C M S BulletinRachael Bieltz, MPH, CHES Bethany (Hallam) Reynolds, MPH Editorial .....234 The malady lingers on Deval (Reshma) Paranjpe, MD, MBA, FACS Editorial .....238 Scientific

Allegheny County MediCAl SoCiety

BulletinAuguSt 2020

Reconnecting during COVID

The malady lingers on

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ArticlesOpinion Departments

Materia Medica .....................254Istradefylline (Nourianz®) Samantha DeMarco, PharmD Rachael Cardinal, PharmD, BCPS

Legal Summary ...................256Pennsylvania Superior Court decision: Further deterioration of the peer review privilegeBeth Anne Jackson, Esq.

Special Report .....................257Pilot of new perinatal Hepatitis C Surveillance Program coming to Allegheny County Rachael Bieltz, MPH, CHES Bethany (Hallam) Reynolds, MPH

Editorial ................................234The malady lingers onDeval (Reshma) Paranjpe, MD, MBA, FACS

Editorial ................................238Scientific misconduct Richard H. Daffner, MD, FACR

Editorial ...............................241Reconnecting during COVIDAndrea G. Witlin, DO, PhD

Perspective ..........................246Telepsychiatry appointment adherence and productivity during COVID-19 Timothy Lesaca, MD Pamela Pyle, AAS

Perspective ..........................249Reflections after 52 yearsRichard L. Green, MD

Membership Benefits ..........244

Society News .......................251• Pittsburgh Ophthalmology Society

Activities & Accolades ........253

On the coverWildflowers

Kimberly Hennon, MD

Dr. Hennon specializes in emergency medicine.

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Editorial

234 www.acms.org

The malady lingers onDeval (Reshma) PaRanjPe, mD, mBa, FaCs

As the COVID-19 pandemic rages on, reports are starting to emerge

which paint a fuller picture of short- and intermediate-term damage to COVID survivors. Long-term studies obviously are years away, but we may increas-ingly see a pattern of symptoms and signs that indicate that while the patient may be considered recovered, signifi-cant ongoing issues remain.

A recent Science article by Jennifer Couzin-Frankel, “From ‘brain fog’ to heart damage, COVID-19’s lingering problems alarm scientists,” reviews some of these effects. Persistent prob-lems include dyspnea, fatigue, tachy-cardia, joint aches, cognitive difficulties, persistent anosmia and multiorgan dys-function. There are no large multicenter peer-reviewed studies on survivors pub-lished yet, only small studies measuring various outcomes with relatively small numbers of subjects. However, the large studies are enrolling and starting. A study enrolling 10,000 COVID survivors and following them initially for one year and then long term for 25 years began in the UK last month, and several others will be starting. (https://www.science-mag.org/news/2020/07/brain-fog-heart-damage-covid-19-s-lingering-problems-alarm-scientists)

Real time studiesThe COVID Symptom Study is an

international multicenter effort created by Massachusetts General Hospital and King’s College, London, in con-junction with ZOE, a private compa-ny, and multiple collaborative study partners including the Nurses’ Health Study. More than 4 million COVID-in-fected people have self-enrolled to self-report symptoms via an app which can be downloaded on the Apple App Store or Google Play. Data gathered can provide real-time information and guidance as to locations of COVID hot spots, alerts to new symptoms, new outbreaks and quarantine/resource planning. Enrollees can check the web-site for real-time results and news. Per-sonal data is protected by the Europe-an General Data Protection Regulation (GDPR), which is much more stringent than U.S. data privacy laws.

So far, the COVID Symptom study has shown that COVID patients seem to fall within one of six clinical subtypes of disease, called “clusters.” Signifi-cantly, cluster classification predicted risk of requiring hospitalization and ventilatory support with more accura-cy than an existing risk model based solely on age, sex, BMI and pre-exist-ing conditions alone, and could make that prediction five days from symptom onset.

The higher the cluster number, the greater the eventual disease severity.

COVID symptom study clusters• Cluster 1 (‘flu-like’ with no fe-

ver): Headache, loss of smell, muscle pains, cough, sore throat, chest pain, no fever.

• Cluster 2 (‘flu-like’ with fever): Headache, loss of smell, cough, sore throat, hoarseness, fever, loss of appetite.

• Cluster 3 (gastrointestinal): Headache, loss of smell, loss of appe-tite, diarrhea, sore throat, chest pain, no cough.

• Cluster 4 (severe level one, fatigue): Headache, loss of smell, cough, fever, hoarseness, chest pain, fatigue.

• Cluster 5 (severe level two, con-fusion): Headache, loss of smell, loss of appetite, cough, fever, hoarseness, sore throat, chest pain, fatigue, confu-sion, muscle pain.

• Cluster 6 (severe level three, abdominal and respiratory): Head-ache, loss of smell, loss of appetite, cough, fever, hoarseness, sore throat, chest pain, fatigue, confusion, muscle pain, shortness of breath, diarrhea, abdominal pain.

Only 1.5% of people with clus-ter 1, 4.4% of people with cluster 2, and 3.3% of people with cluster 3 COVID-19 required ventilatory support. However, these figures were 8.6%,

Editorial

235ACMS Bulletin / August 2020

9.9% and 19.8% for clusters 4, 5 and 6. Almost half of the patients in cluster 6 required hospitalization during the disease course, compared to only 16% of patients in cluster 1.

Generally, people with cluster 4, 5 or 6 COVID-19 symptoms tended to be older, more fragile, more likely to be overweight or obese and/or have comorbid conditions such as diabetes or lung disease than those with clus-ters 1, 2 or 3.

A model to predict severity of disease was developed which com-bined information about age, sex, BMI and pre-existing conditions along with symptoms gathered over just five days from the onset of the illness.

The availability of such a model at day five of symptom onset may be critical given that the average patient requiring ventilatory support presents to the hospital around day 13 after symptom onset. Cluster categorization can provide an early alert to physicians as to which patients are likely to re-quire higher levels of care due to more severe disease and therefore might need early intervention.

If you have COVID patients or know anyone who would like to enroll in this effort, please refer them to https://covid.joinzoe.com/us or direct them to the COVID Symptom Study App.

Resources for recovering COVID patients

Navigating life after the acute phase of COVID can be difficult for patients both physically and psychologically. Patients may be too fatigued to return to work or even to move about their house and perform activities of daily living. They may face stigma from others who believe they are still conta-

gious in the light of scarce and evolving knowledge of the disease. Survivors may be afraid that they are maimed for life or may suffer additional late complications. Many of these “COVID Long Haulers” are turning to online support groups. There may be some role here for physicians to witness and learn what patients are encountering and enduring as with any other chronic disease.

One such support group is Body Politic, aimed at persons ill or recover-ing from COVID-19 and their caretak-ers. The website is www.wearebody-politic.com/COVID19.

Another such group is the Facebook group Survivor Corps, which is aimed at COVID-19 patients and survivors. Both groups were started by COVID survivors with persistent symptoms which their physicians were at a loss to explain, prognosticate or treat (as the average post-COVID course is still unknown). Some felt dismissed by their physicians. Sometimes just knowing that one is not alone in having strange symptoms is enough to calm anxiety and give hope in the face of a myste-rious disease. These resources may prove to be valuable for post-COVID patients.

Prevalence of post-COVID symptoms

An Italian study published as a letter in JAMA analyzed prevalence of COVID symptoms two months post-dis-charge in 143 post-hospitalization COVID patients with a mean age of 56.5; 71% had interstitial pneumonia, 21% were given noninvasive ventilation and 5% were ventilated. Mean hospital stay was 13.5 days. Of these patients, 87.4% had at least one significant

persistent symptom and 55% had three or more (fatigue, dyspnea, joint pain, chest pain). Quality of life was de-creased in 44.1%. (Persistent Symp-toms in Patients After Acute COVID-19 Angelo Carfì, MD1; Roberto Bern-abei, MD1; Francesco Landi, MD, PhD1; et al for the Gemelli Against COVID-19 Post-Acute Care Study Group. JAMA. Published online July 9, 2020.)

Neurologic symptomsCOVID-19 can cause a wide array

of neurological symptoms ranging from encephalitis to cardiovascular accident to Guillain-Barre syndrome. These symptoms can be the reason for hos-pital admission and can persist months afterwards. A recent study accepted for publication in Brain and published online last month reviewed 43 COVID cases at one center with neurologic involvement and delineated five major categories: encephalopathies, inflam-matory CNS syndromes, ischemic strokes due to pro-thrombotic states, peripheral neurologic disorders includ-ing Guillain-Barre, and miscellaneous disorders. Some responded to immu-notherapies. The incidence of acute disseminated encephalomyelitis with hemorrhagic change was significant. Some COVID patients report persistent “brain fog” and cognitive dysfunction which will need to be studied. (The emerging spectrum of COVID-19 neurology: clinical, radiological and laboratory findings. Ross W Paterson, Rachel L Brown, Laura Benjamin, Ross Nortley, Sarah Wiethoff et al. Brain, Published:08 July 2020.)

Cardiac symptomsAs the pathophysiology of

Continued on Page 236

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Editorial

COVID-19 is better elucidated, it has emerged that inflammation and a pro-thrombotic state are characteristics of the disease as is multiorgan involve-ment. Cardiac involvement is particu-larly dangerous and may persist after the acute course of the disease has ended. Several recent studies have shown cardiac abnormalities in post-COVID survivors, regardless of wheth-er their disease was severe enough to require hospitalization.

