ACMS Bulletin April 2022 by TEAM

Bulletin Allegheny County Medical Society

April 2022

Spring Nourishment The Poultice

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Tharian Cherian, MD Cardiac Electrophysiologist Locations: Allegheny General Hospital 320 East North Avenue Pittsburgh, PA 15212 Forbes Hospital 2570 Haymaker Road, Suite 201 Monroeville, PA 15146 Specialties: Detection of irregular heart rhythms through electrophysiological testing Interventions such as arrhythmia managment, atrial fibrillation ablation, and 3D mapping

Allegheny County Medical Society

Bulletin April 2022 / Vol. 112 No. 4

Opinion

Departments

Articles

Editorial ....................................5 Society News .........................20 Materia Medica .......................23 • Spring Nourishment • Pittsburgh Ophthalmology Society • Abemaciclib: Escalating adjuvant Deval (Reshma) Paranjpe, MD, MBA, FACS

hosts 57th Annual Meeting

endocrine therapy for high-risk early-stage breast cancer Karen M. Fancher, PharmD, BCOP

Society News .........................21 Editorial ....................................8 • 42nd Annual Meeting for Ophthalmic • Poultice Legal Summary .....................25 Personnel Richard H. Daffner, MD, FACR

• The Future of Telemedicine William H. Maruca, Esquire

Marta Kolthoff, MD

• 2022 ACMS Meeting and Activity Schedule by Committee

Society News .........................21 Editorial ..................................10 • Greater Pittsburgh Diabetes Club set Meeting Schedule .................28 • Bringing Home Baby to host Spring Program on May 3rd Society News .........................22 Editorial ..................................12 • Pennsylvania Geriatrics Society— • Doomed from Birth: The Ida May Western Division hosts Virtual Fuller Story Joseph Paviglianiti, MD

Conference

Perspective ............................16 • Running Boston Backwards Anthony L. Kovatch, MD

On the cover

Lake McDonald- Glacier Park David Sacco, MD Dr. Sacco specializes in Internal Medicine

Bulletin Medical Editor Deval (Reshma) Paranjpe (reshma_paranjpe@hotmail.com) Associate Editors 2022 Executive Committee and Board of Directors President Peter G. Ellis President-elect Matthew B. Straka Vice President Raymond E. Pontzer Secretary Mark A. Goodman Treasurer Keith T. Kanel Board Chair Patricia L. Bononi DIRECTORS 2022 William F. Coppula Micah A. Jacobs G. Alan Yeasted Alexander Yu 2023 Steven Evans Bruce A. MacLeod Amelia A. Pare Maritsa Scoulous-Hanson Adele L. Towers 2024 Douglas F. Clough Kirsten D. Lin Jan B. Madison Raymond J. Pan

PEER REVIEW BOARD 2022 Niravkumar Barot Kimberly A. Hennon 2023 Lauren C. Rossman Angela M. Stupi 2024 Marilyn Daroski David J. Levenson

PAMED DISTRICT TRUSTEE G. Alan Yeasted COMMITTEES Awards Mark A. Goodman Bylaws Raymond E. Pontzer Finance Keith T. Kanel Membership Matthew B. Straka Nominating Chair Raymond E. Pontzer

Douglas F. Clough (dclough@acms.org) Richard H. Daffner (rdaffner@acms.org) Kristen M. Ehrenberger (kehrenberger@acms.org) Anthony L. Kovatch (mkovatch@comcast.net) Joseph C. Paviglianiti (jcpmd@pedstrab.com) Anna Evans Phillips (evansac3@upmc.edu) Andrea G. Witlin (agwmfm@gmail.com)

ADMINISTRATIVE STAFF

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Executive Director Sara Hussey (shussey@acms.org)

Co-Presidents Patty Barnett Barbara Wible

Governance Administrator Dorothy Hostovich (dhostovich@acms.org) Vice President—Operations and Physician Services Nadine M. Popovich (npopovich@acms.org) Director of Publications Cindy Warren (cwarren@pamedsoc.org)

Recording Secretary Justina Purpura Corresponding Secretary Doris Delserone Treasurer Sandra Da Costa Assistant Treasurers Liz Blume Kate Fitting

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EDITORIAL/ADVERTISING OFFICES: Bulletin of the Allegheny County Medical Society, 850 Ridge Avenue, Pittsburgh, PA 15212; (412) 321-5030; fax (412) 321-5323. USPS #072920. PUBLISHER: Allegheny County Medical Society at above address. The Bulletin of the Allegheny County Medical Society is presented as a report in accordance with ACMS Bylaws, Articles 6, 8, and 11. The Bulletin of the Allegheny County Medical Society welcomes contributions from readers, physicians, medical students, members of allied professions, spouses, etc. Items may be letters, informal clinical reports, editorials, or articles. Contributions are received with the understanding that they are not under simultaneous consideration by another publication. Issued the third Saturday of each month. Deadline for submission of copy is the SECOND Monday preceding publication date. Periodical postage paid at Pittsburgh, PA. Bulletin of the Allegheny County Medical Society reserves the right to edit all reader contributions for brevity, clarity and length as well as to reject any subject material submitted. The opinions expressed in the Editorials and other opinion pieces are those of the writer and do not necessarily reflect the official policy of the Allegheny County Medical Society, the institution with which the author is affiliated, or the opinion of the Editorial Board. Advertisements do not imply sponsorship by or endorsement of the ACMS, except where noted. Publisher reserves the right to exclude any advertisement which in its opinion does not conform to the standards of the publication. The acceptance of advertising in this publication in no way constitutes approval or endorsement of products or services by the Allegheny County Medical Society of any company or its products. Annual subscriptions: $60 Advertising rates and information available by calling (412) 321-5030 or online at www.acms.org. COPYRIGHT 2022: ALLEGHENY COUNTY MEDICAL SOCIETY POSTMASTER—Send address changes to: Bulletin of the Allegheny County Medical Society, 850 Ridge Avenue, Pittsburgh, PA 15212. ISSN: 0098-3772

Editorial

Spring Nourishment Deval (Reshma) Paranjpe, MD, MBA, FACS

he first signs of spring are upon us, in the form of snow, hail, rain and wind. Luckily, good weather is just around the corner and with it comes a flurry of new restaurants to check out for takeout, delivery, dining, and that loveliest of experiences, al fresco dining. Check out these fresh offerings if you’re going out to eat or looking for upscale takeaway: 40 North 40 W. North Ave., North Side (412) 435-1111 40northpgh.com Formerly home to Caselulla and Point Brugge and steps from Allegheny General Hospital, this newcomer is worth a visit. With a diverse menu that leans towards Turkish and Middle Eastern, you will be sure to find something to please. Current menu standouts include Khachapuri (Georgian cheese bread), Smoked Trout with Labneh, and Chevre with Za’atar to start; Borscht for a soup course; assorted salads; Falafel, Lamb sourced from Salem’s, and Pan Roasted Ribeye with Chimichurri as

ACMS Bulletin / April 2022

mains; falafel, lamb and fried chicken sandwiches as lighter options. Dessert includes classics ranging from Coeur a la Crème to Crème Fraiche Panna Cotta and this is one of the few places in town where you can get an Affogato without having to explain how to make one. (It’s an espresso poured over vanilla ice cream—heavenly.) Mola 6018 Penn Ave Pittsburgh, PA 15206 412-365-6688 Sushi, sashimi, hand rolls, poke/rice bowls and bao—arguably the best in Pittsburgh right now. Chef Alex Tang serves up high quality fish and unusual weekly specials—if you’re looking to try kama toro (fatty tuna collar), something you might find on L.A. menus, this is the place for you. Call for reservations. Takeout and delivery available. Lunch specials. Closed Tuesdays.

won’t find at most Chinese-American restaurants. So authentic, in fact, that it has been catering to Chinese expat students at CMU for years. Complete with sushi chef and liquor license. Off the Rails BBQ at Strange Roots Taproom 4399 Gibsonia Road, Gibsonia April 28-30 is the opening weekend for this collaboration in which Off the Rails BBQ is taking over the Strange Roots Experimental Ales Kitchen. Every Thursday through Saturday afterwards while the weather is warm, you can enjoy live music in the large outdoor space there while you partake of the extensive BBQ menu including brisket or pulled pork sandwich/mac and cheese/nachos, St. Louis Ribs, ½ smoked chicken, regular mac and cheese, coleslaw and baked beans.

