP.ORG 37

SMFM showme

Kicks off Summer at Lake of the Ozarks

Family Medicine CONFERENCE

t

he 2019 Show Me Family Medicine Conference kicked off the first day of summer at Margaritaville Resort on June 21-22 this year. Over 75 physicians gathered to earn CME, network with peers, and celebrate family medicine.

Friday's talks consisted of dermatology, mental health, diabetes, Hep C care, and medical marijuana debates. The Legislative Update was held during lunch with Dr. Keith Ratcliff and Dr. Peter Koopman joining MAFP Governmental Consultants, Brian Bernskoetter and Randy Scherr to discuss current and emerging issues that impact Missouri family medicine, physicians, and patients.

The day ended with an "It's 5 O' Clock Somewhere" Happy Hour with exhibitors.

Saturday, Dr. Michael Munger, Board Chair of the American Academy of Family Physicians, spoke to attendees about AAFP strategies for growing the future family medicine workforce, and AAFP advocacy initiatives to build payment reform, policies on enhancing patient care, and physician well-being. Other topics covered were fibromyalgia, osteoarthritis and low back pain management, adjuvant analgesics, medication mythbusters, and otolaryngology.

â&#x20AC;&#x153;The Show Me Family Medicine conference helped me understand the depth and breadth of family medicine and a life dedicated to it. The conference also showed me family medicine is so much more than caring for a community; it is being a part of one. Wow, maybe I am converted.â&#x20AC;?

Rocky Leng, Student University of Missouri - Columbia

38

MISSOURI FAMILY PHYSICIAN SUMMER ISSUE 2019

The MAFP Annual Business Meeting and Awards and Installation Luncheon was a great celebration of family medicine as we introduced the 2019 Family Physician of the Year, Beth Zimmer, MD, Tar Wars Poster winner, Riley Jo Hicklin, and installed your new MAFP President, Dr. Jamie Ulbrich.

New officers were installed, anniversaries were announced, and Degree of Fellow was conferred to: Jennifer Conley, MD, Nevada; Josephine Glaser, MD, Fenton; Amy Lockhert, MD, Osage Beach; Mark Schabbing, MD, Perryville; and Kimberly Zoberi, MD, St. Louis. Resident and student poster contest winners were recognized as well: 1st Place: Can You Elbow Your Way to Diagnosis? Kaci Larsen, MD, Resident, UMC; 2nd Place: Middle School Medical Explorers: A Tool to Increase the Primary Care Workforce, Morgan Dresvyannikov, Student, UMKC; 3rd Place: Chorioamnionitis: A Plague Among Us, Jennifer Livingston, MD, Resident, TMC. Saturday evening ended with the MAFP Family Beach Party. Thank you to all of our attendees, exhibitors, and sponsors who make this conference a success.

Thank You to Our Sponsors

MO-AFP.ORG 39

A Celebration of Membership

Thank you for your continued support and dedication to Missouri family medicine and to your patients.

25 Years of Membership

Tammy Albrecht, MD, Elk Creek Elizabeth Ballard, MD, Branson West Brian Bellamy, MD, Clinton Nishua Bendt, DO, Republic Kent Bogner, DO, Pleasant Hill Kimberly Bohlmann, MD, Rolla William Bryant, MD, FAAFP, Sikeston Rodger Campbell, MD, Stockton Brigitte Cormier, DO, Kahoka Matthew Cormier, DO, Kahoka Jane Daffron, MD, Plattsburg Stephen Dennis, DO, Monett TamarahDuperval-Brownlee,MD,FAAFP,SaintLouis Amie Etters, MD, Warrensburg Randy Foster, DO, Moberly Josephine Glaser MD, FAAFP, Edwardsville Kristen Glover, MD, Springfield Hudda Hantush, MD, Saint Louis Charles Harriman, MD, Lebanon Mary Hastings, MD, Chesterfield William Haynie, MD, Butler Michael Hemmersmeier, DO, O’Fallon Robert Herting, MD, Columbia Catherine Hohn, MD, Chesterfield Sabrina Jordan-Childs, MD, Florissant Kevin Kane, MD, Columbia Anthony Keele, MD, Cape Girardeau Debra Keith, DO, Weston William Kelly, MD, Republic Hee Sun Kim, MD, Springfield Krista Koinzan Boyd, DO, Nixa Candise Kroutil, MD, Strafford Tonya Little, MD, Fenton Brian Mahaffey MD, FAAFP, Ballwin Eric Mai, MD, Saint Louis Lewis Meyerson, MD, O’Fallon Philip Mitchell, MD, Lebanon Peter Montgomery, MD, Lake Saint Louis Robin Morris, MD, Liberty Patrick O'Hara, MD, Perryville Victor Pace MD, FAAFP, Springfield Erika Ringdahl, MD, Columbia Mark Schabbing, MD, FAAFP, Perryville Craig Schmidt, MD, Labadie Matthew Schumer, MD, Cape Girardeau Drew Shoemaker, MD, Boonville Patrick Smith, MD, Saint Clair Samuel Teferra, MD, FAAFP, Kansas City Gregory Terpstra, DO, Potosi Stephen Terrill, MD, Memphis 40

MISSOURI FAMILY PHYSICIAN SUMMER ISSUE 2019

Henry Tiemann, MD, Loma Linda Richard Tipton, DO, Gordonville Deborah Weems, MD, Saint Joseph James Wirkkula, DO, Clinton

30 Years of Membership

David Afshar, DO, Branson John Barth, DO, Holt Kenneth Braton, DO, Grandview Lisa Burns, MD, Town and Country Samuel Crow, DO, FAAFP, Springfield Cynthia Croy, MD, Joplin Steven Eldenburg, DO, FAAFP, Sedalia Ronald Evans, MD, Bolivar Anne Fitzsimmons, MD, Columbia Michelle Franey, MD, Grandview Todd Fristo, MD, Greenwood Sharon George, MD, MPS, FAAFP, Napa, California Gregory Goodwin, DO, FAAFP, Rogersville Charles Halbeck, DO, Saint Louis James Hall, MD, Kansas City Thomas Hamilton, DO, Joplin Tammy Hart, MD, Princeton Robert Heath, MD, FAAFP, Springfield Jimmy Heath, MD, East Prairie Grant Hoekzema, MD, FAAFP, Creve Coeur Elton Hoerning, MD, Mountain Grove Laura Holmes, MD, FAAFP, Cape Girardeau Brenda Izen, MD, Wildwood James Jones, DO, Saint Peters Christopher Kafka, DO, Parkville Nina Kiekhaefer, MD, Jefferson City Rosa Kincaid MD, FAAFP, Saint Louis Thomas Landholt, MD, Saint Louis Mark Lichtenfeld, MD, FAAFP, Chesterfield John Mackel MD, FAAFP, Cape Girardeau Robert Mason, DO, FAAFP, Lake Ozark David Miller MD, FAAFP, Wildwood Michael Misko, MD, CPE, FAAFP, Centerview Linda Myers, MD, Joplin Stephen Nester, MD, Saint Louis Jolene Ostwinkle, DO, Lebanon James Palen MD, FAAFP, Cape Girardeau Rebecca Rezaei, MD, FAAFP, Kansas City Leslie Robins, DO, FAAFP, Saint Charles Daniel Roney, MD, Kansas City Beth Rosemergey, DO, FAAFP, Lee's Summit Jacqueline Ruplinger, MD, Columbia John Salmon, MD, Branson Samantha Sattler, MD, Saint Charles

