Genetic Testing
DEBRA OHREL
We’re advancing breast cancer detection with AI.
Because early diagnosis is lifesaving.
WellSpan is putting revolutionary breast care AI technology to work to help identify breast cancer earlier and with greater accuracy. While our highly trained radiologists continue to review every breast screening image, we’re utilizing AI to help identify the smallest breast cancers earlier than ever before. Because when it comes to early detection, you have WellSpan on your side.
WellSpan.org/Mammo
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2024 BOARD OF DIRECTORS
OFFICERS
Sarah E. Eiser, MD President
Penn Medicine Lancaster General Health Physicians Lancaster Physicians for Women
Stacey S. Denlinger, DO
Immediate Past President
Highlands Family Practice & UPMC Wound and Hyperbaric Center
Robin M. Hicks, DO President-Elect
UPMC Supportive Care & Palliative Medicine
Christopher R. Scheid, DO Vice President College Avenue Family Medicine
James M. Kelly, MD Treasurer
Penn Medicine Lancaster General Health Physicians Family Medicine Lincoln
David J. Gasperack, DO Secretary WellSpan Health
DIRECTORS
Lena Dumasia, MD
Laura H. Fisher, MD
Anna Goetze, DO | Resident
Saima Khalid, MD, MPH, FAAFP, FACOEM
Logan Lawson, DO, MPH | Resident
Jessica Miller, MD | Resident
Karen A. Rizzo, MD, FACS
Daniel J. Schlegel, MD, MHA, FAAFP
Susanne E. Scott, MD, MPH
Danielle Rubinstein, DO
Osvaldo Zumba, MD
EDITORS
D awn Mentzer
Bet h E. Gerber
Stacey S. Denlinger, DO
Family
Hello!
It is hard to believe that the summer of 2024 is already behind us!
In August, we had a great evening with WGAL at our Doctors on Call event where we took calls and answered questions from many residents in our surrounding community. That annual event is always a wonderful occasion to give back and provide some informal, confidential help to people who may need a listening ear. The community really values the opportunity, and our physicians really enjoy it, me included!
As we enter some (hopefully) cooler months ahead, we cover a great variety of topics in this issue. Inside you’ll find articles on brain supplements and cold plunges, including thoughts about the potential benefits. We also review the latest health system best practices and shed some light on how genetic testing is being used to personalize patient care around the county.
I hope you enjoy reading everything in the pages to follow.
Happy fall!
Sarah Eiser, MD Penn Medicine Lancaster General Health Physicians Lancaster Physicians for Women
You’re proud to be a physician. Support the organization dedicated to serving you and your passion. United we are stronger and can work together to make a positive impact in Lancaster County medicine and beyond.
If you aren’t already a member, we hope you’ll consider a membership investment in LCCMS.
Scan the QR code below to learn more.
best pr ctices
• Lancaster General Hospital Completes Trauma & Emergency Department Expansion
• Penn State Health Offers Leading-edge Pediatric Neurosurgery Care in Lancaster County
• A “Tap on the Shoulder”: AI Solution Helps WellSpan Physicians Quickly Detect Breast Cancer
• Practice Management Insights: When Is It Time To Hit The “Reset” Button? ALSO IN THIS SECTION
Brings Gynecologic Care to Those in Need
No matter what age or stage of life a woman is in, maintaining optimal health is important. Sadly, not all women have access to transportation to receive the critical services they need or the ability to pay for them.
Recognizing those challenges, a team of clinicians has worked diligently over the past year to develop a program for women and persons assigned as female at birth (AFAB), who are living in underserved communities in Lancaster and surrounding counties. That program, UPMC Magee-Womens in Central Pa., has a mission to improve the quality of life and well-being of those who are uninsured or underinsured by providing gynecological preventative and related health care services. Denise Turoczi, BSN, RN, OCN, and her team have been instrumental in the development of the program and working with local providers to enhance the care of this population.
“This initiative is near and dear to our hearts. After seeing so many patients with cervical cancer, a preventable malignancy, we decided we needed to reach those patients who otherwise wouldn’t have the resources to get the health screenings and vaccinations they deserve. We want to break down barriers to health care access and support better outcomes for these vulnerable populations,” said Turoczi.
They asked themselves, how can we reach the unreachable?
Determined to launch a program, the team worked with UPMC community health leaders and was able to utilize the UPMC Addiction Recovery Medical Mobile unit one day a week. The 36-foot unit has been converted to a mobile gynecologic office and can accommodate two patients at a time. One patient can be receiving care while another is being registered for services. Privacy and trust are important factors when working with this population.
“We are committed to providing a safe environment while delivering care on the RV and promoting trust with follow-up calls or visits,” Turoczi shared.
Walk-ins are welcome, and no appointments are necessary. As the team develops a monthly schedule in Lancaster, York, Perry, and Dauphin counties, they can offer follow-up appointments.
Services offered in the unit include:
• Pelvic and breast/chest exams
• HPV vaccinations
• STD testing
• Cervical cancer screening/ Pap smears
• Urinalysis
• Pregnancy testing
• Referrals to primary care
In addition to clinical services, patients have access to a financial specialist as well as local community resources and outreach materials.
As awareness of the program continues, patients who have used the service have expressed their gratitude for the convenience and access. One patient shared, “I am thankful that there is a program that can come to my community as it’s hard for me to get transportation.”
The future of the program is bright as funding for the unit and equipment continues to be received.
“Our goal is to have a designated medical mobile unit for gynecological care that would go out to additional locations in central Pennsylvania five days a week, allowing us to expand reach to the unreachable,” said Turoczi.
A look at the registration area and exam room in the UPMC Magee-Womens medical mobile unit for gynecological care, which brings essential health services to patients in underserved communities in Lancaster and surrounding counties.
LANCASTER GENERAL HOSPITAL
Completes Trauma & Emergency Department Expansion
The new entrance on Duke St. welcomes patients to LGH’s expanded and renovated Emergency Department, which is able to serve up to 130,000 patients annually.
Penn Medicine Lancaster General Hospital (LGH) recently celebrated the completion of a multi-year expansion of its Trauma & Emergency Department, providing the highest quality service and experiences for those in need of emergency care.
The last phase of the four-year-long project opened in June 2024. Penn Medicine Lancaster General Health (LG Health) began the expansion project in 2020 to help address the increasingly high demand for emergency services throughout the region.
At 96,000 square feet and an increase from 54 to 96 patient beds, LGH’s expanded and renovated Emergency Department is the largest in the region and is able to serve up to 130,000 patients annually.
The department also doubled the number of behavioral-health treatment rooms for evaluation and acute behavioral health issues to 10, doubled the number of Level 1 trauma bays to four, and added 13 new pediatric-treatment rooms.
Additional features include a dedicated pediatric waiting room, enhanced technology for patient care boards, a dedicated breakroom for EMS workers, a stateof-the-art PATH unit, advanced security technology, and an improved registration process.
ADVANCED CARE CLOSE TO HOME
Michael Ripchinski, MD, LG Health Chief Physician Executive, said the completion of the expansion and renovation of the Trauma & Emergency Department marks an unprecedented investment in the health system as well as the community. The project is one of the largest investments in facilities and technology in LG Health’s history.
“As Lancaster County’s only Level 1 Trauma Center, we have the expertise and technology to handle virtually any type of emergency right on site, 24 hours a day. With skilled physicians and surgeons in every specialty, there is no need to be transported out of the county for advanced medical services.”
LGH is the only accredited Level I Trauma Center in Lancaster County and the second such center within the University of Pennsylvania Health System. The Emergency Medicine team of doctors and care providers at LGH provide exceptional care in a medical emergency, including extremely critical situations like stroke, heart attack, and trauma.
As part of the overall expansion, LGH, which treats an estimated 3,000 trauma cases a year, welcomed four new state-of-the-art resuscitation trauma bays, a CT suite, an EMS Offload area, and decontamination rooms.
LGH’s advanced stroke care is led by a team accredited by The Joint Commission as a Thrombectomy-Capable Stroke Center which can remove the blood clots causing a stroke to improve a patient’s chance of full recovery. The ED and Trauma Department also offers comprehensive cardiac care and is designated as the region’s only ECMO Center of Excellence, using extracorporeal membrane oxygenation therapy to treat people with life-threatening heart and lung failure.
The pediatric treatment rooms are designed with beds located in a space specially designed to provide an enhanced experience for patients and their families. This includes a designated registration desk and waiting area for pediatric patients, as well as child life specialist support. If needed, patients have access to the county’s only pediatric inpatient unit, the Seraph-McSparren Pediatric Inpatient Center on the fourth floor of LGH.