Sakura Teppanyaki and Sushi 5882 Forbes Avenue, Squirrel Hill 412-422-7188 Authentic northwest Chinese cuisine featuring lamb dishes, noodles, pancakes, stews and Chinese brunch—highly traditional dishes you

Continued on Page 6

Editorial From Page 5

Look for more outdoor festivals this year, such as the now famous Picklesburgh downtown. One can only hope that Reyna’s Hatch Chile festival will make a return at the end of the summer. This year’s Three Rivers Arts Festival (Fri June 3- Sun June 12) will be held downtown this year instead of the traditional Point State Park locale, but promises the same outdoor food, music, art and merriment. Traditionally, it also promises rain - so remember your umbrella. Glamorous, hard to get reservations: Gi-Jin 208 Sixth St., Downtown (next to Tako) 412-307-7374 gi-jin.com Buckle your seat belts and wait until it’s safe for you pandemic-wise. The menu is only accessible by QR code. The place seats 34 and it’s a coup to get a table. Prepare for phenomenally plated high quality small dishes and sushi from a talented chef, lovely desserts, and a dazzling variety of sake, gin and cocktails. Pusadee’s Garden 5319 Butler Street, Lawrenceville (412) 252-2683 or resy.com Pusadee’s Garden has undergone an incredible renovation of both physical space and menu that has turned it into a bona fide fine dining establishment. This isn’t the Pusadee’s that you remember. A mixture of

elevated Thai and fusion dishes grace the menu and are often unexpected in their originality. Fusion cocktails complement the concept. Pusadee’s Garden takes reservations for indoor tables; specify if you’d like to sit outside if the weather is nice. If you’re looking for an outdoor reservation only, you may have to call day of as the decision to open the garden depends on the weather. The garden seating doubles the restaurant’s capacity and is as lovely as you might hope. Café Zinho 238 Spahr Street, Shadyside 15232 (412) 363-1500

Chef Toni Pais’s labor of love is a stalwart of the Pittsburgh fine dining scene—cozy, charming, and comforting with reliably excellent cuisine. Mediterranean dishes with an emphasis on Portuguese delights. It’s a dear old friend among Pittsburgh restaurants, always welcoming and always wonderful, a beautiful and romantic gem of a place. In warmer weather, outdoor sidewalk seating is available. Cash or check only; ATM on premises. Call for reservations. Lastly, here are some things to look forward to. Pittsburgh Restaurant Week Summer 2022 is August 8-14, with many restaurants extending until August 21. Prepare for many $22 multicourse meals—it’s a great and inexpensive way to get a flavor for many wonderful local restaurants that you might not put on rotation otherwise. For details, visit www. pittsburghrestaurantweek.com closer to August. Balvanera (a NYC based Argentinian restaurant currently on the Lower East Side) will open in the Strip District (1600 Smallman Street) in the fourth quarter of 2022. This is a case of talent literally being attracted to our fair city-- Chef Fernando Navas’ spouse Meredith Boyle hails from O’Hara township, so it is a homecoming for these married co-owners. Look to be transported via taste and spirit to beautiful Buenos Aires.

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Editorial Editorial adjacent lumbar vertebra, explaining herThe pain.Strip My resident, from Georgia, District Terminal upon seeing the findingsofsaid, (the new redevelopment the in his deep southern “Fellahs, there’s historic fruit anddrawl, vegetable warehouse a lesson Crocks market in here. the Strip) will daah be the(die), site of UnfortunatelyEast for the patient, atoo.” yet-to-be-named Asian foodCT scanning ultrasound exams had hall and barand extravaganza. This joint not been developed. The important project between award-winning local lesson is that for (Everyday most patients with a chefs Mike Chen Noodles) diagnosis of psychosomatic illness, the and Alex Tang (Mola) will feature symptoms and East in factAsian a small seven stallsare runreal, by local number of these patients indeed have restaurants. Imagine feasting on great real abnormalities accounting for sushi, Thai, Cantonese, Chinese, their and symptoms. Korean delights as well as enjoying view of humor bobaSigmund tea and Freud’s a full bar. Opening in was that it was a conscious expression Winter 2022. of thoughts that society usually suppressed or was forbidden.2 As long as the humor, in this case name-

calling, is meant in a benign fashion, it is considered harmless. However, in today’s politically divisive atmosphere, it is best to use humor only when you truly know your audience. As a good example, I remember the not so “good old days,” when it was expected that a speaker at a conference or a refresher course would tell jokes. Many of the “old timers” were very colorful characters. Today, fortunately, speakers are business-like and jokes are tacitly forbidden, since they are bound to offend someone. Finally, we should always remember that no matter how unpleasant some of our patients are to us, they are still our fellow human beings.

Dr. Daffner, associate editor of the ACMS Bulletin, is a retired radiologist who practiced at Allegheny General Hospital for more than 30 years. He is emeritus clinical professor of Radiology at Temple University School of Medicine and is the author of nine textbooks. He can be reached at bulletin@acms.org. The opinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society.

References 1. Shem S. The House of God. Richard Marek Publishers 1978. The2.opinion in this columnJokes is thatand of Freud expressed S, (Strachey J, Trans.). therelation writer and does not necessarily their to the unconscious Newreflect York: the W. opinion of the Editorial Board, the Bulletin, W. Norton, 1960 (Original work published 1905). or the Allegheny County Medical Society.

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Editorial

The Poultice Richard H. Daffner, MD, FACR

poultice, as defined by the Google English Dictionary is “a soft, moist mass of material, typically of plant material or flour, applied to the body to relieve soreness and inflammation and kept in place with a cloth.” The name derives from the Greek word “poltos”, meaning “porridge.” They are also known as cataplasms. The typical poultice is a moist concoction of herbs, bread, or flour that is typically heated and is spread on an injury, or wound, and held in place with a cloth. Poultices are sometimes known as “plasters.” They have been used as a mainstay of

primitive medicine throughout history with various success, particularly in treating muscle and tendon injuries through their counter-irritant properties. Poultices made with moldy bread (penicillium chrysogenum) have been used to treat infected wounds. Poultices were popular medical treatments up until the 1940’s. Today, they are used to treat inflamed legs in horses. So, why mention this bygone treatment now? The COVID-19 pandemic has spawned many false narratives on the use of hydroxychloroquine, an anti-malarial

drug, and ivermectin, a drug used to treat intestinal parasites in farm animals, as potential prophylaxis and treatment for the disease. The main purveyors of these and other conspiracy theories come from the “usual suspects:” QAnon, anti-vaxers, and telehealth companies. So far, scientific trials have shown neither of these drugs to be effective for dealing with the virus. Unfortunately, both have been shown to have serious side effects (cardiac arrythmias with hydroxychloroquine and cardiac, respiratory, and mental problems with ivermectin). So, what does this have to do with poultices?

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Editorial Decades ago, I read an editorial in a medical journal, the source of which I cannot remember, by a physician who was a medical intern during the 1918 -1919 influenza pandemic. He was treating a young mother who was severely ill with the disease. He and his colleagues had done all they could with the available technology and drugs of the day to try and save their patient. However, nothing seemed to work. The author reported that he told the family that they (the medical team) had done everything medically possible, but the woman’s prognosis was not good. “Have you tried a mustard poultice?” the distraught husband asked. The intern, fresh out of medical school, where he had learned the latest in medical therapy, told the family that the use of mustard poultices for severe pneumonia was an “Old Wives Tale,” and that it would not work. (Today, the family might have attempted to get a court order for the folk treatment.) As expected, the woman died. The intern, once again, told the family that they had done everything medically possible. “No, you didn’t,” the bereaved husband said. “You didn’t use the mustard poultice. If you had, my wife, the mother of my children would still be alive!” The case haunted the physician for decades and he wrote that in his heart of hearts he knew (as did his attendings) that the poultice would not have made a difference. However, he also knew, in the eyes of the family, he and his colleagues had not done everything possible. They believed he had killed their loved one.

There is a moral to this story. Folk medicine treatments have been around for as long as humans have been on this planet. Many of them work; most don’t. Many herbal drugs have serious side effects or react with traditional medications. And some have a placebo effect, giving the patient a sense that they are getting better. Author Gerald Green’s 1956 novel, The Last Angry Man, that was made into a movie in 1959, is a story of Dr. Sam Abelman, a testy old general practitioner. In one scene, Dr. Abelman told a young colleague the importance of catering to the patient’s needs. He showed the young physician a machine with brightly flickering lights. “You know what that does?” he asked. “Absolutely nothing. But it impressed the patients, who think it’s helping them.” The author of the editorial, I remember, echoed the same theme. We are obligated by the Hippocratic Oath to alleviate suffering in our patients. The author concluded that if a folk remedy does not cause any untoward side effects, it should be used, if requested by the patient or his/her family, even though it doesn’t work. Regarding the current pandemic, hydroxychloroquine and ivermectin are not folk remedies, have been shown by credible research to be ineffective, and have serious side effects.

Improving Healthcare through Education, Service, and Physician Well-Being.

Dr. Daffner is a retired radiologist, who practiced at Allegheny General Hospital for over 30 years. He is Emeritus Clinical Professor of Radiology at Temple University School of Medicine and is an amateur historian. The opinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society.