Robert Schaaf, MD, FAAFP, Saint Joseph Paul Schoephoerster, MD, Fayette Douglas Smith, MD, FAAFP, Odessa George Solomon, MD, Saint Louis John Symonds, DO, Maryville John Tabb, DO, Lebanon Steve Taylor, MD, Mexico Immanuel Uketui, MD, FAAFP, Saint Joseph Ronald Vance, MD, FAAFP, Bolivar John Wendt, MD, Sedalia Russell Won, MD, Saint Louis Julie Wood, MD, MPH, FAAFP, Leawood, Kansas Elizabeth Wuebbels-Jones, MD, High Ridge

35 Years of Membership

Anne Arey MD, FAAFP, Lees Summit Phillip Asaro, MD, Saint Peters Jonathon Bird, MD, FAAFP, Farmington Kevin Boatright, MD, Farmington Dennis Breed, DO, FAAFP, Kansas City Robert Buffaloe, MD, Harrisburg Clifford Costley, MD, FAAFP, Springfield Peter Danis MD, FAAFP, Saint Louis Daniel Dennis, MD, Trenton Rama Devabhaktuni, MD, Chesterfield William Donnell, MD, Bolivar Edward DuMontier, MD, Farmington William Fish, MD, FAAFP, Kansas City Sidney Griffith, MD, Cape Girardeau Terry Hall MD, FAAFP, Bethany Randal Hamric, MD, FAAFP, Springfield Deborah Herrmann, MD, Marshall William Hines, MD, FAAFP, Florissant Michael Houser, MD, Saint Charles Mark Houston, MD, FAAFP, Villa Ridge Dennis Hughes, DO, FAAFP, Shell Knob Stanley Jones, MD, FAAFP, Sikeston Glen Kirkpatrick, MD, Parkville Timothy Little, MD, Kansas City Layne Lovell, MD, FAAFP, Fenton James Lukavsky, MD, FAAFP, Branson Robert Morgan, MD, FAAFP, Saint Louis Michael O'Dell MD, MSHA, FAAFP, Kansas City Richard Schamp MD, FAAFP, Rockford, Michigan Ann Schumacher, MD, Belgrade Michael Shinn, MD, FAAFP, Kansas City David Showers, DO, FAAFP, Springfield Scott Soerries, MD, FAAFP, Saint Louis John Stanley, MD, Kansas City Michael Steenbergen, MD, Jefferson City Kenton Stringer, MD, Republic

James Turner, MD, FAAFP, Washington Kenneth Weston, MD, Columbia Thomas Wilkins, MD, Kansas City Stanley Wilson, MD, FAAFP, Sedalia Craig Wymore, MD, FAAFP, Leawood, Kansas

40 Years of Membership

Thomas Alderson, MD, FAAFP, Saint Joseph Jeffery Belden, MD, FAAFP, Columbia Edwin Breshears, MD, FAAFP, Fulton David Campbell, MD, FAAFP, Saint Louis R Collison, MD, FAAFP, Springfield Christopher Fletcher, MD, FAAFP, Hollister Polly Galbraith, MD, Naples, Florida Max Goodwin, MD, FAAFP, Liberty Dennis Handley, MD, FAAFP, Boonville Richard Honderick, DO, FAAFP, Coralville, Iowa Lonnie Kennington, MD, FAAFP, Chesterfield Larry Legler, MD, FAAFP, Blue Springs

Peter Marcellus, MD, FAAFP, Branson Charles Nester, MD, FAAFP, Webster Groves Larry Rues, MD, FAAFP, Leawood, Kansas Kevin Smith, MD, Chesterfield F L Thompson, MD, FAAFP, Nevada Gary Thomsen, MD, FAAFP, Lake Ozark William Winkler, MD, FAAFP, Villa Ridge Robert Zink MD, FAAFP, Saint Louis

45 Years of Membership

Jack Colwill, MD, Columbia Robert Laatsch, MD, FAAFP, Lohrville, Iowa Jerry Meyer, MD, Concordia

55 Years of Membership

Jacob Gandlmayr, MD, FAAFP, Ballwin William Green, MD, Saint Louis Bedford Knipschild, MD, FAAFP, Marshall Gene McFadden, MD, FAAFP, Waverly Joe Wall MD, FAAFP, Joplin Paul Williams, MD, FAAFP, Lees Summit

60 Years of Membership William Fair, MD, Chillicothe Marvin Fowler, MD, West Plains

50 Years of Membership

Sammy Farrell, MD, FAAFP, Washington Robert Magee, MD, FAAFP, El Dorado Springs Charles Sincox MD, FAAFP, Washington

MO-AFP.ORG 41

Governmental Consultant Report - 2019 End of Session he First Regular Session of the 100th General Assembly came to a close of Friday, May 17th. This session was the first for Governor Parson’s new administration since taking over in June of 2018.

Governor Parson was reasonably successful in accomplishing the priorities he set out in early January. He was able to get passed a Fast Track program for adults needing Randy Scherr MAFP Governmental Consultant more education and additional job training along with a bonding measure for bridge repair R.J. Scherr & Associates across the state. This session gave rise to the “conservative caucus” within the Missouri Senate.

Those senators stymied many pieces of legislation that ultimately did pass but the time lost in those efforts hurt the prospects of getting other legislation passed. Just for comparisons sake, this session the General Assembly passed 101 pieces of legislation. During 2018 Legislative Session the General Assembly passed 153 pieces of legislation.

t

Brian Bernskoetter MAFP Governmental Consultant Some of the priorities that lay on the Governor’s desk include: R.J. Scherr & Associates • Incentives for General Motors to expand in Wentzville.

• Venue and Joinder reform to improve Missouri’s civil lawsuit environment.

• Further limits on access to abortions.

• Implementing statewide regulations for concentrated animal feeding operations (CAFO).

Some of the Republican priorities that didn’t pass include: • Establishing a prescription drug monitoring program (PDMP).

• Blocking a transmission line from using eminent domain to get access to farm ground in northern Missouri.

• Many different tort reforms failed to pass including: reforms to Missouri Merchandising Practices Act, Statutes of Repose, updates to collateral sources rules, and punitive damages cap.

• Reforms to the Low-Income Housing Tax Credits (LIHTC).

• Implementing a procedure for collecting online sales tax from internet retailers.

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Bills that did pass this session include: Senate Bill 514 is an omnibus bill related to healthcare and was signed by the Governor. There were many provisions in it including: • Creates a number of different healthcare related boards and task forces.

- Substance Abuse Task Force to review drug and substance abuse and draft legislation to curb drug abuse.

- Pregnancy-Associated Mortality Review Board to review maternal mortality and recommend legislation to help at-risk populations.

- Joint Task Force on Radiologic Technologist Licensure to review the current status of licensure of radiologic technologists and develop a plan to address public safety. *Task force includes a physician appointed by the Missouri Academy of Family Physicians.

• Changes reporting and reporting requirements for physicians referring children born with identifiable substance abuse or fetal alcohol symptoms.

• Includes a few provisions to change prior authorization.

- Removes prior authorization for medicationassisted treatment and requires insurers to put those medicines on the insurer’s lowest cost-sharing tier.