A June study in Heart Rhythm showed that up to 20-30% of hospital-ized COVID patients showed elevated troponin levels indicative of myocardial involvement, which the authors suggest is attributable to the high prevalence of ACE-2 receptors in myocardial tissue. ACE-2 receptors are a known target of the COVID-19 virus’s spike protein. (COVID-19 cardiac injury: Implications for long-term surveillance and outcomes in survivors. Mitrani, Raul D., Dabas, Nitika, Goldberger, Jeffrey J. Heart Rhythm. Published June 26, 2020.)

A German study published last month in JAMA Cardiology showed mi-tral regurgitation (MR) abnormalities in an observational cohort of 100 COVID survivors from University Hospital Frankfurt when compared to risk factor matched patients and healthy volun-teers. Among COVID survivors, MR showed cardiac involvement in 78% and active myocarditis in 60% inde-pendent of all other conditions, disease severity, course of illness and time from diagnosis to imaging. Most concerning was that only 33 of these patients had required hospitalization; the rest had recovered at home. This suggests that undiagnosed cardiac disease could be common among even so-called mild

COVID cases. Elevated troponin levels were found in 71% of survivors while 5% had significantly elevated levels. Left ventricle ejection fraction (LVEF) also was compromised in survivors as were other indicators of cardiac function. Cardiac biopsy in those with serious findings revealed active myo-carditis. It is possible that this could correlate with fatigue. (Outcomes of Cardiovascular Magnetic Resonance Imaging in Patients Recently Recov-ered from Coronavirus Disease 2019 (COVID-19). Puntmann VO, Carerj ML, Wieters I et al. JAMA Cardiology. Published online July 27, 2020.)

Pulmonary fibrosisCOVID-related acute respiratory

distress syndrome (ARDS) can impact the old and the young as evidenced by the recent double-lung transplant in a 20-year-old COVID patient in Chicago. A recent article on the Massachusetts General Hospital research website states that up to 25% of ARDS survi-vors develop restrictive lung disease within six months of diagnosis including pulmonary fibrosis, and that proposals to study antifibrotic agents in COVID-re-lated ARDS are emerging. Progressive fibrotic interstitial lung disease would severely impact the quality of life and decrease the life expectancy of sur-vivors. Recently, 22 patients returned to King Edward Memorial Hospital in Mumbai, India, with pulmonary fibrosis a month after discharge after treatment for COVID-related pneumonia. More re-search needs to be done in this regard. The renal and hepatic impact of COVID disease also will need to be studied in the months ahead. (https://advances.massgeneral.org/research-and-innova-tion/article.aspx?id=1238)

In summaryWe all will be seeing both acute

COVID-19 and significant chronic post-COVID-19 signs and symptoms in our patients. It is important to stay informed, be prepared and be vigilant for late sequelae and to refer and/or investigate properly. Long-term survivor studies are starting for both symptoms and organ system involve-ment over time. Be supportive of your patients even when you don’t have all the answers; it’s OK to say so. Patient support groups may be helpful as patients share resources and bond. Counseling also may be indicated, and virtual counseling can be explored.

Dr. Paranjpe is an ophthalmologist and medical editor of the ACMS Bul-letin. She can be reached at [email protected].

From Page 235

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.

We all will be seeing both acute COVID-19 and significant chronic post-COVID-19 signs and symptoms in our patients. It is important to stay informed, be prepared and be vigilant for late sequelae and to refer and/or investigate properly.


2020 ACMS Bulletin Photo Contest

Please note instructions below for participating in the 2020 ACMS Bulletin Photo Contest:

1. Email your VERTICAL jpg photos with a resolution of 300 dpi or higher to [email protected]. Photos should be 8”W x 10”H.

2. You must be an ACMS member physician to submit photos. 3. Include the name of the photo (please keep file names short) as well as

your name, specialty, address and phone number in the email. 4. You will receive verification that your photo has been received and is eligible

to be entered in the contest.a) Horizontal photos will not be considered. b) Photos with low resolution will not be considered.c) Panoramic shots or photos featuring specifically identifiable individuals/

relatives will not be considered.5. The deadline for submission is Friday, October 2, 2020. After this date, a

group of individuals selected by the ACMS Board of Directors and ACMS Editorial Board will vote on the top 12 photos.

6. Winners will be announced on the ACMS website, in the Bulletin and via email. The 1st-place winner’s photo will appear on the January 2021 cover; the remaining winning photos will appear on Bulletin covers throughout the year.

9. Please continue to check the ACMS website and future issues of the Bulletin for further updates and reminders.

10. If you have any questions, please call Bulletin Managing Editor Meagan Sable at (412) 321-5030, ext. 105, or email [email protected].

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Editorial

Scientific misconductRiChaRD h. DaFFneR, mD, FaCR

My editor was emphatic. Months before, I had presented two cases

of disseminated skeletal tuberculosis resembling bony metastases at the annual meeting of the International Skeletal Society. Society rules asked all presenters to submit their work to their journal, Skeletal Radiology. The first case was well-documented with pathologic confirmation that included bacterial growth. The second case had presented days before I was to leave for the meeting. I had performed a biopsy of several of the lesions, which showed caseating granulomas. How-ever, at the time I left for the meeting, bacteriologic confirmation was pend-ing, and I presented the case as a presumed diagnosis. Subsequently, there was no growth of tubercular organisms from the biopsy specimens, not an unusual finding in that disease. I submitted only the initial case, which had absolute proof of the diagnosis. The editor, who attended the meeting, called me to remind me that I had presented two cases. He wanted to know why I didn’t write up the second case. I told him that the pathology was never proven. He reminded me that tuberculosis was one of those diseases where the bacteria often didn’t grow out of biopsy specimens. He asked me, “In your heart of heart, what’s the diagnosis?” I replied, “Tuberculosis,”

and he said, “I agree. Please send the other case.” I told him that without the proof I really did not want to submit a paper that did not have the definitive proof of the diagnosis. He told me I was an honest man and he honored my request to publish the single case.1

Scientific misconduct is broadly defined as violations of the standard codes of scholarly conduct and ethical behavior in the publication profession-al scientific research. The definition implies that there is intentional deceit or gross negligence in preparation of the scientific data that is presented or published. There are several forms of scientific misconduct: fabrication, falsification and plagiarism. Fabrica-tion consists of creating false data or results and/or reporting them. Falsifi-cation is the process of manipulating research material, data, or the results to reach the conclusion that the inves-tigator had desired before the study had been performed. In other words, “fudging” the results. Plagiarism is us-ing another person’s ideas, results, or words without giving appropriate credit. Academicians consider plagiarism the most common type of scientific miscon-duct. More on that topic below.

My first contact with an example of scientific misconduct occurred early in my academic career. One of my col-leagues had developed the first Radiol-

ogy Physician’s Assistant program. The initial class had eight students. During their final year, one of the students, an older man, died of a heart attack. Two years later, the coordinator of the program submitted a paper to one of the radiology journals describing how each of the eight graduates were doing in their new jobs. The problem was that only seven graduated the program. He made up a history for the one who had died. His paper would have been just as valid had he reported on the seven surviving members of the class.

My next example came from none other than my chairman. I was working at the VA hospital, which had a large patient population who had chronic lung disease. The chairman called me one day and asked if I had any CT examples of a specific interstitial lung disease. I checked and could not find any with the diagnosis he wanted. He asked me if I had any cases that looked like the disease that he wanted. I found several and gave the images to him without a second thought. After all, sharing material with colleagues was part of academic life. Months later, I was shocked to see his paper published where he used my images and identified them as the condition he originally asked for. When I mentioned this to him, his response was that since all interstitial lung disease looked alike


Editorial

on CT, who cares that he fudged his results! Being a junior staff at the time and a “good soldier,” I never reported his obvious academic fraud. Howev-er, those two events prompted me to question in my mind: How common was scientific misconduct?

A flawed system“Publish or perish.” These are the

buzzwords that have governed aca-demic life throughout history. There are three areas of academia on which faculty are judged for promotion (and sometimes bonuses): teaching, service and research. Teaching skills should be assessed on how effective the faculty member is in presenting the material to her/his students. In many instances, however, the faculty member’s grades in this area are dependent on how well-liked s/he is by the students. Service is usually defined as membership on one or more department or institution-al committees. In medicine, this also may be graded by how many patients the internist or pediatrician sees, how many operations are performed by sur-geons, or how many imaging studies are interpreted by radiologists. In other words, how many RVUs (relative value units) are generated. And, research is assessed by the number of papers in the peer-review literature. In many instances, this last category is the main one on which promotions are given. This is the infamous “Paper Chase.”

However, the system is flawed. There is little to no oversite of the accuracy or veracity of data presented from most studies. If an investigator is on a federal grant, the research is subject to oversight or auditing by the Office of Research Integrity (ORI) of the U.S. Department of Health and

Human Services (HSS). Of the 23,475 research institutions that report to ORI, approximately 3% show evidence of scientific misconduct.2 If you are not on a federal grant, however, there is little or no oversight. I have published ap-proximately 170 papers in the peer-re-viewed literature as either the principle or co-author. I have never been asked to show my raw data to an editor. There is an implicit “understanding” that the author(s) are being truthful in presenting their findings. If, for exam-ple, I publish a study on 100 patients with XYZ disease, the assumption by the editors and readers is that I really studied 100 patients.