ACMS Bulletin / April 2022

Editorial

Bringing Home Baby Dr. Marta Kolthoff

s a mid-career physician, I remember the time before evidence-based clinical practice dominated medicine. Until the mid2000’s, my medical decision-making relied upon past clinical experience, textbook readings, and guidance from my mentors. A rigorous review of published medical studies typically occurred in the setting of journal clubs or other structured educational events. I probably was not unique in this regard. However, this “historical” approach proved to be far from adequate for my patients and their health outcomes. For medicine in general, the historical, “non-evidencebased” approach certainly led to the perpetuation of longstanding and unproven practices. In the field of obstetrics specifically, this included practices such as “bedrest” for threatened abortions, “npo” status for laboring patients and the shaving of pubic hair for deliveries. Not one of these practices were supported by research but were widely accepted. These practices have been (hopefully!) abandoned and replaced with evidence-based clinical obstetrical practices. Sometimes it is challenging to accept new evidence especially if it means changing long-standing practices. As doctors, we can suffer from a type of cognitive bias called 10

“belief bias.” A “belief bias” causes one to overemphasize preexisting beliefs, knowledge and experiences when considering different arguments. (1) Essentially, despite quality evidence, we as health care providers may continue to adhere to a practice because of a deeply held belief or past patient experience. The belief bias often is fueled by a fear of causing patient harm. One example of a belief bias in OBGYN is continuing to perform yearly pap smears on all patients because of concern over missing the opportunity to prevent cervical cancer. Recently, I realized that I had a belief bias and it really surprised me. As the founder and leader of my institution’s perinatal palliative care program, I try to stay informed about the needs and desires of our families who experience a perinatal death. I see myself as an advocate for our bereaved patients as they navigate their grief journey in a society that is far from supportive and understanding. I felt that I understood the importance of bonding and memory-making as means to prevent complicated grief. The provision of beautiful photographs, mementos, certificates of birth, and memorial events are a top priority for our program. Most importantly, however, we ensured that patients had opportunity to spend time with their deceased baby and perform their “final

acts of parenting” such as holding, bathing, dressing, and introducing to family members.(2) There is substantial evidence in the medical literature that supports these practices. Caring for a deceased baby has been associated with positive memories and the facilitation of a healthy grief process.(3) In addition, a 2008 Swedish cohort study showed an overall beneficial effect of holding a stillborn baby after 37 weeks gestation. Patients in this study had fewer headaches and sleep issues. The authors concluded that holding one’s stillborn baby “makes the baby real and facilitates a healthy mourning process.”(4) Another Swedish study showed an almost 7-fold increased risk of depressive symptoms for mothers who reported not being with their babies for as long as they wished with an adjusted risk ratio 6.9 (95% CI 2.4-19.8)! (5) Finally, a United States— Norwegian collaborative study showed that patients seeing and holding their stillborn baby was associated with lower anxiety symptoms (OR 0.68, 95% CI 0.49-0.95) and a trend towards fewer depressive symptoms (OR 0.72, 95% CI 0.51 – 1.02). The preponderance of evidence regarding the importance of parental time spent with a deceased baby has led to this becoming the standard of care in many countries including the United States.(6) www.acms.org

Editorial How does this relate to belief bias? A few years ago, a mother from our program requested to take her deceased baby home with her before transitioning the baby’s body to a funeral home. My initial response was: “She should not do that. It will traumatize her.” Where did this belief come from? I was scared for my patient and what would she think when her baby’s body began to deteriorate. Ultimately, the patient was allowed to take her baby home with her for a few days. This is in accordance with Pennsylvania state law. When I called her several weeks after she buried her daughter, she told me how meaningful it was to take her home. She was able to hold her, dress her and, in her words, “mother her.” Although grieving, she sounded joyful because she was able to perform the “final acts of parenting.” Why was I reacting with emotion rather than responding with a thoughtful consideration of her wishes as well as a review of the current medical literature? The thought of a dead body at home elicited a visceral reaction in me as well as fear. My deeply held belief or bias also came from living in a very “death-phobic” society. After a good amount of research, I learned that this practice is simply an extension of what we already support and encourage in the hospital setting. Furthermore, this practice is accepted and supported in other countries including Denmark and the United Kingdom.(8) Seeing a stillborn baby provides evidence of the baby’s birth, existence, and death and establishes the patient’s parenthood. It helps, in most cases,

ACMS Bulletin / April 2022

3. Flenady V, Boyle F, Koopmans L, Wilson T, Stones W, Cacciatore J. “Meeting the needs of parents after a stillbirth or neonatal death”. British Journal of Obstetrics and Gynaecology. 2014 Sep;121 Suppl 4:13740. doi: 10.1111/1471-0528.13009. Erratum in: BJOG. 2015 May;122(6):891. Erratum in: BJOG. 2015 May;122(6):891. PMID: 25236648.

to lower the risk of complicated grief that can result from an ambiguous loss such as stillbirth.(9) Parents should be able to decide how much time they need to spend with their deceased baby including time outside the hospital. Hospital staff need to be aware of this option and support the family if they feel it is best for them. The definition of evidence-based medicine not only includes clinical expertise and best available evidence but also the integration of the patient’s values in the process of medical decision-making.(10) As doctors, we do not always know best. Sometimes we ignore the literature and need to reflect on why this is the case. We also need to listen to patients and families. Sometimes that is the best clue that we have a belief bias that stands in the way of caring for our most vulnerable patients, especially those that experience the death of a baby.

References 1. Croskerry P: “50 Cognitive and affective biases in medicine (alphabetically)” (Resource available, Critical Thinking Group at Dalhousie University; https://medicine/ core-units/cpd/programs/critical-thinking/ educational-resources.html) 2. R ich D. “Psychological Impact of Pregnancy Loss: Best Practice for Obstetric Providers”. Clin Obstet Gynecol. 2018 Sep;61(3):628636. doi: 10.1097/GRF.0000000000000369. PMID: 29596074.

4. Rådestad I, Surkan PJ, Steineck G, Cnattingius S, Onelöv E, Dickman PW. “Long-term outcomes for mothers who have or have not held their stillborn baby”. Midwifery. 2009 Aug;25(4):422-9. doi: 10.1016/j. midw.2007.03.005. Epub 2007 Dec 11. PMID: 18069101. 5. Surkan, PJ, Rådestad, I, Cnattingius S, Steineck G, Dickman PW. “Events after Stillbirth in Relation to Maternal Depressive Symptoms: A Brief Report”. Birth, 2008;5: 153-157. https://doi.org/10.1111/j.1523536X.2008.00229.x 6. Homer CSE, Malata A, Ten Hoope-Bender P. “Supporting women, families, and care providers after stillbirths”. Lancet. 2016 Feb 6;387(10018):516-517. doi: 10.1016/S01406736(15)01278-7. Epub 2016 Jan 19. PMID: 26794072. 7. Perinatal Palliative Care. ACOG Committee Opinion No. 786. American College of Obstetricians and Gynecologists. Obstetrics and Gynecology. 2019;134:e84-39 doi: 10.1097/AOG.0000000000003426 8. Zhang S. “How Hospitals Changed Their Approach to Stillbirth”. The Atlantic. 2020 Feb. https//:theatlantic.com/science/archive/2020/02/Danish-hospital-ward-specializes-stillbirth/606454/. 9. Kersting A, Wagner B. “Complicated grief after perinatal loss.” Dialogues in Clinical Neuroscience. 2012;14.2: 187-194 10. Masic, I, Miokovic M, Muhamedagic B. “Evidence based medicine–new approaches and challenges.” Acta Informatica Medica 2008;16.4: 219-225 The opinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society.

Editorial

Doomed from Birth: The Ida May Fuller Story Joseph C. Paviglianiti, M.D.

t seems like everybody is retiring these days, especially physicians. Just in the Fox Chapel/Monroeville area alone, well over 10 pediatricians have retired, or moved onto something “non-clinical,” in the short time since COVID started 2 years ago. That’s a lot of pediatricians calling it quits in a small area. The same thing is happening to physicians all over western Pennsylvania. Lots of factors are at play, but the overwhelming reason seems to be that physicians are just tired of banging their heads against a wall. The daily grind, and all that’s entailed with it, has squashed out much of the joy of taking care of others. In that foreboding spirit, just 6 months ago I sat down and calculated how many days until my Full Retirement Age (FRA), which is 67 (for those of us born after 1960). I created a “Dad’s Retirement Countdown” sign (June 30, 2032 !!) and thumbtacked it to the wall over my messy desk at home. This caused quite a bit of unexpected curiosity and angst amongst my kids, whom I think never before contemplated that dad would slowly fade away as they stepped up to their individual financial responsibilities, or that such a time was in the distant, yet foreseeable future, God willing. Truth be told, I hadn’t realized, or at least not really internalized, that my FRA had 12

been pushed back to 67 until I started writing this editorial… my original retirement sign was for June 30th, 2030 (age 65). I’m sure I have read it before, but 67 really just sunk in as I wrote this article. Now I gotta redo the sign and work for 2 more years. Crap! All this recent retiring of my colleagues got me to thinking about Social Security. Sure, we have all heard the doom and gloom that Social Security is going broke. But is it really? What does that mean to me and those younger than me? America’s first Social Security program was actually the Civil War Pension Program, though these were only paid to Union soldiers, later with survivor benefits. This opened the door for 95-year-old retired Union soldiers to marry 18-year-old brides, so the latter could have survivor benefits and the former could die happy. In fact, the last Civil War bride was receiving a Civil War pension until 1999! But, other than Union Civil War veterans, the general American populace had no such retirement plan. Corporate and/or government pensions didn’t exist. A lifetime of work resulted in a pocket-watch at best. The depression of the 1930s brought the problem of increasing numbers of elderly poor to the

forefront. A variety of pension programs had been proposed since the industrial age started in the mid-1800s, most of which involved some sort of taxation of the rich, but none of them really got anywhere because they were perceived as “welfare” programs, which left a bad taste in most Americans’ mouths. America was a “pick yourself up by your bootstraps” country and “welfare” was for lazy people. Franklin Delano Roosevelt came along and changed the conversation from “retirement welfare” to “social insurance.” This was a new concept where people actually “contributed” to their future retirement pension through mandatory paycheck deductions (i.e., FICA). In June 1934, the Committee on Economic Security (CES) was created to dream up a plan and by January 1935 the Social Security Act