- Streamlines prior authorization process for procedures by requiring insurers to transition to electronic prior authorization by 2021, requires insurers to disclose information on clinical criteria online and prohibits insurers from revoking prior authorization within 45 days of when a provider receives the prior authorization.

• Changes the terminology in statute for physician assistants from “supervision agreements” to “collaborative practice arrangements” to mirror that of APRNs and APs. • Requires use of e-scripts (with exceptions) by 2021 for any prescription of a Schedule II, III, or IV controlled substance.

• Prohibits insurers from paying providers with a payment device the provider has to discount to redeem.

• Removes patients with sickle cell disease from the 7-day opioid limit

• Allows pharmacists to prescribe certain nicotine replacement therapies after joint rule promulgation

by Board of Healing Arts and Board of Pharmacy.

Another omnibus bill was House Bill 399 which was vetoed by the Governor. It contains some of the provisions already listed above. Others not listed include: • New qualification requirements for someone to serve as the Director of the Department of Health and Senior Services.

• Requires insurers to cover more services for those diagnosed with autism spectrum disorder.

House Bill 138 – Signed by the Governor • Known as “Simons Law” – this bill prohibits a health care facility from instituting a do not resuscitate order without oral or written permission from at least one parent or guardian.

Senate Bill 147 – Signed by the Governor (Note: Governor Parson supported the repeal of the helmet law, but vetoed this bill on another provision.)

• This is an omnibus transportation bill but it does contain a provision to allow adult motorcycle riders to not wear helmets provided they have health insurance.

Senate Bill 414 – Vetoed by the Governor • This act creates the "Missouri Health Insurance Innovation Task Force" with the purpose of soliciting concepts and making recommendations for a section 1332 innovation waiver application under the Affordable Care Act. The task force shall focus on improving access to health care, decreasing premiums, and increasing the number of carriers.

Bills/proposals that didn’t pass include: • Assistant Physicians – Assistant Physicians were wanting to create a pathway for independent practice. Despite a late push to include this language in some healthcare omnibus bills these provisions didn’t pass. The supporter of this bill is very passionate about this opportunity for Assistant Physicians.

• Vaccines – there was no real movement beyond holding hearings on bills to prohibit doctors and

schools from discriminating against unvaccinated patients or requiring more information be generated by the state to be given to parents before vaccines could be administered. The anti-vaccine movement is very vocal. They ran into a headwind they could not counter in the wake of the measles outbreak in parts of the U.S. • Primary Care Investment legislation – this was a proposal crafted by MAFP to require insurers to provide the state with amount they are spending on primary care in relation to other healthcare expenditures.

• Suicide Prevention CME – legislation was heard in the Senate Professional Registration Committee to require physicians upon licensure and for two hours every two years to get training on suicide.

• Prompt Credentialing – this bill would have allowed providers to get paid back for services that are rendered to insured patients while the provider is being credentialed by an insurer.

• APRN – There were a lot of variations of bills to change the laws for APRNs but most included establishing an APRN license under the Board of Nursing and allowing the Board of Nursing to set the parameters for scope of practice for APRNs. • PT Access – this bill would have allowed patients direct access to PTs without a diagnosis for a limited number of visits.

Any legislation Governor Parson does sign becomes effective August 28th. There will be a veto session on September 11th for the General Assembly to consider over-riding any vetoes by Governor Parson.

Thank you to all who testified: Jennifer Allen, MD, Washington Peter Koopman, MD, Columbia John Paulson, DO, Joplin Donald Potts, MD, Kansas City Mark Schabbing, MD, Perryville Misty Todd, MD, Resident, UMC James Weiss, MD, Jefferson City And thanks to all those who responded to our “Calls to Action” and wrote letters to your legislators on MAFP’s priority bills. You make a difference!

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Ulbrich Assumes Helm of Missouri Chapter

aime Ulbrich, MD, FAAFP, is the newest MAFP President. Dr. Ulbrich will serve through June, 2020. Dr. Ulbrich lives in Marshall, Missouri with his wife, Sherri, and children, Rachel, Grace, and John.

Dr. Ulbrich runs his own business, Ulbrich Family Medicine, in Marshall. Betsy Garrett, MD, MSPH, introduced Ulbrich. Dr. Ulbrich shared why he chose Dr. Garrett to introduce him: "Dr. Garrett was the single most influential person in my life as a medical student at the University of Missouri – Columbia School of Medicine. She tirelessly guided me through the discernment process of helping me determine my specialty choice. For example, she met with me at Dairy Queen on a Saturday morning to talk with me at great length about family medicine as an option, but never forced it on me; yet allowed me to “figure it out” on my own. Most important though, was the fact that I liked her and the other faculty at MU and felt that “when I grew up” I wanted to be like

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them. They always reflected kindness, compassion, competence, and enjoyment in their work."

Acceptance Speech Mrs. Smith is a 71-year-old WF presenting to the Ulbrich Family Medicine clinic on Tuesday at 8:20 am for her routine follow up appointment. She has a history of A fib, CHF, COPD, hypertension, AODM requiring both long and short acting insulin, hyperlipidemia, and chronic renal insufficiency. She reports some recent weight gain in the last few days and some mild DOE that seem to correlate with her recent visit to her son’s house for a fish fry to celebrate her grandson’s graduation from high school. She denies any chest pain at this time.

She’s excited to tell me about how proud she is of her grandson’s graduation. She knows her family has struggled with some of his poor decisions he has made over the last year, but he pulled it out in the end and was able to graduate on time. I also care for her son and grandson and know a lot of

the details of the trials they have undergone in the last couple of years. She shows me her weight log for the last couple of weeks, revealing about a four to five pound weight gain. She shows me her blood glucose log; her fasting measurements are ranging in the 120-180 range except for the blood glucose the morning after she “just had to” enjoy a piece of graduation cake and ice cream. She admits that she will not be able to afford her short acting insulin this month but should be able to pay for her long acting insulin; the Breo script I sent in last month is just out of the question for now. I notice that she is not really having any difficulty with speech and breathing, but her feet and ankles appear more edematous than they had six weeks earlier when I saw her last. I also see she is in need of a Tdap as it has been over 10 years since her last one, and she has not yet received her recommended Shingrix immunization. Then she asks, “Doctor, how are you and your family doing today? Been fishing lately?”

I pause, and then for a moment in time, my mind travels in slow motion to my front desk. I see Anissa working there with a smile on her face as she’s answering the phone to help someone understand how, since they have not yet met their deductible, that they’re responsible for the amount due minus the copay they had paid during their last office visit.

She’s emailing the accountant the hours for payroll this week. She’s also checking in a patient for their 8:40 am appointment by verifying insurance, making sure we have their email for the patient portal, and confirming they haven’t changed any contact information. There is also a pharmaceutical rep poking his head around the patient, asking Anissa if he could have, “just a second of Dr. Ulbrich’s time.” {thought response} I wonder how my AR is doing.

I reviewed the check book last night and know I have enough to cover payroll this week along with bills that are due including rent, a bill from GSK, McKesson and our internet provider. I hope John, our accountant, gets me the payroll numbers back this afternoon because tonight is the only night this week I have to write out the payroll checks and

submit our 401k retirement account numbers. Our phone system was acting up last week; we were having trouble dialing out. The Voice-over IP system from Texas is telling us that it is our internet speed and/or bandwidth, and the internet company in Marshall is telling us that everything is fine on their end. I hope Anissa tells the drug rep that I am just way too busy this morning and sends him on down the road, and if he would like to actually schedule a time, I would be more than happy to give him five minutes or less.

