rhode island medical j ournalrimed.org/rimedicaljournal/2016/07/2016-07.pdfmedical j ournal rhode...
TRANSCRIPT
M E D I C A l J o u r n A lR H O D E I S LA N D
V O L U M E 9 9 • N U M B E R 7J u lY 2 0 1 6 I S S N 2 3 2 7 - 2 2 2 8
MEMorial’s iNTErNal MEdiciNE rEsidENTs graduaTE pagE 57
lyNN E. Taylor, Md aT ThE whiTE housE
pagE 50
providENcE va dialysis uNiT wiNs icarE award
pagE 51
liaNNa Karp, Md rEcEivEd raKaTaNsKy award pagE 50
RIMS-IBC 405 PROMENADE STREET, SUITE B, PROVIDENCE RI 02908-4811
MEDICAL PROFESSIONAL/CYBER LIABILITY PROPERTY/CASUALTY LIFE/HEALTH/DISABILITY
Until they’re not.
Data theft can happen to anyone, anytime.
A misplaced mobile device can compromise
your personal or patient records. RIMS-IBC
can get you the cyber liability insurance you
need to protect yourself and your patients.
Call us.
401-272-1050
Your records are secure.
I N C O O P E R AT I O N W I T H
M E D I C A l J o u r n A lR H O D E I S LA N D
7 coMMENTary The Misperceived Curmudgeon
Joseph h. FriedMan, Md
11 riMJ arouNd ThE world rome, italy
34 riMs NEws
Convivium 2016
Working for You
Why You should Join riMs
58 hEriTagE 1915: poison pies on the
Fourth of July Create panic in Westerly & stonington, CT.MarY Korr
M E D I C A l J o u r n A lR H O D E I S LA N D
50 LIANNA KARP, MD
received the rakatansky prize at alpert Medical school
51 PROVIDENCE VA DIALYSIS UNIT
wins iCare award
51 MONTY VANBEBER, MD
awarded providence Va hands and heart award
51 SOUTHCOAST CENTERS
FOR CANCER CARE
earns national seal of accreditation from american College of radiology
54 JENNIFER GASS, MD
serves as international breast cancer resource
54 CORNELIUS “SKIP” GRANAI III, MD
receives Gold humanism award
56 MEMORIAL HOSPITAL
graduates Family Medicine residents, Fellows
RI FOUNDATION 41
awards $480,000 for medical research
PEDIATRIC ANXIETY RESEARCH CENTER 43
moves to Bradley campus
45 NIH AWARDS BROWN $11.5M
for computational biology research
45 SOUTH COUNTY HEALTH
opens Medical & Wellness Center in Westerly
45 FATIMA
opens Long-Term Behavioral health Unit
ALBERT WOO, MD 47
named Chief of pediatric plastic surgery at hasbro
PETER SNYDER, PhD 47
to head statewide Committee on neuroscience research
SOUTHCOAST PRESIDENT 48
KEITH HOVAN
to chair Mass. hospital assn. Board of Trustees
DONALD COUSTAN, MD 48
appointed to committee of american diabetes association
KENT, MEMORIAL 50
recognized for Quality stroke Care
LYNN E. TAYLOR, MD 50
honored at White house for ri defeats hepatitis C
iN ThE NEws
pEoplE/placEs
M E D I C A l J o u r n A lR H O D E I S LA N D
coNTriBuTioNs
12 Willingness of rhode island dentists to provide Limited preventive primary CareCaTherine TUYeT Mai danG, Ba
renee r. shieLd, phd
donaLd B. Giddon, dMd, phd
15 Geriatric issues in older dialysis patientsManoJ BhaTTarai, Md
19 influence of Medical student debt on the decision to pursue Careers in primary CareJoseph a. GiL, Md
GreGorY r. WarYasz, Md
doroThY LiU, Bs
aLan h. danieLs, Md
22 surveillance of Travel-related Mosquito-borne illness in rhode islandneha aLanG, Md
JUsTin GLaVis-BLooM, Md
niCoLe aLexander-sCoTT, Md, Mph
Leonard a. MerMeL, do, scM
Maria d. MiLeno, Md
casE rEporTs
24 atypical presentation of infective endocarditisKarUppiah arUnaChaLaM, Md
27 a case of ochrobactrum anthropi-induced septic shock and infective endocarditisFarhan ashraF, Md
EMErgENcy MEdiciNE rEsidENcy cpc
29 The pharma-fever that almost got awayxiao Chi zhanG, Md, Ms
MaTTheW siKeT, Md
WiLLiaM Binder, Md
puBlic hEalTh
32 Vital statisticsroseann GiorGianni, depUTY sTaTe reGisTrar
p u B l i s h E r
rhode isLand MediCaL soCieTY
p r E s i d E N T
rUsseLL a. seTTipane, Md
p r E s i d E N T- E l E c T
sarah J. FessLer, Md
v i c E p r E s i d E N T
BradLeY J . CoLLins, Md
s E c r E Ta r y
ChrisTine BroUsseeaU, Md
T r E a s u r E r
Jose r. poLanCo, Md
i M M E d i aT E pa s T p r E s i d E N T
peTer KarCzMar, Md
E x E c u T i v E d i r E c T o r
neWeLL e. Warde, phd
E d i T o r - i N - c h i E f
Joseph h. FriedMan, Md
a s s o c i aT E E d i T o r
sUn ho ahn, Md
puBlicaTioN sTaff
M a N a g i N g E d i T o r
MarY Korr
g r a p h i c d E s i g N E r
Marianne MiGLiori
a d v E r T i s i N g
sTeVen deToY
sarah sTeVens
E d i T o r i a l B o a r d
John J. Cronan, Md
JaMes p. CroWLeY, Md
edWard r. FeLLer, Md
John p. FULTon, phd
peTer a. hoLLMann, Md
KenneTh s. Korr, Md
MarGUeriTe a. neiLL, Md
FranK J. sChaBerG, Jr. , Md
LaWrenCe W. VernaGLia, Jd, Mph
neWeLL e. Warde, phd
RHODE ISLAND MEDICAL JOURNAL (Usps 464-820), a monthly publication, is owned and published by the rhode island Medical society, 405 promenade street, suite a, providence ri 02908, 401-331-3207. all rights reserved. issn 2327-2228. published articles represent opinions of the authors and do not necessarily reflect the official policy of the rhode island Medical society, unless clearly specified. advertisements do not im-ply sponsorship or endorsement by the rhode island Medical society.
advertisers contact: sarah stevens, ri Medical society, 401-331-3207, fax 401-751-8050, [email protected].
J u l Y 2 0 1 6
V O L U M E 9 9 • N U M B E R 7
Rhode Island Medical SocietyR I Med J (2013)2327-222899 7 2016July 1
© CopYriGhT JanUarY 2013, rhode isLand
MediCaL soCieTY, aLL riGhTs reserVed.
With the right tools, you can domore than insure against risk.
You can avoid it.
At Coverys, we do more than insure against risk. We combine medical
professional liability insurance with industry-leading business intelligence,
education and risk management tools to increase patient safety and help improve
outcomes for policyholders. So you can move from risk-averse to risk-prevention.
To learn how Coverys uses business intelligence to improve clinical, operational
& financial outcomes, call (844) 894-0686 or visit ThinkCoverys.com today.
ProSelect Insurance Company 800.225.6168 www.coverys.com
coMMENTary
7
8
EN
The Misperceived Curmudgeon Joseph h. FriedMan, Md
older colleague recently
who mentioned that
he was a fellow when I
was a medical intern at
the same hospital. He
worked with Dr. B., a very
famous, but no so well
liked, neurologist. In fact,
Dr. B. was usually consid-
ered the most unpleasant
neurologist on earth. Of
course, to my colleague, he was a pleas-
ant, very supportive person underneath
the crusty façade, although my friend
was well aware of the professor’s rep-
utation. I don’t think I hear about cur-
mudgeons nearly as much as I did during
training. I don’t know if this represents
a change, brought about by limited
work hours, women making up half the
classes in medical school, the realization
that a military attitude is out of date,
or, worrisome to me, that I’m possibly
one of these crusty old troglodytes so
no one says anything in my presence.
“Yes,” he said, “he was often very
nasty to the residents, but, to be fair, also
to the attendings. However, if someone
was in trouble, he was always willing
to help and he tried to be supportive.”
I countered with my own experience,
limited to a single teaching confer-
ence. As a medical intern, I knew I
was going into neurology, and that I’d
be at a different program than where
I was a medical intern. Every Satur-
day, Dr. B. had his famous, and highly
I w a s t a l k i n g t o a n regarded “Phenomenol-
ogy Rounds.” What could
excite a budding neu-
rologist more than a
conference focused on
exhibiting the arcane
abnormalities of the neu-
rologically afflicted? So,
after I completed a Friday
night on call early enough
to attend the Saturday
morning conference, I
did. What I observed is still embedded in
my memory, although not the phenom-
enology or the teaching points. After
the first patient was presented, Dr. B., a
man of about 60, looked at the audience
of about 20 doctors, and the resident,
gave a clear indication of having had his
time wasted, and asked, “Why did you
bring her?” Although I was an intern, it
seemed clear that he thought the patient
a “crock” who was simply crazy, and
not only wasting his and all the other
doctors’ time, but that the resident was
a fool for giving credence to her symp-
toms. The patient was clearly offended.
He didn’t care.
The second patient experience was
even more catastrophic. He was a
German-born Jewish man with the
tattooed numbers from a concentra-
tion camp on one arm. I do not recall
his symptoms, nor do I recall how Dr.
B treated him, but I certainly recall
the patient’s response. “I haven’t been
treated this badly since I left the camp
34 years ago. You should be ashamed.”
Even in New York City this is a stun-
ning accusation. When I mentioned this
to my colleague, he nodded and admit-
ted that, while the second case was quite
extreme, even by Dr. B’s standards, it
was believable.
My colleague then mentioned that
he also worked with the Neurology
Department chair, Dr. M. I noted that
Dr. M, from my very few and brief inter-
actions, seemed to have been cut from
the same mold. Shortly after I started
working as an attending, in RI, I called
Dr. M. about a case that was in his area
of expertise. He didn’t know me, and,
although he took the call, his level of
interest was non-existent. “Never heard
of this.” No advice. No sympathy or
encouragement from the world famous
Dr. M. to the neophyte. Two years later
I was first author on a paper in JAMA,
describing the clinical syndrome, no
thanks to him. On another occasion he
joined a small group conversation I was
in at a research investigators’ meeting,
and stunningly ignored the women who
were in the group. It was as if he had
special glasses that produced negative
hallucinations, even after I introduced
the female neurologists.
It is difficult for me to imagine com-
pensatory behaviors that might offset
these Paleolithic behaviors. Can one
justify such behaviors by saying, “Oh,
that’s just his gruff exterior. Inside he’s
really a softie.” I doubt it.
One can never know how one is truly
perceived by others, but we certainly
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 7R h o d e I s l a n d m e d I c a l j o u R n a l
coMMENTary
get some inkling. A transformative
experience for me came many years,
unfortunately, into my attending career.
I was home and answered a page from
a medical house officer about a patient
with a neurological problem. I thought
the call irrelevant and a waste of my
time, but, perhaps more importantly, an
invasion of my privacy and time, which
was unwarranted, because the problem
could easily have been handled without
my input. I didn’t yell at the poor resi-
dent but I was cool and unsympathetic,
clearly indicating my displeasure. My
daughter, then a medical student, was
visiting and heard my end of the con-
versation. “Dad, you were terrible. If I
was on the other end of the phone, I’d
probably be crying.” I certainly have
tried to always be nice to anyone who
calls or pages me. I always think that my
daughter could be on the other end of
the phone. I take solace in having heard
from one of my neurology colleagues in
Florida, with whom I never worked, that
long before this episode, her husband,
then a fellow in a medical discipline at
Rhode Island Hospital, once paged me
about a case of his, and was so impressed
by my demeanor that he still talks about
how nice I was.
I hope I’m not perceived as one of
those, “Gruff on the outside, soft on the
inside” sort of old person. I know that
I do not broadcast a “warm and fuzzy”
personality. I don’t smile a lot. I hope
that I’m nice, supportive, friendly to
those I know. At least I think about it.
But the point of this article is not that
we, as physicians, need to be warm and
open, although that would be nice, but
that we do need to not be the opposite.