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Editorial was proposed. With few changes, the bill passed with large bipartisan support; The Social Security Act was signed into law by FDR on August 14, 1935. Fourteen months from start to finish!! The following year, 1936, was used to gather “worker” information across the country with the help of the US Postal Service, who distributed and collected informational applications (demographic info, work history, etc.). Prior to this, there was no national registry of “occupations, hours worked, etc.,” so this was a huge undertaking. Social Security Numbers and accounts for all Americans were created. Grace Dorothy Owen of New Hampshire received SSN# 001-010001. I’m assuming that is common knowledge since I found it on the Social Security website, otherwise, sorry Grace for revealing your personal info. In retrospect, what an amazing accomplishment to create the Social Security system, gather worker info, and begin collecting and distributing money in just over two years. And the program has survived almost 90 years !!! On January 1st, 1937, all American workers started having retirement deductions taken from their paychecks. These Federal Insurance Contributions Act (FICA) taxes were collected and put into the Social Security Trust Fund. For the first 3 years (1937-39), while the trust fund was building up a cash reserve, those who retired from 1937-1939 were paid a single one-time lump sum. Ernest Ackerman, a trolley operator from Cleveland, retired on January 2, 1937, one day after the Social Security program began. During his one day of participation in the Social Security program, 5 cents was withheld from his last pre-retirement ACMS Bulletin / April 2022

paycheck. Upon retirement the next day, he received the first ever lump sum payout from the Social Security program, for a whopping 17 cents! Others were more fortunate. By 1940, the Social Security Trust Fund had built up enough cash reserves to pay a monthly benefit “until death.” The first monthly payout was to Ida May Fuller of Vermont. A teacher/ secretary, she started working in 1896, but only paid into the Social Security program at its inception, starting in January 1937.Over the last 3 years of her employment from 1937-1939, she paid a sum total of $24.75 of FICA payroll deductions into the Social Security System. She retired in November of 1939 (age 65) and on January 31, 1940, she became the first recipient of the new monthly Social Security check, in the amount of $22.54 per month. In a harbinger of the future of the Social Security program, she lived until age 100, and her monthly Social Security payout totaled $22,888.92! Not bad for a $24.75 investment…but an ominous omen for the program. Over the years, many changes have been made to the Social Security system: survivor benefits, child benefits, SSI/disability, Cost of Living Adjustments (COLAs), etc. But how long can the system last before running out of money? It’s all a matter of 1st grade math: Social Security funds “in,” minus payouts “out.” The United States government is forbidden from “stealing” from the Social Security Trust Fund cash reserve for any reason, not even to build a border wall. In 1940, there were 222,488 retirees receiving Social Security and the fund paid out $35 million in claims that year. In 2008, there were over 50 million retirees/

recipients of Social Security, receiving a total of $615 billion in payments that year. The math went bad in 1983, when Social Security started paying “out” more than it took “in,” thus depleting the cash reserve. To rectify this, the government started to tax Social Security benefits, which previously had been untaxed. This solved the issue, and the Social Security Trust Fund cash reserve started to grow again. For years, though, the actuaries and financial wonks could see down the pike that in 2019, the math would go bad again, and indeed, in 2019 things had reversed. Starting in 2019, the Social Security system is paying “out” more than it takes “in”, taking “in” $1 trillion and paying “out” slightly more than $1 trillion. The Social Security Trust Fund cash reserves still exist (Social Security Trust Fund cash reserves were $2.9 trillion at the end of 2020), but if no reforms are enacted, these cash reserves, which pay “full” monthly benefits to retirees, will be depleted by 2034. Does that mean Social Security will be broke in 2034? No. But after that, the system will only be able to pay “out” what it takes “in” each year (no cash reserves to make up the difference). This would mean an approximate 25% reduction in projected monthly Social Security benefits to retirees starting in 2034. The pandemic, with fewer workers and subsequently lower wage/ FICA taxes being collected has really hurt the system as well. Currently, in 2020, 89.6% of Social Security trust funds come from FICA payroll taxes (6.2% of paycheck from the employee, 6.2% from employer; 12.4% from self-employed). This comes to Continued on Page 14

Editorial From Page 13

approximately $1 trillion dollars “into” the Social Security Trust Fund cash reserves per year. Income taxes on Social Security payments to retirees bring in another 3.6 % ($40.7 billion/ yr) to the reserve. The trust fund earns interest, which generates 6.8% of the cash reserve ($76 billion/yr). Is Social Security something that was doomed from the start? Maybe, due to the Ida May Fuller effect. But multiple national polls show widespread support for continuing Social Security, on both sides of the political aisle and among over 86% of our very politically diverse and divided population. More solutions are needed, but the Social Security fund has faced financial insolvency before and reforms were enacted to save it. As my retirement date of June 30th 2030 2032 looms ahead, I realize it is a decade away, yet will be here before I know it. Here’s hoping that our government can cooperate enough and have enough foresight to hammer out a new solution to ensure the survival of Social Security without too much decline in benefit payout. While never intended to be one’s full retirement income plan, for many Americans, the Social Security system is the only safety net that stands between living out one’s retirement years in poverty. Coming soon: Review of current proposals by the government to fix the Social Security funding problem.

The opinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society.

Thank you for your membership in the Allegheny County Medical Society The ACMS Membership Committee appreciates your support. Your membership strengthens the society and helps protect our patients.

Please make your medical society stronger by encouraging your colleagues to become members of the ACMS. For information, call the membership department at (412) 321-5030, ext. 109, or email membership@acms.org.

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Congratulations to all of our Awardees from Allegheny County PAMED received over 200 nominations recognizing physicians for their hard work not only through the COVID-19 pandemic but day-in and day-out. PAMED celebrated its first ever state-wide recognition of Doctors’ Day. PAMED staff and leaders visited a few nominated physicians in different parts of the state for an in-person presentation of their gift from generous sponsors! Thank you to everyone who took time to nominate a colleague or physician. Phillip Adams, D.O. John Brehm, M.D. Thomas Campbell, M.D. Douglas Clough, M.D. Melissa Dosch, D.O. Salman Fazal, M.D. Louis Heyl, M.D. Micah Jacobs, M.D. Ramzi Khalil, M.D. Akhtar Khan, M.D.

David Lasorda, M.D. David Logan, M.D. Matthew Macken, M.D. Timothy Martin, M.D. Hemlata Moturi, M.D. Charles Mount, M.D. David Nace, M.D. Deval Paranjpe, M.D. Mohan Paranjpe, M.D.

Amy Pare, M.D. Raymond Pontzer, M.D. Asha Potnis, M.D. Andrew Sahud, M.D. Amir Toussi, M.D. Shaka Walker, M.D. Jonathan Weinkle, M.D. Nicole Wheeler, M.D. Don Yealy, M.D.

Recognizing Hard Working Physicians ACMS Bulletin / April 2022

Perspective Perspective

Running Boston Backwards Anthony L Kovatch, MD “Life must be lived forwards, but can only be understood backwards.” — Soren Kirkegaard, Danish philosopher and father of Existentialism (1813-1835) They were there to embrace me in my state of exhaustion after finishing the long race—if only retroactively and in my imagination! It was Saturday, March 12th of 2022. I had started the race on Saturday, October 9th of 2021. I was so exhilarated that we took a picture for Facebook to be remembered for another 50 years. (See photo at end of article.)

After all, it is clearly stated in the rulebook that a VIRTUAL marathon--even the most pre-eminent of them all, the one in Boston—can be run at the time and place determined by the registrant who has paid his fee and on completion will receive his medal. Therefore, I reasoned, delayed gratification is acceptable—even when the delay spans 50 years…. ……..It was a watershed assignment for the fledgling reporter of the sports department of the Daily Pennsylvanian, which in 1972 had

proclaimed itself the #1 student newspaper in the country; he was to write an editorial about the historic Boston Marathon, which was taking place the following Monday, as was the tradition. This being 50 years ago, I cannot now remember why a student in Philadelphia was candidly reporting upon an event in a rival city that was likely to be glorified by a top-notch reporter in a rival institution (Harvard). I had no credentials, being the kind of inferior athlete who hides from the eyes of the world by running alone along the paths of cemeteries or in the darkness of the early night. I do remember well that the title of the editorial in my column called “Kid’s Korner” was purposely insipid and vague: “The Men, the Madness, and the Marathon.” I only half –remember the opening line: “The distance from Hopkinton, MA to Copley Square in the heart of Boston is 26.2 miles---it is forever (or maybe I wrote “eternal”) in a dream.” Never in my wildest dreams did I imagine that a half century later, I would be one of the “Men,” albeit only vicariously. I realize now that, even back in those lost days of youth, I had a flare for melodrama. After a long moratorium from casual running when my children were too young and restless to cooperate in such a monotonous, lonely activity, I www.acms.org