LOCALLY SOURCED FOOD OPTIONS FOR PATIENTS AND VISITORS
Last renovated more than 30 years ago, Lancaster General Hospital included as part of the expansion project a renovated food service program that reflects a recent trend nationwide—hospitals upgrading their dining offerings to emphasize healthful eating and wellness, as well as to promote a sense of community through indoor and outdoor seating areas.
Serving as the hospital’s communal hub for patients, visitors, and health system employees, the Central Table Eatery features a broad selection of locally sourced healthy and handcrafted foods in a comforting environment that includes defined areas to relax, refresh, and rejuvenate.
The hospital’s kitchen prepares over 3,500 meals each day for patients, visitors, and employees. Demand for meals is projected to increase by 20% as a result of the expansion, necessitating a food-prep design featuring multiple stations that flex production based on daily demand.
“We offer a wide variety of delicious, healthy food options that fortify both the body and spirit,” said Nick Del Valle, director of Food Services at LGH. “We also provide a place of respite for our employees during breaks in the workday, as well as hospital visitors, who may be experiencing very challenging times in their lives.”
Leading-edge Pediatric Neurosurgery Care in Lancaster County
Melissa Louis, a caregiver for 12-year-old Caleb Hart, discusses his treatment plan with Dr. Brent O’Neill during an appointment at Penn State Health Lancaster Pediatric Center.
Lancaster County families with children who suffer from neurological conditions can receive care close to home, thanks to pediatric neurology and neurosurgery programs at Penn State Health Children’s Lancaster Pediatric Center.
Dr. Brent R. O’Neill, a pediatric neurosurgeon who cares for patients at the Manheim Township facility, explained that while all surgeries are performed at Penn State Health Children’s Hospital in Hershey, patients with any neurological condition can be cared for at Lancaster Pediatric Center. Post-surgical patients also receive care there.
Penn State Health neurologists and neurosurgeons treat a wide range of conditions, including cerebral palsy, congenital malformations, craniofacial disorders, dystonia, epilepsy, hydrocephalus, intracranial cysts, meningitis, neural tube defects, brain tumors, peripheral nerve disorders and tumors, and spina bifida and other congenital brain and spinal disorders.
Lancaster Pediatric Center offers multidisciplinary clinics to treat children with certain conditions, including spina bifida, neuro-oncology, craniofacial disorders, and spasticity.
The clinics employ a team approach that enables patients to see every provider included in their care on the same day, eliminating the need for numerous appointments at different times and locations.
“We’ve found that this is an effective way to provide care,” O’Neill said. “You never want patients to have to spend more time getting to and from their appointments than they actually spend with their doctors.”
About two-thirds of patients are referred to the neurology and neurosurgery programs at Lancaster Pediatric Center by their pediatricians. Having a local presence facilitates communication and makes working with those physicians to formulate care plans and get patients the treatments they need much more streamlined and convenient.
THE FACILITY ALSO FEATURES A walk-in clinic that provides evaluation and treatment of minor injuries or illnesses and offers sports physicals
FOR CHILDREN UP TO THE AGE OF 18.
“It’s great teamwork and makes for a smooth transition for patients,” said O’Neill, who specializes in and is director of pediatric epilepsy surgery.
A recently opened pediatric epilepsy program at Lancaster Pediatric Center is part of a move by Penn State Health to expand the program systemwide. Epilepsy, described by O’Neill as “more than one seizure without a known cause,” is a
common pediatric neurological disorder. The Centers for Disease Prevention and Control report that about 456,000 children in the United States who are 17 and younger suffer from active epilepsy.
Seizures often can be controlled with medications. However, more aggressive treatments, including brain surgery, sometimes are necessary. While some aspects of pediatric epilepsy are not yet fully understood, significant advancements in treating it have occurred in recent years.
“It’s very exciting to be part of such leading-edge technology and new treatments for these children we work with every day,” O’Neill said.
In addition to pediatric neurosurgery, Penn State Health Children’s Lancaster Pediatric Center offers specialty services in cardiology, allergy and immunology, dermatology, infectious disease, ophthalmology, pediatric surgery, urology, orthopedics, nephrology, oncology, and other disciplines.
The facility also features a walk-in clinic that provides evaluation and treatment of minor injuries or illnesses and offers sports physicals for children up to the age of 18.
Dr. Yatin M. Vyas, vice president and physician leader for Penn State Health Children’s, said the Lancaster Pediatric Center, which opened in 2022, is part of Penn State Health’s effort to provide a full spectrum of care to Lancaster County residents.
“Our commitment to our patients calls on us to find ways to make care more convenient for them,” he said. “Lancaster Pediatric Center ensures that children can benefit from the care they need close to where they and their families live.”
A “Tap on the Shoulder”
AI Solution Helps WellSpan Physicians Quickly Detect Breast Cancer
WellSpan is using artificial intelligence (AI) to enhance its evaluation of screening mammograms, helping radiologists to quickly and accurately analyze the images to detect breast cancer.
“It improves our accuracy,” says Dr. Heidi Beilis, vice president and chief medical officer of diagnostic services. “It is truly a second pair of eyes. We have the physician plus the AI solution. The AI may highlight an area of the breast and say, ‘Don’t overlook this,’ and, in minutes, taps the radiologist
AI identifies abnormalities in mammograms in mere minutes. The technology serves as a second set of eyes, alerting WellSpan radiologists, who are still the foundation of the evaluation, of areas that need further examination.
on the shoulder to help point out an area of concern.”
In the United States, one out of eight women will develop breast cancer. The earlier the cancer is detected, the faster care can be delivered, increasing the chance of survival.
AI training
AI engineers have developed software that looks for patterns in the breast that may indicate areas of possible cancer.
The AI solution in use at WellSpan has been trained on more than a million mammograms provided by clinical sources from around the globe. The tool constantly receives new data, allowing it to get better and better at its job.
It’s like having an additional physician review a mammogram, and it has been clinically proven to enhance the reading accuracy of a radiologist.
AI action
Based on its training, the AI mammography solution:
• Detects any areas that it believes a radiologist should examine more closely, marking them with a diamond or circular shape.
• Assigns the mammographic area of concern an overall score between one and 10. The higher scores indicate a significant area of concern in need of further assessment and validation by the physician.
While the technology offers assistance, physicians are still the foundation of the evaluation.
“The area of flagged concern is always and must be validated by a physician,” Dr. Beilis says. “The AI is not reading the mammogram. Artificial intelligence solutions are simply a solution in our toolkit helping the physician escalate areas of concern for rapid evaluation. If the AI highlights an area, and the radiologist
agrees that it is a true concern, then we move forward with the next steps of evaluation with the patient.”
AI immediacy
The system is so fast that it can produce results in mere minutes and quickly notify a radiologist of an area of possible abnormality, Dr. Beilis says. Sometimes a radiologist can even let a patient know before she leaves the imaging area that further testing will be necessary. The patient can get this care as quickly as possible, often that very same day.
“We don’t want you to have anxiety for days, until you come back,” she says. “We want to address the problem quickly and give you a one-stop solution to diagnosis, if benign or cancer. We want to get the cancer identified early and treated when it’s completely curable. It is simple, we want to save a life.”
AI accuracy
In WellSpan’s testing of the AI tool, it detected more patients who had an area of concern that needed to be examined more closely. Previously, a mammogram showed an area of concern in about 5.5 patients out of 1,000. But with AI, the hope is to increase that number to 8 out of 1,000.
Studies confirm the boost in finding potential concerns. Reading mammograms with the help of AI found 20% more cancers than the routine double reading by two different radiologists, according to a study in Sweden.
The Swedish study also had another important result: the use of AI did not increase false positives or mammograms that appear to have a concerning result but with no cancer found in the breast. Similarly, WellSpan found its callback rate to patients for areas of concern decreased with the tool.
“We want to make sure we don’t call back people who don’t need to be called back,” Dr. Beilis says. “We don’t want to call back people and cause angst or agitation that is not necessary.”
The AI tool also is helpful in reading mammograms of those with dense breasts, which is determined by the tissue makeup of breasts. Women with more glandular and fibrous connective tissue have denser breasts. Because of their makeup, dense breasts are harder to see through on a mammogram. And women with extremely dense breasts are four to five times more likely to get breast cancer than women with fatty breasts.
WellSpan already uses 3D mammography, which is also helpful in evaluating women with dense breasts. The AI tools further enhance the ability to accurately read these mammograms.
AI next steps
One of the next AI enhancements WellSpan will offer later this year for women’s breast health is a high-risk breast cancer assessment questionnaire. Mammograms are recommended for women ages 40 and older, but those with a higher risk of breast cancer should start getting evaluated at a younger age, even as young as 25.
The key is knowing when you are in that high-risk group, due to your background or personal health history. This is important for the patient and the patient’s family.
“If you have a mom, aunt, other family history of cancer, or if you have other risk factors, your physician can guide you through this questionnaire,” Dr. Beilis says. “We want to identify these very young at-risk individuals when the person is curable.”