A common, but relatively minor, form of misconduct is “ghost author-ship.” The journals are crammed with articles containing multiple co-authors. In many instances, the principle author adds the names of everyone who worked on the project. Several of my junior colleagues offered to put my name on papers I reviewed as part of my mentoring of them. I suggested that they only list me in an acknowledge-ment at the end of the paper rather than list me as a co-author. Even more common is the addition of the name of the department or laboratory head as a “courtesy.” Senior faculty who worked on the project often will list their name as the last author. Of the many papers I have written with a resident, I always made sure their name was listed first. Multiple-authored papers are a com-mon way for academicians to build their own resumés.

Plagiarism Plagiarism, as previously men-

tioned, is the most common type of scientific misconduct. Plagiarism may

take several forms. Citation plagiarism is failure to give appropriate credit to the authors of previous work on a similar subject. Citation plagiarism may be inadvertent or willful. In the first instance, the plagiarist is ignorant of the prior work; in the second instance, which is more common, it is deliberate.

Fabrication plagiarism is defined as publishing an unrelated illustration or data from another publication and claiming it is new. This applies not only to publications, but also to scientific presentations. My mentors stressed the importance of crediting borrowed illustrations or clinical images used in scientific presentations. The audience may not know the individual who pro-vided the material, but giving credit is a way of acknowledging the colleague’s contribution that costs you nothing.

Self-plagiarism occurs when the author(s) submit(s) the same paper to multiple journals or use the same data in an article with a different name. I served for many years on the Program Committee of the American Roentgen Ray Society reviewing abstracts for potential presentation at the annual meeting. Not a year went by when one or more papers were submitted with different titles and the same authors, text and data in the abstract. My per-sonal record was a group of seven au-thors who submitted the same abstract seven times each with a different title and a different lead author. Everything else was identical.

“Salami slicing” is a term that editors use for submitting data from one study as an entirely new study. A variation of this is submitting the identi-cal paper to a journal in a different language. One of the best examples of


“salami slicing” was a series of articles by a well-known radiologist on arthritis. The papers, elegantly illustrated with X-ray images and correlative gross and microscopic pathology, were titled “Rheumatoid Arthritis of the Hand,” “Rheumatoid Arthritis of the Wrist,” etc. Although the illustrations of each joint were different, the text was basically the same.

What about equivocal results?Most scientific studies contain three

categories of results: positive, nega-tive and equivocal. How should one deal with equivocal results? There are several ways of dealing with them. The first is to simply state in the paper that a certain number of cases had findings that could not be determined to be either positive or negative. Another way is to divide the equivocal cases equally between positive and negative. From a statistical standpoint, this should not skew your results. Some people, particularly those who are more likely to fudge their results, will include the equivocal cases with the positives to enhance their original theorem. The alternative, and one that I have always used, was to make my equivocal cases negative. In other words, unless the findings were undisputable, they were considered negative. This would make my overall results show fewer posi-tives, but none of the positives could be disputed.

Newer safeguardsEditors now have online tools

available to check for evidence of pla-giarism. The Committee on Publishing Ethics (COPE) and others now allow a paper to be scanned and assessed

for any duplication. Editors also are asking authors who submit illustrations that have been manipulated by pro-grams such as Adobe Photoshop® or others to indicate what has been done. (“Personal identification data has been removed in compliance with HIPAA”). Furthermore, journals are asking authors to attest that their submission is original, has not been published elsewhere and that their conclusions are accurate (as of the date of sub-mission). Several radiology journals are now asking lead authors to verify the contribution(s) of all co-authors (performing the study, gathering data, review of the data, statistical analy-sis, writing the paper, and editing the paper).

Peer review for promotion also has undergone some positive changes. In the past, many institutional promo-tion and tenure committees simply reviewed a candidate’s resumé and letters of recommendation. Now, particularly for promotion to full pro-fessor, committees are using internal and external peer review of the can-didate’s work. They ask the candidate to identify four or five of their “best” publications and these are sent to in-house and outside referees who are asked to assess the papers for their scientific importance and validity. This process uncovered one of the most egregious examples of scientific misconduct at the University of Califor-nia at San Diego School of Medicine. A young radiologist, who was considered an up-and-coming superstar, applied for promotion to full professor. One of the senior faculty reviewing his publi-cations stumbled upon statistics that were replicated in two different papers. The department chairman queried

the candidate’s co-authors, neither of whom were aware of the findings, or if the study had actually been performed. After a 15-month investigation, the committee concluded that of a total of 147 published papers, 13 were clearly fraudulent, 55 were questionable and the remaining 79 were valid. Fortunate-ly, the subject of the investigation is no longer in academics.

The scientific literature is an im-portant vehicle for conveying new information. Unfortunately, the “Publish or Perish” attitude of many academic institutions encourages scientific mis-conduct. Whenever I see an article in a journal that piques my interest, the first thing I look at is the Subjects (Materi-als) and Methods section to determine if it is good science or not. That, to me, is the key for determining if I’m reading a study with valid data or not.

Dr. Daffner, associated 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 Medi-cine. He can be reached at [email protected].

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From Page 239

References1. Frankel DG, Daffner RH, Wang

SE: Case Report 654, Disseminated Tuberculosis. Skeletal Radiology, 1991: 20:130-133.

2. https://en.wikipedia.org/wiki/Scien-tific_misconduct. Accessed 4/4/2020.




Editorial

Reconnecting during COVID

anDRea G. Witlin, DO, PhD“Time it was, and what a time it was, it wasA time of innocence, A time of confidencesLong ago, it must be, I have a photographPreserve your memories; They’re all that’s left you”

– Simon and Garfunkel, “Bookends”

During the early months of my COVID isolation, I reminisced

about this song from my youth. I was impulsively drawn to my online picture albums. Analogous to the sentiments penned by Paul Simon many years ago, I too wondered what would become of our crazy, surreal new world order. Several of the photos from my albums both resonated with and haunt-ed me simultaneously. Some of these “friends” were likely either high-risk like me and/or were living in high-risk ar-eas. I worried that my memories would be all that was left.

In recent years, I toyed with the idea of re-connecting with a select few old friends. But I never felt any urgency to appease my fantasy. Unfortunately, I only progressed to the anonymity of an occasional Google or Facebook search. Most of my “finds” seemed readily accessible. However, distance and my fear of rejection had always stopped me from fulfilling my dreams. I

rationalized that “they” would always be there for me when I decided it was time to connect. I would surreptitiously peak into my perception of their busy lives – their families and grandkids, new practice endeavors, advocacy projects. I justified my inaction by persuading myself that they had no interest in hearing my sad saga of years of illness and my resultant boring life. Alas, late last winter, pre-COVID, I had recently recounted a story from residency and decided to search once again for my old buddy. Only this time, my compla-cency was rudely punctured. The first Google listing was an elusive obituary!

I was beside myself … I searched even more furiously hoping against hope that it was a mistake. The confir-mation of his recent death was unmis-takable. Eerily, no cause of death was listed. There was barely a mention of his family except for two loving grand-children left behind. Barely a mention of the busy OBG practice he had been part of for more than 30 years.

My stomach churned as it did several years prior. I had a similar heart-wrenching experience when I searched for one of my old partners. We were the same age. She had passed several years prior. Again, no cause of death. Just mention of a loving family at her bedside. So, I resolved that come spring, I would

embark upon a road trip and visit a few dear old friends. This time, I wouldn’t take no for an answer … memories would no longer suffice.

Unfortunately, not long thereafter, COVID invaded our lives and disrupted our best laid plans. Initially, I tabled my Google searches and travel plans. I became determined to re-connect as the probability of undertaking my road trip faded. I couldn’t chance any of my friends becoming infected with COVID and no longer being able to speak with them. So, I resumed my searches. It turned out to be more difficult than I had presumed. None appeared active on Facebook any longer. Landline num-bers were still listed, but it was likely the voicemail messages I left were probably never heard. My insecurities regarding rejection crept back in, and I would once again table my efforts.

One of the three friends was a classmate from medical school. Our last communication was 24 years ear-lier during a perfunctory conversation as he referred a patient to me. I had tracked him to a different location in Pennsylvania. Feeling brave one morn-ing, I called that number, only to find out he had retired two years previously and, of course, there wasn’t a forward-ing number. I contacted our alumni office. They attempted to reach out, but


242 www.acms.org

I never got a reply. Then I found one more address to try; I sent an old-fash-ioned typed letter almost begging for a response.

The second of the three was a very close friend from my days in South Jersey. I thought we had an especial-ly close bond as I had delivered her grandchild. I had a selfish need to hear how that child, now an adult, was doing. I even Googled him. We had both moved away and lost contact 24 years ago. I was about to try searching and cold calling her kids, when I sent another “desperate” typed letter.

The third was a former colleague and my maid of honor. Same story – last contact 24 years ago.

I had given up my search and was despondent. Then early one morning, much to my chagrin, I got a text from my old friend and classmate. We talked later that same day for two and a half hours! I don’t think either of us wanted

to hang up. I was mesmerized by his family stories, his practice experiences and advocacy projects. He was equally interested in my life’s journey, career development and my unfortunate career end secondary to illness. We promised to keep in touch and connect in person post-COVID.

As I was about to give up on my second friend, I searched once more. Through a circuitous route, I found a Facebook page and sent a query. Two hours later, I received a phone call. We haven’t stopped writing, texting and calling since. The big little boy that I had delivered just got married!