Perspective Perspective resumed the endeavor in my forties, probably to ward off a mid-life crisis. After finishing near the back of the pack in a couple dozen marathons (typically on page 9 of the 10 pages of results) over the span of a couple dozen years, I was forced by the cancellations wrought by the COVID-19 pandemic to keep up my training by spending my “weekend warrior” hours sludging through a new concept in sporting events: the virtual marathon. These “races” can be run anywhere and anytime one chooses, even in dark cemeteries. Pay a handsome fee, submit a time, and your handsomelycrafted medal arrives in your mailbox within a few days or weeks. There is even some pride in the accomplishment—even for the lastplace finishers like “Slowvatch!” So, when the venerable Boston Marathon became humble and joined the virtual scene in its 125th year, I had no hesitation to fulfill the “eternal dream” I had reported upon 50 years hence. Being a disciple of Doctor George Sheehan---cardiologist, father of 12, elite runner in his later years, internationally-known author of running books (“Running and Being” is his classic), and guru of the generation of us who run, not only for our physical fitness, but more so for our spiritual fitness—I had his battle cry for inspiration: “Like everything else, I want to be challenged. I want to find out whether or not I am a coward. I want to see how much effort I can put out…what I can endure—if I measure up. Running allows that.” There was no better stage for this than Pittsburgh; I had run the true Pittsburgh Marathon and its stepsister, The Great Race, many times over ACMS Bulletin / April 2022

the years. George Sheehan’s son, Andrew, is an investigative reporter for KDKA-TV, the Steel City’s top network. So, the lonely running trails along the Allegheny and Ohio Rivers were my personal course over the two days of my imaginary feat. “I am now running through the campus of Harvard University; there is the statue of Paul Revere; the crowds are cheering me on and giving me high-fives! ” I told myself. I fed my mind with a kind of Kafkaesque inner dialogue, making the most of my vicarious adventure. I was running Boston in my mind---and, as Doctor Sheehan would have argued, in my soul as well.

“Here comes the bonk!” I told myself as I was imagining “hitting the wall” while running mile 20 on Washington’s Landing. “Soon you will be running up the fabled ‘Heartbreak Hill’ and may be overcome by physical and mental fatigue. As you have done in your training, you must run backwards!” Running backwards is hardly for the timid. In spite of qualifying for Boston running forward and well aware of the pitfalls—torn-up feet, calves ready to explode, neck muscle spasms because of constantly having to look behind you, running into trees—Loren Brian Zitomersky took up the challenge of running the entire 26.2 miles backwards in 2018; his inspiration was to raise awareness of the Epilepsy Foundation to honor his brother Brian

who died of intractable seizures. However, in researching this initiative, I believe Zitomersky had the glorification of some other courageous phenotypes on his mind: “There are some blind runners in the Marathon too, and generally they have a guide as well. So there was one blind runner and his guide said to him, ‘Hey, there’s a backwards runner over there.” And the blind guy says really loud, ‘A backwards runner?! That’s crazy….. How can he see where he’s going?! ‘ “Everyone within earshot had a really good laugh with that one.” And so, for a mile or two I did run backwards. I only turned around when I sensed the beguiled faces of casual onlookers. I wanted to shout out: “Don’t look at me like that. I am not going nuts! When Jimmy Piersall hit his 100th career home run, he ran around the BASES backwards!” Piersall had a tumultuous major league career with many honors—and ejections! He was renowned for his antics on and off the field---mostly on. In his autobiography Piersall commented: “Probably the best thing that ever happened to me was going nuts. Who ever heard of Jimmy Piersall until that happened?” In his promising rookie season, he had to leave his team (the Boston Red Sox!) to be institutionalized for a nervous breakdown. He reported this experience in a landmark book, “Fear Strikes Out,” which won him the acclaim and the admiration of the baseball community and the world at large. Overnight, Piersall became the poster child for the talented athlete who endures through a serious mental health obstacle. It was bipolar disorder. Continued on Page 18

Perspective Perspective From Page 17

When logic and proportion have fallen sloppy dead And the White Knight is talking Backwards And the Red Queen’s off with her head Remember what the Doormouse said Feed your head, FEED YOUR HEAD While the characters in “Alice in Wonderland” were feeding their heads with opium and other psychedelic drugs, I was filling my own with gratitude for just finishing the race. Gratitude that the iconic event had gone virtual before my aging body was too worn out by time and life’s considerations to participate even vicariously. Gratitude that my aging mind was competent enough to remember what I had written 50 years ago as a novice and that I could fulfill what I thought at that time was merely a pipedream. Gratitude that I could reasonably claim out loud that 2022 would be the “year of the boomerang” when our everyday lives might return to normalcy, and that “everything new would seem old again” as we understand the dynamics of history backwards. Case in point: At the completion of “The Men, the Madness, and the Marathon,” I ask a runner I interviewed 18

for the story: “Why do you want to run the Boston Marathon?” I did not long remember his name or his level of ability, but I clearly remember his answer: “I want to run the race for the same reason that George Mallory said he wanted to climb Mount Everest: Because it’s there!” Mallory was a greatly respected English mountaineer whose efforts paved the way for Edmund Hillary of New Zealand and his Sherpa, Tanzig Norgayof Nepal, to be the first to climb to the top of Mount Everest in 1953. Mallory made his famous statement in 1923. In 1924 he mysteriously disappeared during an expedition to Everest. His frozen dead body was only discovered 75 years later in 1999.

Mountaineering pioneer George Mallory (1886-1924): “Chance of a lifetime in a lifetime of chance”

It’s breeding and it is training/ And it’s something unknown That drives you/ And carries you home And it’s run for the roses/ As fast as you can Your fate is delivered/ Your moment’s at hand It’s the chance of a lifetime/ In a lifetime of chance And it’s high time you joined in the dance! ----- “Run for the Roses” by Dan Fogelberg (1982) They say that life is a marathon and its mile markers are the years and now and then there’s a water station where you refuel for when you have nothing left. In the closing pages of George Sheehan’s final book on running “Going the Distance,” his son George Sheehan III iterates in his absence: “The end came a few days after Father Brady spoke of Dad’s acceptance of death…It was Friday. He lapsed into a deep sleep that worked its way into Sunday night. A visiting nurse told us that he might die within 24 hours…Dad in a dark blue turtleneck, lying under the covers with a handcloth on his brow, was looking like he did during his days in the Lennox Hotel recovering from a Boston Marathon.” And this is another reason that I am grateful: whether virtual or real, whether 50 years ago or today, whether we are physicians, marathoners, mountain climbers, parents, or just simply passing through--we all stand on the shoulders of giants---MEN (or WOMEN) whose MADNESS pushes the rest of us to overcome not only MARATHONS, but all challenges that are simply THERE.

“

As I crossed the imaginary finish line that day (grandfriends Nora and Liam would be there months later in the grand scheme of things), my head was filled with quotations from the song “White Rabbit” written by Grace Slick of the group Jefferson Airplane in their album “Surrealistic Pillow” (1967—an era of ideologic foment when it was “cool” to be “nuts.”)

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Perspective Perspective

This story was originally posted in the The Pediablog. Allegheny Health Network, on January 6th, 2022: http://www.thepediablog. com/2022/01/06/out-of-the-old-blackbag-14/ The editor, Dr Ned Ketyer, is one of the “giants” I refer to above. Addendum: Just when I thought the race was finally over, I received a request for an alumni donation from the college newspaper for which I wrote the original editorial 50 years ago. I submitted a small amount---50 dollars—to be sure the student newspaper would remain #1 in the country, but I would have rather grabbed the editors by their shirts and yelled into their naïve faces the admonition of George Sheehan: “It’s very hard, in the beginning, to understand that the whole idea is not to beat the other runners. Eventually, you learn that the competition is against the little voice inside you that wants you to quit.” (This is true even when running alone in cemeteries.) I will be sure when they are ready that Dear Sweet Nora and “Big Guy” Liam learn this important fact!

ACMS Bulletin / April 2022

Fifty years from the starting line, they were there with me at the finish line of the virtual Boston Marathon---my “grandfriends” Dear Sweet Nora and “Big Guy” Liam.

Society News

Pittsburgh Ophthalmology Society hosts 57th Annual Meeting The Pittsburgh Ophthalmology Society, under the leadership of President Marshall Stafford, M.D., hosted their 57th Annual Meeting on March 11, 2022 at the Omni William Penn Hotel. After two years of virtual offerings the in-person event attracted over 90 physicians who welcomed distinguished ophthalmologist Uday Devgan, M.D., FACS, Private Practice, Devgan Eye Surgery, Los Angeles; Partner, Specialty Surgical Center, Beverly Hills; and the original Cataract Coach, who served as the 41st Annual Harvey E. Thorpe Lecturer. The named lecture honors Harvey E. Thorpe, M.D., an ophthalmologist whose techniques and inventions of medical instruments contributed to the study of the eye series. Dr. Devgan is world renowned in the field of ocular surgery and has taught surgery in 40 countries and writes teaching columns in eye surgery journals which are distributed worldwide. He has written more than 200 books, chapters, medical papers, and journal articles about techniques of cataract, lens, and LASIK surgery. These writings as well as his instructional surgical videos have helped thousands of ophthalmologists and their patients. Attendees were enlightened and educated with presentations from the following prominent and distinguished guest faculty: Emily Chew, M.D., Director, Division of Epidemiology and Clinical Applications (DECA), at the National Eye Institute, the National Institutes of Health; Chief, Clinical Trials Branch, Bethesda, MD;