We do not burnish our reputations by
cultivating an aura of unapproachability
based on fear of humiliation. Fear is not
respect. It is not necessarily a good thing
that, as an older doctor, you can look
back and say, “Dr. X made me think.
I’d never ask him a question unless I’d
researched it in advance so he wouldn’t
make me feel like an idiot. I learned not
to waste his time.” v
Author
Joseph H. Friedman, MD, is Editor-in-chief
of the Rhode Island Medical Journal,
Professor and the Chief of the Division
of Movement Disorders, Department of
Neurology at the Alpert Medical School of
Brown University, chief of Butler Hospital’s
Movement Disorders Program and first
recipient of the Stanley Aronson Chair in
Neurodegenerative Disorders.
Disclosures on website
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 8R h o d e I s l a n d m e d I c a l j o u R n a l
Exclusive Insurance Partners
80%
of Physicians Who Call Butler & Messier
Save on Their Insurance
Personal & Business Insurance
1401 Newport Avenue | Pawtucket, RIbutlerandmessier.com
Don't be the 20% who could have saved on their insurance.
Saving money and enhancing your coverage is worth a phone call to Butler & Messier
We have partnered with the Rhode Island Medical Society to offer an exclusive Concierge Program designed specifically for medical professionals. Contact Us Now For A No Obligation Second Opinion.
Call Bruce Messier at 401.728.3200 or email him at [email protected]
The Baystate Financial Medical Division (Baystate Financial - MD) was created to specifically address the
unique challenges that face physicians and medical practitioners in today’s financial environment. We
help medical practitioners, at all stages of their careers, plan for the financial future for themselves,
their practice and their families.
The Team at Baystate Financial - MD offers a variety of financial planning and management
services specifically geared to the medical professional and can custom tailor a plan
to meet your individual needs.
For more information please contact Robin Lovely, MBA, CFP®, CDFA
Financial Services Representative 401 Wampanoag Trail Suite 100
East Providence, RI 02915 401-432-8826
Metropolitan Life Insurance Company New York, NY 10166 (MLIC). MLIC markets as Baystate Financial. Securities products and investment advisory services are offered through MetLife Securities, Inc. (MSI) (member FINRA/SIPC), and a registered investment adviser. MLIC & MSI are MetLife companies and are unaffiliated with PIAM and the Massachusetts Medical Society.
L0516466851[exp1216][RI]
Successfully navigate through your many financial options
B AY S TAT E F I N A N C I A L . C O M
riMJ arouNd ThE world
Wherever your travels take you, be sure to check the latest edition of RIMJ on your mobile device and send us a photo: [email protected].
roME, iTaly
paula coro, rN, a nurse in the post anesthesia
Care Unit (paCU) at Women & infants hospital,
paused to view riMJ while visiting rome.
The dramatic Fontana di Trevi dates from 1732 and
features statues of neptune in the center, abundance
on the left, and health (or hygeia) on the right.
hygieia, is the daughter of asclepius, god of medicine,
and is the goddess/personification of health and
cleanliness, or hygiene. hygieia has been depicted
in the ri Medical society seal for more than a century,
and is carved over the entrance of riMs’ former
Francis street headquarters, built in 1912.
The imposing Arco di Constantino spans the Via
Triumphalis and is situated between the Colosseum,
seen on the right, and the palatine hill. at 70 feet in
height, it is the largest of the roman triumphal arches,
and was dedicated in 315 Ce to honor the victory of
Constantine i at the Battle of the Milvian Bridge. By
defeating Maxentius, Constantine i became the sole
ruler of the roman empire. attributing his victory to
the Christian god, Constantine i subsequently legalized
Christianity throughout the empire the following year.
We are read everywhere
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 11R h o d e I s l a n d m e d I c a l j o u R n a l
coNTriBuTioN
12
14
EN
Willingness of Rhode Island Dentists to Provide Limited Preventive Primary CareCaTherine TUYeT Mai danG, Ba; renee r. shieLd, phd; donaLd B. Giddon, dMd, phd
aBsTracT In response to the shortage of primary care physicians and the need for greater intercollaboration among health professionals, dentists with sufficient medical and sur-gical training are an untapped resource to provide lim-ited preventive primary care (LPPC), such as chairside screening for chronic diseases. The objective of this study was to determine attitudes of Rhode Island dentists to-ward becoming more involved in the overall health of their patients. Using a 5-point scale (1 being highest), a pretested sur-vey was administered to 92 respondent RI dentists who were asked to indicate their willingness to become more involved in patients’ overall health, and undergo addi-tional training to provide LPPC. Their moderate level of willingness was offset by great concern for liability, with older dentists being significantly more willing to assume these additional responsibilities than younger dentists (p< .05). Rank order of designation of oral health pro-viders among dentist, dental physician, oral physician, odontologist, stomatologist, and stomiatrist was still dentist first, but with no significant difference between the mean ranks of dentist and oral physician.
KEywords: health care delivery, primary care, terminology, oral health, oral physician
iNTroducTioN aNd BacKgrouNd
Sixty-five million Americans live in areas with a shortage of primary care physicians.1 The 2013 deficit of 8,200 primary care physicians will grow by 2025 to an estimated shortage of 12,500-31,000.2 Despite these projections, medical schools are currently training only one-half the primary care physi-cians needed, with the majority of physician assistants and nurse practitioners choosing better paying, less demanding specialty positions other than primary care.3 In 2013 there were approximately 195,000 practicing, licensed dentists in the United States4 who were already sufficiently trained in medicine and dental surgery to be considered de facto oral physicians.5 Because patients see their dentists more often than their primary care physicians,6 there is an opportu-nity for dentists to provide limited preventive primary care, including chairside screening for chronic diseases such as diabetes, hypertension, hypercholesterolemia, osteoporosis,
domestic/child/substance abuse, and developmental disor-ders; and counseling for obesity and substance abuse; while monitoring patient compliance with prescribed and over-the- counter medications.
Moreover, the recognition of the reciprocal relation between oral and systemic health and disease, together with the increased need for more intercollaboration among health professionals, has fostered the reaffirmation that the mouth is part of the body.7 As such it is essential for survival, socialization, and self-actualization.8, 9 Given some of the bases for these expanded roles, the insistence on continued use of the term “dentist” is too restrictive, referring to only the structure and function of the teeth, and does not connote what dentists can and should do as part of the health care team. Despite the intransigence of dentists who prefer their unaccountable business model, the term oral physician is being considered to better indicate their actual and potential scope of practice.
oBJEcTivE
Based on the need and opportunity for dentists to become more involved in the overall health care of their patients,10 the objective of this study was to determine the willingness of dentists in Rhode Island to undertake chairside screening for chronic disease.
METhod
A 48-question plus demographics survey was developed to determine the attitudes of Rhode Island dentists toward being involved in LPPC. Following pretesting with Cali-fornia dentists, the questionnaires were emailed to a conve-nience sample of Rhode Island dentists. A one-to-five scale was used to indicate the importance of medical screening in the dental office, confidence in medical knowledge, will-ingness to be involved in the overall health of patients, and concern with liability and related insurance issues. Respon-dents were also asked to rank order their preferred titles for oral health professionals: dentist, dental physician, oral physician, odontologist, stomatologist, and stomiatrist.
rEsulTs
Of 520 surveys distributed, 92 (17.7%) were returned by dentists, of whom 75% were male and 25% female, with a
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 R h o d e I s l a n d m e d I c a l j o u R n a l 12
coNTriBuTioN
median age of 45 years. Based on the mean ± standard devia-tion response on the scale of 1– 5, respondents acknowledged the relatively great importance of recognizing underlying health issues (mean=1.77±.41); were moderately confident of their medical knowledge (mean=2.70±0.96); were at slightly less than the midpoint of the scale for willingness to be involved with medical screening in a dental setting (mean=2.53 ±0.67); and, as expected, were quite concerned about liability and related issues (mean=1.44±0.49, p<.01).
Although there were no gender differences, there were sig-nificant differences between older (>59 years) and younger (<50 years) dentists in willingness to perform selected tasks (see Table 1), including obtaining vital signs, sending body fluids for lab analysis, and discussing lab and physical find-ings with patients; as well as a marginally significant greater willingness of older dentists than younger dentists to obtain additional training to provide these services (p=.06). Except for concern with liability for medical screening or conversely for not recognizing underlying medical risks during dental treatment, there were small but significant negative correla-tions between age and specific tasks which they were will-ing to undertake as part of being more involved in the overall health of their patients; that is, the older they were, the less negative they were about engaging in non-dental procedures which could add to patient welfare. Relative to the proposed change in nomenclature from dentist to oral physician to more accurately represent what dentists can and should do, the designation “dentist” was still preferred, receiving the highest rank order among the six possible designations, but with no significant mean rank difference between “dentist” and “oral physician.” (Table 1)
discussioN
The results of this study are consistent with those of several other studies looking at the acceptance of expanded roles for dentists by physicians and patients. From a political and business point of view, most dentists prefer the status quo, in which they are unaccountable for appropriateness and quality of their treatment.11 However, much change is expected with the advent of the Affordable Care Act, and
in another study it was found that dentists recognized the importance of medical screening and were even willing to consider providing it in their practices.12 Patients see no problem regardless of whether dentists were called oral phy-sicians or dentists.13 Similarly, patients were also willing to have medical screening for chronic disease done by dentists and to pay $20 for it.14 In a study of physicians, they were found to have no objection to dentists doing limited preven-tive primary care screening in a dental setting.15 The obser-vation that the older Rhode Island dentists are more willing than younger dentists to become involved may reflect their greater personal and professional security than the younger dentists, who may well be paying off debts associated with their expensive training.
coNclusioN
Although most dentists preferred the status quo, they acknowledged the importance of medical screening as well as its potential liabilities. Older dentists expressed less concern than younger dentists about additional responsibilities with more willingness to receive additional training. Moderate support for the term oral physician was also noted.
AcknowledgmentThanks are due to Dr. Shirley Freedman, Clinical Associate Profes-sor, Department of Surgery, The Warren Alpert Medical School of Brown University, who introduced the authors to the Rhode Island Dental Association and played an integral role in helping collect responses from Rhode Island dentists.
References1. Bodenheimer T, Pham HH. Primary care: current problems and
proposed solutions. Health Aff (Millwood). 2010;29(5):799-805.2. IHS Inc. The complexities of physician supply and demand: Pro-
jections from 2013 to 2025 - final report. https://www.aamc.org/download/426242/data/ihsreportdownload.pdf. Accessed January 19, 2016.
3. Bazemore A, Phillips R, Phillips RI. The changing landscape of primary care: Practical playbook: Duke University, 2015.
4. Munson B, Vujicic M. Supply of dentists in the United States is likely to grow. Health Policy Institute Research Brief. http://www.ada.org/~/media/ADA/Science%20and%20Research/
≤50 Years, n=32 ≥59 Years, n=25 p value for differences
between age groups
spearman rho p value for
spearman rhoMean ± standard deviation
Mean ± standard deviation
obtain vital signs 3.09 ± 1.23 2.38 ± 1.10 =0.026 -0.234 0.027
send body fluids to the lab for analysis 3.84 ± 1.17 3.0 ± 1.10 ≤0.005 -0.317 0.002
Counsel for obesity and substance abuse 3.31 ± 1.09 2.48 ± 1.01 ≤0.005 -0.293 0.006
discuss physical and lab findings with patients 2.09 ± 1.06 1.42 ± 0.58 ≤0.005 -0.282 0.007
obtain additional training 2.34± 1.31 1.82 ± 0.66 =.060 -0.122 0.261
TABLE 1. age differences in Willingness to perform selected procedures
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 R h o d e I s l a n d m e d I c a l j o u R n a l 13
coNTriBuTioN
HPI/Files/HPIBrief_1014_1.ashx. Accessed January 26, 2016.5. Giddon DB. Why dentists should be called oral physicians now.
J Dent Educ. 2006;70(2):111-4.6. Strauss SM, Alfano MC, Shelley D, Fulmer T. Identifying un-
addressed systemic health conditions at dental visits: patients who visited dental practices but not general health care provid-ers in 2008. Am J Public Health. 2012;102(2):253-5.
7. Swann B. The oral physician: an educational model and its potential to impact overall health. J Calif Dent Assoc. 2014;42(10):717-8.