That imbued me with renewed courage, and I sent a “desperate” letter to my third friend. …We just connected!

But the best connection was to my mother and sister. We live 1,200 miles away, but we might as well have been on different continents. Neither of us has been well enough to travel for years. My mother had been un-

able to hear my voice by phone. We communicated infrequently by email. The COVID shutdown began on my birthday weekend. A typical perfunctory birthday email wish has morphed into daily communication. We each worried if COVID would destroy our last chance to see each other. Another “milestone” weekend, a new updated cellphone, and improved hearing aids, facilitated a video call on her 91st birthday – Inde-pendence Day, July 4, 2020!

Dr. Witlin, associate editor of the ACMS Bulletin, is a retired maternal/fetal medicine physician and research-er. She can be reached at [email protected].

Editorial

From Page 241



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June 2020 Dear Colleague: The Allegheny County Medical Society is seeking candidates for the 2021 ACMS Executive Committee, Board of Directors, Delegates to the Pennsylvania Medical Society and Peer Review; we invite your nominations. All members are asked to participate. We especially encourage our resident and young physicians to get involved. The future of medicine depends on you.

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PerspectivePerspectivePerspective

The U.S. healthcare system has been transformed by COVID-19,

with telemedicine technology being one of the most significant drivers of thought and change.1 Prior to COVID-19, telepsychiatry had already experienced significant expansion. The great promise of telepsychiatry was to provide a feasible alternative for scarce mental health services and to alleviate the problem of underdiagnosing and undertreating persons with mental illness.2 By 2019, the entire United States and the District of Columbia pro-vided some coverage for telepsychiatry services for Medicaid members, and 42 states had telepsychiatry commercial payer laws, although there was consid-erable variability across states.3

Despite increased financial reim-bursements and studies suggesting a high degree of patient satisfaction and acceptance, systematic and policy concerns dissuaded many providers from entering telepsychiatry services.4 By 2018, only about 5% of psychiatrists who provided care in the Medicare system had provided at least one telemedicine visit.5 Uncertainty regard-ing state-to-state policy differences, lack of reimbursement parity, lack of comfort with telemedicine technologies, confidentiality concerns, licensure and credentialing restrictions, and mal-practice risks were impediments to the implementation and sustainability of telepsychiatry services.6

As COVID-19 related illnesses necessitated shelter-in-place orders

across the country, many psychiatrists were faced with the challenge of transi-tioning to telemedicine within a matter of days. This difficult transition was made possible by immediate changes in the regulation and reimbursement of telemedicine. Legislation allowed for the easing of telehealth restrictions for Medicaid patients by removing penalties for potential HIPAA violations, changing regulations to allow providers to practice telemedicine across state lines, and suspending the Ryan Haight Act, which had prohibited the use of telehealth when prescribing controlled substances.7 The common denomina-tor of these policy changes is that they address the economic and techno-logical barriers which have hampered the growth of telemedicine. The field of psychiatry, however, is particularly dependent upon personal interaction and subjective client-patient dynamics for successful practice. The unknown and previously unstudied variable is whether psychiatric services can tran-sition to a virtual-meeting format during

a public health crisis without the loss of appointment adherence.

There has been research prior to COVID-19 on adherence to appoint-ments and clinic productivity comparing telepsychiatry to face-to-face meet-ings.8 Although studies have found comparable and sometimes superior adherence with telepsychiatry, they generally involved a retrospective pro-cess in which patients were randomly assigned voluntarily to one modality versus the other. COVID-19, in con-trast, has caused an abrupt and mostly involuntary transition to telepsychiatry. To better understand the impact of this change in psychiatric care delivery, this retrospective chart review was conducted to compare equivalent time intervals preceding versus after telep-sychiatry implementation with the intent of comparing productivity and medica-tion check appointment adherence at a community mental health center.

MethodsThis retrospective chart review study

was conducted at Southwestern Human Services, a community mental health center in Pittsburgh. The variables for study were the total number of psy-chiatric medication checks scheduled, the number of missed appointments (no-shows), and psychiatric productivity, which was defined as the percentage of available psychiatric med check time utilized with patient encounters. Initial psychiatric evaluations and psycho-therapy visits were not included in the

Telepsychiatry appointment adherence and productivity during COVID-19

timOthy lesaCa, mD

Pamela Pyle, aas



study. Telepsychiatry services were started on March 23, 2020, which is the date that Pittsburgh and surrounding regions were ordered by the governor of Pennsylvania to shelter in place due to COVID-19. No telepsychiatry services of any type were performed at the clinic prior to that date. The telepsy-chiatry service time interval studied was the 11-week span from March 23, 2020, to the end date of the shelter in place order, which was June 5, 2020. During this period, the clinic did not offer the option of face-to-face meetings. Jan. 6, 2020, to March 22, 2020, was the 11-week interval preceding telepsychiatry studied for comparison.

For this study, a no-show was defined as a psychiatric med check for which the parent, guardian, or identified client did not attend without advance same-day call or notification. Prior to the transition date of March 23,2020, face-to-face psychiatric med checks were scheduled from two to 12 weeks in advance, with an appointment re-minder by telephone call one business day prior to the scheduled appointment. For the purpose of implementing telep-sychiatry visits as of March 23, patients were contacted by phone 24 hours prior to each scheduled appointment as a reminder that a text message link enabling entry into the psychiatrist’s “Doxy.me” virtual waiting room would be sent to the patient’s cellphone 15 minutes prior to the appointment. “Facetime” or “Google Duo” platforms were used as back-ups in the event of a Doxy.me connection failure. At no point in the study did the clinic utilize a no-show fee or any similar penalty for a missed appointment. Per clinic protocol, all minor-aged patients were required to be attended by a parent

or legal guardian for face-to-face and telemedicine visits, unless otherwise legally emancipated. The no-show rate and psychiatric productivity for the 11-week period prior to the implementa-tion of telepsychiatry med checks was compared to the 11 weeks afterward using a one-tailed Z test for statistical significance (alpha = 0.5).

ResultsFor 11 weeks preceding the im-

plementation of telepsychiatry med checks, 1,053 med checks were sched-uled, of which 948 were attended and 105 were no showed, representing a 9.97% no-show rate. For the 11 weeks after the implementation of telepsychi-atry, 915 med checks were scheduled of which 829 were attended and 86 were no showed, representing a 9.40% no-show rate. There was not a signifi-cant difference in no-show percentages between the compared time intervals. (Z = 0.428, p = .3336)

There were 1,188 med check time slots available prior to the implemen-tation of telepsychiatry, of which 948 were attended, representing a produc-tivity of 79.80%. After the implementa-tion of telepsychiatry, there were 1,012 med check time slots available, of which 829 were attended, representing a productivity of 81.92%. There was not a significant difference in productiv-ity between the compared time inter-vals. (Z = -1.257, p = .10383)

DiscussionThe results of this study suggest

comparable psychiatric med check no-show percentages and productivity before and after the implementation of telepsychiatry services, reflecting the findings of relevant past studies done

prior to COVID-19.8,9 Research on appointment nonadherence in psychi-atry has found a myriad of contribut-ing variables such as transportation problems, motivational limitations and financial concerns about missing work.10, 11 Telepsychiatry would seem to be a potential solution to issues of compliance and productivity, and some pre-COVID-19 studies have found no difference in patient satisfaction with telepsychiatry as a modality when com-pared to face-to-face appointments.12 Despite the temptation to conclude that telepsychiatry is the preferred venue for the future of psychiatric services, there is much to consider.

Abruptly transitioning large numbers of mental health clients to telepsychi-atry amid a public health emergency was an undesired, untested and unstudied experience. The clients in this study had no alternatives to virtual meetings, and adherence does not necessarily equate with satisfaction. The absence of comparative patient satisfaction ratings is an obvious limitation of this study. Another major limitation is the omission of objective measurements to study COVID-19 related influences on mental health. There is mounting evidence that COVID-19 is having a profoundly neg-ative effect on societal mental health, with anxiety, sleep disturbance, irrita-bility and feelings of despair becoming widespread.13

The question remains whether, amid the prolonged physical and emotional isolation of a pandemic, telepsychiatry will enable, enhance, or hinder the con-ventional doctor-patient relationship. One concern is that virtual visits could produce a false sense of presence


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which would worsen preexisting feelings of social isolation.12 Some studies also have found instances of decreased professional satisfaction among providers of telemedicine services.14

In conclusion, this study is further evidence of the transformative impact of COVID-19 on healthcare. Wheth-er patients will be better served as a result remains to be determined. Perhaps the only certainty is that COVID-19 will persist for the foreseeable future, creating a tenacious innate experiment which will force each of us to constantly

re-examine how to best serve the needs of our patients.

Dr. Lesaca is a psychiatrist specializing in children and adolescents. He can be reached at [email protected]. Pamela Pyle has worked in psychiatry for 18 years, with research focused on Community and Child Adolescent Psy-chiatry. She can be reached at [email protected].


From Page 247

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.

References1. Centers for Medicare & Medicaid

Services. Medicare Telemedicine Health Care Provider Fact Sheet. Available online: https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-healthcare-provid-er-fact-sheet (accessed on 30 June 2020)

2. Dorsey ER, Topol EJ. (2016) State of Telehealth. N Engl J Med, 375(2), 154-161.

3. ATA Releases 2019 Update of State-by-State Telehealth Report Cards. Available online: https://www.americantelemed.org/in-the-news/ata-releases-2019-update-of-state-by-state-telehealth-report-cards/ (accessed on 30 June 2020)

4. Bishop, JE, O’Reilly, RL, Maddox, K, Hutchinson, LJ. (2002) Client satisfaction in a feasibility study comparing face-to-face interviews with telepsychiatry. J Telemed Telecare (8), 217–221.