Administered by a physician, the extensive questionnaire predicts a patient’s breast cancer risk with the assistance of AI, using information from other women that has been collected in a large data base.
ADDRESSING THE ISSUES, CHALLENGES, AND OPPORTUNITIES THAT IMPACT TODAY’S MEDICAL PRACTICES
WHEN IS IT TIME TO HIT THE “RESET” BUTTON?
The past three years have been a blur in the medical field for everyone. So many changes have occurred. Processes, staff, regulations, and attitudes have all shifted. How do we as managers get through this and come out at the end feeling like you have done your best?
DEBRA OHREL Practice Manager, Penn Medicine Lancaster General Health Physicians Diabetes and Endocrinology
Within our practice, we have gone through big changes in how we work. We have managed through a pandemic, various staffing volumes, burnout, employee disengagement, and patient dissatisfaction. How do you regroup, rebound, and boost morale?
We have chosen to do a reset. What does that mean? Go to where the work is done and take a deep dive into what is going on in the moment. Then look back to where you were, look at your current state, and determine where you want to be. The only way you can do that is to start at the beginning and go back to the basics. You may feel you do not have the time to do it, but it is important to make the time. In the end, you will gain the insight and information you need to give your team time back in their day.
We have staff members with a range of experience—from three weeks to 30 years. You need to find out what they know, what they need to know, and where they want to be in three years. Once you know who needs to be retrained or refreshed, you can determine where to start. With the exit of staff due to COVID burnout, we found ourselves hiring new employees quickly. We had good intentions of onboarding and providing them with the resources to do their job with success and satisfaction. However, due to high work volumes, it was challenging to provide new employees the full onboarding package. We were also creating unnecessary extra administrative work which brought frustration among the team. Experienced staff were feeling overwhelmed from training new staff, working longer hours, and feeling guilty if they took time off from work.
We eventually reached a point where we had the right volume of staff needed. Now was the perfect time to pause, reflect, and do a “reset.”
So how can you, as a manager, support your team?
Do a reset. Determine what is needed from each employee. Sit with each employee individually and then as a group. You will find employees are a great resource of information. They are doing the work, and they know where the problem lies. They want to be a part of the solution, and they want to be heard. When interviewing each of them, you will see they all have different levels of need due to their years of experience, knowledge, and ambition. Consider going through the
new employee onboarding process and skill set review again. Evaluate the new processes created in the last two years and have each employee walk you through them. Shadow the employee and highlight what they do well. No matter how simple a process may seem, take the time to review it, and revise it to meet your current needs. Frustration can occur if people are not performing tasks in a consistent way, leading to communication breakdowns. Look for opportunities to identify your team’s strengths and weaknesses and opportunities to retrain staff. This should not be intended to be punitive or negative when you identify deficiencies. The employees need to know that your end goal is to have them become successful in their role by giving them the tools and resources they need to do their job. It shows you are listening to their concerns, you are aware how they are feeling, and you want the best work environment for them to be successful.
Things we have done during our reset this year:
• We shared the new onboarding document developed by HR and had every employee complete it. Having everyone sign off gives the manager opportunity to reinforce standard policies. Attendance, cell phones, dress code, etc. – all things that slide by the wayside as time passes.
• Each employee completed the annual competencies and focused on areas of opportunity. We provided retraining and education where needed, and identified staff members who can be the subject matter experts.
• We created a team that helps to evaluate current practice processes. We included providers, supervisors and others that wanted to be included in process improvement. We reviewed processes and revised them to meet our current standards. All staff were updated on the new processes. Staff will be accountable to follow the standards to reduce errors, rework, and stress.
• We tasked the providers to review 20 in-basket messages and identify why they could not have one call resolution
to the message. What did the provider need from the clinical team to address the message quickly and efficiently? We shared these areas of opportunity with the team and are currently working on process improvement to reduce redundancy and waste in the in-basket.
• Our first process we addressed was refills. This is a beast every day that creates havoc in every provider’s in-basket. We are reviewing all the ways a refill comes into the office and where the breakdown occurs that delays the refill. We feel positive we can make a difference, decreasing the volumes of bounce-back to the practice, increasing patient satisfaction, and reducing refills that occur in between the patient’s visits.
• We evaluated what the clinical staff are tasked with daily. We clearly defined what their roles are and assigned tasks to meet their strengths.
• We identified that we needed a higher level of licensure to support providers with in-basket management to reach our goal to reduce in-basket burnout and increase provider productivity.
• We were able to justify the need for additional RN/LPN support.
The above are just a few examples of how we’re working toward our reset. We have great engagement from the team, and we will continue the process over the next several months. I personally have seen positive involvement and see that the team is aware that changes are happening for the better. Having the team onboard to help with brainstorming solutions was eye opening for me. They were excited and felt valued. As a manager, I have always felt I needed to provide the team with the answers. Through this process, I realized we have had the answers all along within our team. We just needed to take the time to pause, reflect, and reset.
JAROD JOHN, MD
Argires Marotti Neurosurgical Associates of Lancaster
Cognitive Supplements for Brain Health
HOW DO THEY WORK? WHAT ARE THE POTENTIAL BENEFITS AND RISKS?
The human brain undergoes constant changes as we age. Aging is not a uniform process and can be influenced by various factors such as genetic makeup, lifestyle choices, and environmental exposures.
Age-related cognitive decline is thought to result from increased brain neuron loss, which can be attributed to the ongoing imbalance of oxidants and antioxidants in the brain. Oxidants cause cellular damage and can worsen inflammation that subsequently contributes to a variety of health issues, including memory loss and dementia. Antioxidants, which include vitamins, minerals, and phytochemicals, maintain health by reducing inflammation.
We will begin with a quick discussion about the processes associated with normal aging. Our brain volume decreases incrementally per year after age 65. Most of this brain volume loss occurs in the frontal and temporal lobes. These regions of the brain are crucial for multiple elements of our cognitive function, but they are critically important for memory and language. Brain cells, also known as neurons, continue to form new connections, and new neurons are formed throughout our lifespan. Unfortunately, the loss of these brain cells outpaces the gains. Therefore, we need to concentrate on preserving our brain cells while improving the function of the brain cells we still have.
An emerging focus is on developing treatments to slow the aging process and enhance overall brain health and cognitive function. It should come as no surprise that diet and lifestyle are, in my opinion, the most essential components for brain health. I recommend MIND (Mediterranean-DASH Intervention for Neurodegenerative Delay) and Mediterranean diets. However, our goal is to discuss supplements that have been marketed as effective treatments to improve memory and prevent the development of cognitive impairment.
Many herbal supplements have been popularly recommended to improve memory. These include ginkgo biloba, ginseng, ashwagandha, curcumin, resveratrol, and lion’s mane mushroom. I also receive many inquiries regarding the benefits of the arguably most popular commercially available supplements, such as Prevagen, Percepta, and Neuriva. I will briefly discuss the supplements separately; however, we need to keep in mind that the studies associated with these supplements have limitations, such as small sample sizes, short durations, and variability in study designs. More rigorous, large-scale clinical trials are needed to establish definitive efficacy and safety for these supplements.
HERBAL SUPPLEMENTS
GINKGO
BILOBA
Ginkgo biloba has been consumed for its nutritional value and possible medicinal benefits for centuries. There has been extensive research into its potential neuroprotective
benefits in the last few decades. It is used in Europe and the United States of America to manage age-related memory decline. The mechanism of action for this supplement has been associated with a reduction in the accumulation of abnormal protein in the brain as well as a reduction in cell death in the brain. It has also been associated with improving blood flow to the brain, modulating brain neurotransmitters, and decreasing oxidants. Studies have shown improved working memory in individuals who were administered ginkgo biloba. It should be avoided in patients who are on blood thinners or who have blood disorders.
GINSENG
Ginseng has also existed for centuries. It is widely sold as a medicinal herb and is used frequently in traditional Chinese medicine. It has been associated with enhanced cognition and antioxidant function. Studies have linked the use of ginseng to improvement in cognitive functioning in Alzheimer’s disease patients. Ginseng has been associated with dizziness, headaches, insomnia, and nausea. Ginseng is a top-selling supplement, but it is essential to obtain it from a reliable source.
ASHWAGANDHA
Ashwagandha is a shrub found in India, Africa, and parts of the Middle East. It has been utilized in Ayurvedic medicine to improve energy, reduce inflammation, and help with anxiety. Studies have shown that this supplement can neutralize the toxic effects of beta-amyloid, which is associated with neurocognitive impairment. It has also been associated with inhibiting oxidative and pro-inflammatory chemicals. Studies have shown that patients who were supplementing with ashwagandha perform better in testing of visual memory, working memory, and attention. It has also been associated with reducing anxiety and stress. Side effects associated with this supplement have included GI upset, diarrhea, vomiting, and nausea.