8. Giddon DB. Mental-dental interface: Window to the psyche and soma. Perspect Biol Med. 1999;43(1):84-97.
9. Maslow A. A theory of human motivation. PsychologR. 1943;50:370-96.
10. Giddon DB, Swann B, Donoff RB, Hertzman-Miller R. Dentists as oral physicians: the overlooked primary health care resource. J Prim Prev. 2013;34(4):279-91.
11. Giddon DB. Should dentists become ‘oral physicians’? J Am Dent Assoc. 2004;135:438-49.
12. Greenberg BL, Glick M, Frantsve-Hawley J, Kantor ML. Den-tists’ attitudes toward chairside screening for medical condi-tions. J Am Dent Assoc. 2010;141(1):52-62.
13. Cooper J. Determination of Attitudes and Knowledge about Patient Perceptions of Expanded Roles and Responsibilities for Dentists as “Oral Physicians”. Boston: Harvard School of Den-tal Medicine, 2009.
14. Greenberg BL, Kantor ML, Jiang SS, Glick M. Patients’ attitudes toward screening for medical conditions in a dental setting. J Public Health Dent. 2012;72(1):28-35.
15. Greenberg BL, Kantor ML, Jiang SS, Glick M. Physicians’ atti-tudes toward medical screening in a dental setting. J Dent Res. 2010;89(Spec Iss B)(abstract number 4931 (www.dentalresearch.org).
DisclaimerThe views expressed herein are those of the authors and do not necessarily reflect the views of Brown University or Harvard University.
Authors Catherine Tuyet Mai Dang, BA, Predoctoral Dental Student,
Class of 2020, University of Pennsylvania School of Dental Medicine.
Renee R. Shield, PhD, Clinical Professor of Health Services, Policy and Practice, Brown University.
Donald B. Giddon, DMD, PhD, Professor of Developmental Biology Emeritus, Harvard School of Dental Medicine; Clinical Professor Emeritus of Behavioral and Social Sciences, Brown University.
CorrespondenceDonald B. Giddon, DMD, PhD277 Linden Street, Suite 208Wellesley, MA 02482781-235-2995Fax [email protected]
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 R h o d e I s l a n d m e d I c a l j o u R n a l 14
coNTriBuTioN
15
18
EN
Geriatric Issues in Older Dialysis PatientsManoJ BhaTTarai, Md
aBsTracT Geriatric syndrome is common among older patients on dialysis. Basic knowledge about its prevalence and man-agement is crucial for nephrologists to provide standard patient care. In busy clinical settings, up-to-date and holistic medical care can be delivered to elderly dialy-sis patients by collaboration of nephrology and geriat-rics teams, or in part by training nephrology fellows the basics of geriatrics.
KEywords: geriatrics, nephrology, palliative care, dialysis
iNTroducTioN
Approximately 46.2 million people (14.5 percent of the total population) aged 65 and older lived in the United States in 2014 [1]. According to US census projections, this number is expected to follow an upward trajectory in the coming years. The likely consequence of this trend is that the prevalence of Chronic Kidney Disease (CKD) among the Medicare popula-tion – which was 10.4 percent in the 2012 report, will surge [2].
The United States Renal Data System, 2014 Annual Data Report, stated that close to half of all dialysis patients are 65 years and older. About 17 to 45 percent of patients accepted for dialysis are older than 75 years [3]. Functional decline, cognitive impairment, depression, and malnutrition are common features of this dialysis population [4].
This article reviews basic geriatrics principles as applied to kidney disease care by briefly describing the major geriat-ric components in patients with kidney disease. These core components are frailty, functional status, cognition, falls, palliative care, polypharmacy, and depression. Each of these is discussed below.
frailTy
The prevalence of frailty can be as high as 73% among patients initiating dialysis and is an independent and strong predictor of mortality and multiple hospitalizations [5]. Dialysis initiation among nursing home residents has been shown to accelerate the progression towards loss of depen-dence in daily activities of living [6]. A systematic com-prehensive geriatric assessment (CGA) provides the best
estimate of a patient’s physiologic reserve, estimating future decline and vulnerability, and even residual life expectancy.
Frailty screening tests can be helpful in selecting patients who may benefit from dialysis treatment, or exclude vulner-able patients at risk of adverse health outcomes. The infor-mation derived from a CGA may help to determine dialysis outcomes and help trigger shared decision-making conversa-tions with the patient and family.
Conservative care has become the standard alternative for dialysis in elderly frail patients with advanced kidney dis-ease to improve the quality of life [7]. The single most effec-tive intervention to improve functionality and quality of life in these frail patients is exercise. Familiarity with Medi-care programs such as Program of All-inclusive Care for the Elderly (PACE) and Acute Care for Elders (ACE) can help frail elderly adults in improving and maintaining functioning.
PACE is an outpatient model in which an interdisciplin-ary team delivers primary care to community-dwelling older adults. ACE, on the other hand, is a model of care targeted to acutely ill hospitalized patients to prevent functional decline or help improve independence if the patient has already declined. Since PACE and ACE can help frail elders maintain functioning within their communities at a low cost, thus likelihood of institutionalization is minimized.
fuNcTioNal sTaTus
Activities of daily living (ADL) and instrumental activities of daily living (IADL) scores generated from a CGA pro-vide prognostic information in older adults. Studies have shown an association of ADLs to survival of elderly dialysis patients [8]. In a group of nursing home residents who under-went dialysis between June 1998 and October 2000, only 13 percent were able to maintain functional status to predialy-sis levels; 58 percent of these patients died over the next 12 months of follow-up [6].
Similar results were recorded in Jassal et al [2009], a sin-gle-center study of people who were 80 years or older [9]. At the onset, 78 percent of the participants were independent as measured by their ADL scores. After starting dialysis over a one-year period, the independence level of these individu-als dropped to 23 percent. It is therefore important to iden-tify those patients who could benefit from physical therapy in a timely manner and make the appropriate referrals to minimize these precipitous declines.
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 R h o d e I s l a n d m e d I c a l j o u R n a l 15
coNTriBuTioN
There are no well-designed studies available to compare functional decline in younger patients initiating dialysis.
cogNiTioN
CKD is an independent and significant risk factor for cog-nitive impairment [10]. Cognitive impairment worsens as kidney function declines. The prevalence of cognitive impairment in dialysis patients is at least two times higher than that of age-matched controls.
The pathophysiologic mechanism postulated for cognitive impairment is vascular injury and direct neuronal toxicity of uremic toxins. Both the kidneys and the brain are low resis-tance end organs with a high volume of blood flow with low susceptibility to vascular damage. Thus, dementia related to vascular causes is more likely to be present than Alzhei-mer’s disease in a dialysis population.
Understanding the basics of pathophysiology involved helps minimize the future risk. Not all the tests that are routinely used in geriatric assessment are designed to detect mild cognitive impairment related to vascular damage in dialysis patients. Relatively quick tests such as Mini-Cog (3 words recall and clock drawing) may be offered for quick screening in busy practice. When prompted, more reliable Montreal Cognitive Assessment (MOCA), which has good sensitivity and specificity for executive function, can be uti-lized [11]. If indicated, referral for neuropsychological tests is warranted.
Often times, patients’ declining cognition goes unrec-ognized even by close family members. Therefore, careful scrutiny and the recommendation of cognition tests should not be delayed. The practitioner should be alert to warn-ing signs, such as when a patient is demonstrating new behavioral changes; non-compliance with medications and dialysis procedure; and is repeatedly asking the same ques-tions. Poor hearing should be ruled out before making this determination, however.
falls
The incidence of falls in elderly non-dialysis patients aged 75 years and above is 0.32 falls per patient-year [12]. This num-ber increases to 1.60 per patient-year on initiation of dialysis, thus putting dialysis patients at four times higher risk of falls compared to the age-matched non-dialysis population [13].
In a study of hemodialysis patients with falls who were followed for two years, there was a two-fold increase in the number and duration of hospitalizations; a 3.5 fold increase in risk of nursing home admission, and a 2.13 fold increased risk of mortality [14]. When a hip fracture occurs, these patients are at a four times higher risk of hip fracture and a two-fold higher risk of 1-yr mortality.
Given these dire and preventable consequences, basic knowledge of screening dialysis patients at risk of fall is everyone’s responsibility. Asking about a history of falls and
conducting simple tests for gait and balance such as the Get Up and Go test and the Functional Reach test can identify most older adults who are susceptible to fall hazards. Such adults can benefit from timely referral for comprehensive geriatric evaluation.
hospicE aNd palliaTivE carE
The majority of nephrologists do not feel they are suffi-ciently well-trained to make end-of-life treatment decisions [15]. Discussions on the patient’s goals of care and advanced care preferences are a crucial part of the older adult encoun-ter; this is even more crucial in frail older adults with multi-ple comorbidities in imminent need of dialysis who may not do well on dialysis.
Respecting patients’ values and preferences while keeping them comfortable and providing spiritual, psychosocial, and practical support both to patients and their family caregiv-ers in such situations are key tenets of the palliative care approach. Helpful tools such as ePrognosis can estimate life expectancy and weigh the risks and benefits of proposed inter-ventions to establish appropriate goals in a vulnerable patient.
Patients aged 75 and older who have CKD stage 5 with advanced neurodegenerative disease, high comorbidity scores (modified Charlson Comorbidity Index score of 8 or greater), significantly impaired functional status (Kar-nofsky Performance Status Scale score of less than 40), or severe malnutrition (serum albumin level less than 2.5 g/dL) do poorly with dialysis [16]. In these patients, physicians should recommend a time-limited trial of dialysis treat-ment. Dialysis can also be offered to address specific patient goals, such as living long enough to see a grandchild’s birth, or a child’s graduation. However, if such patients decide to continue treatment, the physician has little or no support yet for withholding dialysis. In this scenario, the physician should continue to review the treatment tolerance with patients and their families at specified intervals. Better understanding of the dialysis burdens and benefits with a trial of dialysis enables patients and their families to make informed decisions. Guidelines for shared decision-making in the appropriate initiation and withdrawal from dialysis are available [16].
polypharMacy
Dialysis patients take 10-12 daily prescribed and over-the-counter medications on average. It is necessary to understand physiologic changes that occur with aging, such as decreased hepatic and renal function and altered fat distribution, which can result in inappropriately high serum drug levels even with appropriate equivalent doses for younger indi-viduals. This basic understanding can help make treatment safe, convenient, and effective. Helpful tools such as Screen-ing Tool of Older Persons’ potentially inappropriate Pre-scriptions (STOPP), Screening Tool to Alert doctors to Right
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 R h o d e I s l a n d m e d I c a l j o u R n a l 16
coNTriBuTioN
Treatment (START) and the Beers criteria list of medications can be of significant value in guiding treatment decisions.
dEprEssioN
Depression affects dialysis patients of all ages. Studies com-paring its prevalence, course and treatment outcome to younger patients is lacking in older dialysis patients. How-ever, given that the majority of dialysis patients are older than 65, it is an indication that older adults are at higher risk of developing depressive symptoms, which is usually due to high symptom burden. The prevalence of depression in CKD stage 5 in some reports is as high as 39 percent, although this number varies based on the method used to diagnose depression. Depression in CKD is further associated with increased mortality, lower treatment compliance, increased health-care utilization, and lower self-rated quality of life. Depression in dialysis patients may be a result of poor dialy-sis tolerance, inadequate pain control, and other unfavorable social situations. Frequent assessment of dialysis patients for depression is mandated. The Beck Depression Inventory for depression is a validated tool in cancer patients and can be used in dialysis patients [17]. Treatments for depression exist and can be extremely effective.
discussioN
The treatment decisions in elderly patients with advanced kidney disease are complicated by the interaction between various treatment domains. In order to improve medical care for elderly patients with kidney disease in general, collabora-tive care between nephrologists and geriatricians is needed.
However, an alarming shortage of geriatricians exists across the country. To further complicate matters, the num-ber of medical graduates interested in pursuing nephrology training is decreasing. The limited resources create a formi-dable barrier for physicians to provide the best medical care possible for these patients.
One solution to this problem is to integrate geriatrics and palliative care into nephrology training. This approach will not only minimize the demand for collaborative care, it will also provide added skills to nephrologists that are necessary to provide state-of-the-art care to these vulnerable individuals. While the ultimate goal of this approach is not to produce geriatric nephrologists, it instead aims to train graduating nephrologists to recognize the risk that patient frailty poses to the health and overall well-being of a patient.
