Central PA Medicine Winter 2022 by Hoffmann Publishing Group

Your Community Resource For What’s Happening In Healthcare

WINTER 2022

Official Publication of the Dauphin County Medical Society

I am a virus. page 12

plus Colon Cancer Screening in 2022 page 6

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Central PA

Dauphin County Medical Society

400 Winding Creek Blvd. • Mechanicsburg, PA 17050

(833) 770-1541 • dauphincms.org 2022 DCMS BOARD OF DIRECTORS Shyam Sabat, MD President Jaan E. Sidorov, MD Immediate Past President Joseph Answine, MD President-Elect Andrew Lutzkanin, III, MD Vice President Everett C. Hills, MD Secretary/Treasurer

MEMBERS-AT-LARGE Mukul Parikh, MD Michael D. Bosak, MD John Forney, MD

WINTER 2022

Contents Features

"Rethinking" Depression

Colon Cancer Screening in 2022

A Patient, A Person, A Friend

I Am a Virus

Do the "Little Things" Really Matter?

Virginia E. Hall, MD FACOG FACP Andrew J. Richards, MD, FACS, FASCRS Andrew R. Walker, MD Saketram Komanduri, MD John C. Mantione, MD

EDITORIAL BOARD Joseph F. Answine, MD, Editor in Chief Ariel Jones, Executive Director

In Every Issue

Robert A. Ettlinger, MD Gloria Hwang, MD Puneet Jairath, MD Heath B. Mackley, MD

President's Message. . . . . . . . . . . . . . . . 4

Legislative Updates. . . . . . . . . . . . . . . . 24

Restaurant Review. . . . . . . . . . . . . . . . . 22

DCMS News. . . . . . . . . . . . . . . . . . . . . . . 28

Mukul L. Parikh, MD Meghan Robbins, MS2 Shyam Sabat, MD The opinions expressed in this publication are for general information only and are not intended to provide specific legal, medical or other advice or recommendations for any individuals. The placement of editorial opinions and paid advertising does not imply endorsement by the Dauphin County Medical Society. All rights reserved. No portion of this publication may be reproduced electronically or in print without the expressed written consent of the editor.

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President’s Message

DEAR DCMS MEMBERS, We will soon be welcoming Spring 2022 and probably peak-Covid is behind us. The data is getting better every day; international travel is also opening up gradually. Still, not let our guard down, please encourage your older and other vulnerable patients to get vaccine-boosted, if not already. I want to thank and expresses my gratitude to all our DCMS members for their resilience during these tough times and their unwavering service to their patients. Shyam Sabat, M.D. President, DCMS

The practice landscape in and around our county is rapidly changing. Some new hospitals have opened up, some have partially wound down services, several practices have been acquired by bigger hospital systems. Our DCMS along with PAMED is actively monitoring the situation and trying to safeguard interests of our physicians. The PAMED ‘Collaborative’ is an on-going state-wide effort to support and bring together independent and smaller practice groups to increase efficiencies, so that they can better follow regulatory compliance rules and get the ‘quality-associated’ payment benefits. Our DCMS has played a significant role in the Collaborative since its inception. We will be rolling out several CME opportunities in the coming months and of course, the PAMED website CMEs are always available FREE for our members to support their state licensing requirements. I would encourage our members to reach out to their friends and colleagues to sign up to PAMED and DCMS membership to access the FREE CMEs, get the networking and help in physician advocacy. We are exploring the possibility of merging with our adjacent Lebanon County Medical Society (LCMS) to increase administrative efficiencies. LCMS has a much smaller membership base and a smaller activity footprint than ours, and they would be benefitted by our active community, access to our networking, magazine and other resources. We will keep you updated on that in the coming months.

t, MD Shyam Saba

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Colon Cancer Screening in 2022 By JEROME BURKE, MD, FACG

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Introduction

The lifetime risk for colon malignancy in the U.S. is 5 percent. It should be noted that men have a 20 percent higher incidence of CRC and African Americans have a 20 percent higher incidence than Caucasions and are more likely to be diagnosed at a more advanced stage. First Degree Relatives (FDR) of patients with CRC have double the risk of CRC. It should be noted that 70 percent of CRC occurs in individuals with no family history (FH) of CRC or genetic syndromes. About 30 percent of patients with CRC have a FH of CRC or – less frequently – have a genetic predisposition such as Lynch Syndrome and Heriditary Polyposis Syndrome.

Colorectal Cancer ( CRC ) is a lethal and yet preventable disease both nationally and worldwide. There are roughly 150,000 cases diagnosed yearly with 50,000 annual fatalities in the United States.The overall 5 year survival for this diagnosis is 60 percent but when discovered at an early stage ( Stage A or B ) survival rate jumps to 90 percent making strategies that enable early detection so vital. Physicians and Public Health officials are dismayed that upwards of 35 percent of the eligible population does not participate in any CRC screening programs. The reasons for this are complex and include lack of access to testing for vulnerable and low income communities, The majority of CRC arises from adembarrassement and fears about testing and enomas that undergo molecular changes lack of a systematic approach to screening that progress to malignant neoplasm – a by health care providers. Nonetheless, process that may take upwards of 10 years. there has been a gradual decrease in CRC Appoximately 30 percent of CRC have morality in the United States over the Sessile Serrated lesions which more often past two decades whereas other developed occur in the right colon, are sometimes countries have seen a rise in CRC. This flat and harder to detect on colonoscopy trend can at least partly be attributed to and likely have a more aggressive biology. more robust screening protocols in the U.S. Unlike screening for Breast and Prostate Cancer, CRC screening can prevent the Risk and Protective Factors development of cancer in the first place by The most important risk factor for CRC employing colonoscopic polypectomy to is advancing age with over 90 percent of short circuit the progression of precancerous CRC cases diagnosed after age 40. The lesions to invasive CRC. incidence of CRC rises steeply after age 60 and continues to rise with each successive decade. In addition to FH of CRC, patients Epidemiology with a FDR under age 60 diagnosed with There is significant global variation in advanced polyps have higher risk. Other the incidence of CRC with North America, risk factors include a personal history of Europe, Australia and New Zealand having CRC or colon polyps, Inflammatory Bowel high rates of disease and Africa along with Disease, and Pelvic Irradiation. EnvironSouth Asia having the lowest rates. Dr. mental factors that are linked to increased Dennis Burkitt, a surgeon in the British risk include smoking, moderate to heavy Medical Service serving overseas during alcohol use, obesity, high intake of red meat, the post World War II era, observed that diets low in fiber, Diabetes, low levels of colonic diseases such as diverticulitis and physical activity, low socioeconomic status CRC were rare among Africans. He at- and possibly post cholecystectomy state. tributed this to lack of fiber intake in the Reported protective factors include high western diet. Population studies suggest physical activity, diets rich in fresh fruits that offspring of immigrants who move and vegetables, supplemental calcium, from low incidence areas for CRC to high Vitamin D, and folate. Wide spread use of areas assume the rates of their adopted land low dose aspirin for cardiac prophylaxis has suggesting major environmental influences been associated with a decrease in CRC in in CRC development. the middle aged population – particularly

in men. NSAID prescription use has been shown to attenuate polyp development in high risk patients with polyposis syndromes but are not advised routinely secondary to the occurrance of adverse effects such as gastrointestinal bleeding and kidney injury.