5. Choi S, Wilcock AD, Busch AB, et al. (2019) Association of characteristics of psy-chiatrists with use of telemental health visits

in the Medicare population. JAMA Psychiatry (7), 654–657.

6. Cowan, KE, Mckean, AJ, Gen-try, MT, Hilty, DM. (2019). Barriers to use of telepsychiatry: clinicians as gate-keepers. Mayo Clinic Proceedings (94), 2510–2523.

7. Center for Connected Health Policy. Telehealth Coverage Policies in The Time of Covid-19. Available online: https://www.cch-pca.org/resources/covid-19-telehealth-cover-age-policies (accessed on 30 June 2020)

8. Shulman M, John M, Kane JM. (2017). Home-based outpatient telepsychiatry to improve adherence with treatment appoint-ments: a pilot study. Psychiatr Serv. (68), 743–746.

9. Leigh H, Cruz H, Mallios R. (2009) Telepsychiatry appointments in a continuing care setting: kept, cancelled and no-shows. J Telemed Telecare. (15), 286–289.

10. Lesaca T. (2017) The impact of queue-controlled modified open access

scheduling on no-show rate in a community mental health child psychiatry med check clinic: A pilot study. Patient Exp J. (4), 141-144.

11. Gordon M, Antshel KM, Lewandows-ki L, et al. (2010) Predictors of missed ap-pointments over the course of child mental health treatment. Psychiatric Services. (61), 657–659.

12. García-Lizana F, Muñoz-Mayorga I. (2010) What about telepsychiatry. A system-atic review? Prim care companion. J Clin Psychiatry. (12), 2–6.

13. Chakraborty N. (2020) The COVID-19 pandemic and its impact on mental health. Prog Neurol Psychiatry (24), 21-24.

14. Manguno-Mire GM, Thompson JW, Shore JH, Croy CD, Artecona JF, Pickering JW. (2007) The use of telemedicine to eval-uate competency to stand trial: A prelimi-nary randomized control study. J Am Acad Psychiatry Law (35), 481–489.

Where-to-Turn cards give important information and phone numbers for victims of domestic violence. The cards are the size of a business card

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Where to turn… Domestic Abuse Palm Cards Available at ACMS


Reflections after 52 yearsRiChaRD l. GReen, mD


I am now 52 years post-medical school graduation and have practiced Allergy

in Pittsburgh for 45 years. During my sojourn in this medical career, I have taken the opportunity on three occasions to look back and reflect on where we have been, where we are going and what it all means – a pontification of sort. I now am seeing patients two days a week … when we are not in lockdown … so consider myself still practicing actively. I am liv-ing proof that if you live long enough, there is no end to the surprises that life may have in store for us. So, I thought I would make effort number four of philosophizing.

I thought it might be interesting for younger colleagues to see what ob-servations I made in previous writings. In 1991, in an article in the ACMS Bulletin, I listed some of the wrenching changes that were occurring in the practice of medicine but optimistically concluded: “With no conceit intended, let me say that there is nothing more satisfying, more demanding, more important, more emotionally rewarding than the practice of medicine. The one-on-one daily contact with our patients, the intellectual challenges, the demands of constant learning and growth, are unsurpassed in any other field. Ours is still among the noblest callings, and physicians must still work

constantly to earn our patients’ trust and confidence. … Our children need not be discouraged from such a rigor-ous and rewarding calling. The rules of the game have changed and the innovations of the next 20 years will be logarithmically more wrenching, but the physician’s role as a compassionate caregiver should be just as necessary and just as fulfilling.”

Fast forward to 1998, again in the Bulletin, I commented on the advent of managed care and computers in our practices. I then concluded: “As I age, I realize more and more that the practice of medicine is like running a marathon. It is a lot about putting one foot in front of the other, showing up in all kinds of weather and persevering through a lot of adversity. It means pushing oneself daily for the principal, and helping our patients cope with their personal, physical, and psychological needs. It means being there for them, ignoring the pummeling from insurance companies, the media, the myriad of other distractions. It means trudging on through thick and thin, carrying the mantel that was bestowed upon us, and being worthy examples for the next generation of those lucky enough to be called physicians. The rewards are plentiful in personal satisfaction and patient gratitude, in dealing face to face, one on one, with people who

need us, who can teach us a lot about life and our own mortality.”

And in 2001, in a somewhat lighter vein, in a personal narrative published in the Medical Economics Journal, I discussed how adding music to my life, learning how to play the cello, provided a “source of inner tranquility, a sense of serenity and harmony … an ideal antidote for the stresses of modern medical practice.”

So now, in 2020, who could have anticipated the stresses brought on by the COVID-19 virus: a pandemic of se-vere illnesses and deaths, the wearing of masks and face shields in patient encounters? These surpass all of the wrenching challenges that came be-fore … and the astronomical demands being made on young physicians as they strive heroically to go about their work are unparalleled. Additionally, financial pressures on office practices have never been seen like this before. From my perspective, it appears that the new breed of young physicians have risen magnificently to the chal-lenge. They are bright, determined, dedicated. And as I concluded in my remarks in 1998: “This next genera-tion of physicians are the brightest, most talented, worldly, idealistic, and altruistic group. Their patients will treat them with the same trust, respect and


250 www.acms.org


love that our patients have given to us. The bottom line is, and will be, that our patients continue to need us and want us to provide compassionate and unfailing support as they navigate the uncertain waters of illness. We must not squander that trust.”

After 52 years, I remain optimistic. We will survive these latest uniquely devastating circumstances. Someday, we will look back on this period as a crisis which was met and successfully overcome! And life will go on.

Dr. Green has been practicing Allergy in Pittsburgh for more than 45 years. He can be reached at [email protected].

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.

From Page 249

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PerspectivePerspectiveSociety News

POS 2020-21 monthly meeting dates and speakers announced

David Buerger, MD, FACS, presi-dent, is pleased to announce the Pitts-burgh Ophthalmology Society (POS) 2020-21 academic meeting series. A total of five meetings are sched-uled, beginning September 2020 and concluding with the Annual Meeting in March 2021.

In light of the COVID-19 public health mandates and government regulations to prevent the spread of disease – including social distancing, limited crowd sizes and face coverings – and epidemiology projections, the POS will offer Virtual programs on the following dates:

• Thursday, September 10 and Thursday, October 8 (note new date).

The remaining meetings are scheduled as in-person programs at this time. We will continue to monitor the situation and alert members should there be a need to transition to a virtual offering.

Details on the virtual meeting, in-cluding agenda and registration will be published in the August newsletter and emailed to all members.

We look forward to providing an engaging and robust virtual experience and appreciate your patience as we continue planning!

At the time of print, the remaining meetings are scheduled as in-person meetings and will be held in the Ohio Ballroom at the Rivers Casino on the North Shore of Pittsburgh. Our top priority is the health and safety of all participants during the COVID-19 pandemic. We will continue to closely monitor regulations and guidelines rec-ommended by the Centers for Disease

Control and Prevention (CDC) and will notify you should information change. Should it be deemed necessary, programs will pivot to virtual meeting offerings.

Likewise, we are working with our hospitality partner to ensure safety measures and best practices are in place by adhering to the health guide-lines set forth by the CDC, the Penn-sylvania Department of Health, the Allegheny County Health Department (ACHD) and the City of Pittsburgh.

Members are asked to take note of the day of each meeting as a few meetings are not scheduled on a Thursday. Mark your calendar for the following dates:

Thursday, Sep-tember 10 – The first virtual meeting of the season wel-comes Christopher D. Riemann, MD. Dr. Riemann is affiliated with the Cincinnati Eye Institute. He serves as volunteer associate professor at the University of Cincinnati, Department of Oph-thalmology, and director, Vitreoretinal Fellowship, as well as a member, Clinical Governance Board, Cincinnati Eye Institute. He also is Ophthalmolo-gy Section Leader at Bethesda North Hospital.

Dr. Riemann specializes in medical and surgical vitreoretinal diseases including diabetic retinopathy, macu-lar degeneration, retinal detachment, retinopathy of prematurity, vascular diseases of the retina, uveitis, histo-plasmosis, complications of anterior segment surgery, endoscopic posterior segment surgery and ocular trauma, in collaboration with the other Retinal

Surgeons at Cincinnati Eye Institute. Thank you to Thierry Verstraeten, MD, for inviting Dr. Reimann.

Thursday, Oc-tober 8 – The Octo-ber virtual meeting welcomes Kenneth A. Beckman, MD, FACS. Dr. Beckman is director, Corneal Services, at Compre-hensive Eyecare of Central Ohio. He is a board-certified ophthalmologist and cornea specialist, has been practicing ophthalmology in Columbus since 1996 and joined Comprehensive Eye Care in July 2012 as director of Corneal Services.

Dr. Beckman is a past president and past treasurer of the Columbus Ophthalmology and ENT Society and a past member of the Board of Trustees for Prevent Blindness Ohio. Dr. Beck-man is active in clinical ophthalmology research and has been involved in numerous clinical studies. He has pub-lished articles in ophthalmology jour-nals and has presented his research at national meetings, such as the Ameri-can Society of Cataract and Refractive Surgery. He was recently involved in two FDA trials for the treatment of keratoconus and corneal ectasia using collagen cross-linking technology. Thank you to Deepinder Dhaliwal, MD, for inviting Dr. Beckman.