"You have the privilege of helping so many people through physical, emotional, or relational issues that no one else can. That is the true joy of family medicine."

I turn and look down the hallway where Mandy is triaging a phone call with a patient who has been febrile overnight, experienced several bouts of emesis along with diarrhea, and isn’t really sure if he can make it out to be seen or not. She also has an insurance company on line two trying to get a precertification on a CT of the abdomen/pelvis for a patient we had seen the previous afternoon with mild left lower quadrant pain, slight elevation in white blood count and a history of diverticulitis in the past. The original computer prior auth did not go through and she is trying to arrange a peer-topeer as the patient is at the hospital and radiology is waiting for the precert to proceed. She’s also scheduling a follow-up with my first patient of the day who needs a disability placard as he has end stage OA and is not able to walk any distance with his four-point walker.

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{thought response} I probably need to get the patient Mandy is talking to on line one in to be seen this morning before lunch, you know, sooner rather than later. I wonder how much time out of my day the peer to peer is going to take for me to re-present the important information the reviewer should have already reviewed before getting me on the phone only to regurgitate what was already in my note. I’ll get, “Oh, I see that now,” after telling them what is already in my note or, “Well, I’m not sure that really meets our criteria but I’ll approve it this time.” Last time I was on the phone for 23 minutes when I had to do a peer to peer. Mr. Jones sure has aged since I first started seeing him 23 years ago. I hope he doesn’t have any problem getting his placard at the license office and I’m not sure why I have to spend time justifying his need to the state.

I turn to room #3 where Enetta is rooming Mrs. Lee for her Well Woman exam. She brought her son with her because he has been febrile overnight with a sore throat and cough and wondered if Dr. Ulbrich could just take a “quick look” at him. {thought response} I know that Anissa already collected a copay and put her son in the schedule because if she had not, she knows I would have went ahead and seen him and not documented like I should because she tells me I have no backbone and I can never not see someone once they get past her. I remember when I delivered Mrs. Lee’s first son 10 years ago and how cool doing OB was in the day prior to our state liability crisis when we had to cease doing OB as our premiums were going from 24 to over 50 thousand dollars, and there was no way we could continue to make ends meet if we were to continue. I wonder what’s going on with her son in there. That’s the fourth kid I have seen since yesterday with similar symptoms. I wonder if Dr. Cramer or Dr. Keuhn has been seeing any of this stuff in town.

In the lab, Darren is drawing a fasting lipid profile, cbc, cmp, hba1c, collecting urine for a microalbumin on a 52-year-old African American male scheduled for an appointment on Thursday. He also has two more patients in the waiting room that are waiting for similar testing as well. {thought response} I wonder if Darren is going to ask me for another diagnosis code to submit with the lipid panel this time. I hope it has been three months since his last a1c and not a day or hour too soon as it will be denied from his insurance. My red blood cells live 120 days but maybe his don’t live that long. Who really knows? Man, I wish I had Darren’s job. Draw blood all day. Go home at night and watch Royals baseball! Wow! I’m jealous!

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I return to exam room #2 with Mrs. Smith, finally. I continue to gain more history, review her medications for clarification and compliance, perform a physical exam, order some lab tests, and make a few changes to her medications. I also engage her in some shared decision-making, along with education on salty fish fries and how this is not a great idea in someone with an EF of 30 percent.

She kindly nods her head in agreement, but she and I know that at the next fish fry on the calendar, she will be present and accounted for and we can have a similar discussion at her next visit. I finish my note and esign as we are wrapping up and I hear, "by the way doctor, the real reason I came in today was I wanted to talk with you about……” You can fill in the blank here. Its addendum time and sometimes that note is longer than the original!

"I want you to know as President of the MAFP, I feel the frustration that is out there."

I’m sure my Tuesday morning is not unlike many of yours as family docs in other parts of this great state of Missouri. I share your frustrations as I have given you a sample of 15 minutes at Ulbrich Family Medicine in Marshall, Missouri. I’m frustrated with rising drug costs that my patients cannot afford. I’m frustrated with insurance companies interfering with the practice of medicine with stupid prior auth’s for procedures and drug approvals. I’m frustrated with Medicare requiring me to jump through hoops for MACRA telling me that this process will allow me to take better care of my patients. I have to pay 495 dollars per year to allow someone to do a cyber security audit so I can check that box on my MACRA list. I’m frustrated that I cannot give my Medicare patient in my office a Shingrix or Tdap shot at point of care because I cannot bill Medicare part D, but the pharmacy down the street can. I am frustrated as a small business owner that I cannot really negotiate a fee schedule with insurance companies and how hospitals can charge a facility fee and receive sometimes two to three times what I can get reimbursed from Medicare for doing the exact same thing. It is also frustrating to me that as a small business owner, I cannot compete to recruit physicians and mid-level providers with hospital systems and FQHC’s as they offer salaries that I cannot come close to offering.

I tell you all this because I want you to know as

President of the MAFP, I feel the frustration that is out there. As Cliff Knight, MD, Senior Vice President of Education, for the AAFP recently stated, “I’m convinced from the discussions I’ve led, that there is an epidemic of loneliness amongst physicians.” “I thought I was the only one that feels this way”, is a typical comment I hear. He goes on to say, “A little peer support can go a long way and might really help someone who is struggling in silence, ashamed that they suffer from human conditions when physicians are often expected to be super-human.”

I, for one, am not super human. Nor are any of my colleges that are here today. I present this clinical scenario to make a point. Despite all the frustrations out there, I can think of nothing better in the world (besides Darren’s job--just kidding) that I would like to be doing come Monday morning. FYI, we also have a lot of fun at work. We know how to continuously kid with each other to keep the mood light. We celebrate birthdays, preholidays, holidays, nurse’s day, doctor’s day, administrative professionals’ day, doughnut day, first day of spring, summer, fall and winter and any other excuse we can to celebrate. We have dress down day at a drop of a hat for any excuse we can find as well. We can usually make light of about anything if you give us some time. We have even been able to spot Ninja Warriors in our clinic at various times.

I get to share in the human experience of Mrs. Smith’s grandson’s success. I get to be a part of my patient’s passing as expected and sometimes not.

I can experience a mom’s joy and a father’s pride when they bring in a newborn, and usually get to hear later in the week from a grandparent of the same child on a separate visit that includes photos of their proud moments as well. I have the obligation to give someone their cancer diagnosis and walk through the process with them as they go forward.

It is weird that some of these patients won’t start their treatment until they know the cancer doctor has called and talked to me about it. Then it is okay with them to get started. You have the privilege of helping so many people through physical, emotional, or relational issues that no one else can. That is the true joy of family medicine.

At the state level, the MAFP Board met last summer for two exhaustive days creating a strategic plan. In that plan, we proposed three areas of focus.

The first is to continue to improve advocacy efforts at the capitol. Second, to increase public awareness of family physicians. The third, to create a pipeline for recruitment of the brightest Missouri students to become Missouri family physicians. A timeline was set to achieve these goals associated with each of these items. If you see a board member

this weekend, thank them for taking time away from their families to create this for the academy.