Chris Albanis, M.D., Comprehensive Ophthalmology and Refractive Surgery; Chief Medical Officer, Ocular Partners, Inc. President, Arbor Centers for EyeCare, Clinical Associate, The University of Chicago; Chairperson, Advocate Christ Medical Center, Department of Ophthalmology Chicago, IL; and Steven R. Sarkisian, Jr., M.D., founder, and CEO of Oklahoma Eye Surgeons, PLLC. In addition, attendees welcomed local faculty José- Alain Sahel, M.D., Distinguished Professor and Chairman, The Eye and Ear Endowed Chair, Department of Ophthalmology; Director, UPMC Eye Center, University of Pittsburgh School of Medicine, Pittsburgh, PA. Kenneth Cheng, MD Pittsburgh Ophthalmology Society Board of Director, provided a brief and informative legislative update. The Society gratefully acknowledges all industry representatives who sponsored or exhibited at the event. A complete list of exhibitors can be found on the Society website at www.pghoph.org. Following the meeting, members and their guests enjoyed networking and dinner at the Terrace Room in the Omni William Penn Hotel. Planning for the 2022-2023 educational series is underway. If you know of an exceptional speaker whom you would like to see present at an upcoming meeting, contact Nadine Popovich, administrator by email npopovich@acms.org

Guest Faculty at the 57th Annual meeting include (l to r) Chris Albanis, MD., José- Alain Sahel, MD; Marshall Stafford, MD, POS President; Uday Devgan, MD, FACS; Steven Sarkisian Jr., MD, and Kenneth Cheng, MD

Uday Devgan, MD, FACS, 41st Annual Harvey E. Thorpe Lecturer and Marshall Stafford, MD, President, after the presentation of the Thorpe Scroll

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Society News 42nd Annual Meeting for Ophthalmic Personnel attracts large crowd Running concurrently with the POS 57th Annual Meeting was the 42nd Annual Meeting for Ophthalmic Personnel. This year, 148 attendees comprised of ophthalmic technicians, assistants, coders, photographers,and front staff attended this full-day program. The well-respected program is designed specifically for ophthalmic personnel to enhance the quality, expertise and safety of ophthalmic patient care. The program featured a hybrid of plenary and breakout sessions, all of which were approved for 1.0 IJCAHPO credit. Participants selected their own Agenda in the afternoon, choosing from several front- and back-office courses. The popular, Ophthalmic JEOPARDY! session returned. The session educated audience members by providing ophthalmic ‘pearls for their practice’ in a fun and interactive learning environment. Course directors Pamela Rath, M.D., Avni Vyas, M.D., and Zachary Koretz, M.D. worked tirelessly to plan this high-level educational offering. The Society depends and relies on local expertise and talent to present each session. This year was no exception, with local physicians and health care professionals providing quality presentations. The course directors would like to thank all Pittsburgh Ophthalmology Society (POS) members who participated as a speaker for the program.

ACMS Bulletin / April 2022

Greater Pittsburgh Diabetes Club set to host Spring Program on May 3rd The Greater Pittsburgh Diabetes Club (GPDC) will host their annual spring program, Tuesday, May 3, 2022. The in-person event will be held in the Babb, Inc. Building, 850 Ridge Ave, Pittsburgh, PA, beginning at 6:00 pm with the popular Vendor Showcase. Following a brief welcome, the dinner and program will begin at 7:05 pm. The meeting is open to members of the Club and non-members (guest fee will apply). The GPDC is pleased to welcome guest speaker Joseph Aloi, M.D., Section Chief for Endocrinology and Metabolism, Wake Forest Baptist Health, Winston Joseph Aloi, MD Salem, NC. He will present Integrating Diabetes Technology with Inpatient Care. Thank you to the following who provided support for the program: AstraZeneca, Bayer, Boehringer-Ingelheim, Dexcom, Novo Nordisk, Inc., Tandem Diabetes, and Xeris Pharmaceuticals. Dr. Aloi is the current Chair of the American Diabetes Technology Interest Group at the American Diabetes Association. He is very involved with trials examining the continuous glucose monitors, inpatient glucose management software and is well published in this field. Dr. Aloi is an active investigator and is focused on bringing technology to help improve the care of persons with diabetes. He is a moderator for many national and international diabetes meetings and serves on the Carolinas Society of Endocrinology Board of Directors. For more information and to register for the program, please visit www. pghdiabetesclub.org. Registration is now open with a fee of $15 for members and a guest fee of $40.00 (which includes 1 year of membership in the GPDC). Questions can be directed to Nadine Popovich, administrator by email to: npopovich@acms.org or to (412) 321-5030.

Society News Pennsylvania Geriatrics Society—Western Division hosts Virtual Conference Over 380 healthcare professionals gathered virtually to attend the 30th Annual Clinical Update in Geriatric Medicine held March 31 through April 1, 2022. This stellar two-day educational event attracted attendees from 25 states, including California, North Carolina, New York, Texas, and Washington and representation from Canada and Puerto Rico. Attendees recognized and appreciated the convenience of attending the conference from their home or office, while participating in dynamic educational sessions. An added benefit for all registrants: the ability to view recorded lectures and download the handout materials, up to 30 days after the conference, and receive CME/CE credits. With the fastest growing segment of the population comprised of individuals more than 85 years of age, this conference is a premier educational resource for healthcare professionals involved in the direct care of older people. Presented by the Pennsylvania Geriatrics Society – Western Division, UPMC/University of Pittsburgh Aging Institute and University of Pittsburgh School of Medicine Center for Continuing Education in Health Sciences, the program offered an evidence-based approach to help clinicians take exceptional care of these often-frail individuals. Highlights of the meeting included Live Q&A Sessions with presenters. By using the chat feature, attendees had the opportunity to engage with speakers in these informative sessions.

Back by popular demand, the Geriatric Cardiology Expert Panel featuring Parag Goyal, M.D., MSc, providing an update in heart failure; Deirdre O’Neill, M.D., addressing considerations and nuances when prescribing anticoagulation in older adults with atrial fibrillation; and Daniel Forman, M.D., presenting: management of hypertension informed by aggregate risk assessment and shared decision-making. Immediately following, the cardiology panel participated in a live, rapid-fire Q&A session. Moderated by Shuja Hassan, M.D., a Course Director, the lively session included a framework

for each presenter to comment and host a dialogue with their colleagues on a variety of cardiology questions. Thank you to our Premier Sponsors: Highmark Blue Cross Blue Shield Allegheny Health Network and UPMC Health Plan, and to all the exhibitors who sponsored the program. The Virtual Exhibit Hall featured seven exhibitors and offered attendees the opportunity to engage with representatives to learn more about their products and resources. Congratulations to the winners of the raffle (sponsored by the Society): Michelle Govan, Carla Loughner, Lynne Roberts, Antonina Eyster and Peter Moulder. Each received a $50 Visa Gift Card.

The Rapid Fire Cardiology Panel included (top l. to r.): Parag Goyal, MD; Deirdre O’Neill, MD; Daniel Forman, MD and moderator Shuja Hassan, MD.

Ask the Experts session featured (from top l. to r.) Susan Greenspan, MD; Shuja Hassan, MD, moderator; and Neil Resnick, MD www.acms.org

Materia Medica

Abemaciclib: Escalating adjuvant endocrine therapy for high-risk early-stage breast cancer Karen M. Fancher, PharmD, BCOP Hormone receptor positive (HR+), human epidermal growth factor receptor 2 negative (HER2–) breast cancer represents nearly 70% of breast cancer cases.1 The vast majority such breast cancers are diagnosed in early stages. The 5-year relative survival for this cohort of patients exceeds 94% when all stages are considered together. However, this figure drops from 100% for localized disease at presentation to 89.9% with regional disease, and further to 30.6% for metastatic disease.2 Treatment of early-stage HR+ breast cancer varies by stage and typically includes combinations of surgery, radiation and chemotherapy. Following initial treatment, adjuvant endocrine therapy with aromatase inhibitors or tamoxifen with or without ovarian suppression is the standard of care and has been associated with a significant reduction in risk of recurrence and death.1,3 Unfortunately, approximately 20% of patients treated with adjuvant endocrine therapy will develop a breast cancer recurrence within 10 years.4 Such recurrences are often at distant sites and disease cure is no longer feasible.1,4 As a result, much work is being done to identify approaches to enhance or escalate treatment of high-risk HR+ early breast cancer.

CDK4/6 Inhibitors One of the hallmarks of cancer cells is the ability to evade extracellular and intracellular signals that limit proliferation.5 Within the cell cycle, cyclin-dependent kinases (CDKs) regulate critical checkpoints. CDK 4 and 6 mediate the transition from the G1 phase into the S phase of the cell cycle. These kinases phosphorylate the retinoblastoma protein (pRb), which ultimately allows the cell cycle to progress to the S phase of cell division.6 In HR+ breast cancers, upon binding of estrogen

ACMS Bulletin / April 2022

to the estrogen receptor, CDKs are activated. Therefore, CKD4 and CDK6 inhibitors are important drug targets in HR+ breast cancer due to the ability to arrest the cell cycle and block cell growth.7 CDK4/6 inhibitors are already a mainstay in the treatment of metastatic HR+ breast cancer.3 Three CDK4/6 inhibitors, palbociclib, ribociclib, and abemaciclib, have all demonstrated improvements in progressionfree survival and/or overall survival when used in combination with endocrine therapy for the first-line treatment of HR+, HER2– advanced breast cancer.5 More recently, the addition of a CDK4/6 inhibitor to adjuvant endocrine therapy has been investigated in several key trials.