TURMERIC
Turmeric, particularly its active compound curcumin, has been studied for its potential neuroprotective effects. It exhibits antioxidant and anti-inflammatory properties, which may help reduce cognitive deterioration and enhance memory. However, more research is needed to establish definitive benefits for cognitive health.
Since the gastrointestinal tract poorly absorbs curcumin, curcumin supplements formulated to improve absorption and bioavailability are usually preferred. Turmeric has been associated with bloating, and it may interact with blood clotting medications. It should also be avoided in patients who have gallbladder disease.
RESVERATROL
Resveratrol is a potent antioxidant polyphenol found abundantly in grapes and red wine. It has been associated with improved cellular protection and enhanced cerebral blood flow. Some studies have shown a link between decreased hippocampus atrophy among patients who supplement with resveratrol. The hippocampus plays an important role in memory formation. Daily supplementation with up to 1,500 milligrams of resveratrol for a period of up to three months is generally safe. Side effects can include GI discomfort. Additionally, resveratrol can inhibit blood clotting, making it unsuitable for individuals preparing for surgery or those on anticoagulant medications.
LION’S MANE
Hericium erinaceus, also known as lion’s mane mushroom, is a medicinal and edible mushroom that may have neuroprotective action. It supports the health of brain cells and prevents damage to them through antioxidative and anti-inflammatory effects. Lion’s mane mushrooms are readily available at grocery stores, restaurants, and supplement shops. They can be consumed raw, dried, or cooked in powders, liquids, and capsules. Some side effects include nausea, vomiting, diarrhea, dizziness, skin sensitivity, headache, GI discomfort, and allergic reactions.
BRAIN HEALTH SUPPLEMENTS
Lastly, we can discuss the most popular commercially available brain supplements: Prevagen, Neuriva, and Percepta.
PREVAGEN
The main ingredients in Prevagen are apoaequorin and vitamin D. Apoaequorin is a protein originally derived from the luminescent proteins of jellyfish. It is believed to be a calcium-binding protein, which is essential because impaired calcium has been associated with advanced cell aging.
NEURIVA
Neuriva ingredients include multiple B vitamins and coffee fruit extract. B vitamins and caffeine have been connected with reduced brain aging and improved memory.
PERCEPTA
Percepta contains cat’s claw and oolong tea extract. Its unique feature is that it targets plaques in the brain. Brain plaques are associated with neuroinflammation and have been linked to accelerated memory loss and dementia.
The side effects of all of these supplements are similar, with nausea and GI discomfort being the most commonly experienced.
THE BOTTOM LINE:
PROCEED WITH CAUTION AND TALK WITH YOUR PHYSICIAN
There is an undeniable demand for dietary supplements in this country. However, it is vital to approach the claims made in supplement advertisements with skepticism. Unlike prescription medications, nutritional supplements are not subjected to rigorous testing or evaluation by the FDA. While supplements may offer benefits in specific situations, patients must discuss supplement use with their physicians to avoid potential toxicity and interaction with their current medication regimen.
I hope that I have been able to provide some valuable guidance to help understand the pros and cons of a few of the available supplements to assist in maintaining our cognition as we age. I also want to repeat my earlier statement that diet (vegetables, fruits, nuts, seeds, legumes, potatoes, whole grains, herbs, spices, fish, seafood, and extra virgin olive oil) and avoiding harmful lifestyle choices (smoking, heavy alcohol use, and sedentary activity level) are critical to maintaining a healthy brain. Sleeping problems and low mental stimulation can also decrease cognitive abilities. Maintaining proper nutrition and staying active cognitively and physically will consistently outperform supplements. So, I will end with my tried and true mantra that I use daily for my patients: “If you don’t use it, you will lose it.”
Cold Water Immersion
AGE-OLD WELLNESS PRACTICE OR DANGEROUS FAD?
STACEY DENLINGER, DO
The practice of cold exposure and cold water immersion (CWI) has been long described in many ancient cultures throughout the world for treatment of various ailments and general maintenance of health. The wellness benefits have made a popular resurgence recently and are promoted widely through news and social media. Several companies offer at-home cold plunge products, and there are “wellness centers” that offer consumers “pay per treatment” sessions. I have personally been using cold water immersion as part of my exercise recovery for approximately eight months and was asked to write an article that would review the evidenced-based health benefits and risks related to these practices.
THE HISTORY
As was mentioned in the introduction, cold exposure as a therapy is not a new practice at all. It dates back to ancient times and has been practiced in many cultures all over the world for centuries. The Egyptians are believed to be the earliest documented adopters of daily cold baths. Following that, both the Greeks and Romans utilized cold therapy as treatments for ailments and also as part of a “health maintenance” routine. Recently, I visited the Roman Baths in the United Kingdom and the audio tour characterized the practice of cold and hot exposure as a way to maintain and restore wellness to the body. This practice spread across Europe and continued into the Middle Ages and into the 18th to 20th centuries as sanatoriums were built for treating mental health conditions and respiratory illnesses. More recently, influential people like Wim Hof, along with scientific counterparts, have applied physiologic understanding and evidence to show the benefits and potential risk of cold exposure.
THE PURPORTED BENEFITS
The internet reveals the proclaimed benefits of cold water immersion include:
• Improved mood
• Better sleep
• Improved concentration
• Reduced muscle soreness
• Better recovery from exercise
• Enhanced immune function
• Improved stress management and resilience
• Accelerated metabolism that could enable weight loss
HOW COLD IS COLD ENOUGH?
It’s not well defined what temperature and exposure duration is required to achieve the benefits. It can be anywhere from 28-60 degrees Fahrenheit, and the duration as short as 15 seconds to 30 minutes. There is not a single recipe that is linked to a particular benefit.
WHAT RESEARCH INDICATES
An example of some research on the impact of CWI on the immune system includes an observational study on self-reported illness episodes among cold water swimmers and non-cold water swimmers and even a controlled, nonblinded study that involved injecting regular CWI practitioners with endotoxin and measuring their clinical and serologic (chemical findings in the blood) reactions. Both of these were small studies but do support that these particular groups of people display a stronger immune response with less reported illnesses. In similar ways to preventing illness, CWI has immediate anti-inflammatory consequences that reduce muscle injury following exercise and improve recovery.
Highlands Family Practice and UPMC Wound Healing Services
There has also been research specifically studying the effect of CWI on the autonomic nervous system (ANS). In case you aren’t familiar with the ANS, it is comprised of the sympathetic and the parasympathetic systems. The sympathetic system is responsible for your body’s involuntary response to a stimulus, commonly expressed as the “fight or flight” response, which is a physiological reaction to a perceived threat. The parasympathetic system is responsible for the “rest and digest” response, which relaxes the body after stress or danger. The complex network of chemical reactions as a response to an internal or external stimulus has been attributed to the theory of chronic stress as a contributor to many mental health problems and chronic disease states we are seeing on the rise. An over- or under-production or activity of certain neurotransmitters like epinephrine and norepinephrine have downstream effects on hormone production and stress response, which may reduce our body’s ability to prevail against diseases from the common cold to cardiac disease and even cancer. To understand the benefits of practices like extreme temperature exposure, one must consider the concept of “hormetic stress exposure,” which is the concept that short exposures to stress over time help the body biologically adapt to more harsh conditions. Promoters of these practices suggest that modern conveniences have made living as humans more comfortable, and over time, there has been a reduced capacity to adapt to stress and new challenges. By introducing a controlled, hormetic stress response, one can improve the body’s ability to adapt, which is thought to be the key to survival.
POTENTIAL RISKS
As with all potential treatments, there is potential risk. The most obvious risk is a drop in core body temperature below 95 degrees Fahrenheit, the definition of hypothermia. This can happen in even modest cold temperature exposure if it occurs over an extended period of time. More immediate reactions can be intense and less indolent. For the first month of my cold plunge experience, this happened to me every time I got into the tub. I could not suppress the reaction. It can be explained by the “cold shock” response of the nervous system. It is characterized by increased heart rate, increased respiratory rate, and hyperventilation, which leads to constriction of the blood vessels, elevated heart rate, and
decreased blood flow to the brain. It is a direct effect of the stimulation of the sympathetic nervous system or the “fight/flight” response I mentioned earlier. Thankfully for me, it only lasted a minute or two, but the consequence of this reaction could lead to sudden decreased blood flow to the heart, causing a myocardial infarction, a.k.a. a heart attack. Decreased blood flow to the brain can lead to a syncopal event, or “blacking out,” a dangerous thing to occur if you are submerged in water. Hyperactivity of the respiratory system in someone who has a hyperactive airway to begin with could lead to sudden bronchospasm or an asthma attack.