Notwithstanding that nephrologists are generally incred-ibly busy physicians, the development of a focused exam tailored to specific patient symptoms and needs, to conduct a quick assessment within a few minutes, is needed. This assessment can equip nephrologists to make informed deci-sions about whether to transfer a patient to a geriatrician for comprehensive geriatric assessments (CGA) by which a mul-tidisciplinary team diagnoses and treats medical, functional
and psychosocial issues in a coordinated and integrated plan for an elderly patient. For an extremely busy nephrology practice, this model of co-management can help identify patients at risk and refer them for CGA.
Many nephrology fellowship programs in the country have recognized the need to train their fellows in geriatrics and palliative care as a part of holistic nephrology care, but most of them are able to do the bare minimum because of lim-ited resources. Professional societies, such as the American Society of Nephrology, the American Geriatrics Society, and the National Kidney Foundation have taken steps to address the issue of inadequate geriatrics skills in the nephrology workforce.
Medical schools have started integrating geriatrics into medical school training courses. Similarly, nephrology asso-ciations have been incentivizing their residents and fellows to travel to national conferences; they are also providing research scholarships for their young physicians. Nonethe-less, these positive steps remain inadequate given the wid-ening gap between the increasing need and demand and the static number of nephrologists. Since the American Board of Internal Medicine Nephrology certification exam does not include geriatrics content and only fewer than 2 percent of ethics and palliative care content [5], this issue remains unsolved at the present time.
Important discoveries and refinements have been made as a result of better awareness of the intricacies involved in the association of aging and kidney disease. It will be illumi-nating to see nephrology trainees develop into professionals who are able to handle the challenges of caring for an aging population with kidney disease through enhanced exposure to geriatrics content and pertinent clinical experiences. The need to prepare all nephrology trainees to successfully man-age the care of older adults can be addressed by a singular commitment of education leaders to incorporate relevant geriatrics content as well as clinical experiences within all nephrology courses.
Acknowledgment
The author would like to thank Prof. Lance D. Dworkin and Renee
R. Shield, PhD, for reviewing the manuscript.
References1. http://www.census.gov/newsroom/pressreleases/2015/cb15-
113.html. Accessed on May 9, 2016.2. U.S. Renal Data System. USRDS 2013 Annual Data Report: At-
las of Chronic Kidney Disease and End-Stage Renal Disease in the United States. National Institutes of Health, National Insti-tute of Diabetes and Digestive and Kidney Diseases; Bethesda, MD, USA: 2013.
3. ERA-EDTA: The 2013 ERA-EDTA Annual Report, 2013.4. Parlevliet JL, Buurman BM, Pannekeet MM, Boeschoten EM, ten
Brinke L, Hamaker ME, van Munster BC, de Rooij SE: System-atic comprehensive geriatric assessment in elderly patients on chronic dialysis: A cross-sectional comparative and feasibility study. BMC Nephrol 13: 30, 2012.
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 R h o d e I s l a n d m e d I c a l j o u R n a l 17
coNTriBuTioN
5. Bao Y, Dalrymple L, Chertow GM, Kaysen GA, Johansen KL. Frailty, dialysis initiation, and mortality in end-stage renal dis-ease. Arch Internal Med 172: 1071-1077, 2012.
6. Kurella Tamura M, Covinsky KE, Chertow GM, Yaffe K, Landefeld CS, McCulloch CE. Functional status of elder-ly adults before and after initiation of dialysis. N Engl J Med. 2009;361:1539–1547.
7. Carson RC, Juszczak M, Davenport A, Burns A: Is maximum conservative management an equivalent treatment option to dialysis for elderly patients with significant comorbid disease? Clin J Am Soc Nephrol 4: 1611–1619, 2009.
8. Genestier S, Meyer N, Chantrel F, Alenabi F, Brignon P, Maaz M, Muller S, Faller B: Prognostic survival factors in elderly renal failure patients treated with peritoneal dialysis: A nine-year ret-rospective study. Perit Dial Int 30: 218–226, 2010.
9. Jassal SV, Chiu E, Hladunewich M. Loss of independence in pa-tients starting dialysis at 80 years of age or older. N Engl J Med. 2009;361:1612–1613.
10. Etgen T, Chonchol M, Förstl H et al. Chronic kidney disease and cognitive impairment: a systematic review and meta-analysis. Am J Nephrol 2012; 35: 474–482.
11. Tiffin-Richards FE, Costa AS, Holschbach B, Frank RD, Vassili-adou A, Kru¨ger T, Kuckuck K, Gross T, Eitner F, Floege J, Schulz JB, Reetz K: The Montreal Cognitive Assessment (MoCA) - a sen-sitive screening instrument for detecting cognitive impairment in chronic hemodialysis patients. PLoS One 9: e106700, 2014.
12. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med 1988; 319: 1701–1707.
13. Cook WL, Tomlinson G, Donaldson M, Markowitz SN, Naglie G, Sobolev B, Jassal SV: Falls and fall-related injuries in older dialysis patients: Clin J Am Soc Nephrol 1:1197–1204, 2006.
14. Abdel-Rahman EM, Yan G, Turgut F, Balogun RA: Long-term morbidity and mortality related to falls in hemodialysis pa-tients: Role of age and gender - a pilot study. Nephron Clin Pract 118: c278–c284, 2011.
15. Davison SN, Jhangri GS, Holley JL, Moss AH: Nephrologists’ re-ported preparedness for end-of-life decision-making. Clin J Am Soc Nephrol 1:1256–1262, 2006.
16. Renal Physicians Association: Clinical Practice Guideline. Shared Decision-Making in the Appropriate Initiation of and With-drawal from Dialysis, 2nd edition. Rockville, MD: RPA, 2010.
17. Wildiers H, Heeren P, Puts M, Topinkova E, Janssen-Heijnen ML, Extermann M, Falandry C, Artz A, Brain E, Colloca G, Fla-maing J, Karnakis T, Kenis C, Audisio RA, Mohile S, Repetto L, Van Leeuwen B, Milisen K, Hurria A: International Society of Geriatric Oncology consensus on geriatric assessment in older patients with cancer. J Clin Oncol 32: 2595–2603, 2014.
18. http://www.abim.org/~/media/ABIM%20Public/Files/pdf/ex-am-blueprints/certification/nephrology.pdf. Accessed on May 3, 2016.
AuthorManoj Bhattarai, MD, Geriatrics Fellow, Division of Geriatrics,
Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI.
CorrespondenceManoj Bhattarai, MDGeriatrics Fellow, Division of GeriatricsRhode Island Hospital593 Eddy Street Providence, RI [email protected]
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 R h o d e I s l a n d m e d I c a l j o u R n a l 18
coNTriBuTioN
19
21
EN
Influence of Medical Student Debt on the Decision to Pursue Careers in Primary CareJoseph a. GiL, Md; GreGorY r. WarYasz, Md; doroThY LiU, Bs; aLan h. danieLs, Md
aBsTracT
purposE: To determine if medical student debt has an effect on medical student specialty choice.
METhods: A cross-sectional survey was distributed to students at 12 medical schools across the United States to assess the effect of debt on specialty choice.
rEsulTs: In total, 415 students responded to the survey; 98 medical students reported that they were pursuing a primary care residency (PCR) and 250 reported that they were pursing a non-primary care residency (NPCR). There was no significant difference in average student loan debt anticipated by medical students pursing PCR and NPCR ($142,217 vs $150,784; P>0.46). Medical students pur-suing a PCR reported lower estimated salaries on aver-age than medical students pursuing NPCR ($137,711 vs $241,804; p<0.01). Of the surveyed students, 62% of stu-dents who are pursuing PCR and 77% of the students who are pursuing a NPCR would not have pursued medicine as a career if residents were responsible for paying tuition.
coNclusioN: This study revealed no significant differ-ence between the student debt of medical students pur-suing PCR compared to those who are pursuing a NPCR. However, a large majority of medical students would not pursue a career in medicine if faced with the responsibility of paying tuition for residency.
KEywords: medical student debt, residency tuition, primary care salaries, careers
iNTroducTioN
The cost of medical school attendance and the level med-ical student debt has substantially increased over the last decade with individuals’ debt levels sometimes approaching $350,000.1–4According to the Association of American Med-ical Colleges (AAMC), medical school tuition continues to increase annually.4–6 A major concern is that the increas-ing levels of medical student debt are contributing to the decline in medical student interest in pursuing a primary care residency due to the relatively lower reimbursement of primary care physicians compared to subspecialists. 2,7 Previ-ous investigations have demonstrated that medical student debt has a variable influence on career choice; some studies
suggest that this influence plays a major role in career choice while other studies suggest that debt has no influence.8–14
Although the impact of medical student debt on career choice is not clear, the rate of medical student debt growth is unsustainable.1 The purpose of this study was to assess the influence of medical student debt on career choice. Our hypothesis is that medical student debt has a strong influence on career choice. Additionally, in 2014, a report from the Insti-tute of Medicine Committee on the Governance and Financ-ing of Graduate Medical Education considered options for potential funding sources for Graduate Medical Education.15 One source they considered was to require residents to pay tuition. Given our hypothesized influence of medical school debt on career choice, we hypothesize that if residents would be required to pay for residency, a career in the medicine would be less desirable.
METhods
After obtaining approval from our institutional review board, we designed and distributed a cross-sectional survey for allopathic medical schools in the United States. Medical students were asked if they planned a career in a primary care or non-primary care specialty, what their anticipated salary was within their first 5 years of practice, and if they would have pursued medicine as a career if residents were required to pay tuition.
The survey was initially piloted with six PGY-1 residents in the Brown University orthopaedic department to assess survey comprehension. The survey was then distributed to the deans of student affairs in medical school in the United States requesting them to distribute the survey to their med-ical students. The survey was distributed via the REDCap (Research Electronic Data Capture) program (Vanderbilt University, Nashville, TN), which is a tool provided by the Lifespan Biostatistics Core. Study data was also collected and managed using the REDCap program. REDCap program is a secure, web-based application designed to support data cap-ture for research studies. REDCap program does not record IP addresses.
For statistical analysis, anticipated medical student debt and anticipated level of annual income were compare with a two tailed t-test with a cutoff of p< 0.05 for signifi-cance. Comparison of categorical data was performed with Chi-square analysis. Statistical analysis was performed
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 R h o d e I s l a n d m e d I c a l j o u R n a l 19
coNTriBuTioN
utilizing Microsoft Excel (Microsoft Corporation, Redmond, WA) and StatPlus: LE (AnalystSoft Inc, Walnut, CA).
rEsulTs
In total, 12 medical schools distributed the survey (n=12) with a response rate of 6.6% (n=415). When asked about career plans, 98 medical students reported that they were pursuing a primary care residency (PCR), 250 reported that they were pursing a non-primary care residency (NPCR), and 67 reported that they were undecided.
There was no significant difference in average student loan debt that was anticipated by medical students pursing PCR ($142,217) compared to medical students pursuing a NPCR ($150,784) (P>0.46). There was a significant differ-ence between the residents pursuing a PCR ($137,711) and between those pursing a NPCR ($241,804) in the estimated salary that the students anticipated on earning annually in the first 5 years of their practice (p<0.01) (Figure 1).
Overall, 62% of students who planned to pursue PCR and 77% of the students who are pursuing a NPCR would not have pursued medicine as a career if residents are required to paying tuition for post-graduate training (p<0.01) (Figure 2).
discussioN
The cost of medical school attendance and medical student debt has increased over the last decade, and according to the Association of American Medical Colleges (AAMC), medi-cal school tuition continues to increase annually. 4–6 Rising medical student debt may be contributing to the simulta-neous decline in medical student interest in pursuing a career in primary care.2 Phillips et al performed an analysis of medical student debt and its effect on intentions to pur-sue careers; it revealed that medical students from middle income families who anticipated more debt were less likely to pursue residencies in primary care.2
Schwartz et al demonstrated that in comparison to 1990, medical student interest in general internal medicine decreased in 2007, and medical students were also gradu-ating medical school with higher levels of debt.7 Grayson et al surveyed first- and fourth-year medical students to deter-mine the influence of economic factors on career choice.16 They found that medical students with higher levels of debt reported a higher value for the importance of income and anticipated to earn more than medical students with less debt. Medical students who reported a higher value for the importance of income were more likely to switch from pur-suing a primary career to a high paying non-primary care career. This switch was associated with a higher anticipated medical student debt and higher anticipated income.