Thursday, De-cember 3 – Dr. David Buerger invited colleague, Roberta Gausas, MD, to speak to members in De-cember. Dr. Gausas is director of Oculofacial

Dr. Riemann

Dr. Beckman

Dr. Gausas


41st Annual Meeting for Ophthalmic Personnel scheduled for March 12, 2021

The 41st Annual Meeting for Oph-thalmic Personnel, presented by the Pittsburgh Ophthal-mology Society, is scheduled for Friday, March 12, at the Pittsburgh Marriott City Center. Planning for this well-respect-ed annual program, which is designed for Ophthalmic techni-cians, assistants, technologists, scribes and administrative personnel, is currently underway.

Course directors Pamela Rath, MD, Avni Vyas, MD, and Jared Weed, MD, are reviewing topics and speakers for presentation and look forward to offering a slate of excel-lent sessions.

Look for a Save the Date postcard and email to be sent in September. Course information will be posted on the POS website at www.pghoph.org.

and Orbital Surgery Division, Department of Ophthalmology, at Scheie Eye Institute, University of Pennsylvania School of Medicine.

Thursday, January 7, 2021 – The first meeting of the new year welcomes I. Paul Singh, MD, Glaucoma Specialist, The Eye Centers of Racine and Kenosha Racine, Wisc. Thank you to Ian Conner, MD, PhD, for inviting Dr. Singh.

Throughout his career, Dr. I. Paul Singh has been involved with clinical research and has published papers in several ophthalmology jour-nals. He also has presented his research at various national meetings and universities.

He has brought several new technologies to the Racine and Kenosha areas and was the first in Wisconsin to implant the smallest devices in the human body, the iStent, for the treatment of glaucoma. Dr. Singh also has pioneered the use of in-office lasers to remove visually significant floaters. Recently, he was instrumental in bringing laser-assisted cataract surgery to the area. He enjoys giving lectures and teaching seminars around the globe to help other doctors adopt these and other newer technologies and techniques.

Wednesday, February 10, 2021 – The final monthly meeting will welcome Faruk H. Örge MD, FAAO, FAAP. Dr. Örge is the William R. and Margaret E. Althans Chair and Professor; director, Center for Pediat-ric Ophthalmology and Adult Strabismus; Rainbow Babies and Children’s Hospital and University Hospitals Eye Institute; professor, Ophthalmology and Pediatrics Case Western Reserve University SOM; fellowship program director; associate program director – Ophthalmology Res-idency UH / CWRU SOM; and medical director for Quality – UH Eye Institute.

Dr. Örge is widely recognized for his clinical expertise and is listed in the Best Doctors of America (since 2009), Top Doctors (since 2011) and Who’s Who (2014). Dr. Örge has served on and led many committees (Online, Public Education, Program committees) of the American Associa-tion of Pediatric Ophthalmology and has joined the AAPOS Board of Directors in 2018 as a director at large. He is an examiner for the American Board of Ophthalmology and

252 www.acms.org

PerspectivePerspectiveSociety News

Dr. Örge

Dr. Singh

From Page 251 serves as the AAPOS liaison to the ABO.His innovations in teaching include work with ORBIS/

Cyber-sight, AAPOS and the AAO, with interests in tele-medicine, live webinars (first to produce national and international sessions in the field of ophthalmology), online journal clubs, and unique learning tools such as an inter-active strabismus and retinoscopy simulators. He is the editor-in-chief for the AAO’s newly formed KTEF Pediatric Ophthalmology Education Center, the largest online educa-tional source in the world for pediatric ophthalmology and strabismus; it has been visited more than 1 million times by visitors from more than 200 countries since its inception in 2015.

Members will receive registration information one month prior to the date of each scheduled program. Reg-istration will be handled online only. Please visit the POS website periodically for updates and to register, www.pghoph.org.


PerspectivePerspectiveActivities & Accolades

White House names ACMS member to nursing home task force on COVID-19 response

David A. Nace, MD, MPH, CMD, presi-dent of AMDA, The Society for Post-Acute and Long-Term Care Medicine in Pennsyl-vania, chief medical officer of UPMC Senior Communities in Pittsburgh and a member of the Board of Directors of the Pennsylvania Geriatrics Society – Western Division, was selected among the top leaders in the long-term care industry to serve on the newly formed federal nursing home task force. In this role, Dr. Nace will review nursing homes’ response to the COVID-19 pan-demic and recommend new regulations and procedures for future emergency situations.

Task force members will work to formulate best practices to protect nursing home residents on three fronts:

• Putting nursing home residents first by ensuring they are protected from COVID-19 and improving the responsiveness of care delivery to meet the needs of all residents to maxi-mize quality of life for residents

• Strengthening regulations to enable rapid and effective identification and mitigation of COVID-19 transmission in nursing homes

• Enhancing federal and state enforcement strategies to improve compliance with infection control policies in response to COVID-19

The White House Commission is meeting regularly this summer with plans to provide a report the first week of Sep-tember 2020.

Dr. Nace

Here’s to the

Heroes

If you’re an active or retired specialty physician interested in volunteering at

our clinic, please call (941) 917-2566.

For nearly 30 years, the Sarasota Memorial Community

Specialty Clinic has been the place where Sarasota County’s

most financially vulnerable residents can find the specialized

healthcare assistance they need. But it would be little more

than a building without the tireless physicians, who volunteer

their most precious resource—time—and contribute their

invaluable medical skills to the community they serve.

Thanks to dedicated volunteer physicians like Dr. Fredric Jarrett,

our clinic community will always find an expert hand, a sympathetic

ear and the high quality medical care it deserves. Our patients

remember that, and, if you see Dr. Jarrett around town, we hope

you will too.

COMMUNITY SPECIALTY CLINIC

Fredric Jarrett, MD,Vascular Surgeon

ACMS member honored for volunteer workFredric Jarrett, MD, FACS, FRCSC, recently was

recognized as Volunteer Doctor of the Month at Sarasota Memorial Community Clinic in Florida.

Dr. Jarrett, a longtime ACMS member, is a surgeon and practiced in Pittsburgh for 37 years. He is the author of “To Fruit Street and Beyond: The Massachusetts General Hospital Surgical Residency.”

For classified advertising information, including special

member rates, email Meagan K. Sable

at [email protected], call (412) 321-5030,

or visit www.acms.org.

254 www.acms.org

Materia Medica

Istradefylline (Nourianz®) samantha DemaRCO, PhaRmD RaChael CaRDinal, PhaRmD, BCPs

Background

Istradefylline (Nourianz®) is an ad-enosine receptor antagonist (A2A

antagonist) approved as adjunctive treatment in Parkinson’s disease since September 2019.1 It is recommended as an adjunctive treatment to levodopa/carbidopa in patients experiencing an increase in OFF time.1 OFF times occur when a patient’s levodopa/carbi-dopa medication is no longer working effectively and Parkinson’s symptoms, such as rigidity, slow movement and tremors, return. Istradefylline is formu-lated as a once daily oral tablet.

SafetyThere are no labeled contraindi-

cations for istradefylline.1 However, in clinical trials, istradefylline demonstrat-ed elevated plasma drug concentration three times higher in patients with hepatic impairment.2 Individuals with moderate hepatic impairment (Child-Pugh B) should not exceed a maximum daily dose of 20 mg.1 Istradefylline should be avoided in patients with severe hepatic impairment (Child-Pugh C).1 It is important to obtain baseline liver function tests before initiating the medication. No dosage adjustments are required in renal impairment.

It also is recommended to avoid istradefylline in patients taking strong inducers of CYP3A4, such as carba-mazepine, phenytoin, St. John’s Wort

and rifampin.1 Istradefylline dosing should not exceed 20 mg when pa-tients are concomitantly taking strong CYP3A4 inhibitors, such as azole antifungals, due to increased plasma concentrations of istradefylline.3,4 On the other hand, cigarette smoke expo-sure decreases plasma concentrations of istradefylline. It is recommended that individuals who smoke ≥20 cigarettes per day start with 40 mg of istradefyl-line daily.1

Dose dependent occurrences of hal-lucinations (2.0 - 5.9%) and psychiatric episodes (17.8 - 27.6%) were observed in clinical trials.5,6 These effects were associated with the 40 mg dose of is-tradefylline. These behaviors subsided with dose reduction of 40 mg to 20 mg daily or discontinuation.5

TolerabilityIstradefylline is a well-tolerated oral

agent that can be administered with or without food.6 The most common adverse effects include mild to moder-ate dyskinesia, insomnia and gastro-intestinal effects, such as nausea and diarrhea.5,6,7 The incidence of adverse events is ≥5%. Clinical trials report similar discontinuation rates among is-tradefylline versus placebo groups due to side effects, with dyskinesia being the most common reason for therapy discontinuation.6,7

EfficacyIstradefylline has been shown to be

effective in lowering the percentage of daily OFF time versus placebo. Efficacy in reducing the Parkinson’s

OFF symptoms was studied in three, randomized, double-blind, parallel group trials.