Hopefully everyone was able to listen to the advocacy update yesterday. We legislated a Primary Care Investment bill this year. We have continued to fight legislation expanding scope of practice for assistant physicians, nurse practitioners, doctors of nursing, pharmacists, athletic trainers, and anyone else who wants to practice medicine. Many states also share in the successes and failures like we have and do in Missouri.

At the national level, you got to hear Dr. Munger this morning speak about national issues that are being addressed. Payment reform, reducing administrative burden, and some welcome changes with the ABFM are but a few items that are they are working on. One of the most exciting items for me to hear about this spring at our leadership conference in Kansas City is how the AAFP is working with some AI companies to help improve our capabilities and capacities through these technologies.

"I get to share in the human experience of Mrs. Smith’s grandson’s success. I get to be a part of my patient’s passing as expected and sometimes not. I can experience a mom’s joy and a father’s pride when they bring in a newborn, and usually get to hear later in the week from a grandparent of the same child on a separate visit that includes photos of their proud moments as well."

My vision for the next year is quite simple: 1. Follow the strategic plan laid out by the MAFP last summer. I don’t feel like recreating the wheel, and if I were to do anything else, it would not be in keeping with what we have collectively agreed are our top priorities.

2. Try to continue to strengthen our board by improving our efficiency at meetings and allow us to MO-AFP.ORG 47

be more forward thinking. I want us to spend 80 percent of time with strategic planning and 20 percent on logistics. In other words, create a strategic agenda.

3. I want to meet with as many physician members as possible this year. Through various means such as social media, blogs, interactive media, emails, and phone calls.

I want to hear your story and know how you feel about various topics. I am very interested in what everyone thinks. Everyone is entitled to their opinion. We at the state level have not taken a stance on controversial issues based on moral and ethical differences of opinion based on religious or non-religious preferences. I feel the national academy could learn a lesson from us in this regard.

4. Rural Family Physician recruitment and retention seem to be a hot button topic even at the national level. I heard a lot of discussion at our leadership conference this spring regarding strategies to increase and improve upon this.

Everyone has a theory like payment reform, or increases in taxes to help fund these projects. In other words, put more money into it. I would be most interested, going forward, to see if a simple design in practice formation may be a feasible way to have physicians fill the gap in small towns in Missouri. It takes a person who wants to run a small business to go out today and start a practice. I have not heard or been impressed with the willingness to invest in this or the training that is provided to help achieve this. It is a scary notion to run your own business but also very

gratifying and freeing at the same time.

I would like to thank so many people for giving me the opportunity to stand before you today. I would like to thank our membership: all of our members here today and all the ones working in clinics, ER’s, and hospitals across this state that could not be here. If all the MAFP members could be here right now, the state would be in a crisis.

Thanks to MAFP staff, Kathy, for great leadership, and Sarah and Becki for making her look so good! My past mentors, Drs. Betsy Garrett, David Driggers, Steve Taylor, John Haynes, and my past partners, especially David Keuhn and Justin Cramer. My patients, who have taught me so much over the years and allowed me to be a part of their lives. My office family, Anissa, Mandy, Enetta, Darren, and their families, for them working even when they are sick or recovering from various ailments, for being nice to me and making me have fun at work. My family, Sherri, my wife of 26 years, thanks for allowing me to “marry up” and raising our kids while having a full-time job teaching nursing at the MU Sinclair School of Nursing, travelling one hour each way, each day. You definitely drew the shorter straw.

Rachel, for helping me be true to myself. Grace, for being a testament of courage and fortitude. John, for always finding humor even when it is not always appropriate. Lastly, I give thanks to my God for the courage to live this life and stand up in front of some the smartest people in the state and have them listen to what I have to say. Thank you.

IT’S NOT A JOB, IT’S A WAY OF LIFE. CoxHealth opportunities Recruiting BC family medicine physicians to practice in outpatient clinics: • Marshfield, Missouri – new facility • Springfield, Missouri • Lamar, Missouri • Harrison, Arkansas • Branson, Missouri • Monett, Missouri - hospitalist Opportunities are also available in addiction medicine and pain medicine.

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LOWER COST OF LIVING

72

MILES OF TRAILS

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1-800-869-4201 | paula.johnson@coxhealth.com 48

MISSOURI FAMILY PHYSICIAN SUMMER ISSUE 2019

NONSTOP FLIGHTS

Advantages: • Practice in a health system with more than 80 clinics and 200+ primary care physicians serving 24 counties • National Health Service Corps certified sites available • Receive a sign-on bonus and SPRINGFIELD MISSOURI relocation allowance

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Transition Conference Recap

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wo days in Kansas City were filled with learning at this year’s Transition to Practice Conference for Family Medicine Residents and Students. Beginning at noon on June 7, and ending at noon on June 8, provided a compact time period with hands on opportunities to learn and practice applying sutures to pig's feet, understand the value of organized medicine and the role that each family medicine student, resident and physician plays in impacting their future, the benefits and challenges of a rural family physician, and keeping with the times, an overview of the role that artificial intelligence will play, or plays, in family medicine. All wrapped up with a networking opportunity with residency programs, recruiters, residents, and students.

Thank you for your donations to the Family Health Foundation of Missouri which made this conference possible!

References for Dr. Dave McCarthy’s article, Suspect, Detect, and Correct, from page 16: Recent articles: (1) Vitamin D and the Skin: An Update for Dermatologists Am L Clin Dermatol 2018 Apr 19(2) 223-225 (2) Vitamin C and Immune function Nutrients 2017 Nov 9 (11) 1211 (3) Vitamin C in Dermatology Indian Dermatol Online J 2013 Apr-Jun 4(2) 143-146 (4) Skin Findings Associated with Nutritional Deficiencies Cleveland Clinic Journal of Medicine 2016 October: 83(10) 731-739 (5) Clinical Outcome of Septic Patients with Undetectable Vitamin D levels at ICU Admission Intensive Care Med Exp 2015 (Dec) 3 (Suppl 1) (6) Hydrocortisone, Vitamin C and Thiamine for the Treatment of Severe Sepsis and Septic Shock CHEST 2017 151(6) 1229-1238 (7) The Vitamin C, Thiamine and Steroids in Sepsis (VICTAS) Protocol Trials, 2019 Apr 5, 20(1): 197 (8) The Roles of Vitamin C in Skin Health Nutrients 2017, 9, 866 Historic Article: Clinical Guide to the Use of Vitamin C

Adapted from Vitamin C as a Fundamental Medicine: Abstracts of Dr. Frederick Klenner, 1988 by Lendon Smith, MD YOUTUBE videos: • ICU Nurses Discuss Vitamin C Therapy for Sepsis (2 min) • Full Interview with Dr. Marik (Vitamin C for Sepsis) (13 min) • Andrew Saul – High Dose Vitamin C Therapy for Major Diseases (53 min) • Vitamin D: The Miracle Supplement Video (Brigham and Women’s Hospital) (3.5 min) Current Books: (1) Vitamin D: Physiology, Molecular Biology and Clinical Applications Vol. 1 2nd edition (2010) Michael Holick MD (editor) (2) The Orthomolecular Treatment of Chronic Disease: 65 Experts on Therapeutic and Preventive Nutrition Andrew Saul, PhD, editor (2014) (3) Primal Panacea by Thomas Levy, MD (2011) Historic Books: (1) Vitamin C Merck Service Bulletin (1956) (2) The Healing Factor: Vitamin C Against Disease by Irwin Stone, PhD (1972) (3) Vitamin C in Health and Disease edited by Lester Packer and Jurgen Fuchs (1997)

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Zimmer, Named 2019 MAFP Family Physician of the Year r. Sarah Cole had the distinct honor to announce Beth Zimmer, MD, Weldon Springs, Missouri, as the 2019 MAFP Family Physician of the Year at the Show Me Family Medicine Conference.