Gil et al calculated the total increase in medical student debt after medical school in hypothetical cases of an ortho-paedic surgery resident and an internal medicine resident with $180,000 of debt that is a result of unsubsidized
Stafford loans which currently have a 6.8% interest rate.17 They reported that for an orthopaedic resident at a six training year program with one year of subsequent fellow-ship who chooses forbearance for all loans during residency and fellowship, the total interest accrued depends on the post-training repayment program chosen. They reported that a Standard Repayment plan will result in a total repay-ment of $383,302, representing a 113% increase in debt after medical school. Alternatively, if the resident chooses the Extended Repayment plan, this will result in a total repay-ment of $577,940, representing a 221% increase in debt after medical school. In the case of an internal medicine resident, a Standard Repayment plan will result in a total repayment of $311,284, representing a 73% increase in debt after medi-cal school, while an Extended Repayment plan will result in a total repayment of $469,355, representing a 161% increase
Figure 2. Comparison of the number of medical students who would
or would not pursue a career in medicine if residents were required to
pay tuition.
Figure 1. Comparison of anticipated medical student debt and antici-
pated annual income during the first five years of practice.
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 R h o d e I s l a n d m e d I c a l j o u R n a l 20
coNTriBuTioN
in debt after medical school. Therefore, medical students ultimately pay far more than the estimated cost of their education while lenders make a significant profit on loans.
Although medical school tuition continues to rise, medi-cal schools still face substantial financial pressure. In 2014, a report from the Institute of Medicine Committee on the Governance and Financing of Graduate Medical Education considered options for potential funding sources for Gradu-ate Medical Education.15 One source they considered was to have residents pay tuition. Of the respondents of this sur-vey, 62% of students who are pursuing PCR and 77% of the students who are pursuing a NPCR would not have pursued medicine as a career if residents were responsible for paying tuition. Therefore, if residents are required to pay for resi-dency, highly qualified students will decide against careers in medicine due to unreasonable financial pressures associated with physician training.
A substantial limitation of this is study is the low response rate despite the authors repeated attempts to recruit medical schools to assist in the goal of understanding the influence of medical student debt on career selection. Medical schools often cited policies regarding the distribution of surveys from outside of their own institutions and they noted that the AAMC Graduation Questionnaire (GQ) addressed simi-lar questions we sought to answer in our study. A significant limitation of the GQ is that it is only distributed after medi-cal students already are committed to a residency. Therefore, conclusions regarding the selection of career are significantly limited by selection and recall bias. The advantage of our survey is that it captures perceptions of medical students as they advance through their education. Therefore, it may more accurately capture the factors that influence career selection.
coNclusioN
The results of our study suggest that there is no difference between the student debt of medical students pursuing PCR compared to those who are pursuing a NPCR. However, the salary the students anticipated on earning annually in the first 5 years of their practice was significantly different between these two groups. Additionally, the majority of med-ical students would not pursue a career in medicine if faced with the additional financial burden of being responsible for paying for tuition to be in residency. Student debt appears to affect career choice in today’s medical school trainees. Efforts to minimize student debt and encourage career choice based on factors other than debt burden are needed.
References1. Greysen SR, Chen C, Mullan F. A history of medical student
debt: observations and implications for the future of medical education. Acad Med J Assoc Am Med Coll. 2011;86(7):840-845.
2. Phillips JP, Weismantel DP, Gold KJ, Schwenk TL. Medical student debt and primary care specialty intentions. Fam Med. 2010;42(9):616-622.
3. Youngclaus J, Fresne, J. Trends in Cost and Debt at U.S. Medical Schools Using a New Measure_of Medical School Cost of Atten-dance. Analysis in Brieft. 12(2) 2012. https://www.aamc.org/down-load/296002/data/aibvol12_no2.pdf. Accessed May 11, 2015.
4. Doroghazi RM, Alpert JS. A Medical Education as an Invest-ment: Financial Food for Thought. Am J Med. 2014;127(1):7-11.
5. AAMC Tuition and Student Fees Reports. https://services.aamc.org/tsfreports /select.cfm?year_of_study=2014. Accessed May 16, 2015.
6. Jolly P. Medical school tuition and young physicians’ indebted-ness. Health Aff (Millwood). 2005;24(2):527-535.
7. Schwartz MD, Durning S, Linzer M, Hauer KE. Changes in med-ical students’ views of internal medicine careers from 1990 to 2007. Arch Intern Med. 2011;171(8):744-749.
8. Bazzoli GJ. Does educational indebtedness affect physician spe-cialty choice? J Health Econ. 1985;4(1):1-19.
9. Kassebaum DG, Szenas PL. Relationship between indebtedness and the specialty choices of graduating medical students: 1993 update. Acad Med J Assoc Am Med Coll. 1993;68(12):934-937.
10. Kassebaum DG, Szenas PL. Factors influencing the specialty choices of 1993 medical school graduates. Acad Med J Assoc Am Med Coll. 1994;69(2):163-170.
11. Phillips J. Educational debt and career choice: every student matters. Fam Med. 2013;45(7):516.
12. Phillips JP, Petterson SM, Bazemore AW, Phillips RL. A Retro-spective Analysis of the Relationship Between Medical Student Debt and Primary Care Practice in the United States. Ann Fam Med. 2014;12(6):542-549.
13. Grayson MS, Newton DA, Thompson LF. Payback time: the associations of debt and income with medical student career choice. Med Educ. 2012;46(10):983-991.
14. Morra DJ, Regehr G, Ginsburg S. Medical students, money, and career selection: students’ perception of financial factors and re-muneration in family medicine. Fam Med. 2009;41(2):105-110.
15. Graduation Questionnaire (GQ) - Data and Analysis - AAMC. https://www.aamc. org/data/gq/. Accessed December 12, 2015.
16. Grayson MS, Newton DA, Thompson LF. Payback time: the associations of debt and income with medical student career choice. Med Educ. 2012;46(10):983-991.
17. Gil JA, Park SH, Daniels AH. Variability in United States Allopath-ic Medical School Tuition. Am J Med. August 2015. http://www.ncbi.nlm.nih.gov/pubmed /26241346. Accessed October 21, 2015.
AuthorsJoseph A. Gil, MD, Department of Orthopaedic Surgery, Warren
Alpert Medical School of Brown University, Providence, RI.
Gregory R. Waryasz, MD, Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI.
Dorothy Liu, BS, Warren Alpert Medical School of Brown University, Providence, RI.
Alan H. Daniels MD, Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI.
DisclosuresNo funding was obtained in support of this study. The authors have no relevant conflicts of interest to report.
CorrespondenceJoseph A. Gil, MDDepartment of Orthopaedic SurgeryWarren Alpert Medical School, Brown University593 Eddy Street, Providence, RI 02903401-444-4030 Fax [email protected]
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 R h o d e I s l a n d m e d I c a l j o u R n a l 21
coNTriBuTioN
22
23
EN
Surveillance of Travel-Related Mosquito-borne Illness in Rhode Islandneha aLanG, Md; JUsTin GLaVis-BLooM, Md; niCoLe aLexander-sCoTT, Md, Mph; Leonard a. MerMeL, do, scM;
Maria d. MiLeno, Md
aBsTracT Malaria and Dengue are some of the common infections occurring in persons traveling to countries endemic for these infections. Chinkungunya virus infection is anoth-er illness that can occur in people who have travelled to areas endemic for chikungunya virus infection. Herein we report cases of malaria, dengue, and chikungunya in Newport Hospital, The Miriam Hospital and Rhode Island Hospital between January 1, 2010 and December 31, 2014.
KEywords: Travel-related infections, local transmission, mosquito-borne infections
iNTroducTioN
Approximately 1,500 to 2,000 cases of malaria are reported yearly in the United States, almost all in recent travelers (1). Although dengue rarely occurs in the continental United States, it is endemic in Puerto Rico and in many popular tour-ist destinations in the Caribbean, Latin America, Southeast Asia and the Pacific Islands (2). Beginning in 2014, cases of chikungunya virus infection were reported among U.S. trav-elers returning from affected areas in the Americas and local transmission was identified in Florida, Puerto Rico, and the U.S. Virgin Islands (3). With a large number of foreign-born individuals in Rhode Island (13.1%) (4), herein we report cases of malaria, dengue, and chikungunya in our hospital system between January 1, 2010 and December 31, 2014.
METhods
After Institutional Review Board approval, a list of patients diagnosed with malaria, dengue, or chikungunya between January 1, 2010 and December 31, 2014 at Newport Hospital, The Miriam Hospital and Rhode Island Hospital was obtained using the Theradoc software program in the Rhode Island Hospital Department of Epidemiology and Infection Control. Once these patients were identified, their medical records were reviewed to assess details regarding their acute illness.
rEsulTs
Of 35 identified cases, 51% were reported in 2014 (Figure 1). We identified 23 cases of malaria, 22 caused by Plasmo-dium falciparum and one by P. vivax/ovale. All cases were
diagnosed by thick and thin smears (Table 1). The majority of cases had recent travel to Africa. All cases of P. falciparum were hospitalized; 16 were treated with atovaquone and proguanil, 2 with quinine sulphate and clindamycin, 2 with quinine sulphate and doxycycline, 1 with chloroquine, and 1 with atovaquone, proguanil and doxycycline. The time inter-val from return to the U.S. until diagnosis of malaria ranged from 2 to 30 days. The one case of P. vivax/ovale occurred in a patient who had traveled to Ethiopia seven months earlier. This patient was hospitalized and treated with mefloquine.
Malaria Dengue Chikungunya
Total Cases 23 8 4
age ± sd (years) 38 ± 21 22 ± 18 36 ± 22
Gender, n (%)
Male 12 (52%) 7 (87.5%) 2 (50%)
Female 11 (48%) 1 (12.5%) 2 (50%)
Country of recent travel, n (%)
nigeria 6 (26%)
dominican republic 5 (62.5%) 2 (50%)
Liberia 5 (22%)
haiti 1 (4%) 1 (25%)
Guinea 2 (9%)
other 9 (39%) 3 (37.5%) 1 (25%)
Table 1. demographics of patients with travel-related infections
Figure 1. Travel-related infection diagnosis at time of diagnosis
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 R h o d e I s l a n d m e d I c a l j o u R n a l 22
coNTriBuTioN
There were 8 cases of dengue, all diagnosed by serology. One had past dengue infection, 1 had probable past infec-tion, 2 had equivocal values for IgG and IgM, 2 had elevated IgM levels, and 2 had elevated IgG and IgM levels. Most cases had recent travel to the Dominican Republic. Six of the 8 cases were hospitalized. The time interval from return to the US until diagnosis of dengue was 7 to 45 days.
Four cases of chikungunya were diagnosed; all were diag-nosed serologically. The time interval from return to the United States until diagnosis of chikungunya was 8 to 45 days.
discussioN
Most of the cases reported herein were detected in 2014. This may indicate greater awareness of these diagnoses among practicing physicians, greater incidence of these diseases in endemic countries visited by our patient population, or addi-tional, unknown reasons. Although the male to female ratio was similar in cases of malaria and chikungunya, there was a strong male preponderance with dengue diagnosed in our hospital system, as previously reported (2). Most dengue cases reported travel to the Dominican Republic in September, coinciding with the rainy season.
Some of the limitations of this study reflect the fact that chikungunya is not a reportable disease to the Rhode Island Department of Health and it may be underreported in this study. Data from only 3 hospitals were collected. Data on whether the patients infected with malaria were using anti-malarials was not collected. Data on how many of the people infected with malaria were visiting Africa for medical reasons (teaching, research, etc.) was not studied.
Chikungunya virus is most often transmitted by the Aedes aegypti and Aedes albopictus mosquitoes, which are the same species that transmit dengue virus (5). These mos-quitoes are found throughout much of the Americas, includ-ing parts of the Southern US. Since chikungunya is new to the Americas, most people in the region are not immune and infected travelers could spread the virus to mosquitoes upon their return home, leading to local transmission and further infections (6) as in infrequent reports of autochthonous cases of chikungunya and dengue in the US (7). Although most cases of chikungunya infection are self-limited, chronic arthritis affects a small number of infected cases (8). Our experience suggests that these patients’ symptoms can wax and wane and may present with joint pain weeks after their initial onset of symptoms leading to an extended period of time from infection to diagnosis.