The first trial included 610 patients who were randomized to receive either placebo, 10 mg istradefylline, 20 mg istradefylline, or 40 mg istradefylline daily.5 The second study included 196 patients who were randomized to re-ceive either placebo or 40 mg istrade-fylline daily.6 The third study included 231 patients who were randomized to receive either placebo or 20 mg istradefylline daily.8 Each of the trials studied the reduction in daily OFF time experienced by patients with Parkin-son’s disease who were already taking levodopa/carbidopa over a course of 12 weeks.

In all three clinical trials, the addi-tion of istradefylline to levodopa/carbi-dopa resulted in a significant reduction in OFF symptoms compared to place-bo.5,6,8 The first trial observed that OFF symptoms were reduced by 1.1 hours in both the 10 mg and 20 mg istrade-fylline groups and 1.5 hours in the 40 mg istradefylline group compared to placebo.5 LeWitt, et al., found istrade-fylline 40 mg daily reduced daily OFF time by 18% (1.2 hours) compared to placebo.6 The third study observed an average absolute reduction percent-age of OFF time from baseline of 9.3% (1.6 hours) in the istradefylline 20 mg group versus 5.0% (0.9 hours) in the placebo group.8 Significant reductions in Parkinson’s OFF symptoms were evident within two weeks of starting istradefylline.6,8


Materia Medica

PriceThe average wholesale price for

an individual without insurance for a 30-day supply of either the 20 mg or 40 mg tablets of istradefylline is estimat-ed to be $1,800.9 There is a patient assistance program available for those who are uninsured through Kyowa Kirin Cares.

SimplicityIstradefylline is available in 20 mg

and 40 mg oral tablets. Initial dose titration is not required; the dosage may be increased based on individual need and tolerability.1 This medication

should be taken once daily in addition to Parkinson’s medications that contain a levodopa/carbidopa combination. It can be taken with or without food.

Bottom lineIstradefylline (Nourianz®) is an ef-

fective agent for patients experiencing Parkinson’s disease OFF symptoms while currently taking levodopa-carbi-dopa.5,6,7 Istradefylline is not first line for treatment of Parkinson’s disease and should only be added as an adjunctive agent to levodopa/carbidopa combination Parkinson’s disease med-ication therapy.1 It is a well-tolerated oral agent with relatively minimal risk

of adverse effects. Hepatic function, history of smoking and concomitant medications must be considered when choosing a dose for therapy initiation.

At the time of authorship, Dr. De-

Marco is a PGY-1 Pharmacy resident at UPMC St. Margaret and can be reached at [email protected]. Dr. Cardinal is a PGY-2 Ambulatory Care Pharmacy resident and can be reached at [email protected]. Heather Sakely, PharmD, BCPS, BCGP, provided editing and mentoring for this article and can be reached at [email protected].

References1. Kyowa Kirin International. Nourianz (Is-

tradefylline) [package insert]. U.S. Food and Drug Administration website. https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/022075s000lbl.pdf Accessed October 19, 2019.

2. Rao N, et al. Effect of Moderate Hepat-ic Impairment and Cigarette Smoking on the Pharmacokinetics of Istradefylline. Parkin-sonism Rel Disord. 2007;13(suppl 2):S104.

3. Rao N, et al. Evaluation of the Phar-macokinetic Interaction of Istradefylline and Ketoconazole. Parkinsonism Rel Disord. 2007;13(suppl 2):S104.

4. Knebel, W. et al. (2012), Popula-

tion Pharmacokinetic Pharmacodynamic Analysis of Istradefylline in Patients With Parkinson Disease. The Journal of Clinical Pharmacology, 52: 1468-1481. doi:10.1177/0091270011420566

5. Pourcher E, Fernandez HH, Stacy M, Mori A, Ballerini R, Chaikin P. Istradefylline for Parkinson’s Disease Patients Experiencing Motor Fluctuations: Results of the KW-6002-US-018 study. Par-kinsonism Relat Disord. 2012;18(2):178.

6. LeWitt PA, Guttman M, Tetrud JW, Tuite PJ, Mori A, Chaikin P, Sussman NM, 6002-US-005 Study Group. Adenosine A2A Receptor Antagonist Istradefylline (KW-6002) Reduces “off” Time in Parkinson’s Disease:

A Double-blind, Randomized, Multicenter Clinical Trial (6002-US-005). Ann Neurol. 2008;63(3):295.

7. Fernandez, H, et al. Istradefylline as Monotherapy for Parkinson disease: Results of the 6002-US-051 trial. Parkinsonism and Relat Disord. 2010; 16:16-20.

8. Hauser, R. et al. Study of Istradefylline in Patients with Parkinson’s Disease on Levodopa with Motor Functions. Movement Disorders. 2008; 23(15):2177-2185.

9. Istradefylline: Drug Information. UpTo-Date Inc. https://www.uptodate.com/contents/istradefylline-drug-information. Accessed on November 11, 2019.

ACMS Members:Professional announcement advertisements

are available to ACMS members at our lowest prices.

Contact Meagan Sable, managing editor, at [email protected].

Congratulatory message?

Retiring? New Partner?

New Address?

Legal Summary

Beth Anne JAckson, esq.

In Leadbitter, J. v. Keystone Anesthesia v. Petraglia1 (Leadbitter), the Pennsylvania

Superior Court (Superior Court) further eroded the evidentiary privilege afforded by the Peer Review Protection Act (PRPA).2 Over the last several years, the protection offered to the proceedings and records of a review committee has been whittled down by a series of cases that are inapposite.

Statutory background. The Pennsyl-vania General Assembly’s goal in passing PRPA was “to serve the legitimate purpose of maintaining high professional standards in the medical practice for the protection of patients and the general public.” The Gen-eral Assembly determined that “because of the expertise and level of skill required in the practice of medicine, the medical profession itself is in the best position to police its own activities.” The statute states that:

“The proceedings and records of a review committee shall be held in confi-dence and shall not be subject to discovery or introduction into evidence in any civil action against a professional health care provider arising out of the matters which are the subject of evaluation and review by such committee. …”

Case background. In Leadbitter, the plaintiff’s attorney sought to compel St. Clair Hospital to produce the “unredacted credentialing file” of the defendant, Dr. Carmen Petraglia. All of the remaining undisclosed documents in the credentialing file were, as the Superior Court deter-mined, “peer review” documents protected by PRPA. Nevertheless, the Superior Court

stated that it was compelled to follow the analysis of the Pennsylvania Supreme Court (the Supreme Court) in Reginelli v. Boggs,3 (Reginelli).

In Reginelli, the Supreme Court addressed a situation in which an indi-vidual, a physician employee of a staffing company, reviewed the performance of another physician employee, Dr. Boggs. The Supreme Court ruled that the lone physician reviewer was not a “review com-mittee” and, therefore, neither her employ-er nor the hospital could claim a privilege under PRPA with respect to that review, as it did not qualify as “peer review.” But the opinion went further and gratuitously stated – in a footnote – that credentialing activities were not protected by the PRPA evidentiary privilege.4

Leadbitter deals with an entirely differ-ent factual scenario. The Superior Court found that the records requested statuto-rily qualify as “peer review” documents. However, it followed the Reginelli impo-sition of a distinction between a “review organization” and a “review committee” to determine whether the documents were protected from disclosure by PRPA. Rather than making a different finding based on patent objective distinctions and allowing the issue to be determined on appeal to the Supreme Court, the Superior Court invited the Supreme Court – in a footnote – to grant allocator and address the issue directly.

Conclusion. Both Leadbitter and Reginelli have seriously undermined PRPA. The Leadbitter decision, issued in February, has pretty much flown under the radar as health providers have, understandably,

been primarily engaged with the COVID-19 pandemic. No legislation has overturned Reginelli and its progeny. It is time for that to change.

DISCLAIMER: This article is for informational purposes only and does not constitute legal advice. You should contact your attorney to obtain advice with respect to your specific issue or problem.

Ms. Jackson is a shareholder in the Health Care Practice Group of Brown & Fortunato, P.C., which is headquar-tered in Amarillo, Texas and serves healthcare

providers nationally. She is licensed in both Pennsylvania and Texas and maintains an office in the greater Pittsburgh area. She can be reached locally at (724) 413-5414 or at [email protected]. Her firm’s website is www.bf-law.com.

Pennsylvania Superior Court decision: Further deterioration of the peer review privilege

References1. 1414 WDA2018 (Pa. Super. Ct.

2020).2. Pa. Stat. Ann. 63 P.S. §425.2.3. 1818 A.3d 293 (Pa. 2018).4. For a more in-depth review of

Reginelli, see Jackson, Beth Anne, “Peer Review: A ‘narrow evidentiary privi-lege,’”Allegheny County Medical Society Bulletin, Vol. 108, No. 5 (May 2018). The term “gratuitously” is used because the status of credentialing records was not squarely before the court.

Allegheny County Medical Society www.acms.org • (412) 321-5030


Special Report

Pilot of new perinatal Hepatitis C Surveillance Program coming to Allegheny County

RaChael Bieltz, mPh, Ches

Bethany (hallam) ReynOlDs, mPh

Nationally, among women tested for hepatitis C virus (HCV) infection,

there was a 36% increase in positivity in women of childbearing age and a 39% increase in positivity among pregnant women from 2011-2016.1 In Allegheny County, the incidence of hepatitis C in women of childbearing age increased 51% from 2009-2018. In 2018, 20% of newly reported hepatitis C cases in Allegheny County were in women of childbearing age (Chart 1). Vertical transmission of hepatitis C is estimated to occur in 5 to 10% of births.2

With more women of childbearing age becoming infected with hepatitis C, we expect more frequent vertical trans-mission to infants. Moreover, with the southwestern region of Pennsylvania being disproportionately affected by the opioid epidemic, Allegheny County will likely continue to experience increases in HCV infections.