CRC Screening in Average Risk Patients Average risks individuals refer to those who have no FH or personal history of CRC or polyps, no genetic syndromes , no history of IBD and no gastrointestinal symptoms. The prevailing consensus among major advisory bodies including the American Cancer Society (ACS), United States Preventative Task Force (USPSTF) and the American College of Gastroenterology (ACG) advise that average risk patients begin screening at age 45 and continue to age 75. This has been motivated by an recent increase in the incidence in left sided colon cancer in younger patients in recent years. The USPSTF and ACG give “conditional” support recommendation citing weaker evidence of efficacy compared to beginning screening at age 50 where the evidence is more compelling. Decisions as to whether to continue screening after age 75 need to be individualized based on the patient’s comorbid conditions and previous screening history and not solely chronological age. As a rule of thumb, if a patient’s life expectancy is less than 10 years as harmful effects may outweigh benefits and should be discontinued.

CRC Screening in High Risk Patients Colonoscopy is the recommended procedure for screening in high risk patients. These include patients with a FDR with CRC or an advanced adenoma, IBD or a family history of a genetic syndrome. Screening should be carried out at age 40 or 10 years earlier than the diagnosis of the index case whichever is earliest. If the FDR was diagnosed under the age of 60, a 5-year interval follow up is advised. For those whose FDR were diagnosed at a more advanced age- a 10 year follow up Continued on page 8

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is recommended provided the initial exam is negative. Screening intervals for IBD and Genetic syndrome patients are more frequent and individualized depending on the circumstances. Patients who have a personal history of colon polyps or CRC undergo “surveillance” colonoscopy and generally undergo colonoscopy every 3 to 5 years and are not considered in the “screening” category. 8

Winter 2022 Central PA Medicine

FIT- Cologuard) and serologic testing ( Epi CRC screening modalities can be broadly proColon 2.0 ) which detects septin 9 DNA divided into four basic columns: Endos- hypermethylation. Though the serologic test copy – which includes colonoscopy, flexible is FDA approved, it is not recommended sigmoidoscopy, and capsule endoscopy, as a primary screening tool because of its Imaging – CT Colonography, stool based lack of sensitivity and will not be further studies which include, Fecal Immunochemi- discussed. More narrow screening can be cal Testing (FIT), Guaiac Based Fecal Occult further categorized as Step 1 - Colonoscopy Blood Test (gFOBT) and Multi-Targeted and Step 2 which includes all other tests Stool DNA Tests with Fit (MTsDNA / in that an abnormal result of all other tests

CRC Screening Methods

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must be followed up with colonoscopy. The ideal screening test should be sensitive and specific, inexpensive, easy to administer and safe. No one method checks all of these boxes. The pros and cons of each of these methods will now be reviewed.

Stool-based Testing F.I.T. Fecal Immunochemical Test (FIT) FIT testing requires one stool sample to be submitted annually and there are no dietary or medication restrictions. It detects human blood in the stool and is reported as positive or negative based on a quantitative reaction to reagent. The test has high sensitivity -80 percent and -94 percent specificity in pooled studies. Advantages - FIT is accurate, inexpensive, ( 20 dollars ) and does not require bowel preparation or dietary restrictions. It is particularly helpful in low resource communities and receives high marks from all reviewing advisory societies. Disadvantages - Results are optimal if the stool sample is processed within 24 hours as accuracy degrades over time and with high ambient temperatures. Best results are obtained if the test is done on an annual basis. Sensitivity for detecting precancerous adenomas is low. Multitarget Stool DNA Tests with FIT (MTsDNA/FIT - Cologuard) MTs DNAFIT is composed of a molecular assay that detects KRAS and two other gene mutations associated with CRC. Gene amplification techniques are employed to test for markers for methylation for biomarkers for CRC. This is combined with traditional FIT testing and a full stool sample is collected. The exam is done every 3 years. Sensitivity for detecting CRC is high 92 percent but sensitivity is lower than FIT alone. Results are reported as positive or negative, so it is unclear which component of the test, MTsDNA or FIT, is responsible for the positive test. Advantages – The exam is done at home with no bowel preparation, is non-invasive and annual exams are not required. Sensitivity for CRC detection is high.

Disadvantages - The test is costly (several hundred dollars) and has lower specificity than FIT.

those screened. Examinations are performed every 10 years in average risk patients.

Advantages – The major advantage Overall MTsDNA/FIT is less cost effec- for colonoscopy has high sensitivity and tive than annual FIT testing. This study is specificity compared to other screening not well suited for low resource commu- methods and provides diagnostic and nities. There is uncertainty with respect to therapeutic capabilities. Adenomas and how to follow up on a positive result in the Sessile serrated lesions can be removed setting of a negative colonoscopy. Sensitivity endoscopically at the time of procedure thus for detecting precancerous adenomas is disrupting the polyp to CRC progression. superior to FIT but still relatively low Colonoscopy can detect flat, sessile lesions that frequently escape other screening compared to colonoscopy. tests. Moreover, a negative exam by a high performing endoscopist is associated with Guaiac-Based Fecal Occult Blood Test a low risk for CRC for the next 5-10 years. (g FOBT)This method identifies hemo- Despite high “upfront” compares favorably globin in stool via a peroxidase reaction of for “years of life saved”compared to other impregnated paper slide, turning it blue on screening procedures i.e. mammography. contact. This is the oldest of screening tests Disadvantages - Disadvantages include and requires 3 stool samples on successive cost (cost highest among all of screening days. Sensitivity is wide ranging (31- 79 methods – varies regionally – 800 dollars percent) with one time use with a specificity to several thousand dollars), extensive of over 85 percent. Best practice is to do bowel preparation with possible dehydrathe exam on an annual basis. Multiple tion and electrolyte imbalance, time off randomized controlled trials, when properly from work and need for anesthesia with performed, reduce mortality from CRC. attendant risks. Serious procedure related Various brands exist but it is advised that complications include colon perforation high sensitivity Hemoccult Sensa be used. (1 in1000-2000), major bleeding post Advantages - Examination is low cost polypectomy and cardiopulmonary events (less than 20 dollars ), reasonable sensitivity related to anesthesia. Protective benefit of when properly performed and helpful in colonoscopy is highly operator dependent settings where resources are limited. with outcomes dependent on quality meaDisadvantages - The study is done on an sures such as the endoscopist’s adenoma annual basis and three separate stool studies detection rate and cecal withdrawal time. are provided which may make compliance Adequacy of colonic preparation can be difficult. Patients are advised to restrict problematic particularly in the detection intake of red meat during testing and avoid of flat right colonic lesions. Patients over the use of NSAIDs and ASA. Accuracy 65 are at higher risk for procedure related degrades over time and cards are sent to the complications. Canadian studies suggested lab via mail frequently. For these reasons, that colonoscopy was not highly effective FIT has largely replaced g-FOBT as the in preventing proximal or right sided CRC. preferred low-cost stool-based screening test. It should be noted that examinations were frequently performed by primary care providers and general surgeons, not gastroenterologists. Colonoscopy is not Visualization Screening Tests readily available in many low resource Colonoscopy Colonoscopy is often concommunities. sidered the “gold standard” when it comes to colorectal cancer screening. Sensitivity Flexible Sigmoidoscopy The procedure is for detecting CRC or precancerous lesions performed in the office setting frequently over 10 cm is over 95 % and 95 % specific. without sedation. The distal 40-60 cm of Pooled observational studies indicate a 68 Continued on page 10 percent reduction in CRC mortality for Central PA Medicine Winter 2022 9

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the colon is examined. A five year interval is recommended. The exam requires a limited bowel preparation. Mortality from CRC in studies is reduced by 50%. This result is primarily in the occurrence of left sided or distal colonic lesions. Advantages - The examination does not require sedation and time off from work. The bowel preparation is limited. Flexible Sigmoidoscopy is best done in conjunction with stool-based studies.