In conclusion, of the approximately one million people residing in Rhode Island, we identified 35 cases of malaria, dengue or chikungunya over five years with the largest number of cases identified in 2014. Travelers returning from areas with mosquito-borne infections, including dengue, chikungunya and Zika virus, are recommended to take steps to prevent mosquito bites for 3 weeks to prevent local trans-mission (9). We believe that by making travelers aware of
mosquito-borne infections and reducing their risk by use of insect repellents, mosquito netting, screened windows and access to a pre-departure travel clinic would reduce the risk of these and other travel-related illnesses in our patient popu-lation. Nevertheless, it is likely that we will see greater num-bers of these infections in our state based on the large number of people who vacation or have families in the Caribbean.
AcknowledgmentsWe thank Stephen Parenteau, MS, Department of Infection Control and Epidemiology for providing us the list of patients diagnosed with malaria or dengue or chikungunya between January 1st 2010 to December 31st 2014 in Lifespan hospitals.
References1. Centers for Disease Control and Prevention. Malaria Facts.
http://www.cdc.gov/malaria/about/facts.html.2. Centers for Disease Control and Prevention. http://www.cdc.
gov/Dengue/3. Centers for Disease Control and Prevention. http://www.cdc.
gov/chikungunya/geo/united-states.html4. United States Census Bureau. http://quickfacts.census.gov/qfd/
states/44000.html5. Chikungunya Virus. http://www.cdc.gov/chikungunya/trans-
mission/index.html6. Centers for Disease Control and Prevention. Chikungunya in
the Americas.7. Kendrick, K., Stanek, D., Blackmore, C. and Centers for Disease
Control and Prevention. Notes from the field: transmission of chikungunya virus in the continental United States—Florida, 2014. MMWR Morb Mortal Wkly Rep 2014; 63(48):1137.
8. World Health Organization. Guidelines for Prevention & Con-trol of Chikungunya Fever. 2009. http://www.wpro.who.int/mvp/topics/ntd/Chikungunya_WHO_SEARO.pdf
9. Centers for Disease Control and Prevention. Prevention | Zika Virus. 2016. http://www.cdc.gov/zika/prevention/
AuthorsNeha Alang, MD, Department of Internal Medicine, Newport
Hospital.
Justin Glavis-Bloom, MD, Warren Alpert Medical School of Brown University.
Nicole Alexander-Scott, MD, MPH, Director, Rhode Island Department of Health.
Leonard A. Mermel, DO, ScM, Professor of Medicine, Warren Alpert Medical School of Brown University.
Maria D. Mileno, MD, Associate Professor of Medicine, Warren Alpert Medical School of Brown University.
CorrespondenceNeha Alang, MDDivision of Hospital Medicine, Newport Hospital11 Friendship StreetNewport, RI [email protected]
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 R h o d e I s l a n d m e d I c a l j o u R n a l 23
casE rEporT
24
26
EN
Atypical presentation of infective endocarditisKarUppiah arUnaChaLaM, Md
aBsTracT The HACEK group of organisms are one of the infrequent causes of infective endocarditis. Infective endocarditis should be recognized and treated promptly to prevent ex-cessive morbidity and mortality associated with the dis-ease. Sometimes the diagnosis is delayed due to vague and subtle presentation. Through this case report, risk factors of Cardiobacterium hominis endocarditis and its atypical presentation is illustrated to increase the recognition of infective endocarditis as one of the differential diagnosis.
KEywords: infective endocarditis, HACEK, cardiobacterium hominis, atrial fibrillation
iNTroducTioN
In the United States, an estimated 10,000 to 15,000 new cases of infective endocarditis (IE) are diagnosed each year.1 To date, less than 100 cases of Cardiobacterium hominis (C. hominis) endocarditis have been reported in the English med-ical literature.2 The HACEK group of bacteria (Haemophilus species, Aggregatibacter species, Cardiobacterium hominis, Eikenella corrodens, and Kingella species) are a small, het-erogeneous group of fastidious, gram-negative bacteria that frequently colonize the oropharynx and have long been rec-ognised as a cause of infective endocarditis. These organisms have been historically reported as causing infection in <5% of patients of IE.3,4 This case report describes the atypical presentation of infective endocarditis due to a rare organism.
casE prEsENTaTioN
An 80-year-old man with St. Jude’s prosthetic mitral valve replacement done in 2009, with a history of Alzeimer’s dementia and stroke, presented with bright red blood per rectum and palpitations. He was fatigued and felt unwell for nearly 6 weeks before the presentation. He lives with his wife at home and had a dental procedure 2 months before the presentation. He was given prophylactic amoxicillin for 5 days after the procedure. In the emergency room, he was found to be diaphoretic, pale and drowsy. He was hypoten-sive to systolic blood pressure of 70 mm Hg and tachycardic to 150/min. On exam, he was pleasantly confused and ori-ented to person and place only. Oral examination revealed
grossly poor dentition with dental caries. Cardiovascular exam showed a holosystolic murmur in the left 5th intercos-tal space medial to the nipple area. Initially the EKG looked like supraventricular tachycardia and after adenosine therapy the atrial fibrillation was clearly evident.
He was resuscitated with intravenous fluid boluses; the laboratory tests showed severe anemia with a haemoglobin of 6.4 g/dl and supratherapeutic INR of 5.4. He was trans-fused with 3 units of fresh frozen plasma and 3 units of packed red blood cells. During the hospitalization, he had a temperature of 102 degrees Fahrenheit; the blood culture was done which showed gram-negative bacteria in two bot-tles. He was started on intravenous ceftriaxone empirically.
The microbiology studies showed specific characteristics like cluster of gram negative bacilli and a waxy growth on the blood culture bottle. [Figure 1] Biochemical tests showed specific indole positivity which differentiates from other HACEK group of organisms.
The transthoracic echocardiogram done initially showed a normal ejection fraction without any obvious vegetations. The trans-esophageal echocardiogram done due to high sus-picion for IE showed a mobile vegetation of approximately 1 cm in size adherent to atrial surface of the mitral valve. But the patient didn’t have any significant mitral regur-gitation and there was no evidence of valve dehiscence
Figure 1. Gram stain of blood showing gram-negative bacilli in clusters.
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 R h o d e I s l a n d m e d I c a l j o u R n a l 24
casE rEporT
or abscess or valve rupture. [Figure 2 & 3]The patient was treated for 6 weeks with
intravenous ceftriaxone and surgical treat-ment was not indicated. He recovered well in a rehabilitation facility.
discussioN
IE with Cardiobacterium hominis, a member of the HACEK group of microorganisms, is usually insidious in onset, with a prolonged subacute course characterized by leukocyto-sis, anemia, splenomegaly, embolic phenom-ena, congestive heart failure and weight loss.
C. hominis endocarditis is known for a spectrum of unusual clinical presentations, non-specific symptoms and protracted clinical course. It has been reported to occur after den-tal procedures, upper GI endoscopy and colo-noscopy. Incidence among elderly patients are higher due to the above risk factors and increased use of prosthetic valves and devices implants. Other rare presentations include septic arthritis, mycotic aneurysm, congestive heart failure and acute coronary syndrome.
C. hominis produces indole and is oxidase- positive. It ferments glucose, sorbitol, man-nose, sucrose and, in most cases, maltose and mannitol. It does not demonstrate ure-ase, catalase, nitrate reductase, phenylala-nine deaminase, beta galactosidase, lysine decarboxylase, ornithine decarboxylase or arginine dihydrolase activity. These character-istics help distinguish it from other members of the HACEK group.10
Although C. hominis is of relatively low virulence, endovascular infection compli-cates 95% of all cases of bacteremia, with the aortic valve being most commonly affected.5,6 Peripheral and central nervous sys-tem emboli occur frequently in C. hominis endocarditis, noted in 51% and 21% of cases, respectively, especially when the aortic valve is involved.5,7,8 Prognosis is generally favourable, with a 93% cure rate for both native and prosthetic valve infection.5 A third-generation cephalosporin is the drug of choice for infection with HACEK organisms.9
Most often this disease has a chronic clinical course and requires prolonged antibiotic therapy. Association of atrial fibrillation with C. hominis endocarditis is rare and can be present either at the time of presentation or develop after hospitalization. This case report illustrates the atypical pre-sentation of rare case of C. hominis subacute bacterial endo-carditis (SBE) and also stresses the recognition of important risk factors like poor dentition, prosthetic valves in elderly patients for prompt diagnosis of prosthetic valve endocarditis.
References1. Bayer A.S.: Infective endocarditis. Clin Infect Dis 1993; 17:313-322.2. Malani A.N., Aronoff D.M., Bradley S.F., and Kauffman C.A. Eur
J Clin Microbiol Infect Dis 2006; 25:587-595.3. Lerner PI, Weinstein L (1966). Infective endocarditis in the
antibiotic era. N Engl J Med 274:199–206.4. Pelletier LL, Petersdorf RG (1977). Infective endocarditis:
a review of 125 cases from the University of Washington Hospitals, 1963–72. Medicine 56:287–313.
5. Malani AN, Aronoff DM, Kauffman CA. Cardiobacterium homi-nis endocarditis: Two cases and a review of the literature. Eur J Clin Microbiol Infect Dis. 2006;25:587–95.
6. Chambers ST, Murdoch D, Morris A, et al. HACEK infective en-docarditis: Characteristics and outcomes from a large, multi-na-tional cohort. PLoS One. 2013;8.
Figure 2. Vegetation on the mitral valve seen on transesophageal echocardiogram
Figure 3. Mobile vegetation prolapsing (arrow) into the left atrium with mild mitral regur-
gitation by transesophageal echocardiogram.
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 R h o d e I s l a n d m e d I c a l j o u R n a l 25
casE rEporT
7. Chentanez T, Khawcharoenporn T, Chokrungvaranon N, et al. Cardiobacterium hominis endocarditis presenting as acute embolic stroke: A case report and review of the literature. Heart Lung. 2011;40:262–9.
8. Lena TS, De Meulemeester C. A case of infective endocarditis caused by C. hominis in a patient with HLAB27 aortitis. Can J Neurol Sci. 2009;36:385–7.
9. Baddour LM, Wilson WR, Bayer AS, et al. Infective endocarditis: Diagnosis, antimicrobial therapy, and management of complica-tions: A statement for healthcare professionals from the Com-mittee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Coun-cils on Clinical Cardiology, Stroke, and Cardiovascular Sur-gery and Anesthesia, American Heart Association.Circulation. 2005;111:394–434.
10. Wormser GP, Bottone EJ. Cardiobacterium hominis: Review of microbiologic and clinical features. Rev Infect Dis 1983;5:680-91.
AuthorKaruppiah Arunachalam, MD, Clinical Instructor in Medicine, Department of Internal Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island.
DisclosuresNone
CorrespondenceKaruppiah Arunachalam, MDDepartment of Hospital MedicineAlpert Medical School of Brown University593 Eddy StreetProvidence, RI [email protected]
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 R h o d e I s l a n d m e d I c a l j o u R n a l 26
casE rEporT
27
28
EN
A case of Ochrobactrum anthropi-induced septic shock and infective endocarditisFarhan ashraF, Md
aBsTracT Ochrobactrum anthropi is a gram-negative rod of low vir-ulence. Infections due to this organism are uncommon; however in immunocompromised hosts it can cause se-vere infections. Among the many infections it can cause, infective endocarditis is very rare. Even rarer is infective endocarditis of the native valves, as Ochrobactrum antropi affects damaged or prosthetic valves almost exclusively. This case describes native valve endocarditis due to Ochrobactrum anthropi.
KEywords: infective endocarditis, sepsis, Ochrobactrum anthropi
casE rEporT
A 58-year-old woman with a past history of atrial fibrillation not on anticoagulation, end- stage renal disease with a failed kidney transplant, now on dialysis, coronary artery disease, moderate aortic stenosis, and pacemaker for 3rd degree heart block came in with chest pain for 2 days. She described the pain as substernal, sharp, non-radiating and 8/10 in inten-sity. She denied any difficulty breathing, fevers, chills or pal-pitations. She was a smoker in the past, and denied drug use.
Her vitals were: Temperature 98.1 degree Fahrenheit, heart rate 90/min, blood pressure 128/61 mmHg, respiratory rate of 16/min and oxygen saturation was 100% on room air. On examination she had a regular heart rate and a 2/6 ejec-tion systolic murmur was heard in the aortic area, consistent with her history of aortic stenosis. No other murmurs were heard, and her lungs were clear. The rest of the examination was remarkable for a dialysis catheter in internal jugular vein and a scar at the site of the kidney transplant. Labora-tory work-up showed hemoglobin of 8.1mg/dl which was her baseline. Her white count was not elevated, creatinine was 6.7mg/dl, and electrolytes were within normal range. The 1st troponin was negative. Electrocardiogram (EKG) showed ventricle-paced rhythm, Sgarbossa score was 0. The chest X-ray showed cardiomegaly which was stable compared to previous X-ray. Her pain responded to nitroglycerine and she was admitted to rule out acute coronary syndrome and to have an ischemia work-up after consultation with her cardi-ologist. Her home dose of aspirin, atorvastatin, metoprolol, and clopidogrel were continued.