Additionally, there are many symptoms people feel with hyperventilation due to a sudden change in the body’s acid/base chemistry. Rapidly blowing off carbon dioxide (the byproduct of respiration) leads to elevation in your blood pH and shifts in your body’s bicarbonate and electrolyte levels. The symptomatic sensation people feel may include confusion, muscle weakness, shortness of breath, chest pain, racing heart, and numbness and tingling in the hands or feet. Anyone who’s ever had a panic attack can tell you these symptoms are disconcerting and can cause an impending sense of doom. Alternatively, there is a counter autonomic response to cold water stress called the “diving response,” characterized by activation of the parasympathetic nervous system that causes profound lowering of the heart rate, decreased rate of breathing, redirection of blood flow to vital organs, and the release of red blood cells (cells that carry oxygen) from the spleen. The diving response is triggered by immersing the face in cold water while holding your breath. Both of these responses can have dangerous health consequences. However, when applied in a graduated and controlled way, evidence shows that one has the ability to subject voluntary control over these autonomic processes to prevent the extreme response. This is the hormetic stress response.
FOOD FOR THOUGHT
In summary, evidence supports small and intentional exposure to stress can improve one’s ability to adapt to the environment, both emotionally and physically. Anecdotally, I have experienced significant reduction of post-workout soreness and improved recovery between workouts. Also, despite seeing people routinely
with viral and bacterial infections on a regular basis in clinic, I rarely get sick. Though as it is with many intentional lifestyle practices, most people participating in CWI, me included, are not doing this in isolation. Interviews of people who practice CWI also report a routine sleep habit, mindfulness practices, regular exercise, and structured nutrition plans. Even Wim Hof’s method has three pillars, and cold exposure is just one of them, with the other two being breath work and power of the mind.
As I tell my patients, because it operates on a circadian rhythm, the body responds best to a predictable and routine schedule. Sudden disruptions or stimuli can have catastrophic consequences, especially if you may have some pre-established underlying physiological handicaps, e.g., metabolic diseases like diabetes, neurodegenerative diseases like multiple sclerosis, or respiratory diseases like asthma. It does not mean a person with these conditions can never practice CWI, but like initiating a medication, it should be discussed with a health care provider and adjusted to meet the individual needs of the person and the condition. And as with all treatments, preventive or disease specific, there are benefits and potential risks. The age-old adage, the dose makes the poison likely applies. Too cold, too much, too fast is the wrong approach.
WORKS CITED
Espeland, D., de Weerd, L., & Mercer, J. B. (2022). Health effects of voluntary exposure to cold water – a continuing subject of debate. International Journal of Circumpolar Health, 81(1). https://doi.org/10.1080/22423982.2022.2111789
Hof, Wim. The Wim Hof Method: Activate Your Full Human Potential. Sounds True, 2020
Kox, Matthijs et al. Proc Natl Acad Sci USA. “Voluntary activation of the sympathetic nervous system and attenuation of the immune response in humans.” 2014 May 20; 111(20): 7379-7384.
Malgoyre, Adrien, Bruna Goncalves, and Lucile Albertini. “Does the Wim Hof Method Have a Beneficial Impact on Physiological and Psychological Outcomes in Healthy and Non-Healthy Participants? A Systematic Review.” International Journal of Environmental Research and Public Health, vol. 19, no. 8, 2022, p. 4787. https://doi.org/10.3390/ijerph19084787.
“Doctors on Call”
Several hundred Susquehanna Valley residents called to speak with physician volunteers from Lancaster City & County Medical Society (LCCMS) on August 14 during the “Doctors on Call” TV broadcast. LCCMS partners with WGAL 8 to bring the annual public health broadcast to area TV news viewers.
The physicians spoke one-on-one with callers of all ages from throughout the viewing area. Popular topics of the calls included pain (both orthopedic and non-orthopedic), gastrointestinal issues, skin problems, and respiratory issues.
The physician volunteers, all members of Lancaster City & County Medical Society, provided health care information to callers and guided them to seek medical care if needed. For callers lacking medical insurance or health care access, the doctors directed them to area low-cost clinics and other resources to meet their needs.
WGAL 8 news anchor Susan Shapiro hosted the program and interviewed several of the physicians on current health topics, including James Rochester, MD, FAAFP, who also answered questions live on WGAL’s Facebook page.
Dr. Long, Dr. Eiser, and Dr. Medina answering viewer medical questions.
“We’re so pleased to be able to continue to partner with WGAL to share this valuable resource with the community,” said Beth Gerber, Executive Director of Lancaster City & County Medical Society and the Lancaster Medical Society Foundation. “Our physician members are committed to protecting public health and advocating on behalf of their patients every day. They look forward to this annual opportunity to connect more broadly with area residents.”
LCCMS physician members who volunteered for this year’s “Doctors on Call” event included: Bethany Bustamante, MD, Penn Medicine Lancaster General Health; Sarah Eiser, MD, Penn Medicine Lancaster General Health; Katherine Hicks-Courant, MD, Penn Medicine Lancaster General Health; Joy Long, MD, Lancaster Orthopedic Group, PC; James Medina, MD, FACEP, Lancaster Emergency Associates, Ltd.; Michael Pavlica, MD, Family Eye Group; Karen Rizzo, MD, FACS, Lancaster Ear, Nose and Throat; and James Rochester, MD, FAAFP, Lancaster Orthopedic Group, PC.
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Lena Dumasia, MD; Janice McClune, CRNP; Hyatt P. (Tracy) DeGreen III, DO; and Roxana Ramos, CRNP
Dr. Rochester monitors WGAL’s Facebook page to respond to online inquiries.
Susan Shapiro is live on WGAL with Dr. Hicks-Courant, Dr. Long, Dr. Pavlica, and Dr. Bustamante in the background.
Stephen Scull, MD, FACEP
Lancaster Emergency Associates, Ltd
It’s our pleasure to highlight a Lancaster City & County Medical Society member’s “passion outside of practice” in each issue of Lancaster Physician. Beyond their commitment to health care, LCCMS members have many other talents, skills, and interests that might surprise you. In this issue, we’re thrilled to feature Stephen Scull, MD, FACEP, and his passion outside of practice.
Storm Chasing
Would you briefly describe your passion outside of practice for those who might be unfamiliar with it?
Over the years, I’ve developed a passion for severe weather. This includes the science behind various kinds of severe weather, following severe weather events, and, recently, actively pursuing severe weather, a.k.a. “storm chasing.”
How did you develop an interest in your passion outside of practice?
Growing up outside of Buffalo, NY, I’ve lived through severe winter weather the majority of my life. If I had not pursued medicine as a career, I likely would have ended up in meteorology. This interest continued alongside my professional pursuits in medicine. Because
the majority of weather data (satellites, radar, weather models) are managed by the federal government, there has always been easy access to this information and data for anyone with an interest.
How long have you been participating in this activity?
I’ve been interested in severe weather my whole life but recently participated in my first “storm chase” this past June with a couple of lifetime friends. We joined a college research trip covering 11 states and 4000+ miles over nine days. I earned college credit for the first time in 17 years and met a bunch of people from all over the world with a similar passion for severe weather.
Why is this pursuit special to you?
Like medicine, meteorology is an actively evolving science with new information and continuous discoveries. And also like medicine, there is so much that we still don’t know or understand. I’m sure storm chasing also fits into the stereotype that emergency medicine docs are adrenaline junkies.
What else would you like readers to know about this passion?
Storm chasing isn’t all social media personalities dangerously chasing tornadoes in the Midwest. The vast majority of people we encountered were scientists studying these severe storms with the goal of improving weather modeling and predictions to increase warning times for people in the path of dangerous storms.
A rotating mesocyclone over McCook, Nebraska
Funnel cloud and supercell outside Sioux Falls, South Dakota
Dr. Scull (far right) and two close friends in front of a large supercell in northern Oklahoma
Genetic Testing KEY FOR PERSONALIZED MEDICAL CARE
SUSAN SHELLY Writer
The field of genetic testing has exploded since the first testing was employed more than 30 years ago as a means of detecting mutations for sickle cell disease.
Increasing knowledge and understanding of genetic conditions, higher acceptance and demand for testing, and decreasing costs have led to dramatic changes in how patients are diagnosed and screened for genetic conditions, who receives testing, and how the information gathered is used.
While it’s largely agreed that the potential benefits of genetic testing are huge, concerns have been raised over testing equity, how tests are used, confidentiality, and other issues. Physicians, researchers, and others are working to address those issues as advancements continue.
Many members of the local medical community expressed enthusiasm about the possibilities genetic testing offers and are working to ensure access to those who may benefit from testing.
Lancaster Physician reached out to the health care systems serving Lancaster County residents to find out more about how genetic testing is being used, their efforts to involve community members in testing initiatives, and their thoughts about the future of genetic testing. We spoke with representatives from Penn Medicine Lancaster General Health, WellSpan Health, and Penn State Health.