Capsule Colonoscopy Capsule Colonoscopy is a method of CRC screening approved for use by the FDA and European Medicine Agency as a screening tool. The sensitivity for detection polyps over 6 mm and CRC was 69% with a specificity of 86 Advantages - Non-invasive study, mod- percent. The examination will detect the erate costs, and good sensitivity. CTC is majority of CRC particularly with updated especially helpful for patients who are technology. Advantages – non- invasive –moderate cost unable to have a full colonoscopy secondary to altered anatomy or are unwilling to - good sensitivity and specificity - helpful for patients who are unable to have complete undergo colonoscopy. colonoscopy secondary to anatomic issues Disadvantages – A rigorous bowel prepaor unwilling to undergo colonoscopy. ration is required, radiation exposure and lesions over 1 cm in upwards of 90 percent in expert and high-volume centers. The procedure is low risk for complications and does not require sedation. It does require an extensive bowel prep much like that necessary for colonoscopy.

Disadvantages - Requires limited bowel prep. Sedation is not routinely administered and can be uncomfortable. It does not evaluate proximal colon lesions which are lower sensitivity in detecting flat – right responsible for 50% of advanced lesions sided colon lesions. Positive results require particularly in older patients and females. follow up colonoscopy which makes this Because of patient discomfort and guidelines study a less cost effective screening measure. advocating full colonoscopy, popularity of The presence of extra colonic findings on this test has declined. imaging may lead to further unnecessary investigations. Published data on CTC were generated by high volume centers. CT Colonography The examination is Community hospitals that do less frequent performed every 5 years for screening. exams may have less optimal results. Colorectal neoplasm detection of CRC and 10 Winter 2022 Central PA Medicine

Disadvantages – Full bowel preparation is required. Moderate cost. Abnormal results trigger full colonoscopy. This test is used more frequently in Europe and not widely available in the US.

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Conclusions CRC remains a major international and national health care challenge. Screening procedures are designed to detect early CRC and in the case of colonoscopy, prevent its development. Multiple options are available for screening and it is often postulated that the best screening test is the “one that gets done.” The method chosen for CRC screening in the population is most often driven by patient preference, advice given by primary care providers, and cost considerations. The ACG advises that the most efficient and effective strategy for colon cancer screening is either annual FIT testing or Colonoscopy every ten years. Since FIT testing best results are obtained when done on an annual basis, it requires diligence on behalf of both providers and patients. Proponents of MTs-DNA/FIT may disagree with this assessment. Colonoscopy is the most sensitive and specific study in detecting CRC and premalignant polyps and providing therapeutic capability when these lesions are detected. Best outcomes occur when the procedure is performed by an examiner who scores high on quality metrics. The bottom line is that CRC is largely a preventable disease. Advisory Boards recommend screening the general population between ages 45-75 based on evidence from multiple studies. Barriers to screening continue to exist and a primary determinant of who and how patients are screened is insurance status. Patients with private health insurance have higher screening rates compared to those with government sponsored insurance. It is not surprising that those with no health insurance have the lowest screening rates. Many African Americans and individuals with low socio-economic status have higher CRC mortality as a result of disparities in health system access to screening, diagnosis, and treatment. Most screening in the U.S. occurs on an “opportunistic basis” which is arranged at the discretion of a primary care provider or a request by patients to be screened. Organized screening processes are much more effective boosting CRC screening rates and include mail notification, email reminders, phone calls and utilization of EMR reminders. A study of Kaiser Permanente’s Northern California with 4 million members demonstrated a rise in screening rates from 38 percent in 2000 to 82 percent in 2015 by utilizing these measures. The effects of the COVID-19 Pandemic on screening in general and CRC in particular are yet to be elucidated but no doubt will be deleterious and will challenge providers and patients going forward. March is colon cancer awareness month. Let us do our part in CRC screening advocacy as providers not only every March but throughout the calendar year.

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I am a virus. By VIRGINIA E. HALL, MD, FACOG, FACP

12 Winter 2022 Central PA Medicine

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I am a virus. I need to join or infect you. I cannot live without you. Sometimes you will become very ill or you might not even live when I infect you. I have two parts but the part that needs to join you is covered by my clothing which is called a nucleocapsid or delivery system. My nucleocapsid is protein or some form of sugar. You would not run around without clothing and neither do I. Just like you, my clothing covers the essential part of me – my RNA or my DNA. It is my clothing that lets me attach to parts of you and then other portions of my clothing allow me to fuse with you. Once I have become attached and fused with you, I can do what I need to do to survive. I have two functions in my life one is to reproduce and make more of me and the other is to mutate or change so I can continue living. Your immunity proteins and cells remember me so I need to change or mutate so your body does not have a memory of my prior visit or visits like my RNA cousin, the flu. I

sometimes need to mutate so I can join with you more quickly or with more of you. Most times I am silent as I start my association with you. Your nose may be slightly more runny than usual and you think it may be due to weather or dust or a new pet. You may have a sore throat or an irritating cough you readily attribute to weather changes or ventilation issues. You may have nausea that you attribute to stress or a new food you tried or some family member’s lack of culinary skill. You may have abdominal pain as I attach to your intestinal lining and you may experience somewhat more frequent trips to the bathroom necessitating more of the Charmin or whatever toilet paper you use. You may get a headache or upturn in your usual body temperature or just feel tired and rundown with you attributing it all to stress, too much work, or need for a vacation. You see I want you to make excuses for me so you do not seek care in the early stages as I want to to pass my brother and sister viruses on to other people. Most times early in the attachment or infection process you have no idea I am entering you and I like it that way. I am willing to use your own receptors (attachment spots) if they suit my purpose. All of this allows me to enter your cells and allow the payload, my viral genome, to be duplicated many times over. You have an advantage over me. You have cells which contain both RNA and DNA and not all your cells do the same thing. I can do only two things after infecting you – reproduce and mutate. I really do not want to make you sick enough so that you take measures against me such as masking, frequent hand washing, social distancing, vaccinations, antibody treatments and intravenous and oral medications. But I do need to make you sick enough so I can reproduce and mutate and get to live. I certainly do not mean to kill you but sometimes that happens as your previous medical ailments may allow your lack of recognition of what I am doing go into overdrive destroying essential parts of you. A perfect example of a virus mutating year after year is the influenza (flu for short) where vaccines need to be changed from year to year.