She was monitored on telemetry without any significant events. Her chest pain remained under control. The 2nd tro-ponin was negative, however 3rd was very mildly elevated at 0.034 ng/ml. A stress test was scheduled for the next day after an inpatient cardiology consult. However, the next day around midnight she became confused and hypotensive, with a blood pressure of 60/40 mm Hg. The heart rate at that time was 120/min, and she remained afebrile. She was initially given normal saline and then albumin, but there was minimal improvement of the blood pressure. She was also noted to have a fever of 103 Fahrenheit on a repeat set of vital signs. Examination at that time did not reveal any-thing new: there was no obvious skin infection, her dialysis catheter site was clean, and no new murmurs were heard. Work-up at that time included complete blood count, tro-ponin and blood culture drawn from periphery and her dial-ysis catheter. EKG was unchanged from previous. She was treated empirically for hospital-acquired infection with van-comycin and piperacillin/tazobactum. Due to persistently low blood pressure she was started on phenylephrine drip. Her blood pressure responded to phenylephrine, and her mental status also improved very quickly. Within 24 hours she was weaned off the phenylephrine drip. Her blood pres-sure remained stable, and she did not have a fever again. Her troponin continued to trend up and peaked at 0.5ng/ml. In the absence of chest pain and EKG changes, this was consid-ered demand ischemia due to septic shock. Her white cell count was never elevated throughout this process.
The blood culture from her dialysis catheter and periphery grew Ochrobactrum anthropi sensitive to Meropenam and resistant to Beta Lactams. Subsequently, Meropenam was started and previous antibiotics were discontinued. The dialysis catheter was also replaced, the tip of original cath-eter was found to have a thick biofilm. The tip was also sent for culture, and it also grew the same organism. Repeat blood cultures remained negative. Considering the fact that she had a pacemaker, a transthoracic echocardiogram was performed, which did not show any vegetation. A transe-sophageal echocardiogram was then done, which showed 1 cm vegetation on Mitral Valve (Figure 1). She subsequently had her pacemaker leads removed, given the presence of vegetation, and semi-permanent epicardial pacemaker leads were placed. She was treated with antibiotics for 6 weeks without any further complications.
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 R h o d e I s l a n d m e d I c a l j o u R n a l 27
casE rEporT
discussioN Ochrobactrum anthropi is an aerobic gram negative rod of low virulence which is widely distributed in aquatic envi-ronment. In many ways it bears resemblance to Pseudomo-nas. Due to its low virulence, Ochrobactrum anthropi rarely affects immunocompetent hosts, but can cause a variety of infections in immunocompromised hosts. It is thought to be associated with central lines, catheters and other foreign objects. 1,2 It has binding abilities similar to those of Staph-ylococcus epidermidis and Staphylococcus aureus,3 which would explain its association with central lines and other foreign bodies. In our case the internal jugular dialysis cath-eter was the most likely portal of entry. Transplant-related infections due to contaminated pharmaceuticals have also been reported.4
Even though Ochrobactrum anthropi has been reported to be a cause of various infections more frequently over the last 20 years, it still remains a very rare cause of endocarditis. In almost all the reported cases of endocarditis, the affected individuals had a prosthetic valve or rheumatic valve dis-ease.4-7 This case though, describes undamaged native valve endocarditis. To our knowledge, only 1 case of undamaged native valve endocarditis has been reported previously.8
Ochrobactrum anthropi is resistant to most beta lactams, and usually needs treatment with carbapeman, ciprofloxa-cin, trimethoprim/sulfamethoxazole or gentamycin. 8,9 The resistant to beta lactams is due to production of AmpC β-lac-tamase by the organism.10 This β-lactamase is chromosomal, inducible, and is resistant to inhibition by clavulanic acid.11
Even though it is considered to have low virulence, Ochrobactrum anthropi can cause severe infections in immunocompromised hosts. Therefore it is important to consider this bacterium in immunocompromised hosts who deteriorate suddenly. Similarly once the organism is identi-fied, antibiotics should be switched to carbapeman, cipro-floxacin, trimethoprim/sulfamethoxazole, or gentamycin to cover it appropriately, even before sensitivities are available. It is uncertain whether every patient with positive blood
culture for Ochrobactrum anthropi should be screened for endocarditis, but patients who have any hardware in their heart (prosthetic valves, pacemakers, defibrillators), which was true in our case, should get a transthoracic echocardio-gram, and even a transesophageal echocardiogram to rule out infective endocarditis. As described in our case above, transthoracic echocardiogram can miss vegetation, which can result in a shorter duration and insufficient treatment of the endocarditis.
References1. Cieslak TJ, Robb ML, Drabick CJ, Fischer GW. Catheter-associ-
ated sepsis caused by Ochrobactrum anthropi: report of a case and review of related nonfermentative bacteria. Clinical infec-tious diseases : an official publication of the Infectious Diseases Society of America 1992;14:902-7.
2. Gill MV, Ly H, Mueenuddin M, Schoch PE, Cunha BA. Intrave-nous line infection due to Ochrobactrum anthropi (CDC Group Vd) in a normal host. Heart & lung : the journal of critical care 1997;26:335-6.
3. Alnor D, Frimodt-Moller N, Espersen F, Frederiksen W. Infec-tions with the unusual human pathogens Agrobacterium spe-cies and Ochrobactrum anthropi. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 1994;18:914-20.
4. Mahmood MS, Sarwari AR, Khan MA, Sophie Z, Khan E, Sami S. Infective endocarditis and septic embolization with Ochro-bactrum anthropi: case report and review of literature. The Jour-nal of infection 2000;40:287-90.
5. Romero Gomez MP, Peinado Esteban AM, Sobrino Daza JA, Saez Nieto JA, Alvarez D, Pena Garcia P. Prosthetic mitral valve endocarditis due to Ochrobactrum anthropi: case report. Journal of clinical microbiology 2004;42:3371-3.
6. Shivaprakasha S, Rajdev S, Singh H, Velivala S. Prosthetic aortic valve endocarditis due to Ochrobactrum anthropi. Indian jour-nal of medical sciences 2011;65:69-72.
7. McKinley KP, Laundy TJ, Masterton RG. Achromobacter Group B replacement valve endocarditis. The Journal of infection 1990;20:262-3.
8. Ozdemir D, Soypacaci Z, Sahin I, Bicik Z, Sencan I. Ochrobac-trum anthropi endocarditis and septic shock in a patient with no prosthetic valve or rheumatic heart disease: case report and review of the literature. Japanese journal of infectious diseases 2006;59:264-5.
9. Thoma B, Straube E, Scholz HC, et al. Identification and an-timicrobial susceptibilities of Ochrobactrum spp. International Journal of Medical Microbiology 2009;299:209-20.
10. Cieslak TJ, Drabick CJ, Robb ML. Pyogenic infections due to Ochrobactrum anthropi. Clinical infectious diseases : an offi-cial publication of the Infectious Diseases Society of America 1996;22:845-7.
11. Nadjar D, Labia R, Cerceau C, Bizet C, Philippon A, Arlet G. Molecular characterization of chromosomal class C beta-lact-amase and its regulatory gene in Ochrobactrum anthropi. Anti-microbial agents and chemotherapy 2001;45:2324-30.
AuthorFarhan Ashraf, MD, Internal Medicine Resident, Memorial
Hospital of Rhode Island/ Warren Alpert Medical School of Brown University.
DisclosuresNone
CorrespondenceFarhan Ashraf, MDMemorial Hospital of Rhode Island111 Brewster Street, Pawtucket, RI [email protected]
Figure 1. Transesophageal echocardiogram showing vegetation, marked with blue arrow. The vegetation is about 1cm x 0.7cm in size, and adherent to mitral valve annulus.
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 R h o d e I s l a n d m e d I c a l j o u R n a l 28
EMErgENcy MEdiciNE rEsidENcy cpc
From the Case Records of the Alpert Medical School of Brown University Residency in Emergency Medicine
29
31
EN
The pharma-fever that almost got awayxiao Chi zhanG, Md, Ms; MaTTheW siKeT, Md; WiLLiaM Binder, Md
dr. xiao chi ZhaNg: A 68-year-old man was brought into the Emergency Department by his family with chills and altered mental status. Two days prior to his ED presenta-tion, the patient had an episode in which he “spaced-out” and was unable to comprehend or acknowledge his wife. She reported that he did not have any signs of seizure activity and did not have any focal weakness. The episode lasted approximately 30 minutes and he returned to his baseline. Today he had another episode, but this time associated with chills and rigors. His past medical history was significant for chronic back pain due to bony metastasis from Stage IV non-small cell lung adenocarcinoma, requiring palliative gamma knife radiation, as well as a daily oral chemotherapy agent, erlotinib, an oral tyrosine kinase inhibitor. Additional medications included sertraline and methadone, which had recently been increased from 2.5 mg to 5 mg three times daily. Review of systems was negative for any recent travel, exposure to sick contacts, or pulmonary, abdominal and uri-nary complaints. Of note, the patient had developed a sta-ble and unchanged truncal rash ever since he was started on erlotinib, 15 months prior to presentation.
On arrival to the ED, the patient‘s vital signs were 106.2 F (41.2 C), blood pressure 137/78 mm Hg, pulse rate of 109, respiratory rate of 20, with an oxygen saturation of 90% on room air. His physical exam was notable for normal reactive pupils without papilledema, a supple neck without menin-gismus, mild oral thrush, tachycardia with regular rhythm and a diffuse, blanchable, papular rash along the trunk and proximal extremities He was alert and oriented x4, fully conversant, with 3+ patellar reflexes bilaterally and mild clonus, but otherwise had a normal neurological and mem-ory exam.
Initial laboratory studies including a complete blood count (CBC), a comprehensive metabolic panel (CMP), a lac-tic acid level, a urinalysis, and a point of care rapid strep and influenza were normal. A non-contrast CT of the brain was unremarkable, and a chest x-ray revealed an apical lung mass consistent with the patient’s known lung cancer. An abdom-inal CT scan demonstrated an incidental pathologic acetab-ular fracture, but did not reveal any sources of infection.
dr. sarah gaiNEs: A fever greater than 41.0°C is quite elevated and unusual. Is this dangerous? What was your differential?
dr. MaTThEw siKET: Humans generally tolerate tempera-tures below 41° C (105.8° F). In contrast to hyperthermia, in which an imbalance between heat generation versus dissipa-tion occurs without up-regulation of the hypothalamic set point, fever as a host defense against infection rarely reaches dangerous levels in neurologically competent individuals. Very high temperatures can be related to urosepsis, intraab-dominal sepsis, C. difficile colitis, meningitis, and central venous catheter infections. Hyperpyrexia, defined as tem-perature > 41.5°C (106.7°F) is an uncommon result of infec-tion and usually implies central fever, neurologic malignant syndrome, malignant hyperthermia, adrenal insufficiency, or a drug related cause.1 Our patient was hyperpyrexic, sug-gesting either a limited spectrum of infectious diseases or a medication-related disorder.
dr. EliZaBETh goldBErg: What were your next steps in diagnosis and management of this patient?
dr. ZhaNg: Our patient had a change in mental status as well as a remarkably elevated temperature. Our initial con-cern was for encephalitis or meningoencephalitis as delay in treatment can result in devastating morbidity and mortality. A lumbar puncture was performed with an opening pressure of 15cm H2O, 500+ RBCs in tube 4, 1 nucleated cell, 71% PMN, 17% lymphs, and normal glucose and protein. The patient was empirically treated for encephalitis of unclear etiology with IV cefepime, acyclovir, and vancomycin and was admitted to the floor for additional workup. Of note, his fever defervesced to 38.6 °C with 1g of IV acetaminophen.
dr. BrucE BEcKEr: I have two questions. First, why did you obtain a CT of the brain prior to the lumbar puncture? Sec-ond, why was this patient treated with antiviral medication and antibiotics?
dr. ZhaNg: While all patients with suspected encephalitis or meningitis should have a lumbar puncture for CSF eval-uation, a computed tomography (CT) of the brain is not necessarily indicated as it can lead to a delay in appropri-ate treatment. A retrospective study in Sweden showed that
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 R h o d e I s l a n d m e d I c a l j o u R n a l 29
EMErgENcy MEdiciNE rEsidENcy cpc
patients who underwent immediate LP without CT received antibiotics 1.6 hours earlier than those who had a CT. The treatment delay resulted in a relative increase in mortality of 13 percent per hour of delay.2 If an LP is delayed or con-traindicated (such as thrombocytopenia, history of epidural abscesses, or concern for herniation), the providers should obtain peripheral blood cultures and give empiric antibiotics.