In response to this increase, the Pennsylvania Department of Health and Allegheny County Health Depart-ment are collaborating to pilot a new

Chart 1: Chronic Hepatitis C among women of reproductive age, Allegheny County, Pa.

Hepatitis C Surveillance Program among pregnant women and infants in Allegheny County. The primary foci of this program will include:

• Providing education on the Cen-ters for Disease Control and Preven-tion’s (CDC’s) updated hepatitis C testing recommendations

• Increasing appropriate testing among pregnant women, women of childbearing age, and infants exposed to hepatitis C

• Facilitating linkage to care among pregnant women, women of childbearing age, and infants exposed to hepatitis C

Updated Hepatitis C testing recommendations

In 2020, the CDC published updated hepatitis C screening recommendations

to include universal screening of all adults, at least once, and all pregnant women during each pregnancy. Along with these updates, the CDC continues to recommend individuals with risk fac-tors, including people who inject drugs, be tested regularly (Table 1 – Persons Recommended for Hepatitis C Testing). The CDC recommends that healthcare providers implement these universal screening practices if the chronic hepati-tis C prevalence is greater than 0.1% in the population that they serve. Modeling results using NHANES data found that no states have a prevalence of less than 0.1% in adults.3 This same modeling estimated that the prevalence of hepati-tis C in Pennsylvania was 0.93% at the time of the study.3


258 www.acms.org

Special Report

Increasing testing and linkage to care

The CDC acknowledges that data is lacking regarding when to screen during pregnancy. Screening for hepati-tis C alongside other routine screen-ings may reduce the stigma associated with targeted screening based on risk factors.5 Testing early in pregnancy

allows for the Society of Maternal Fetal Medicine guidelines on birth interven-tions and prevention of vertical trans-mission to be considered. However, testing once in early pregnancy may miss the individual that contracts the vi-rus later in pregnancy. Retesting those with risk factors later in the pregnancy will help to identify the virus and aid in preventing vertical transmission.

Even in mothers with known hepa-

titis C status, appropriate testing and subsequent linkage to care for those infants is not routine.6 In a retrospective cohort study of women who delivered at Magee-Womens Hospital of UPMC between January 1, 2006, and Decem-ber 31, 2014, Chappell, et al., iden-tified 1,043 mothers as having HCV infection. Of those 1,043 infants born to mothers with HCV infection, 323 in-fants had record of receiving well-child

From Page 257

Table 1: Persons Recommended for Hepatitis C Testing, 2020 CDC Guidelines4

1. Universal hepatitis C screening: • Hepatitis C screening at least once in a lifetime for all adults aged ≥18 years, except in settings where the

prevalence of HCV infection (HCV RNA-positivity) is <0.1% • Hepatitis C screening for all pregnant women during each pregnancy, except in settings where the

prevalence of HVC infection (HCV RNA-positivity) is <0.1%2. One-time hepatitis C testing regardless of age or setting prevalence among persons with recognized risk factors or exposures:

• Persons with HIV • Persons who ever injected drugs and shared needles, syringes, or other drug preparation equipment,

including those who injected once or a few times many years ago • Persons with selected medical conditions, including persons who ever received maintenance

hemodialysis and persons with persistently abnormal ALT levels • Prior recipients of transfusions or organ transplants, including persons who received clotting factor

concentrates produced before 1987, persons who received a transfusion of blood or blood components before July 1992, persons who received an organ transplant before July 1992, and persons who were notified that they received blood from a donor who later tested positive for

HCV infection • Health care, emergency medical, and public safety personnel after needle sticks, sharps, or mucosal

exposures to HCV-positive blood • Children born to mothers with HCV infection

3. Routine periodic testing for persons with ongoing risk factors, while risk factors persist: • Persons who currently inject drugs and share needles, syringes, or other drug preparation equipment • Persons with selected medical conditions, including persons who ever received maintenance

hemodialysis4. Any person who requests hepatitis C testing should receive it, regardless of disclosure of risk, because many persons might be reluctant to disclose stigmatizing risks


Special Report

visits within the UPMC system. How-ever, only 96 (30%) of those infants with well-child visit records received hepatitis C testing. Furthermore, 73 of the 96 children screened received recommended initial hepatitis C testing. The current CDC recommendations for testing exposed infants consists of:

• HCV RNA testing at or after age 2 months, or

• Anti-HCV testing at or after age 18 months

The above testing recommenda-tions are supported by the Infectious Disease Society of America, the Amer-ican Association for the Study of Liver Diseases, and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.7-10

Once hepatitis C infection status is known, direct-acting antivirals are approved by the U.S. Food and Drug Administration for treatment in children age 3 years and older. In addition to testing and linkage to care for those

infants born to mothers with known hepatitis C infection, women typically have increased interaction with the medical system during pregnancy. This increased interaction presents an op-portunity to link women to postpartum treatment to prevent perinatal hepatitis C exposure in future pregnancies. Furthermore, if direct-acting antiviral agents become a recommended treat-ment during pregnancy, early identifica-tion of the virus will be beneficial.

Collaboration needed for a successful pilot program

As part of this pilot promoting educa-tion, testing and linkage to treatment for hepatitis C, the Allegheny County Health Department and the Pennsylvania Department of Health will be requesting your assistance with additional data on pregnant women with diagnosis of hep-atitis C as well as infants born to women with hepatitis C. These data will support further development of a widespread

perinatal Hepatitis C Surveillance Pro-gram and inform recommendations for appropriate screening, evaluation and follow-up in this population. By working together, we can ensure availability of clinical guidance, health communication materials, and other tools for providers and patients.

Rachael Bieltz, MPH, CHES, is a public health consultant with the Allegh-eny County Health Department. She has previous experience in public health research, practice and health education. She can be reached at [email protected].

Bethany (Hallam) Reynolds, MPH, is an Epidemiology Research Associate with the Pennsylvania Department of Health. She has previous experience with Hepatitis C Surveillance, hospital Infection Prevention, and qualitative research in healthcare. She can be reached at [email protected].

References 1. Schillie, S. F., Canary, L., Koneru, A.,

Nelson, N. P., Tanico, W., Kaufman, H. W., Hariri, S., & Vellozzi, C. J. (2018). Hepatitis C Virus in Women of Childbearing Age, Pregnant Women, and Children. Ameri-can journal of preventive medicine, 55(5), 633–641. https://doi.org/10.1016/j.ame-pre.2018.05.029

2. Vertical transmission of the hepatitis C virus: Current knowledge and issues. (2008). Paediatrics & child health, 13(6), 529–541.

3. Rosenberg ES, Rosenthal EM, Hall EW, et al. Prevalence of Hepatitis C Virus Infection in US States and the District of Columbia, 2013 to 2016. JAMA Netw Open. 2018;1(8):e186371. doi:10.1001/jamanetworkopen.2018.6371

4. Schillie S, Wester C, Osborne M, Wesolowski L, Ryerson AB. CDC Rec-

ommendations for Hepatitis C Screening Among Adults—United States, 2020. MMWR Recomm Rep 2020; 69(No. RR-2):1-17. DOI: http://dx.doi.org/10.15585/mmwr.rr6902a1

5. Havens PL, Anderson JR. Updated CDC Recommendations for Universal Hep-atitis C Virus Screening Among Adults and Pregnant Women: Implications for Clinical Practice. JAMA. Published online April 09, 2020. doi:10.1001/jama.2020.3693

6. Chappell, C. A., Hillier, S. L., Crowe, D., Meyn, L. A., Bogen, D. L., & Krans, E. E. (2018). Hepatitis C Virus Screening Among Children Exposed During Pregnancy. Pe-diatrics, 141(6), e20173273. https://doi.org/10.1542/peds.2017-3273

7. American Association for the Study of Liver Diseases (AASLD); Infectious Diseases Society of America (IDSA). HCV guidance: recommendations for testing,

managing, and treating hepatitis C. Alexan-dria and Arlington, VA: AASLD and IDSA; 2019. https://www.hcvguidelines.org

8. Infectious Diseases Society of America; American Association for the Study of Liver Diseases Recommendations for testing, managing and treating hepatitis C. Available at: http://www.hcvguidelines.org/. Accessed December 20, 2017

9. Centers for Disease Control and Prevention Hepatitis C FAQs for health professionals. Available at: https://www.cdc.gov/hepatitis/hcv/hcvfaq.htm#g4.

10. Mack CL, Gonzalez-Peralta RP, Gupta N, et al.; North American Society for Pediatric Gastroenterology, Hepatol-ogy, and Nutrition . NASPGHAN practice guidelines: diagnosis and management of hepatitis C infection in infants, children, and adolescents. J Pediatr Gastroenterol Nutr. 2012;54(6):838–855

To refer your patient, call1-844-MD-REFER (1-844-637-3337).

Most major insurance plans are accepted.

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Help your patients overcome obesity.Our specialists offer new treatments for weight loss.

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Documents

C M S BulletinRachael Bieltz, MPH, CHES Bethany (Hallam) Reynolds, MPH Editorial .....234 The malady lingers on Deval (Reshma) Paranjpe, MD, MBA, FACS Editorial .....238 Scientific