Most of the viruses that infect people are RNA. These include polio, Norwalk, rubella, yellow fever, coronavirus, rabies, measles, mumps, Ebola, influenza, rotavirus, HIV, rhinovirus (causes 50% of common colds), and hepatitis A, C, D, and E to name some. DNA viruses that can make humans sick include hepatitis B, parvovirus, human papilloma virus (HPV, which can cause genital warts and various cancers later in life), adenovirus, herpes simplex, and vaccinia which causes smallpox. This list does not include all the viruses but any self-respecting virus like me must acknowledge my cousins. In case you haven’t guessed, I am the coronavirus (SARS-CoV-2) responsible for COVID-19. COVID-19 is the name given to the disease from the fact that I am a new coronavirus found in 2019. My official name is severe acute respiratory syndrome coronavirus 2. This is in acknowledgment of my 2002 sibling that caused illness mostly in China, Taiwan, Singapore, and Toronto, Canada. My cousin was quickly contained with the help of the World Health Organization and the health departments and agencies of countries around the world. I am a bit more clever than my older sibling as I spread more quickly and was not contained. Many of the countries where my sibling had many cases were willing to mask and to social distance. We shall return to that later. I spread through air droplets. These droplets come from people who are already growing me in their cells. When they cough or sneeze, I get a high speed ride to the next person – especially if they don’t cover their mouth and nose. If they use their hands instead of coughing and sneezing into their elbows and then shake hands or touch most surfaces, I can live for up to 96 hours (4 days) waiting for my next victim. Hand washing is one of my big enemies. In the virus world you are called a host. Yelling and singing are good pathways for me to get to other people. So are playing brass and woodwind instruments with the woodwinds being my favorites as air comes out through all the holes that are not covered. Continued on page 14 Central PA Medicine Winter 2022 13

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hypertension, chronic lung disease, sickle cell anemia, cancer chemotherapy, immune suppressing drugs for noncancers, renal dialysis, and age are conditions that make me able to infect in higher numbers in those patients with one or more of those conditions. I am more likely to kill people who have these conditions by destroying primarily their lungs when the cytokine storm causes severe inflammation and damage such that the tissues cannot repair themselves.

My favorite attachment site is the nose as there are ACE2 receptors (angiotensin converting enzyme receptors). You know these receptors well as they control your blood pressure and heart rate. You have them in your lungs, and throughout your digestive tract including your liver as well. When I first get into you and start infecting (joining) you, you may feel like you are coming down with one of my virus cousins, the common cold or the flu. You have a headache, runny nose, fever, and/or muscle aches. I am different from the cold and the flu as I will make you sick more quickly and keep you sick longer. That is if you ever get symptoms as 40-45% of those infected have no symptoms and yet shed me. You are shedding me for up to 2 days before you develop symptoms – if you ever do. Although I spread by an airborne path, I do not always cause cold-like symptoms of runny nose, cough, sore or scratchy throat, and/or fever. Sometimes you experience nausea, vomiting, and/or diarrhea (Did you know 41% of those I infect will shed me in their stool?). 14 Winter 2022 Central PA Medicine

I am unique as loss of smell and/or loss of taste are some more favorite things for me to do to you. The first week I make you sick has been described by some as “the worst case of flu I have ever had.” Only I am not the flu. I have a surprise for you during that second week of infection. Your body, finally recognizing me as not part of you, will try to destroy all of your cells I have managed to infect. Many physicians and other health care practitioners call this the cytokine storm. The cytokines are sugar and protein combinations called glycoproteins manufactured by T cells and help B cells. Both T and B cells are special white blood cells called lymphocytes. These cells help protect us against bacteria, fungi, and even cancers. They also can destroy organ transplants if drugs that suppress these cells are not carefully monitored. Some autoimmune diseases such as rheumatoid arthritis, lupus, inflammatory bowel disease and multiple sclerosis need immunosuppressants as well. I go through all this explanation to tell you who is likely to get into deep trouble when I infect them. Obesity, diabetes mellitus,

So how can you outsmart me? First and foremost is to get fully vaccinated with a COVID vaccine. Pfizer and Moderna are a two dose schedule with a booster dose six months or more after the second dose. These vaccines are available for ages 5 and up. Studies are currently underway for ages 6 months to 5 to see if you can protect these little children from me like people age 5 or higher can be protected now. Johnson and Johson has a one dose vaccine but this is not preferred as there were, in a small number (less than 1 in a million) of blood clots in lungs, strokes and low platelets (these normally make your blood clot when in higher numbers if you are injured). I was delighted to learn that some of you used excuses such as the vaccines are not studied enough to be safe (mRNA technology has been used for medical treatment since mid 1990s), you don’t like getting shots (who does?), or that personal freedom with the ability to choose overrules your obligation to take care of your family and fellow citizens. Some of you think you might be microchipped with the vaccine which is obtained from multiple dose vials; that would require microscopic vision plus the ability to separate TEN microchips into individual doses. Other ways to outsmart me is to wear a mask in enclosed spaces or in crowd settings, stay six feet apart, wash hands frequently, and avoid touching your face – nose, mouth and eyes. If you do these simple things, I have less chance to join or infect you. Washing hands frequently is important as I can live on many surfaces for up to 4 days and you all touch tables, chairs, and doorknobs more often than you realize.

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If you want me to join or infect you: 1. Do not get vaccinated and boosted. 2. Do not wash your hands. 3. Do not wear a mask. 4. Do not avoid crowded places or indoor gatherings. 5. Do not stay 6 feet away from people you do not know or who have been exposed to COVID. If you think you have COVID, congratulations. We are going to be close friends although you may get sick enough to be hospitalized or even die. There are drugs that can be taken early to prevent me from increasing my numbers inside you. Some are monoclonal antibodies which require intravenous placement or under the skin (subcutaneous) administration and dosing depending on where you are in your illness. The recently approved pills are in scarce numbers but may interact with medications you take for medical problems. It is particularly important if you have to see another physician to get Paxlovid or Molnupiravir to review all your medications and supplements with them. The antibodies and tablets both work best against me if given in the first ten days of illness. I am so happy when you do not care for others by asserting your rights are more important than others’ rights to uninfected air which we all share. As I continue to mutate to continue living, I will get more skilled at evading the vaccine, but the more of you who avoid vaccination and get the disease, the more I get a chance to mutate. With the current omicron variant which has 57 mutations different from the original SARS-CoV-2, I am more infective. However, vaccination, especially coupled with a booster, prevents hospitalization. Most hospitals find that 90% of those there are unvaccinated. No matter how smart you think your immune system is, I am smarter. If you want me to join you, follow those 5 simple rules I have listed above. I will be seeing you soon.

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Do the “Little Things” Really Matter? By GWENDOLYN POLES, DO

soft “hello,” an “eye smile,” a door held, wearing a mask to protect others as well as ourselves, yielding to another vehicle in heavy traffic, or tipping generously for home delivery are all examples of ways we can thank strangers and possibly decrease everyone’s stress during these past 2+ years of Covid. No one could have predicted Covid or how the world would be relentlessly impacted.