Dr. Zimmer is a retired Lieutenant Colonel from 22 years of service in the U.S. Army Reserves and has volunteered for many mission trips in China and Peru. She and her husband, Dr. Stanley Carter, DVM, are advocates for suicide prevention.

Dr. Zimmer and her husband had one child, CPL Christopher James Carter, who died by suicide while on active duty as an Army Ranger at age of twentytwo. They formed a non-profit charitable foundation, the Chris Carter Charity for Life, which supports those struggling with mental health issues, and those who have experienced human loss. Dr. Zimmer also has voluntarily devoted much effort towards Suicide Prevention, reducing stigma, promoting Mental Health Wellness and improving Suicide Care in both the military and civilian populations. In January, Dr. Zimmer received the 2018 Greater St. Louis Community Health Award from the St. Louis Academy of Family Physicians.

Dr. Zimmer earned her medical degree from University of Missouri, Columbia. Dr. Zimmer trained in the Family Medicine Residency at St. John’s Mercy Medical Center in St. Louis, Missouri, where she served as Chief Resident.

She has practiced Family Medicine in St. Charles County, Missouri, for 30 years. Dr. Zimmer has served on numerous local and state medical association committees and has been recognized with many awards for her service to help those with mental illness.

d

Acceptance Speech Thirty years as a family doctor, I have been blessed with extensive opportunities. My family provided the support and encouragement allowing me to pursue my childhood dream of being a family doctor. My educators, mentors and peers gave me the knowledge.

However, my biggest gift has been the confidence of my patients in entrusting their lives and families’ lives to me. It is these thousands of these caring, and often reciprocal relationships, most whom I now can honestly 50

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call friends that is my greatest gift. I have been blessed.

So, to stand here and receive accolades for these privileges seems wrong but I am sincerely and deeply appreciative.

"If WE are not screening and addressing suicidality, who will?"

However, I now look to a new chapter in my role as a family physician. This role was definitely not a path I thought I'd be on. It has been placed before me by circumstances, but I feel the need to pursue and attack this challenge as passionately as I was in my youth about becoming a "Marcus Welby" modeled family doctor. I now know these same attributes are important in my new endeavor. My new role would best be described as a Suicide Prevention physician champion.

You see, I lost my only child to suicide four years ago.

It was then I learned how uneducated I was in caring for a suicidal person, either personally or professionally.

So, I got educated, and I am now on a mission to help educate all on Best Practice Suicidal Care. I want no one else to learn of the core deep, devastation, and I mean devastation, and lifetime regret, a death by suicide brings to a family, community, or a provider.

After these 30 years in practice, I believed I delivered comprehensive healthcare and thought myself pretty savvy on mental health care. But "Suicide" was not a topic with which I was comfortable and I believed this topic belonged in the behavior health field, not mine. I had not realized the tremendously growing national increase in suicides.

I didn't know that suicide has increased over 35 percent since the turn of the century, now landing it in the top ten of all causes of death, the second most common cause of death for those ages 5-35, and fourth most common for those 36-55. And, in children under 13, one child dies by suicide every five days in our country.

But here is this stat that is really pertinent to this group: Almost two thirds of those who die by suicide have seen their primary care physician within a month of their death and over a third within a week of their death, the majority of these visits are not for a mental health reasons and the majority of those who die by suicide do not have a mental disorder diagnosis.

So, if we are not screening and addressing suicidality, we are missing a major opportunity to identify and support our patients through a most critical and common risk of death.

What I also learned is, often a suicidal person wants us to ask, and the majority will admit their suicidality if approached in a non-judgmental manner. That they really don't want to die, but their feelings of isolation, burdensomeness and hopeless can lead to tunnel vision to see no other manner to relieve their internal pain. This suicidality can come and go rapidly and can be permanently cured. But it needs to be addressed directly.

We, in family medicine have a unique role of trusting relationships with our patients. If WE are not screening and addressing suicidality, who will?

But It get it. The "S" word is an uncomfortable subject and most of us are not confident caring for a suicidal person. We already have too much on our plates, and opening pandoras box to another schedule slowdown is daunting. However, in less time than it takes to do a blood pressure check, we can effectively screen. But screening doesn't do any benefit if we don't have competent intervention. We can’t rely on our mental

health partners to do it all. Mental health referrals to an unknown provider often are not completed or may be delayed several months, if obtainable at all. EDs are not the most therapeutic place for mental health delivery and hospitalization may increase suicide risk. Therefore, we need become comfortable with this topic to develop the confidence to deliver competent suicidal care.

I have joined with Mercy to initiate and implement the Zero Suicide initiative. I developed a CME to educate primary care on Best Practice screening, evaluation, triage, and management of a suicidal person. I have also helped develop EPIC tools and templates to assist providers in secondary screening, triaging into risk group, suggesting appropriate interventions, resources, and documentation. I am able and eager to share all this information with any other provider personally or with any groups or systems.

Before we depart, please take out your cell phones and if you haven't already done so, enter the National Suicide Lifeline Number: 1-800-273-8255. This is a national number, but routes locally, and can be used for crisis intervention or resources.

You don’t have to wait until a crisis to use the number, but in a crisis, you’ll be glad it’s handy. Share this with your family, friends, staff, you never know when you might need it and who’s life you may end up saving.

We can and need to address this devastating preventable cause of death. I beseech you to join me in making a world of zero suicide.

MO-AFP.ORG 51

MAFP Heads to Washington, DC

his year’s gathering of family physician leaders in Washington, DC, set records of attendance and contact with legislators during the Family Medicine Advocacy Summit, May 20-21. Over 300 family physicians participated in a day-long meeting learning about priority issues of the AAFP such as payment innovations, delivery systems, modernizing graduate medical education, healthcare in the media, rural health disparities, and primary care investment. This was followed by a full day of appointments with legislators where Missouri’s eight delegates shared stories and made the case for family medicine. Kurt Bravata, MD, Bolivar, an AAFP Key Contact, and the delegation met personally with Congressman Billy Long (R-District 7).

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This year’s message addressed: • Support or co-sponsor teaching health center funding (Missouri has one mental health facility in Joplin).

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MISSOURI FAMILY PHYSICIAN SUMMER ISSUE 2019

• Requiring high-deductible health plans to include a set of primary care visits at no cost to the patient.

• Reform the GME funding and training to promote primary care and increase rural physician workforce.

• Support funding to research gun violence.

• For our Congressmen/women, join the House Primary Care Caucus which advances public policy to promote primary care workforce as the foundation of today’s healthcare system.

Congressman Blaine Luetkemeyer (R-3) and Congressman Jason Smith (R-8) are already members.

"We are specialists, we are specialists in primary care."

-Kurt Bravata, MD

This is the second year that Kurt Bravata, MD, has attended the conference. He states, “I enjoyed it twice as much! Knowing what to expect and having built a comfortable rapport with my team, I felt more confident and at ease. From orientation to listening to informative presentations by impressive speakers, and participating in discussion forums, the whole experience prepared me for our meetings with our elected leaders. Our first advocacy meeting was with a staff member in the hallway outside Senator Roy Blunt's office. Although we were initially disappointed that we could not meet Senator Blunt, we were soon thrilled as Senator Mitt Romney shared a friendly greeting as he passed, followed by Senator Mitch McConnell.