The monarchE Trial Abemaciclib (Verzenio®) is a selective small molecule inhibitor or CDK4/6.6,8 Abemaciclib is structurally different than palbociclib and ribociclib, resulting in a greater selectivity for CDK4 compared to CDK6. CDK4 plays a greater role in breast tumorigenesis, making it an attractive compound for study.9 The phase 3 monarchE trial randomized high-risk HR+ patients (n=5637) to two years of abemaciclib combined with 5-10 years of endocrine therapy, or endocrine therapy alone.1 Inclusion criteria were the findings of at least four positive lymph nodes or one to three positive nodes with one of the following additional risk factors: tumor size ≥5 cm or grade 3 histology (Cohort 1), or one to three positive nodes and a Ki-67 proliferation index of ≥ 20% (Cohort 2). Patients were of a median age of 51 years and the majority were post-menopausal at diagnosis (56.5%). Patients may have received up to 12 weeks of endocrine therapy prior to randomization. Radiation, adjuvant, and neoadjuvant chemotherapy were received in 95.4%, 58.3%, and 37.0% of the study population, respectively. Aromatase inhibitors were the most prescribed endocrine therapy (68.3%, including 14.2% treated concurrently with ovarian suppression).

The monarchE trial reported a benefit in invasive disease-free survival (IDFS).1,11 At two years, the addition of abemaciclib to endocrine therapy improved IDFS from 89.3% to 92.3% (p=0.0009) in the intent-to-treat population. Furthermore, distant recurrence-free survival (DRFS) was increased from 90.8% to 93.8% (p=0.0009).10 This benefit was maintained at three years for both IDFS (88.8% vs. 83.4%, p<0.0001) and DRFS (86.1% vs 90.3%, p<0.0001).11 When patients in Cohort 1 were stratified based on Ki-67 index, those who were Ki-67high had an absolute benefit in three-year IDFS of 7.1% (HR 0.63, 91% CI 0.49-0.80).1,11 In contrast, patients in Cohort 1 with a low Ki-67 index demonstrated a less pronounced absolute benefit of 4.5% (HR 0.70, 91% CI 0.51-0.98). While both subsets of patients derived a benefit from abemaciclib, the magnitude of benefit was reduced based on this biomarker. Based on the results of the monarchE trial, the FDA approved abemaciclib, in combination with endocrine therapy, for the adjuvant treatment of adult patients with HR+, node-positive, early breast cancer at high risk of recurrence and a Ki-67 score ≥20% on October 12, 2021.12 The Ki-67 IHC MIB-1 pharmDx assay was approved as a companion diagnostic. Importantly, the FDA-approved indication may expand pending additional follow-up data such as overall survival in the intent-to-treat population.

Dosage and Administration The dose of abemaciclib in the monarchE trial was 150 mg by mouth twice daily.1 In contrast to palbociclib and ribociclib, which are taken for 21 days out of 28-day cycles, abemaciclib is taken continuously. Doses may be taken with or without food.8 Abemaciclib is extensively metabolized by cytochrome P450 (CYP) 3A4, and therefore the concomitant use of strong CYP3A4 inhibitors Continued on Page 24

Materia Medica From Page 23 or inducers should be avoided if possible; specific dose adjustments are recommended by the manufacturer if concomitant therapy is required.6,8

Adverse Effects and Management As previously noted, abemaciclib is more potent against CDK4 than CDK6. This difference in potency results in a different spectrum of adverse effects than palbociclib and ribociclib.9 In clinical trials of abemaciclib, the most common adverse effects were diarrhea and fatigue; this is in contrast to trials of palbociclib and ribociclib, where hematologic effects such as neutropenia were frequently noted. Diarrhea has been noted in up to 90% of patients who receive abemaciclib, commonly occurring within the first week of treatment initiation.9 This effect is often self-limiting, with resolution in approximately 7 days.6,9 Most cases of such diarrhea can be managed with increased oral fluid intake and antidiarrheal therapy, and do not require treatment modification or dose reduction.6 However, up to 10% of patients develop severe diarrhea. In the monarchE trial, diarrhea of any grade was reported in 82.2% of patients who received abemaciclib, with 7.6% of patients having grade ≥3 symptoms.1 Patients should be educated that at the first sign of loose stools, antidiarrheal therapy such as loperamide should be initiated, oral fluids intake should be increased, and the healthcare provider should be contacted for further instructions and appropriate follow-up.8 Other events frequently reported with abemaciclib include neutropenia, nausea, fatigue, abdominal pain, and decreased appetite.6 In the monarchE trial, other commonly reported adverse effects included neutropenia (44.6%), fatigue (38.4%), abdominal pain (34%), nausea (27.9%), anemia (22.9%), and arthralgia (20.5%).1 Due to the risk of neutropenia, complete blood counts should be monitored prior to the start of abemaciclib, every two weeks for the first two months, monthly for the next two months, and then as clinically indicated.8 Patients should also be educated regarding

the possibility of developing neutropenia and to immediately contact their healthcare provider should a fever occur. According to the prescribing information, if white blood cell growth factors are required for the treatment of neutropenia and/or febrile neutropenia, abemaciclib should be held for at least 48 hours after the last dose of white blood cell growth factor and until toxicity resolves to less than grade 2. Abemaciclib should be resumed at the next lower dosage recommendation, unless dosage reduction had already performed for the toxicity that led to the use of the growth factor. The initiation, dosage and duration of white blood cell growth factor therapy should be administered as per current treatment guidelines. In clinical trials of abemaciclib, hepatotoxicity was infrequently reported (<5%).8 In the monarchE trial, increases in aspartate aminotransferase (AST) and/ or alanine aminotransferase (ALT) occurred in approximately 10% of patients. The manufacturer recommends that liver function tests (LFTs) should be monitored prior to the start of therapy, every two weeks for the first two months, monthly for the next two months, and as clinically indicated, with dosage adjustments as appropriate.

Future Directions The landscape of treatment options for early-stage HR+ breast cancer continues to evolve as we learn how to best tailor individual treatment based on risk stratification. Identifying high-risk patients for escalation of therapy is now a major focus of clinical research. The monarchE data supports incorporating two years of adjuvant abemaciclib therapy in select high-risk patients, making abemaciclib the first drug to receive FDA-approval for adjuvant hormonereceptor positive breast cancer in over 15 years.12 However, there have also been trials of palbociclib and ribociclib in this setting, with results varying across trials. No direct comparisons have been made between the CDK4/6 inhibitors in this setting to date, and therefore the most appropriate use of these agents in HR+ early breast cancer remains undefined. Comparative studies and longerterm follow-up are eagerly awaited.

Dr. Fancher is an associate professor of pharmacy practice at Duquesne University School of Pharmacy. She also serves as a clinical pharmacy specialist in oncology at the University of Pittsburgh Medical Center at Passavant Hospital. She can be reached at fancherk@duq.edu or (412) 396-5485. REFERENCES 1. Johnston SR, Harbeck N, Hegg R, et al. Abemaciclib combined with endocrine therapy for the adjuvant treatment of HR+, HER2–, node-positive, high-risk, early breast cancer (monarchE). J Clin Oncol. 2021;38:3987-98. 2. C ancer Stat Facts: Female Breast Cancer Subtypes. Available at https://seer.cancer.gov/ statfacts/html/breast-subtypes.html . Accessed March 26, 2022. 3. N CCN Clinical Practice Guidelines in Oncology. Breast Cancer. Version 2.2022. https://www.nccn. org/professionals/physician_gls/pdf/breast.pdf. Accessed March 26, 2022. 4. E arly Breast Cancer Trialists’ Collaborative Group (EBCTCG). Aromatase inhibitors versus tamoxifen in early breast cancer: patient-level meta-analysis of the randomised trials Lancet. 2015;386:1341-52. 5. M urphy CG. The role of CDK4/6 inhibitors in breast cancer. Curr Treat Options in Oncol. 2019;20:52. 6. P alumbo A, Lau G and Saraceni M. Abemaciclib: the newest CDK4/6 inhibitor for the treatment of breast cancer. Ann Pharmcother. 2019;53:178-85. 7. S herr CJ, Beach D, Shapiro GI. Targeting CDK4 and CDK6: from discovery to therapy.Cancer Discov. 2016;6:353-67. 8. V erzenia [prescribing information]. Indianapolis, IN: Eli Lilly and Company, 2017. 9. Thill M and Schmidt M. Management of adverse events during cyclin-dependent kinase 4/6 (CDK4/6) inhibitor-based treatment in breast cancer. Ther Adv Med Oncol. 2018;10:1758835918793326. 10. O ’Shaughnessy JA, Johnson S, Harbeck N, et al. Primary outcome analysis of invasive disease-free survival for monarchE: abemaciclib combined with adjuvant endocrine therapy for high risk early breast cancerSan Antonio Breast Cancer Symposium. 2020;Abstract GS1-01. 11. H arbeck N, Rastogi P, Martin M, et al. Adjuvant abemaciclib combined with endocrine therapy for high-risk early breast cancer: updated efficacy and Ki-67 analysis from the monarchE study. Ann Oncol. 2021; 32: 1571-81. 12. U S Food and Drug Administration. FDA approves abemaciclib with endocrine therapy for early breast cancer. https://www.fda.gov/drugs/ resources-information-approved-drugs/fdaapproves-abemaciclib-endocrine-therapy-earlybreast-cancer. Accessed March 26, 2022.