Our health care workers are experiencing a very difficult season due to the prolonged Covid pandemic, this unlike any season in recent memory. Covid has impacted all sectors of society in such a profound way but especially health care. Since I am retired, I can only imagine how they persevere, maintain a caring spirit, and continue to provide the high level of care they’re committed to despite current circumstances. To shine a light on health care disparities I’ve previously written about my and other patients’ challenges during encounters with the health care system. For people of color, especially Blacks/African Americans, these challenges existed pre-Covid. Some examples include health care 16 Winter 2022 Central PA Medicine

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professionals making harmful, inaccurate assumptions; demonstrating a lack of compassion; poorly managing severe pain; etc. One of the steps I took to address my concerns during those emergency department visits and hospitalizations over the previous two years was to file complaints with the patient representative. Each time I spoke with her, I requested to speak with the respective department heads. Oftentimes we are discouraged with the response and outcome of trying to make change through appropriate channels; but sometimes it works. Overall, this proved to be an effective strategy.

During my recent emergency department visits and hospitalizations protocols were still being followed. Even amid the Covid induced chaos staff were pleasant, caring, and upbeat. I made it a practice to ask nurses, technicians, physicians, transport workers, housekeeping staff, and dietary workers how they were holding up and offered words of thanks and praise for their efforts and kindness. Even though the food left much to be desired I said to myself “give thanks” – the food service workers came to work during challenging times. We have no idea what others are going through – do they have childcare challenges, are they caring for a disabled relative, what about transportation issues, are there issues that I could not imagine?

Unfortunately, I’ve had multiple hospitalizations and emergency department visits over the past few years but especially in the past several months. As a result, I have been able to witness true system change. One specific conversation with a department head proved genuine and productive. Protocols were developed and eventually implemented. I was also able to speak with a group of my colleagues virtually to share my personal experiences that also impacts others who do not have “voice” – patients who lack the privilege that I have as a physician. My desire was to implement change for all patients, not just for myself.

As we continue to navigate through this season, I encourage all of us to take a really deep breath, recognize this won’t last forever (although it feels like it has and will), perform self-care, connect with your spirituality, and be kind. So often the “little things” such as a soft word or an “eye smile” go a long way. It takes a lot less energy to just be kind. Through expressions of kindness, you will feel a whole lot better!

Additionally, a medication error in the programming of the electronic medical system was discovered and corrected. If this doesn’t demonstrate the importance of patient feedback to health systems (and other entities) I don’t know what does.

A person finds joy in giving an apt reply — and how good is a timely word! Proverbs 15:23 (NIV)

A soft answer turneth away wrath: but grievous words stir up anger. Proverbs 15:1 (KJV)

Peace of Mind in Uncertain Times. Find it with a Domani Wealth Advisor.

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Features

“Rethinking”

DEPRESSION By JOSEPH F. ANSWINE, MD, FASA 18 Winter 2022 Central PA Medicine

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irst and foremost, I am not a psychiatrist so when talking about depression, I may be no more educated on the disease as a layperson. However, as an anesthesiologist, I am fascinated by the brain and how it works. Furthermore, as a person, I, just like everyone else, am not free of some level of mental illness even if it’s just a reactionary depression secondary to a bad outcome.

When we are depressed, we just need to boost the levels of these neurotransmitters in our central nervous system to “excite” the depressed brain.

This article is a discussion and not absolute science so if my psychiatry colleagues want to chime in with an article or letter to the though it is expanding is still childlike or just editor, please do so. “the tip of the iceberg.” Up until recently, my understanding of But, the worlds of anesthesiology and the etiology of depression was that it is as psychiatry are beginning to come together simple as an imbalance of monoamines such as new therapies are involving medications as serotonin and norepinephrine. When we are from the anesthesia world or substances that depressed, we just need to boost the levels of are easily described as “mind altering.” these neurotransmitters in our central nervous Recently, a stereoisomer of ketamine, esketsystem to “excite” the depressed brain. That amine, has become FDA approved in a nasal is why tricyclics and now SSRIs and SNRIs spray form to treat severe depression especially are drugs of choice. But of course, it is the with suicidal ideation. The development of brain, so it cannot be that easy. Furthermore, this medication stems from the identification these medications alone or in combination of ketamine usually administered by infusion are far from universally effective. And, why as a treatment to dramatically lessen depressive would resetting the computer by artificially symptoms. Quickly as in hours as compared creating a seizure or a series of them lessen to weeks with standard monoamine therapy. the symptoms? But, to understand a mechanism of action What if by repetitive thinking or actions, for such a response is difficult when dealing we create neural pathways, good or bad, and with ketamine since it is considered a “dirty” shut down others; or form synapses to create drug meaning its effects are diverse and most pathways while allowing others to degenerate are poorly understood. We teach that it is a or sit idle? And, what if the frequently used non-competitive antagonist at the N-methyl neural pathways are not “healthy” ones; D-aspartate (NMDA) receptor which binds ones that create thoughts and feelings that the excitatory neurotransmitter, glutamate. are not compatible with a happy life? Could However, it is both an antagonist and agonist this actually be the origin of depression or depending on which of the many receptors anxiety? Studies show that regional blood it actually does bind to. It even has minimal flow to certain areas of the brain are altered affinity for the opioid receptor. One theory in some with psychiatric disease. That would behind the dramatic anti-depressive effect be consistent with alterations in used and/or is that ketamine creates “synaptogenesis” unused neural pathways. Currently, electroor rejuvenates currently unused neural shock therapy, vagus nerve stimulation and pathways to give a person a “choice” as to trans cranial magnetic stimulation are utilized what thought process to accept with the to open neural pathways as determined by hope that we process “happier” thoughts. changes in regional blood flow. Ok, that is “childlike” in the explanation but Now, after studying the effects of anesthetics you get it. The effect with ketamine is far on the brain and realizing that what “puts a from universal, many times short lived; but, patient to sleep” is not even close to be fully nonetheless, impressive and reproducible. understood, I realize that my education even

But, ketamine is not the only “new” therapy being studied. There is significant interest in the psychedelic drugs such as Dimethyl tryptamine (DMT) and psilocybin (the active compound being psilocin). Groups from Johns Hopkins have recently published studies with statistically significant improvement in depressive symptoms compared to placebo models. Again, depression as with other mental illness usually involves abnormal activity in parts of the brain such as the prefrontal and limbic brain regions, and when exposed to these psychedelic substances, through their serotonergic activity leads to reactivation of other portions of the brain. This hyper activation is likely responsible for the hallucinatory effects but again it is creating new neural pathways which could be the source of the significant improvement in mood. Again, I am not an expert in psychiatric disease, but I am fascinated by the effects of medications on the brain hence being an anesthesiologist. And, the crossover of psychiatry into utilizing molecules that alter perception and separate the brain from noxious stimuli (anesthesia) to improve psychiatric symptoms puts it into my pond and peaks my interest. Now, anesthesiologists should not now go out and attempt to treat these disease processes because there are loads of other non-medicinal therapies involved with caring for such individuals that are far, far out of the reaches of my specialty, but it’s fascinating how we as physicians grow with the times requiring us to change our theories of how the body works in order to advance therapy and improve outcomes.