Randall A. Oyer
PENN MEDICINE LANCASTER GENERAL HEALTH
Genetic testing has become an essential part of diagnosing, understanding, and treating cancer, and team members at the Cancer Risk Evaluation Program at Lancaster General Health’s Ann B. Barshinger Cancer Institute are on a mission to help Lancaster County residents understand its value.
Continued on page 24
Dr.
Caroline Malpass
“We understand that learning about their genetics and inherited risk factors for cancer can be scary for people,” said Caroline Malpass, a licensed genetic counselor who helps lead the Cancer Risk Evaluation Program. “But having that knowledge really puts the power back in their hands and can help patients make the best possible decisions about how to move forward.”
The hope is that Lancaster County residents can learn about their genetic information at a young age, thereby enabling them to understand their risk for developing cancer before it occurs.
If testing identifies a genetic change associated with an increased chance for cancer, the person who’s been tested can work to manage that risk, as advised by their primary care provider. Also, awareness of an inherited gene change often allows for early detection and rapid treatment should cancer occur.
Genetic testing is integral to LG Health’s precision medicine program, which employs cancer treatment specifically designed for a particular patient. In addition to helping predict risk for cancer, genetic testing is used to tailor treatment once cancer has been detected, explained Dr. Randall A. Oyer, executive medical director of cancer services at LG Health and a clinical professor of medicine at the Perelman School of Medicine at the University of Pennsylvania.
Understanding the unique traits of a patient and their cancer cells can help physicians develop the most effective and appropriate individualized treatment plan for each person. That, according to Oyer, is the hallmark of precision medicine.
“Precision medicine is precision about the body and about the patient as a person,” Oyer said. “It takes into account a person’s treatment preferences, what matters most to someone, and other medical conditions that may be present.”
Malpass works in the community to spread the word about genetic testing, providing information and assurance.
People primarily are concerned about three issues, she explained: privacy, insurance implications, and fear that genetic testing will reveal something they are loath to deal with.
Regarding privacy, a patient’s genetic information is normally included in their medical records, which are covered by the 1996 HIPAA Privacy Rule, Malpass said. The rule states that those with access to medical records must protect a person’s health information by limiting how it’s used and disclosed.
The Genetic Information Nondiscrimination Act of 2008 prohibits health insurance companies and most employers from discriminating against someone based on their genetic information, according to Malpass. Some providers of life, disability, and longterm care insurance, however, may require access to medical records before deciding whether to provide coverage.
The last concern—fear of what genetic testing may reveal—is the most difficult to address, Malpass said. Every person feels differently about the prospect of testing, and every person’s feeling must be respected.
What she and Oyer want individuals to understand, however, is that knowledge of genetic information can benefit not only the person tested, but also family members for generations to come.
“The person in the family who gets the initial testing often gives a gift to the rest of the family,” Oyer said.
While the use of genetic testing has been on the rise in the past decade, it is certainly not new. University of Pennsylvania researcher Peter Nowell was credited in 1959 with helping to uncover the first genetic mutation linked to cancer—the Philadelphia chromosome.
Since then, Oyer said, the medical community’s understanding about genetic and molecular causes of cancer has increased dramatically, leading to the discovery of new drugs, more targeted and effective
treatments, and the ability to predict who is at increased risk for the disease.
“I’ve been in practice for more than 40 years and am greatly encouraged by the progress that’s been made in cancer treatment,” he said. “We’ve made great strides and will continue to do so as we learn more and more about employing genetics to help detect and treat cancer.”
WELLSPAN HEALTH
Dr. David Kann is convinced that population genomics will enable health care providers to achieve great strides in preventing disease, enable them to detect disease earlier when it does occur, and treat it more effectively.
“It’s going to have a great, cascading effect as we move into the future,” predicted Kann, medical director of precision medicine and one of the lead researchers for WellSpan Health’s Gene Health Project, a community health research program that offers no-cost genetic tests to help determine potential risk for heart disease; stroke; and breast, ovarian, colon, and other cancers.
Qualified participants, who must be 18 years or older, can use their MyWellSpan account to enroll and receive a copy of their results. A simple blood test is performed locally, with the sample sent to a partnering laboratory for DNA analysis.
The program, with a goal of enrolling 100,000 patients in four years, has in its first year consented about 30,000 patients for genetic testing and tested more than 23,000. Of those tested, 323 were found to have a genetic variant that puts them at risk for one of the three conditions designated by the Centers for Disease Control and Prevention as Tier 1 applications: hereditary breast and ovarian cancer syndrome, Lynch syndrome, and familial hypercholesterolemia.
Kann personally contacts and speaks with each person who is discovered to have a genetic variant. By the time their conversation has ended, he said, everyone understands the value of having been tested, both to themself and others.
Dr. David Kann
“There’s a saying that if you find one, you find eight,” Kann explained. “Once a person knows they have the diagnosis, they can tell their children and grandchildren, and those family members benefit, too.”
Using the find-one, find-eight theory, WellSpan’s Gene Health Project has already impacted about 2,600 people who may be at increased risk for certain diseases—an example of the cascading effect Kann speaks of.
WellSpan is one of about 15 hospital systems across the country participating in comprehensive population genomics programs in partnership with Helix, a California-based population genomics and viral surveillance company.
Kann praised Helix, which is powered by one of the largest CLIA (Clinical Laboratory Improvements Amendment)-certified, CAP (College of American Pathologists)-accredited sequencing labs in the world. The company also employs best practices in data security to avoid any misuse of stored information.
“The results we’ve been getting from Helix are excellent,” said Kann, who leads the Gene Health Project with Dr. Anwar A. Chahal, director of the Center for Inherited Cardiovascular Diseases.
In addition to predicting inherited risk for certain diseases, genetic testing can help in developing new medications and understanding which patients will benefit from them, Kann explained. It enables providers to employ personalized medicine to treat patients based on their particular DNA, and target treatment to specific areas.
“Precision medicine is the way of the future,” said Kann. “It’s about early prevention, and then giving the right therapy to the right person at the right time.”
Kann credited Roxanna Gapstur, president and CEO of WellSpan Health, and Dr. Anthony Aquilina, executive vice president and chief physician officer, for
initiating the Gene Health Project and enabling its inception.
“This opportunity has presented itself as a new way of looking at medicine,” Kann said. “We’re looking forward to benefitting many, many people through this project.”
Kann stressed that participation in the Gene Health Project benefits everyone, as researchers will use collected information to study wide-ranging questions about how DNA impacts health and how to best treat certain diseases.
All community members are encouraged to participate, and efforts are underway to involve a wide swath of the population. The program adheres to a “Sequence Once, Query Often (SOQO) model, which encourages physicians to consult test results often and use the information contained within them to help determine what is going on with patients. Test results are saved to patients’ electronic medical records, giving providers easy access.
“This information is incredibly valuable because it can help doctors rule out or rule in possibilities for a patient’s condition and figure out the best treatment for it more effectively than they were able to do in the past,” Kann said. “It’s all in that genetic testing. That’s your whole life story.”
PENN STATE HEALTH
Genetic testing that helps researchers better understand how each patient’s cancer develops, along with precision medicine that guides which drugs will be effective in treating it and how much medication should be used, are powerful new tools for fighting cancer in adults and children.
Dr. Giselle Saulnier Sholler, division chief of Pediatric Hematology and Oncology at Penn State Health Children’s Hospital in Hershey, is optimistic that cancer care will continue to advance and improve—to the benefit of patients who can experience better outcomes with fewer negative side effects.
“There’s so much going on in cancer research that’s hopeful,” Sholler said. “We’re working so our patients can not only survive, but thrive and live happy, healthy lives.”
Sholler, who has been with Penn State Health for a little more than a year, is the founder and chair of the Beat Childhood Cancer Research Consortium, a worldwide network of more than 55 universities and children’s hospitals working to discover new therapies and cures for pediatric cancer patients that now is based in Hershey.
The consortium has successfully opened and managed a number of multi-site clinical trials, including four trials using molecular guided therapy in children whose cancer tumors had relapsed.
After much effort, the Beat Childhood Cancer Research Consortium received approval in December 2023 from the U.S. Food and Drug Administration for difluoromethylornithine, a drug designed to prevent relapse in high-risk neuroblastoma.
That drug, called Iwilfin, is now available for patients across the United States.
At Penn State Health Children’s Hospital, which serves Lancaster County patients, genetic testing is offered to every patient diagnosed with cancer. Sholler explained that complete genomic sequencing and analysis of tumors at both diagnosis and time of relapse is hugely helpful in understanding each child’s cancer.
“We are able to look at the mutations that caused the cancer and the pathways that are driving it,” said Sholler, who also is a professor in the Penn State College of Medicine departments of pediatrics and pharmacology. “We get very, very deep into each child.”