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Legal Summary

The Future of Telemedicine William H. Maruca, Esquire In 1962, the Hanna-Barbara cartoon series The Jetsons depicted the futuristic world of 2062, in which suburban office workers commuted in flying cars, Rosie the robot handled housekeeping chores, and doctor visits were conducted by videoconference. In 2022, many employees work primarily from home and don’t need flying cars, Roombas do the vacuuming, and telemedicine visits have become commonplace. The rapid growth of telecommuting and telemedicine got a boost from the COVID-19 public health emergency (Roombas, not so much), but as the pandemic finally begins to recede, the special approvals and exceptions granted for telemedicine are being reevaluated. Recent legislation ensures that remote delivery of healthcare as we have come to know and rely on it will continue for at least a while after the emergency is officially over, and that extension will give policymakers a window of opportunity to enact permanent changes. The Consolidated Appropriations Act, 2022 (“2022 CAA”) was signed into law on March 16, 2022, and extends the COVID-19 Medicare

telehealth waivers and flexibilities for an additional 151 days after the official end of the federal Public Health Emergency (“PHE”). The 2022 CAA was an omnibus spending bill that authorized $1.5 trillion in federal expenditures and included the telehealth extensions along with funding for all federal agencies for the remainder of fiscal year 2022. As of this writing, the PHE is set to expire on April 16, 2022, but it is expected to be renewed until at least July. The special rules that will now continue for five months after the PHE ends are as follows:

Geographic requirements for telehealth: Before COVID-19, telehealth visits were only reimbursable by Medicare in specified facilities such as hospitals and Federally Qualified Health Centers. Under the PHE, those location requirements were waived, and telehealth services were reimbursable when delivered to the patient at any location within the United States, including the patient’s home (the patient’s location is referred to as the “originating site.”) The 2022 CAA continues the waiver for 151 days after the end of the PHE.

Expansion of practitioners eligible for telehealth reimbursement: Under the COVID-19 PHE rules, occupational therapists, physical therapists, speechlanguage pathologists, and qualified audiologists are eligible for Medicare reimbursement for telehealth visits along with physicians, and those practitioners will remain eligible for 151 days after the PHE ends under the 2022 CAA.

Extending telehealth services for FQHCs and RHCs. Federally Qualified Health Centers and Rural Health Clinics will continue to be able to serve as both originating sites and “distant sites” (the location of the provider) for 151 days after the PHE ends. Prior to the PHE they could only serve as originating sites. In-person requirements for mental health: Medicare coverage of telemedicine mental health visits would require an in-person exam within six months of the first telehealth service and subsequent in-person visits every 12 months, effective immediately after the PHE ends based on 2020 changes. Such in-person visit requirements will now not be required until 151 days after the end of the PHE. Continued on Page 26

ACMS Bulletin / April 2022

Legal Summary From Page 25

Audio-only telehealth services: Prior to the PHE, Medicare only paid for simultaneous video and audio visits. The PHE rules authorized payment for audio-only visits such as professional consultations, office visits, and office psychiatry. Audio-only visits will remain reimbursable for 151 days after the end of the PHE.

Telehealth visits to recertify hospice care: Hospices are required to conduct a recertification of eligibility for the hospice benefit every 180 days, which had to be done face-to-face prior to the PHE. The CARES Act passed in 2020 permitted these evaluations to be performed via telehealth but required both video and audio technology. This process will continue to qualify for 151 days after the end of the public health emergency.

Extension of deductible exemption for telehealth services: The CARES Act permitted, but did not require, employers that sponsored high deductible health plans (“HDHPs”) to provide first-dollar telehealth and other remote care services through the end of 2021. Over 80% of employer sponsored HDHPs elected to cover telehealth services on a pre-deductible basis. The 2022 CAA restores this option prospectively for the months of April 2022 – December 2022. Those telehealth or other remote care services do not need to be preventive or related to COVID-19 to qualify for the relief. Note that for calendar plan year HDHPs adopting this extension, there will be a three-month gap from January 2022 – March 2022 in which the standard deductible will still apply. The goal of the Act’s five-month grace period is to give Congress time to evaluate the effectiveness of telehealth and to develop a longrange legislative plan to continue those COVID-era changes that are beneficial to Medicare recipients and modify or phase out those that are not. Anticipate vigorous lobbying from stakeholders who have become accustomed to the lenient treatment of telemedicine during the PHE. The news for telemedicine isn’t all smooth sailing. Most states adopted telehealth parity or coverage rules and loosened licensure requirements during the early months of the COVID-19 pandemic, generally via state-level declarations of emergency, but now over half of those states have lifted their emergency declarations and

some or all the telehealth flexibility changes tied to them. Licensure requirements are generally regulated at the state level, and one of the most contentious issues has been what constitutes “practicing medicine” within a state in the case of telemedicine. While state legislatures rushed to solve access issues early in the crisis, they have begun to backtrack, and the state regulatory environment remains fluid. One way to keep track of developments is to follow The Alliance for Connected Care, which monitors state telemedicine rules at connectwithcare.org and advocates for continuation of regulatory support for telehealth. We are only 40 years away from the world of The Jetsons, and whether those flying cars may finally arrive by then, it’s a good bet that telemedicine will still be around. William H. Maruca, Esquire is a healthcare partner in the Pittsburgh office of the national law firm Fox Rothschild LLP and can be reached at 412.394.5575 or wmaruca@ foxrothschild.com www.acms.org

from Chef Anthony beers and fun

selected to open their own restaurant featured along with a down to earth, within the space, with 12-18 months to rustic menu. Nonalcoholic wines and win over an audience and establish their cocktails also will be showcased. 25 Penn Ave., brand. You can try a little of everything G’s On Liberty, 5104 Liberty Ave., from all four restaurants during the Bloomfield dda Coffee & Tea same meal – heaven for foodies. G’s turns former Alexander’s Italian wntown cafes. Adda Tupelo Honey, 100 West Station Bistro into a seasonal scratch kitchen ong Bengali tradition Square Drive, South Side with creative food and cocktails. ectual discourse with Craving fried green tomatoes, Coming in the fall. d coffee. Here’s your buttermilk biscuits, shrimp and grits And finally … t of Adda, with a and banana pudding – and oh yes, Chengdu Gourmet, McKnight s and coffees. fried chicken and waffles? Tupelo Township Please make your medical society stronger The ACMS Membership Committee appreciatesRoad, Ross by encouraging your colleagues to quare delights: Honey Café will open this fall in Station Chengdu Gourmet (the beloved your support. Your membership strengthens become members of the ACMS. For information, quare, 6425 Penn Square to remedy that, in style. James Beard-nominated Squirrel Hill call the membership department the society and Con helps protect our patients. Alma Downtown, 613 Penn hole-in-the-wall Sichuan restaurant at (412) 321-5030, ext. 109, or email rito’s Alta Via pizza Ave., Downtown that regularly inspires pilgrimages from membership@acms.org. venture to Bakery The new jewel of the Downtown all over Western PA) is planning an asual California style Cultural District features insanely good outpost on McKnight Road at the site of cousin, AVP. Enjoy Miami/Latin/Caribbean cuisine along the former Oriental Market, in the plaza e-forward dishes with live jazz. next to Red Lobster. This will offer nd sandwiches for Gaucho Parrilla Argentina, 146 a much larger dining space – 6,000 even days a week. Sixth St., Downtown square feet – and an expanded dining quare, 6425 Penn The resident jewel of the Downtown menu. Something to look forward to in Cultural District dazzles with an early 2022. 500 Cedar Run - Hartwood Acres 9 Edgewood - Fox Chapel $1,625,000 $1,630,000 own Richard incredible array of steaks and wood Enjoy, and be safe. a restaurant called fired meats with a variety of sauces a reservation in the and accompaniments. Takeout and Dr. Paranjpe is an ophthalmologist ome enjoy its vast dine-in available. and medical editor of the ACMS post, complete with Wild Child, 372 Butler St., Etna Bulletin. Julie Rost She can be reached at f space and both The brainchild of Chef Jamilka reshma_paranjpe@hotmail.com. julierost.com 1613 Overton - Summerset at Frick 1 Trimont 960D - Mt Washington dining. Borges, Wild Child emphasizes coastal $715,000 Office: (412) 521-5500 x251 $1,400,000 The opinion expressed in this column is that of Cell Phone: (412)370-3711 y Square, 6425 and island cuisine and is sure to delight. the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, iberty Mount Oliver Bodega, 225 or the Allegheny County Medical Society. Square is the Brownsville Road, Mt. Oliver

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2022 ACMS Meeting & Activity Schedule By Committee Finance Committee April 26 Keith T. Kanel, MD, Chair August 30 November 15

Board of Directors May 10 Patricia L. Bononi, MD, Chair September 13 December 6 Delegation April 27 Deborah Gentile, MD, Chair Bruce A. MacLeod, MD, Vice Chair

House of Delegates October 21-23

Meetings begin at 6:00PM. If you are interested in attending any of the meetings, please contact Mrs. Hostovich at 412.321.5030.

ACMS Bulletin April 2022

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