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Features

A PAT IENT, A P E RS O N,

d n e i r aF By JOSEPH F. ANSWINE, MD, FASA

bout a decade and a half or so back, I was a new trustee on the Pennsylvania Medical Society board. During one of my first society board meetings, a staff person asked if I could talk to another about anesthesia. She needed surgery and wanted to know if I could take care of her. She was going to be admitted to one of my local hospitals. I met my future patient and found out that she needed a relatively quick urological

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procedure. However, she wasn’t without co-morbidities especially significant lung disease. The day came and in my opinion I gave her the perfect anesthetic. As I was patting myself on the back, she went into major bronchospasm and spent the night in the ICU. The next day, she recovered nicely, and I gave her my cell number and said call if I can help you in any other way. Little did I know that she was a wizard at texting and I would get daily messages and pictures of Daisy, her dog. As time went on, she needed another short procedure. I gave the perfect anesthetic again, and she ended up in the ICU again. I began to question my abilities but she was forgiving and our friendship continued. I received more texts and more pictures of Daisy dressed in outfits appropriate for the season, a pirate costume for Halloween or Stars and Stripes for the Fourth of July. In 2014, I broke my ankle, had surgery and was using a knee walker while at work. She asked how I was doing so I sent her a picture of me in scrubs with my scooter. Within a week I received a picture of Daisy in scrubs on a scooter. Daisy and I became August in the 2015 Daisy calendar that my patient had made. More anesthetics occurred, and less complications thankfully. As time went on, her health continued to deteriorate, but her spirits never faltered. She eventually went into nursing home care. Her biggest concern was not being with Daisy. Daisy eventually went into foster care and passed away peacefully at a ripe old dog age. My patient was given Daisy’s ashes to keep with her as a memento of the most photogenic pooch.

trips to the ICU post op but who is keeping track. This kind lady even broke her femur while the nurses were transferring her from the bed to a stretcher after a procedure in order to get her back to the long term care facility. A few were concerned about a lawsuit but I told them they would likely just get M&Ms.

MY FINAL MESSAGE: Patients are people and friends, and the world is full of

She passed away January of this year. Our last text exchange: “Don’t want to go under anesthesia without you. You won’t but better not to have it. You are right again.” She was blessed with great friends and two took it upon themselves to take care of her after her death. They gathered her belongings and contacted her “power-of-attorney” which is a distant relative since she had no close living ones. As occurs commonly, with the long term care needs, my patient was left without the funds for burial. However, her friends were determined to have her and Daisy buried with her mom. They worked their magic and a very reasonable price was set by the funeral home to get my patient and her dog to their final resting place.

We still needed some money though and the three of us could have put it together ourselves, however, we decided to ask our friends at the Pennsylvania Medical Society for help. We each took our own paths to contact friends at her old stomping grounds. It was decided that I would handle any funds we would receive. The ladies asked for my PayPal account number. I said “huh.” So, all were told to send checks or cash to my home address. Whatever we didn’t collect, the three of us would cover the rest. Within two weeks, I collected three times what was needed to pay the funeral home in full. Let me write this one more time. I received “3” times the amount needed from her friends at the Med Society!

generous and kind

individuals.

My patient’s health continued to deteriorate over the months and years including a cancer battle, however her spirits never wavered and the anesthetics continued for various reasons. But, each one came with a massive bag of M&Ms and a “There’s my number 1” each time I arrived. Every nurse and doctor she came in contact with knew of our friendship.

Even the American Society of Anesthesiologists knew of it since she contacted them telling them of “my amazing skills.” A few

We decided that the balance of the money will be donated to charities including the Foundation in my patient’s name. My final message: Patients are people and friends, and the world is full of generous and kind individuals. Thank you all from the bottom of my heart.

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A N

T S E T A U K C H L

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RESTAURANT REVIEW

By ROBERT ETTLINGER, MD

usually write up newer restaurants to fully experience our neck of the woods, but will go with a long-established one this time. Final Cut Steakhouse, located in the center of Hollywood Casino in Grantville, ranks up near the top of the list of multi-starred restaurants in Central PA. I gather that a lot of people haven’t had the pleasure, since it’s a little bit out of the immediate way for many of us. Fully blocking out the din of the surrounding slot machines, the round dining area features super high ceilings and elegant Hollywood relics, with pictures of the likes of Humphrey Bogart and Joan Crawford gazing down at the diners. A huge party room circular table has a lazy Susan for sharing bites. Obviously, the star choices are the steaks (filet, ribeye, porterhouse and New York strip) and chops (pork, lamb and bone-in veal). The Angus beef is aged and seasoned with tricolored peppercorns and sea salt, broiled in a 1600 degree oven, and finished with sweet Wagyu butter. They can be enhanced with four seafoods and six sauces. Partakers at our table described them, in the words of Spinal Tap, as an 11 out of 10. As one might expect, the wine bottle and glass selection is extensive. Apps are fairly standard (shrimp cocktail, charcuterie, oysters, butternut squash ravioli), yet presented in a very eye-catching way. Soups included a lobster corn chowder that was excellent, or a few colorful salads can kick start the main course. It was tough to choose from specialties to be had in lieu of the steaks and chops. The crab cake was the real deal, atop a Belgian endive and mustard buerre blanc. Pappardelle with shrimp and scallops were served in a saffron cream. Short ribs were reported to melt in your mouth, along with mashed potatoes and fried Brussel sprouts. The head and sous chefs, there for years, didn’t stop there. The reported top dessert choice is vanilla bean creme brulee. I had no complaints about a big slice of New York cheesecake with strawberry compote, graham crumble and citrus creme. While pricey, Final Cut is a perfect place for a special occasion, or to splurge with some of the cash you know for sure you’ll win at the blackjack tables.

FINAL CUT STEAKHOUSE 777 Hollywood Blvd, Grantville, PA 17028

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LEGISLATIVE UPDATES

PENNSYLVANIA MEDICAL SOCIETY Quarterly Legislative Update

s we come to a close on the 2021 calendar year, we also reach the midway point of the 2021-2022 regular legislative session of the Pennsylvania General Assembly. 2021 saw a return to a bit of normalcy at the state Capitol amidst the COVID-19 pandemic, but a new normal has certainly arrived. While many legislators are present on session voting days, remote voting is an option that many legislators have decided is the safest way for them to represent their constituents. Many offices, which had previously been easily accessible, are now locked or require advance appointments.