The clinical data of children who enroll on a Beat Childhood Cancer clinical trial is combined with that of other participants, enabling all the consortium’s collaborations to study the data together.
Continued on page 26
Dr. Giselle Saulnier Sholler
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Artificial intelligence (AI) is used to analyze, compare, and predict outcomes based on the data, giving practitioners the ability to better tailor treatments to individual patients. That is a divergence from traditional means of treating pediatric cancer, Sholler explained.
“Traditionally, everyone with the same diagnosis receives the same treatment in pediatric cancer,” she said. “It’s standard chemotherapy that affects the entire body and causes someone’s hair to fall out and can damage a child’s heart.”
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As genetic testing enables researchers and doctors to better understand how and why mutations occur and cause cancer, they can focus on newer medicines that specifically target the mutations found only in the cancer cells and identify patients who can benefit from the drugs.
“That’s a much better way of treating patients than just using a therapy that a good percentage won’t respond to,” Sholler said. “It’s important to know not only which drugs work, but which don’t.”
And because a person’s genes also influence how they will process certain medications, Sholler’s team employs pharmacogenomics—a piece of precision medicine—to help them predict a drug’s effectiveness and determine how much of a particular medication to prescribe.
Changing the standard of care in medicine is difficult, Sholler said, but necessary if treatment is to keep moving forward. Medical care is advancing quickly, partially fueled by increased use of genetic testing and study.
“Research is improving outcomes and creating hope. It’s going to be exciting to see where the next five or ten years take us,” Sholler said.
HOFFMANN SHI M
LEGISLATIVE UPDATES FALL 2024
With this legislative session coming to an end, there was a flurry of activity on bills that relate to PAMED’s legislative priorities. One area to highlight is PAMED’s continued vigorous opposition to bills that would expand the scope of practice to non-physician providers throughout the Commonwealth. Senate Bill 25 (Bartolotta) and House Bill 1825 (Guenst), bills that would allow for the independent practice of nurse practitioners, were both reintroduced.
At the time of this writing, Senate Bill 25 passed out of the Senate Consumer Affairs and Professional Licensure Committee. Senate Bill 25 is currently awaiting final consideration from the PA Senate. House Bill 2037 (Bullock) was introduced, which would allow pharmacists to vaccinate children as young as age three, and we expect a Senate companion bill to be introduced in the near future. We have also seen a push to allow psychologists to prescribe medications in House Bill 1000 (Frankel). PAMED, and our physician specialty partners, will continue to advocate for physician-led team-based care.
The Pennsylvania Senate recently considered Senate Bill 739 (Vogel), legislation which
would require health insurers to cover and pay for health care services provided via telemedicine. Senate Bill 739 passed the PA Senate with a vote of 49-1 and then passed the PA House with a vote of 194-8. The bill was then signed by Governor Josh Shapiro.
Another advocacy priority for the Pennsylvania Medical Society is restrictive covenant legislation. As mandated by the PAMED House of Delegates, we continue to discuss the issue of non-compete agreements in physician contracts with a number of legislators. Interest in this area seems to be growing as lawmakers learn more about how these contractual agreements negatively impact patient access and continuity of care. Rep. Dan Frankel (D-Allegheny) has introduced House Bill 1633, a proposal that would outright ban the use of non-compete agreements in all physician employment contracts.
On April 17th, the Pennsylvania House of Representatives passed House Bill 1633 by a vote of 150-50. The bill had previously passed out of the House Health Committee on March 27th with a vote of 21-4. The bill was amended in the Health Committee to include a rural exemption, which PAMED
had previously agreed to in previous sessions. PAMED pursued an amendment on the House floor, sponsored by Representative Torren Ecker, that would exempt private practices from the prohibition. The amendment failed with a vote of 99-102. House Bill 1633 was recently unanimously approved by the Senate Health and Human Services Committee. House Bill 1633 was then passed by the full PA Senate and signed into law by Governor Shapiro in July. PAMED will continue to advocate for further non-compete protections for physicians, including a private practice exemption.
The 2023-2024 Pennsylvania General Assembly legislative session is quickly coming to an end. There are only about five legislative session days between now and the end of 2024. While there are only a few number of days left this session, PAMED will continue to monitor legislative activity and advocate for you. Please keep an eye out for future versions of the Legislative Version of The Dose for a complete run-down of the entire 2023-2024 session.
PIZZERIA LUCA
reviewed by CELIA TONG, MD Lancaster Radiology Associates, Ltd.
As transplants to Lancaster, my husband and I have been excited to explore the local dining options. Our most recent adventure took us to Pizzeria Luca on a Thursday evening. Coming from pizza powerhouses like Philadelphia and Boston, where pizza is deeply rooted in the city culture, we were curious to see how this local spot would measure up.
Arriving at Pizzeria Luca, my husband, Josh, our 14-month-old daughter, Vera, and I were greeted warmly by two hostesses. Both indoor and outdoor seating was available. Opting for the covered patio, we enjoyed the fresh air and the charming, light-hearted decor. The space was adorned in a coral and green color palette, complemented by basil plants on each table—simple yet endearing touches that added a personal flair.
With Vera happily seated in her highchair and occupied with the salt and pepper shakers, we started our evening with drinks. We placed our orders on our phones through a QR code system. The interface was intuitive, making it a breeze to browse through the options. I chose the Amalfi Spritz, a vibrant, citrus-forward concoction that was both refreshing and zesty. Josh went for a classic Negroni Sbagliato, which was heavier on the Campari base and bitter notes but equally delicious. These paired perfectly with our appetizer, the house-made focaccia, which was delightfully seasoned with extra virgin olive oil and a touch of sea salt.
Despite having a digital menu and ordering system, our assigned waiter was fantastic. He checked in frequently to make sure everything was going well and was quick to address any questions we had. His attentive service made the experience feel personal, even though we were handling all of the ordering online.
For the main course, we decided to dive into their pizza offerings. The Tropea pizza immediately caught our attention, featuring tropea onions, taleggio creme, mozzarella, and 'nduja sausage. The onions provided a subtle sweetness, while the 'nduja sausage delivered a gratifying kick of spice. Each bite was a harmonious blend of flavors and textures.
Next, we sampled the Nino pizza, which boasted organic tomato sauce, papaccelle peppers, smoked mozzarella, ricotta cheese, and wild oregano. The sweetness of the papaccelle peppers beautifully blended with the creaminess of the mozzarella and ricotta, while the tomato sauce had the perfect acidity to offset the richness.
Vera, our little pizza enthusiast, was particularly fond of the crust. She munched away with her incoming bottom teeth, clearly appreciating its crunchy yet airy texture and flavor. Josh and I also made a note of the crust as a standout on its own and a strong foundation for any variety of toppings.
As the evening drew to a close, we couldn’t resist indulging in dessert, which was also a highlight. We opted for the Siciliano, a velvety soft serve crowned with vibrant Amarena cherries and a generous swirl of pistachio paste. This was topped with a delicate drizzle of extra virgin olive oil and a sprinkle of sea salt. The interplay of different flavors made this dessert truly unique and delicious. We made the mistake of letting Vera have a bite, as she nearly threw a small tantrum as we finished off the last of the dessert.
At the end of our visit, we completed the payment through the same QR system, which made checking out fast and easy. Overall, we felt the process was streamlined without sacrificing the personal touch of good service.
In the end, Pizzeria Luca surpassed our expectations. From the pleasant ambiance and warm service to the exceptional food, we left feeling completely satisfied and excited to return.
PIZZERIA LUCA
1200 Christopher Place | Lancaster, PA 17601 717-869-4876 | pizzerialucalancaster.com
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Sameera M. Syed, MD,
FACOG, MSCP
UPMC Obstetrics & Gynecology Specialists-Lititz
I am a board-certified OBGYN and have also achieved certification as a Menopause Practitioner by the North American Menopause Society. I currently serve as the Medical Director at UPMC Obstetrics & Gynecology Specialists-Lititz, a role that has me involved in the administrative side of medicine as well.
My family and I have grown to love the Lititz and Lancaster area. The growing diversity in the community, the small town farmers markets, variety of available cuisines (including Indian!), and the proximity to larger cities are all features that we enjoy.
What do you like best about practicing medicine?
The nobility of this profession and opportunity to educate, help and optimize the health of an individual is what drew me to this profession. No two patients are exactly the same in terms of their medical, socioeconomic, and prognostic issues, resulting in a learning phase on a daily basis that is exciting. As I practice and gain experience, seeing the blend of technology and medicine making advances is thrilling, and I am honored to be a part of this.