We then met with the Legislative Assistant for Senator Josh Hawley.” During an active discussion, Dr. Bravata stated that, “We are specialists, we are specialists in primary care,” with Chris Weihs in Senator John Hawley’s office.

We met at length with Congressman Blaine Luetkemeyer and Congressman Billy Long. During our meeting with Congresswoman Vicky Hartzler’s staff, she surprised us by stopping in and took a few moments to meet us and engaged in a brief conversation. “Although there was some disheartening conversation about the budgetary restrictions imposed by partisan gridlock in DC; all of the legislators and their staffers expressed a reassuring level of interest, understanding, and support for the issues we discussed.”

Ann Lottes, MD, commencing her career as a new family physician, learned from fellow delegates who have been

involved in advocacy over the years. Dr. Lottes reviewed the issues with them and learned about the most effective ways to approach the legislative assistants and legislators.

A highlight for Dr. Lottes was the opportunity to speak with Zach Gates, Senior Legislative Assistant for Congresswoman Ann Wagner, her elected representative. “Though our district is primarily suburban, he was well aware of the need for more physicians and was curious about proposed legislation (HR 1358).” This bill would reform graduate medical education and increase the number of physicians working in rural, community hospitals by reforming CMS rules and increasing the funding limits for residents at those hospitals.

Dr. Lottes Ann attended the breakout session on primary care investment because of the Missouri legislation that was introduced this year. “They presented persuasive evidence that money spent on primary care provides good value. They also made it clear that, as each state regulates insurance differently, there is no ‘one-size’ legislation to bring this about.”

This year’s meeting was an exceptional opportunity to meet with our elected leaders and tell our story, build relationships with them, and become a resource on health care policy. With this year’s conference the largest ever, we are hoping next year will bigger, stronger, and more impactful. Family physicians are passionate and energized to make changes to policies that impact their patients, communities, and state.

ASSISTANT PROFESSOR - FAMILY MEDICINE CLINICIAN EDUCATOR Saint Louis University, a Catholic, Jesuit institution dedicated to student learning, research, health care, and service is seeking applicants for a full time faculty position (Assistant Professor) in the department of Family and Community Medicine.

A board-certified family physician with strong clinical skills and commitment to training future family physicians is sought for an academic faculty position in a vibrant and collaborative department. Practice will consist of a clinical ambulatory practice with faculty colleagues in an innovative Patient Centered Medical Home on the medical campus at Saint Louis University with an option for inpatient medicine. Join a large academic faculty for clinical teaching of medical students and residents in clerkships, electives, seminars, and mentoring of medical students for family medicine careers. Support and mentorship is provided for scholarship and research.

Application must be made online at http://jobs.slu.edu and must include a cover letter and curriculum vitae.

Applicants may also send their curriculum vitae with an introductory letter describing their past experience and three letters of recommendation to: Christine Jacobs, MD, Professor and Chair, Family and Community Medicine, 1402 S. Grand Blvd., St. Louis, MO 63104, or via e-mail to christine.jacobs@health.slu.edu. Calls with questions are welcome: 314-977-8480. Review of applications begins immediately and continues until the position is filled.

Saint Louis University is an affirmative action, equal opportunity employer, and encourages nominations of and applications from women and minorities.

MO-AFP.ORG 53

ACLF/NCCL Draws Leadership to KC he Annual Chapter Leadership Forum (ACLF) and the National Conference of Constituency Leaders (NCCL), held concurrent meetings April 27-30, in Kansas City. This year’s meeting provided opportunities to develop leadership skills, as well as craft resolutions to be brought before this year’s Congress of Delegates in September.

Missouri had a full delegation representing the special constituencies:

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Women – Amelia Frank, MD, Columbia LGBTQ – Theresa Drallmeier, MD, St. Louis New Physician – Kara Mayes, MD, St. Louis IMG – Arihant Jain, MD, Cameron Minority – Afsheen Patel, MD, Kansas City

L-R: MAFP Executive Director, Kathy Pabst; John Paulson, DO; Jamie Ulbrich, MD; Kara Mayes, MD; Arihant Jain, MD; Sarah Cole, DO; Amelia Frank, MD; Theresa Drallmeier, MD; and Afsheen Patel, MD

In addition, your elected MAFP leaders, Sarah Cole, DO, FAAFP, MAFP Board Chair; John Paulson, DO, PhD, FAAFP, President Elect; and Jamie Ulbrich, MD, FAAFP, President, attended sessions to prepare them for their advancement in the leadership of the chapter.

During a town hall meeting, the AAFP leadership: AAFP Board Chair Michael Munger, MD, President John Cullen, MD; President-elect Gary LeRoy, MD; and EVP and CEO Doug Henley, MD, fielded questions from inquiring members. The panel was moderated by with Speaker Alan Schwartzstein, MD. This Q/A session covered AAFP’s role and influence in the CMS Primary Care Initiative, health care reform, board certification, mid-level providers, rural/urban practice, EHRs, family physician workforce shortage, and the opioid epidemic. Gary LeRoy, MD, AAFP President 54

MISSOURI FAMILY PHYSICIAN SUMMER ISSUE 2019

Elect, noted that his Dayton, Ohio clinic “serves an urban population, and he agreed that health care reform is about identifying and fixing obstacles that affect patients regardless of practice setting or location.” Following the town hall meeting, CMS Chief Medical Officer, Patricia Meier, MD, provided an update on CMS projects.

Many resolutions were adopted during this threeday meeting. Some are listed below (provided by AAFP), and others are available on the AAFP website: • AAFP to consider providing child care at certain AAFP events.

• Taking race out of medicine to further promote health equity.

• AAFP to create a policy that speaks against the use of race as a proxy for biology or genetics in management guidelines, instead identifying race as a social construct.

• AAFP to advocate that estimated glomerular filtration rate be reported without regard to race, including by working with other medical groups such as the American Society of Nephrology.

• Work to improve access to care for homebound patients.

• Create a toolkit on implicit bias that can be used to educate the entire health care delivery team.

• Develop an anti-racism policy that includes verbiage encouraging members to participate in training on racism and implicit bias and to identify structural racism in their practices.

• Advocate that EHR vendors include sexual orientation and gender identity fields in their products.

• Oppose any legislation that limits medical decisionmaking in gender-affirming care for children and adolescents.

• Including gender-neutral language in its publications and producing patient education materials that use gender-neutral language (adopted).

• Work to improve access to care for homebound patients.

• Support standardized front-of-label food packaging.

• Advocate abolishing corporal punishment in schools, and; • Form a committee to study barriers that prevent FPs from obtaining privileges to practice operative and/or nonoperative obstetrics.

• Support use of a CDC toolkit for screening and

prescribing both pre- and post-exposure prophylaxis.

In addition, the resolution asks the AAFP to develop CME on the topic.

• Develop a policy regarding the assistant physician and associate physician designations that outlines their role on a health care team led by a fully trained physician, and discouraging them from being called family physicians.