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Across the country we’re seeing tensions rise in state capitols, and in Washington, over election reforms, mask and vaccine mandates, over-crowded hospitals, and the overall impact COVID-19 has had on businesses and our economy. It has been challenging for all, especially those dedicated to patient care. As we look to 2022, politics may very well trump policy as legislators and legislative candidates eye the May primaries and November General Elections. 2022 also marks the creation of new legislative district maps that could potentially change the composition of the General Assembly and leave some legislators to decide if they should bow out of office or face the harsh reality of running against a colleague. Further, the eyes of the nation have shifted to the Commonwealth as we near a primary election for an open U.S. Senate seat in addition to the election of a new Governor’s. At last count, there are currently ten announced candidates seeking the republican nomination for Governor while Attorney General Josh Shapiro stands as the only democratic candidate. Despite the currently political environment, the Pennsylvania Medical Society (PAMED) continues to work tirelessly to defend the practice of medicine, protect the physician-patient relationship and ensure that we are always mindful of legislation and regulation that could potentially impact the practice of medicine. The pandemic continues to provide policy issues and challenges in addition to the existing priority issues that PAMED advocates on behalf of, which include scope of practice and prior authorization. The first year of the current legislative session provided a few highlights for PAMED. Among these were the enactment of Senate Bill 425 as ACT 61 of 2021. ACT 61 was a PAMED-supported effort to provide a remedy to the Pennsylvania Supreme Court ruling which had changed how consent was obtained in hospitals and other clinical settings by attending physicians. PAMED was able to support or provide neutrality on various agreements with

Advanced Practice Providers including the Senate Bill 705 - (Vogel) - Telemedicine passage of Senate Bill 416 (CRNAs) and -This legislation was voted favorably out of Senate Bills 397/398 (PAs). the Senate (46-4) and has been referred to Another key issue that saw movement the House Insurance Committee. PAMED was Senate Bill 225, an extensive effort supports this effort and will work to move to reform the prior authorization process. this bill through the legislative process While this effort has a long road ahead, it once again. advanced out of the Senate Banking and Insurance Committee for the first time and there is some level of optimism that it may be taken up before the full Senate early next year.

House Bill 681 seeks to provide a fair approach to both employed physicians and provider employers while setting specific requirements for when the use of restrictive covenants is appropriate. This bill has advanced out of the House Health Committee and is awaiting final consideration before the full House.

Senate Bill 416 - (Gordner) - This legislation officially recognizes certified registered nurse anesthetists (CRNAs) in the Commonwealth of Pennsylvania as well as outlining requirements for certification of CRNAs. PAMED followed the anesthesiologists’ lead in supporting this effort. This legislation has unanimously passed both the Senate (50-0) and the House (201-0). Signed into law as Act 60 of 2021.

House Bill 931 - (Toohill) - House Companion legislation.

Senate Bill 425 - (Gordner) - Informed Lastly, Senate Bill 705 that seeks to pro- Consent - PAMED supported this effort to vide legislative framework for the practice provide a remedy to a court ruling which of telemedicine has advanced out of the had changed how consent was obtained Senate. We have seen this effort reach the in hospitals and other clinical settings by Governor’s desk in the past only to see attending physicians. PAMED supported it vetoed. We are hopeful that this effort this effort which passed the Senate (50-0) might reach a compromise in the second and the House (201-0). Signed into law year of this session. as Act 61 of 2021. While these are only a few highlights of the current legislative session, detailed below is a list of other issues that we are actively monitoring along with a brief summary. PAMED continues to engage in a number of legislative issues as well as participating in a large coalition to prevent any changes to the current Pennsylvania Supreme Court Civil Procedure rules regarding venue in medical malpractice professional liability cases.

House Bill 1420 - (Thomas) - Health Care Heroes Act - PAMED supports this effort to establish a public awareness campaign to provide information regarding the programs and services available for first responders, healthcare workers, and other workers suffering from mental health issues related to COVID-19. Having unanimously passed the House (202-0), this bill now awaits a vote in the Senate Health and Human Services Committee.

House Bill 245 – (Kaufer) – InternaHouse Bill 1082 - (DelRosso) - PAMED tional Medical Graduates (IMGs). Seeks to supports this legislation, which establishes modernize the process by which graduates an education program for providers on early of international medical schools become diagnosis of Alzheimer’s disease and other licensed. Passed the House (201-0) and dementias and incorporates information has advanced out of the Senate Consumer about the disease into existing public health Protection & Prof. Licensure Committee outreach programs. This bill passed the and now awaits action from Senate Ap- House (201-1) and is now awaiting final propriations. We anticipate this bill to get consideration by the full Senate. to the Governor’s desk in the near future. Continued on page 26 Central PA Medicine Winter 2022 25

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LEGISLATIVE UPDATES with specific guidelines and restricts. This bill was recently voted out of the Senate Consumer Protection and Prof. Licensure Committee, but it is not anticipated that this bill will advance beyond the Senate in its current form. Likely, any movement on this issue would come in the form of a bill/amendment that starts from the agreed upon pilot program. (HCO2108) – (Hickernell) – Co-sponsorship memo recently introduced to advance the pilot program legislation. House Bill 681 – (Ecker) – PAMED has worked closely with the sponsor of this bill, Rep. Ecker, to advance legislation dealing with restrictive covenants in health care practitioner employment contracts. This effort would seek to provide a fair approach to both employed physicians and provider employers while setting specific requirements for when the use of restrictive covenants is appropriate. This bill has advanced out of the House Health Committee and is awaiting final consideration before the full House.

House Bill 1280 - (Jozwiak) - Patient Test Results - PAMED will be working with the cardiologists to advance this bill through the House after it recently was voted favorably out of the House Health Committee. This bill amends the Patient Test Result Information Act in addressing how patients receive notifications after certain tests, etc. Senate Bill 397 – (Pittman) – Physician Assistants (PAs); seeking to help physician assistants work and practice with increased efficiency. The bill allows for modernization for physician assistants to practice while maintaining their role under supervising physicians. This legislation has recently passed the Senate (50-0) and House (2000); signed into law as Act 78 of 2021. (DO ACT) Senate Bill 398 – (Pittman) –This legislation has passed the Senate (50-0) and House (200-0) and has been signed into law as Act 79 of 2021. (MD ACT) 26 Winter 2022 Central PA Medicine

Senate Bill 225 – (Phillips-Hill) - Prior authorization reform bills. There is a large coalition with multiple provider entities and patient advocacy groups seeking to make wholesale changes to the prior authorization process in the Commonwealth. PAMED has played an integral role in developing this legislation and working to advance it. While this legislation will require ongoing efforts to continue to advance it through the legislative process, it was voted out of the Senate Banking and Insurance Committee. PAMED continues to work with a broad coalition to pass this important legislation. House Bill 225 – (Mentzer) – House Companion legislation. Senate Bill 25 - (Bartolotta) – PAMED opposes this legislative effort which seeks to grant CRNPs independent practice authority. PAMED has long opposed these efforts, but last session agreed to listen/ negotiate a pilot program where CRNPs would be granted independent practice

House Bill 958 – (Zimmerman) – PAMED opposed this effort that would prohibit pediatricians from deciding not to provide care to unvaccinated patients or patients whose parent or legal guardians choose to utilize a vaccination schedule that varies from the vaccination schedule recommended by the CDC. While this bill advanced out of the House Health Committee, PAMED does not believe this effort will advance beyond there. House Bill 1033 - (Rapp) - This bill requires health insurers to cover treatment plans of Lyme disease or related tickborne illnesses as prescribed by a health care practitioner; issues over what type of treatments could be covered (experimental long-term antibiotic for example). Although PAMED opposed this effort, this legislation has passed the House (136-66) and has been referred to the Senate Banking and Insurance Committee. Senate Bill 621 - (Brooks) - Publishing of vaccine availability by physicians - PAMED opposed this legislation which would require physicians that provide the COVID-19

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vaccine to pay for the weekly publication of vaccine data, such as the number of vaccines they have available, in local newspapers. Further, it would require that physicians in private practice vaccinate any individual who shows up even when an established relationship does not exist. This bill failed at the Senate Health and Human Services Committee level and has been referred to the committee by a motion to reconsider.

bill was signed into law as Act 72 of 2021.