Practicing obstetrics/gynecology with a chance to serve and take care of women in some of their happiest and also most vulnerable moments in life is an absolute privilege. Every patient interaction has not only taught me aspects of medicine but also different aspects of life in general. I thoroughly enjoy my field of practice due to the variety it offers, including seeing women in their adolescent, childbearing, menopausal, and geriatric years; performing surgeries that range from cesareans to robotic hysterectomies and more; as well as teaching medical students and training residents in this fascinating field.
Are you involved in any community, non-profit, or professional organizations? If so, please list the groups:
Where do you practice and why did you settle in your present location or community?
After my residency training at Indiana University (IUPUI) in Indianapolis, IN, my husband and I relocated to the northeast to be closer to our families. Joining OBGYN of Lancaster (now UPMC Obstetrics & Gynecology Specialists-Lititz) back in 2010 was one of the best career and personal decisions I made. I feel very fortunate to work alongside my outstanding partners, who are like family to me after 14 years of being here. Our group is cohesive, respectful of one another, and share a common goal of providing the best possible evidencebased care for our patients.
My family and I are involved in the community, appreciate interfaith activities, and participate in events related to the Islamic Community Center of Lancaster, Indian Organization of Lancaster County, South Asian Association of Lancaster, Church World Service, and Jewish Community Center. I have enjoyed serving on the board of Girls on the Run (GOTR), which aims to educate and empower young girls to become confident, independent members of society.
I am also an active member of American College of Obstetricians & Gynecologists (ACOG), American Academy of Gynecologic Laparoscopists
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(AAGL), North American Menopause Society (NAMS), and Pennsylvania Medical Society.
What are your hobbies and interests when you’re not working?
I love spending time with my children. We travel together a lot, experiencing cultures and history around the world and creating beautiful memories. We love going on impromptu day trips to NYC and visiting Instagrammable spots that my children may find interesting. I am also an avid tennis fan and absolutely enjoy watching an exciting tennis match any day. Some of my favorite trips were to the US Open and Wimbledon!
During the COVID phase, I took on the new hobby of gardening and working on our backyard; still do not think I have a green thumb, but I keep trying.
For what reason(s) did you become a member of the Lancaster City & County Medical Society and what do you value most about your membership?
I became a member of the LCCMS to interact with other members of the medical community in our area. As a member of several years, I have enjoyed reading about community physicians and participating in different events. The pre-COVID meet and greets were a great way to know other physicians in the community and interact in an informal setting. I also enjoy learning how physicians, especially female physicians, strive hard to maintain a good work-life balance doing amazing creative activities and projects. Lancaster Physician magazine addresses a variety of topics, and I enjoy reading about everything including the new physicians in the area, the latest political updates related to medicine, news from other healthcare systems in Lancaster County, and of course the fun restaurant reviews!
IN REMEMBRANCE
DANIEL D. WERT, DO
After decades of caring for others, Daniel D. Wert, 85, of Landis Homes, Lititz, PA, passed away on July 7, 2024, after a lengthy battle with cancer. He was the son of the late Daniel and Esther (Umberger) Wert. After graduating from Lancaster Mennonite High School, he spent two years in Honduras as administrator in a TB hospital. Upon returning to the U.S., he enrolled in the Philadelphia School of Nursing for Men, followed by a year at Eastern Mennonite College to obtain his B.S. in nursing. He studied to become a nurse anesthetist and worked in that capacity for two years.
Dan graduated from Philadelphia College of Osteopathic Medicine and did a three-year anesthesia residency at Hershey Medical Center. He served as chairman of Community Anesthesia Associates of Lancaster for 16 years.
After retiring, he made many medical trips around the world with several organizations. He also made solo trips to the mountainous areas of Honduras to provide relief to women suffering from painful varicose veins. He helped train many anesthesia residents in the capital city of Tegucigalpa, Honduras.
Dan was a member of the Unitarian Universalist Church of Lancaster, where he sang in the choir. He was also very involved in the establishment of the Planned Parenthood Keystone Health Center in Lancaster.
Daniel was the husband of Miriam Shank Wert for 56 years. Also surviving are a son, Doug Wert of Milford, PA; a daughter, Cindy Williams of Lancaster; two sisters, Nancy Augsburger of Lititz, and Lois, married to Thomas Chamness of Lititz; brother, James, married to Kathy Martin Wert of Toronto, Canada; and sister-in-law, Esther Glick Wert of Goshen, IN. He was preceded in death by a brother, Robert Wert.
WellSpan Family Health – Georgetown
WellSpan is a regional leader in high-quality care with a mission of “working as One to improve health through exceptional care for all, lifelong wellness, and healthy communities.” WellSpan Family Health – Georgetown is dedicated to that mission.
WellSpan Family Health – Georgetown is a primary care practice in southern Lancaster County and was established in 2013 at the request of Plain Community members. The local community wanted quality primary care providers that were geographically accessible. Therefore, our providers, nurses, and clinical support team strive to improve our community’s health by use of modern evidence-based and innovative care while maintaining and respecting the culture and beliefs of the community we serve.
The team is made up of Keith Wright, MD, Certified Nurse Practitioner (CRNP) Robin Skosko, and newly hired Certified Physician Assistant (PA-C) Matt McCarty. Over the past decade, our practice has provided quality care to patients whose medical needs range from preventative care to management of complex medical conditions. Dr. Wright’s vision when opening the practice was to ensure we provide easily accessible quality care to our community by including multiple services under one roof. Our office accomplished this by offering our patients onsite lab, imaging, and limited medication dispensing services, and we continue to partner with other respected health care providers.
Our providers are dedicated to meeting our patients wherever they are in their health care journey. This means that, when needed, we travel to meet our patients at their homes. Our patient-, family-, and community-centered approach to medical care is unique and does not fit a one-sizefits-all model. Our office is always accepting new patients and has been honored to be part of this community for the last 10 years. Our team is dedicated to providing high-quality care and an exceptional patient experience.
From L to R: Keith Wright, MD; Matteson McCarty, PAC; Robin Skosko, CRNP
FRONTLINE GROUPS FALL 2024
Frontline Practice Groups have made a 100% membership commitment to LCCMS and PAMED. We thank them for their unified support of our efforts in advocating on your behalf and facilitating an environment for physicians to work collaboratively for the benefit of the profession and patients.
Argires Marotti Neurosurgical Associates of Lancaster
Avalon Primary Care
BestFit Virtual Health + Wellness PLLC
Campus Eye
Carter MD Aesthetics
College Avenue Family Medicine
Community Services Group
Conestoga Eye
Dermasurgery Center PC
Dermatology Associates of Lancaster Ltd.
DermDox Dermatology Centers PC-Leola
Eye Associates of Lancaster Ltd.
Eye Health Physicians of Lancaster
Family Eye Group
Family Practice Center PC – Elizabethtown
General Surgery of Lancaster
Glah Medical Group
Hospice & Community Care
Lancaster Arthritis & Rheumatology Care
Lancaster Cancer Center Ltd.
Lancaster Ear Nose and Throat
Lancaster Family Allergy
Lancaster Radiology Associates, Ltd.
Lancaster Skin Center PC
Manning Rommel & Thode Associates
Nemours duPont Pediatrics Lancaster
Neurology & Stroke Associates PC
Patient First – Lancaster
Penn Medicine Lancaster General Health Care Connections
Penn Medicine Lancaster General Health Physicians Diabetes & Endocrinology
Penn Medicine Lancaster General Health Physicians Family Medicine Lincoln
Penn Medicine Lancaster General Health Physicians Family Medicine New Holland
Penn Medicine Lancaster General Health Physicians Family Medicine Norlanco
Penn Medicine Lancaster General Health Physicians Family Medicine Susquehanna
Penn Medicine Lancaster General Health Physicians Gynecologic Oncology
Penn State Health Medical Group –South Lancaster
Pennsylvania Specialty Pathology
Retina Associates of Lancaster
Surgical Specialists—UPMC
Union Community Care – Duke Street
Union Community Care – Hershey Avenue
Union Community Care – Kinzer-Church Street
Union Community Care – New Holland Avenue
Union Community Care – Water Street
UPMC Breast Health Associates
UPMC Heart and Vascular Institute
UPMC Pinnacle Plastic & Aesthetic Surgical Associates
WellSpan ENT & Hearing Services - Ephrata
WellSpan ENT & Hearing Services - Lancaster
WellSpan Ephrata Cancer Center
WellSpan Family Health – Georgetown
WellSpan Surgical Specialists – Ephrata
Bethany G. Bustamante, MD Penn Medicine Lancaster General Health Physicians, Gynecologic Oncology
Heather Elliott Practice administrator - WellSpan Family Health – Georgetown
Germaine Rival, DO Penn State Health Lancaster Medical Center –Emergency Medicine
Kiran Turaka, MD Campus Eye Center
Saturday, December 7 Lancaster Country Club for more info visit www.lancastermedicalsociety.org
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ORTHOPAEDIC EXPERTS NEAR YOU:
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