Amelia Frank, MD, Columbia, shared her experience, “I feel in this group of family physicians, we come together to advocate for and support ourselves, our colleagues, and our patients with joy and determination. I now know the fierce pride of working on a resolution in a jumbled group of focused strangers and knowing that our work means something; that our resolution can go forward to a larger group of family physicians who will actually stop and listen to us: to those who might not have the loudest voices. I also come home with something different every year. I come home with a new determination and a new drive, a new sense of joy in my job and in the people I work with, fighting the fights every day.”

Theresa Drallmeier, MD, St. Louis, is a first-time attendee and represented the LGBTQ delegation.

She was, “Inspired by the many interesting people I met, all of whom were motivated advocates for the field of family medicine, for our patients, ourselves,

and the systems that we work in. I was excited to have the opportunity to co-author a resolution to improve CME offerings in pre-exposure prophylaxis training for HIV. PrEP is a primary care initiative that has great evidence but is under-prescribed, so it was great to advocate for increased training and awareness through the AAFP. I left the conference with a greater drive to be an advocate and voice within my community, healthcare system, and beyond.”

Second time attendee, Arihant Jain, MD, represented the IMG delegation. “NCCL has given me a chance to think beyond medicine, but for medicine.

I had the opportunity to learn about challenges faced by and issues going on with AAFP and family medicine and what is being done to tackle them. Getting inspired from leaders to advocate and further family medicine to increase access to care and reduce cost that is facing today's healthcare in America.” He also learned about the legislative/policy making process of AAFP by participating in resolution writing and going through various reference committees and parliamentary business session. Dr. Jain stated, “NCCL gave me confidence to speak up and address my concerns related to and affecting practice of family medicine. I hope to keep representing Missouri at NCCL to continue developing lifelong relationships, continue to be inspired to advocate for family medicine and being a better leader.”

PRIME Registry: Building the Future of Primary Care The PRIME Registry is unleashing the potential of patient and community data to build better primary care, helping shift the focus beyond individual disease diagnoses to measuring what really matters to patients and clinicians.

Join PRIME Registry, and help shape the future of primary care.

See u

AAFP

s at

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Septe MX m 24-28 ber , 2019 Booth #1436

*American Board of Family Medicine Diplomates are eligible for three years of PRIME enrollment FREE. After the first three years, the price per Diplomate is only $260/year.

email: PRIME@theabfm.org Visit: www.primeregistry.org The project described was supported by Funding Opportunity Number CMS-1L1-15-002 from the U.S. Department of Health & Human Services, Centers for Medicare & MO-AFP.ORG 55 Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

Middle School Medical Explorers:

A Tool to Increase the Primary Care Workforce

r Morgan Dresvyannikov, UMKC MAFP Alternate Student Director

56

eflecting on my journey into medicine, I have come to realize that there are very few healthcare exposure opportunities in middle school as compared to high school.

While middle school is a time of maturation, examination and self-discovery, rarely is it thought of as the time for students to make lifelong career decisions. Yet, without the stresses of AP tests, college applications, and the impending fear of graduation, middle school serves as a fertile ground for exploring what their future might look like in primary care.

At my middle school, we had one career fair day where parents would come and talk about their different career choices. There was a wide variety of pathways, but the only healthcare representation included a physical therapist and optometrist. At the time, I thought healthcare would be a fun thing to do, so I signed up for both of these sessions. After spending only 45 minutes with the physical therapist, seeing their different equipment, and hearing about what they did during the day, I decided that sounded exactly like something I would be interested in. Over the next two years, that is what I told everyone I wanted to do when I grew up. Long story short — middle school is a very impressionable time.

I was very fortunate to have a family that supported me in whatever I aspired to be. From seeing my mom go back to nursing school and becoming a nurse practitioner when she was forty, to my dad helping me find shadowing opportunities, to attending my grandparent's healthcare appointments; all of these experiences taught me that I wanted to be a healthcare leader and help people to the best of my ability. More importantly, without these experiences, I would have never made it this far: to my last year of medical school intending to become a family doctor.

So how do we help students decide if healthcare is for them? How do we increase the primary care workforce that we are so desperate to grow? How

MISSOURI FAMILY PHYSICIAN SUMMER ISSUE 2019

do we help the AAFP reach their goal of having 25% of medical students choose family medicine by 2030? How do we help educate future generations about healthcare basics that could save lives?

We meet them where they are. We go into middle schools. We explain the value of primary care and all that it entails. We let them get handson healthcare experience in a safe environment.

We teach them skills that could save lives, whether or not they go into the healthcare field.

At about this time last year, I was introduced to a highly motivated teacher, Andrew Hoskins, at Heritage Middle School in Liberty, Missouri who teaches a health class and robotics club. After meeting with him and the school’s principals, Kerry Broyles and Scott Carr, we started to brainstorm ways that we could help improve their students' healthcare education over the next year.

Luckily, getting face time with the students was pretty simple since the school already had built in "enrichment time" twice a week where the students could decide what sounded attractive to them and sign up for that particular session.

This is how Middle School Medical Explorers (MedEx) was started. At the beginning of the year, we had the students fill out a survey to see their level of interest in healthcare, knowledge of family medicine, likelihood of pursuing a career in primary care, and to rate workshops that sounded most interesting to them. During the year, we held approximately sixteen different hands-on workshops that taught over fifty different seventh and eighth-grade students topics such as CPR Basics, Trauma Basics, Stroke Education, EpiPen Training, Sports Medicine, Wilderness Medicine, Medical MythBusters, Primary Care Jeopardy, and Art in Medicine.

To top it all off, I was able to facilitate a field trip to UMKC’s Simulation Center for twenty-four students who had been involved throughout the entire year. The field trip included a high-fidelity anaphylaxis case, a standardized patient stroke encounter, task trainer competitions, and learning

Suturing workshop

CPR Basics workshop

Art in Medicine poster created by students

Wilderness Medicine workshop

High-fidelity Anaphylaxis Case

After each of the workshops, students would fill out a quick satisfaction survey, and 93% of the students rated every workshop as either a four or five-star experience. Also, based on the end of the year survey, we concluded that the twentyfour students who participated throughout the entire year had a significant increase in interest of healthcare, knowledge of family medicine, and the likelihood of pursuing a career in primary care.

What started as one of my hobbies and a way to give back to the community, has proven to be a much greater pipeline project than I ever could have imagined. The responses and impact from just this year alone have been so overwhelmingly

positive, that we have decided to expand to up to seven schools in Missouri for the next school year. In order to enable teachers to practice at their full scope, while also not having the program be limited to medical student volunteers’ availability or proximity, we have created a video series that can be used in the classroom. Not only that, but after discussing with the teachers what they would like, we have increased our curriculum to 45 lessons that could be used as a daily class for a quarter, 1 Unit (5 lessons) a month, or even be a MedEx after school club. These additional lessons also include more core subjects, have added a medical technology unit, and have even created a “A Day in the Life” series of what 15 different healthcare careers look like, how long they take to pursue, and things a middle schooler can start to think about to see where they might fit best on the healthcare team.

In conclusion, Middle School Medical Explorers allows students to get excited about a potential future in primary care while also giving them the motivation to excel in their current classes. We currently still have a couple of middle school slots available for this upcoming school year, so if you know of a highly motivated teacher and middle school that would be interested in implementing this MedEx program at their school, please check out our website at www.medicalexplorers.com or send me an email at mam5xc@mail.umkc. edu.

MO-AFP.ORG 57

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