House Bill 1319 – (DelRosso) – This legislation is intended to curb the predatory practices of Pharmacy Benefit Managers (PBMs) by targeting the practices being used by them to interfere with the funding stream health centers and 340(b) plans used to fund the care they provide to low-income, uninsured residents. PAMED supports this effort and anticipates a committee vote in Senate Bill 671 - (Hutchinson) - Retain- House Health during early 2022. ing Health Care Innovations Act - PAMED House Bill 1440 – (Millard) – PAMED opposes this effort to extend the emergency supports this legislation that would establish administrative regulation changes granted a Medical Imaging and Radiation Therapy to health care facilities, practitioners, Board of Examiners which would license and providers by Governor Wolf during and establish qualifications for individuals the COVID-19 pandemic. This bill has in the Commonwealth of Pennsylvania advanced out of the Senate Health and who perform medical imaging or radiation Human Services Committee and has been therapy procedures. The House Professional referred to Senate Appropriations. Licensure Committee held an information

House Bill 1700 – (Sonney) – Disclosure of disingenuous physician complaints - This bill would no longer require physicians to acknowledge the existence of a complaint filed against their medical license if the case were closed without any formal action. PAMED supports this effort and will advocate to advance these bills. This legislation has been referred to the House Professional Licensure Committee. (DO ACT) House Bill 1701 - (Sonney) - (MD ACT) House Bill 192 - (Topper) - Interstate Medical Licensure Compact Act - PAMED supports this effort which would allow Pennsylvania to fully join the Interstate Medical Licensure Compact Act (IMLC). The IMLC provides a streamlined process that allows physicians to become licensed in multiple states with a mission of increasing access to health care. This bill has passed the House (201-0) and now awaits consideration in the Senate Consumer Protection and Prof. Licensure Committee. House Bill 1774 – (Flood) – PAMED supports this effort to extend the sunset date for the Achieving Better Care by Monitoring All Prescriptions Program. This

hearing on the topic and the bill awaits action by this committee.

House Bill 1562 – (Pickett) – PAMED strongly worked to oppose this effort to expand access to the PDMP and as of this time, this legislation has yet to be brought up for a committee vote. It is currently sitting in House Insurance and at this time we do not anticipate movement on this bill that grants private health care insurers access to the PDMP, when they have no enforcement abilities and no compelling rationale as to why they should have access to this hypersensitive information.

House Bill 1959 – (Pennycuick) – This legislation authorizes the clinical study of the efficacy and cost/benefit optimization of the psilocybin-assisted therapy in the treatment of PTSD, traumatic brain injury and various mental health conditions. PAMED has new policy to support clinical studies to determine the full efficacy of the use of psilocybin as appropriate. This bill is currently awaiting a vote by the House Health Committee. Senate Bill 196 – (Ward) – Co-pay accumulator legislation; requires insurers or pharmacy benefit managers to count any amounts paid by the enrollee or paid on behalf of the enrollee by another person when calculating an enrollee’s overall contribution to the plan’s deductible. PAMED is still working through this effort to determine a position while the bill awaits action from the Senate Banking and Insurance Committee. House Bill 1664 – (Gleim) – House companion legislation. House Bill 605 – (Ecker) – This COVID liability legislation specifically requires certain cases alleging personal injury damages because of exposure to COVID-19 to be subject to expedited compulsory arbitration programs. Having passed the House (107-94) this bill now awaits action from the Senate Judiciary Committee. Should this legislation advance to the Governor’s desk, it is likely it would be vetoed as similar legislative efforts have ended in the same result.

House Bill 1005 – (Cox) – PAMED is opposing this effort that would require House Bill 1186 – (Quinn) – Legislation emergency physicians to provide informa- to amend the Acupuncture Licensing tion that is frequently not available during Act to provide for the title protection for the time in which care to a patient is being licensed acupuncturists and practitioners. delivered. Specifically, this bill requires PAMED worked to provide language information to be added to the PDMP on amending this bill that resulted in a when Narcan/Naloxone is used to combat position of neutrality. HB1186 advanced an overdose by emergency responders or as amended out of the House Professional medical professionals. This bill advanced Licensure Committee and is to now before out of the House Health Committee and the full House. PAMED will continue to work to prevent this effort from becoming law.

Stay up to date on PAMED’s legislative priorities at

www.pamedsoc.org/Advocacy Central PA Medicine Winter 2022 27

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DCMS NEwS

FRONTLINE GROUPS The Dauphin County Medical Society thanks the following for their 100 percent membership commitment and their unified support of our efforts in advocating on behalf of physicians and the patients they serve.

 Allergy Asthma & Immunology

 Morganstein De Falcis Rehabilitation Institute-Harrisburg

 Brownstone Dermatology Associates

 Patient First-Harrisburg

 Central PA Surgical Associates Ltd

 Penn State Health Medical Group-Hershey

 Conestoga Eye-Hershey

 PinnacleHealth Express

 Cummings Associates PC

 PinnacleHealth Radiation Oncology

 Elena R Farrell DO

 Premier Eye Care Group

 Family Internal Medicine

 Saye Gette & Diamond Dermatology Assoc PC

 Family Practice Center PC-Millersburg

 Schein Ernst Mishra Eye

 Forti & Consevage PC

 Stratis Gayner Plastic Surgery

 Gastroenterology Associates of Central PA PC

 Tan & Garcia Pediatrics PC

 George M Kosco III DO & Associates

 UPMC Arlington Group

 Harrisburg Gastroenterology Ltd

 UPMC Heart and Vascular Institute-LCV

 Hershey Pediatric Center

 UPMC Pinnacle Colon & Rectal Surgery

 Hershey Pediatric Ophthalmology Associates PC

 UPMC Pinnacle Harrisburg Transplant Services

 Hershey Psychiatric Associates

 UPMC Pinnacle Harrisburg-Emergency Room

 Houcks Road Family Practice

 UPMC Pinnacle PHCVI Cardiovascular & Thoracic Surgery

 James R Harty MD

 Woodward & Associates PC

 Jatto Internal Medicine & Wellness Center PC  John E Muscalus DO

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NEW MEMBERS Nicholas George Abourizk, MD

Jonathon Kirk Maffie, MD

Benjamin Ravichander, MD

Samuel Thomas Arcieri, MD

Qurat-ul-Ain Mansoora, MD

Michelle Ashley Rizk, MD

Jennifer Elizabeth Coles, MD

Ciara Marshall

David E. Wilmot, MD

Joshua Ryan Dellinger, MD

Katie McHale, DO

Sophia Yen, MD

Amanda Dubbs

Rafay Nasir

Thomas Zacharia, MD

Nicole Fye

Madison Oxford

Michael Kozak

Jonathan Toan Pham

R E I N S TAT E D MEMBERS Chelsea Lynn Cambria, DO Michael Taylor Faschan, MD Margaret Mary Fitzsimons, MD Stephanie Anne Schultz Horst, MD Michael P. Krall, DO Jessica Lynn Mann, MD Kevin Louis Rakszawski, MD Frederick Curtis Sudbury, MD Mark Tulchinsky, MD

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