The reasons for obtaining brain CTs prior to LPs are to assess for potential mass lesions or increased intracra-nial pressure, which may lead to a fatal cerebral hernia-tion during removal of CSF. The indications for obtaining brain CTs include a history of immunocompromised states, malignancy, seizures, abnormal level of consciousness, focal neurologic deficit and papilledema.3,4 Since our patient has a history of metastatic cancer with altered mental status, we felt that a CT prior to performing the LP was indicated.
HSV encephalitis is a fatal disease process if untreated, especially in patients presenting with diffuse cerebral edema or intractable seizures.5 Prompt acyclovir therapy for HSV encephalitis can decrease one year mortality from 70% to approximately 14% although persistent neuropsychiatric and epileptic sequelae will persist in well over 20 percent of the surviving population.6 Consequently, empiric IV acy-clovir was initiated while awaiting confirmation from CSF studies, including CSF cultures, PCR, and viral serologies.
We administered empiric antibiotics prior to obtaining our CSF results because bacterial meningitis is a devastat-ing disease with significant mortality despite appropriate and timely administration of antibiotics. The overall case fatality rate is 16.4%, with mortality increasing linearly with age, from 8.9% (age 18-34) to 22.7% (age 65+).7 A delay in antimicrobial treatment for pneumococcal meningitis of more than 3 hours significantly increases mortality and results in greater neurologic deficits at discharge.8
dr. williaM BiNdEr: Would empiric antibiotics have affected the gram stain and CSF cultures?
dr. ZhaNg: Administration of antibiotics can reduce the yield of gram stain and cultures, but the pathogen can still be cultured from the CSF for several hours after antibiotics.9
However, a special consideration should be made for patients with meningococcal meningitis, as one study demonstrated that three out of nine CSF cultures, obtained within one hour prior to LP, were negative.10 This is in contrast to pneu-mococcal meningitis in which 4 to 10 hours were required before the CSF cultures were sterile after antibiotics.11
dr. aNdrEw NaThaNsoN: It appears that you have cov-ered the patient for infectious organisms. However, given the elevated temperature, was there further concern for a non-infectious cause of the hyperpyrexia?
dr. ZhaNg: On admission, the patient was afebrile with unchanged repeated blood work. His blood, urine, and CSF (HSV, CMV) cultures and PCR were negative, his respiratory viral studies were normal, and consequently his antibiotics
were discontinued. A careful review of the patient’s med-ication revealed that his methadone dose was recently increased from 2.5mg TID to 5mg TID two weeks prior to hospital admission due to increased back pain. This coin-cided with the patient’s initial febrile episode. In the set-ting of hyperpyrexia, hyperreflexia, and clonus, the patient was diagnosed with serotonin syndrome secondary to opiate dose increase. Sertraline was subsequently discontinued and he remained alert, oriented, and afebrile for the remainder of his hospital stay.
dr. JEff fEdEN: How did methadone use lead to serotonin syndrome?
dr. ZhaNg: Serotonin syndrome is a potentially danger-ous condition associated with increased serotonergic activ-ity in CNS, (i.e. autonomic hyperactivity, neuromuscular abnormalities, altered mental status) due to synergistic drug-drug interaction or intentional overdoses of serotonin reuptake inhibitors (SSRI or SNRI). It is usually more acute in onset (<12 hours) than neuroleptic malignant syndrome (NMS), which occurs over 1–3 days and is associated with akinesis and rigidity, decreased levels of consciousness, and mutism.12 Additionally, the creatinine kinase (CK) level is usually markedly elevated (typically, greater than 1000 IU/L, and up to 100,000) in NMS. 13 Our patient’s CK was 206 IU/L.
Serotonin syndrome is often associated with multiple med-ications which increase serotonin release. Co-intoxication with CNS stimulants (cocaine, amphetamine, MDMA) can also precipitate serotonin syndrome both increasing the release and impairing serotonin reuptake, while CNS depres-sants (opiates) can act as direct serotonin agonists. Approx-imately 8% of Caucasians are deficient in the cytochrome P450 2D6 enzyme and are more susceptible to serotonin tox-icity if taking medications such as venlafaxine, paroxetine, tricyclics, dextromethorphan, and methadone.14 There are no data to suggest that erlotinib is related to serotonin syn-drome. However, erlotinib inhibits the cytochrome enzyme CYP3A4, which can result in the accumulation of serotoner-gic drugs such as methadone, and consequently may have contributed to this patient’s syndrome.15
dr. ilsE JENouri: Are there any specific diagnostic criteria for serotonin syndrome?
dr. ZhaNg: Serotonin syndrome is diagnosed through clinical exam findings and detailed history consistent with worsening autonomic symptoms in the setting of known exposure to serotonergic substances. Common serotonin syndrome physical findings include agitation (or altered mental status), hyperthermia, hyper-reflexia, akathisia, tremors, diaphoresis, and muscle rigidity.16 In the absence of additional medical co-ingestions, cerebral infections or mass effects, clinicians can use the Hunter Toxicity Criteria Deci-sion Rules 17 to diagnose serotonin syndrome. The Hunter Criteria is 84% sensitive and 97% specific when compared with a diagnosis of serotonin syndrome made by a medical
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 R h o d e I s l a n d m e d I c a l j o u R n a l 30
EMErgENcy MEdiciNE rEsidENcy cpc
toxicologist if a patient has taken a serotonergic agent and meets one of the following conditions:• Spontaneous clonus• Inducible clonus PLUS agitation or diaphoresis• Ocular clonus PLUS agitation or diaphoresis• Tremor PLUS hyperreflexia• Hypertonia PLUS temperature above 38ºC PLUS ocular
clonus or inducible clonus
There are no specific confirmatory laboratory tests to con-firm serotonin syndrome; however, one may consider order-ing CBC, CMP, CK, UA, drugs of abuse, coagulation studies, as well as radiographs, brain CT and/or lumbar punctures to narrow the differential diagnoses.
dr. Edward ruhlaNd: What is the management of serotonin syndrome?
dr. ZhaNg: The primary management of serotonin syn-drome is discontinuation of the offending agent (i.e. seroto-nergic agents) and supportive care. Patients should be placed on placed on continuous cardiac monitoring, while receiv-ing supplemental oxygen to maintain SpO2 > 94 percent and IV fluids for volume depletion. Benzodiazepines can be used to control agitation as well as elevated blood pressures and heart rates. While antipyretic agents, such as acetamino-phen do not typically have a role in controlling for fever, as the increase in body temperature with serotonin syndrome is due to an increase in muscular activity as opposed to an alteration in the hypothalamic temperature set point, it is interesting to note that our patient defervesced after one dose of acetaminophen. Patients with persistent fever above 106F (41.1C) can be considered for sedation, paralysis and intubation. Cyproheptadine, a histamine receptor antago-nist, may be considered if the patient continues to exhibit agitation and abnormal vital signs despite conservative supportive care and benzodiazepine.
dr. laura McpEaKE: How did the patient fare after discharge?
dr. ZhaNg: The patient returned to his psychiatrist two weeks after hospital discharge for additional therapeutic recommendations for treating his depression. After a long discussion, both physician and family agreed that prescrib-ing additional antidepressants may result in recurrence of serotonin syndrome, especially in the setting of an expected increase in opiate prescription over time. Fortunately, the patient had great support from family and friends and demonstrated a realistic, yet positive view on his progno-sis; he elected to seek alternative methods for managing his depression with palliative care and has not had any recurrent serotonin syndrome symptoms.
References1. Cunha BA. Clinical approach to fever in the neurosurgical in-
tenvsive care unit: Focus on drug fever. Surg Neurol Int. 2013; 4: S318 – S322.
2. Glimåker M, Johansson B, Grindborg Ö, et al. Adult bacterial meningitis: earlier treatment and improved outcome following guideline revision promoting prompt lumbar puncture. Clin In-fect Dis 2015; 60:1162.
3. Hasbun R, Abrahams J, Jekel J, Quagliarello VJ. Computed to-mography of the head before lumbar puncture in adults with suspected meningitis. N Engl J Med 2001; 345:1727.
4. Gopal AK, Whitehouse JD, Simel DL, Corey GR. Cranial com-puted tomography before lumbar puncture: a prospective clini-cal evaluation. Arch Intern Med 1999; 159:2681.
5. Glimåker M, Johansson B, Grindborg Ö, et al. Adult bacterial meningitis: earlier treatment and improved outcome following guideline revision promoting prompt lumbar puncture. Clin In-fect Dis 2015; 60:1162.
6. Glaser CA, Honarmand S, Anderson LJ, et al. Beyond viruses: clinical profiles and etiologies associated with encephalitis. Clin Infect Dis 2006; 43:1565.
7. Hjalmarsson A, Blomqvist P, Sköldenberg B. Herpes simplex encephalitis in Sweden, 1990-2001: incidence, morbidity, and mortality. Clin Infect Dis 2007; 45:875.
8. Thigpen MC, Whitney CG, Messonnier NE, et al. Bacterial meningitis in the United States, 1998-2007. N Engl J Med 2011; 364:2016.
9. Auburtin M, Wolff M, Charpentier J, et al. Detrimental role of delayed antibiotic administration and penicillin-nonsusceptible strains in adult intensive care unit patients with pneumococcal meningitis: the PNEUMOREA prospective multicenter study. Crit Care Med 2006; 34:2758.
10. Geiseler PJ, Nelson KE, Levin S, et al. Community-acquired pu-rulent meningitis: a review of 1,316 cases during the antibiotic era, 1954-1976. Rev Infect Dis 1980; 2:725.
11. Kanegaye JT, Soliemanzadeh P, Bradley JS. Lumbar puncture in pediatric bacterial meningitis: defining the time interval for re-covery of cerebrospinal fluid pathogens after parenteral antibiot-ic pretreatment. Pediatrics 2001; 108:1169.
12. Talan DA, Hoffman JR, Yoshikawa TT, Overturf GD. Role of empiric parenteral antibiotics prior to lumbar puncture in sus-pected bacterial meningitis: state of the art. Rev Infect Dis 1988; 10:365.
13. Tse L, Barr AM, Scarapicchia V, Vila-Rodriguez F. Neuroleptic Malignant Syndrome: A Review from a Clinically Oriented Per-spective. Curr Neuropharmacol. 2015; 13: 395 – 406.
14. Pelonero AL, Levenson JL, Pandurangi AK. Neuroleptic malig-nant syndrome: A review. Psychiatr Serv. 1998; 49: 1163 – 1172.
15. Frank C. Recognition and treatment of serotonin syndrome. Ca-nadian Family Physician. 2008; 54: 988 – 992
16. Volpi-Abadie J, Kaye AM. Serotonin Syndrome. Ochsner Jour-nal. 2013; 13: 533 – 540
17. Ganetsky, M, Brush, E. Serotonin syndrome—what have we learned? Clin Ped Emerg Med 2005; 6:103.
18. Dunkley EJ, Isbister GK, Sibbritt D, et al. The Hunter Serotonin Toxicity Criteria: simple and accurate diagnostic decision rules for serotonin toxicity. QJM 2003; 96:635.
AuthorsXiao Chi (Tony) Zhang, MD, MS, Emergency Medicine Resident,
Alpert Medical School of Brown University.
Matthew Siket, MD, Assistant Professor of Emergency Medicine, Alpert Medical School of Brown University.
William Binder, MD, Associate Professor of Emergency Medicine; Alpert Medical School of Brown University.
CorrespondenceWilliam Binder, MDEmergency Medicine Foundation593 Eddy Street, Providence, RI 02903401-444-5411Fax [email protected]
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 R h o d e I s l a n d m e d I c a l j o u R n a l 31
puBlic hEalTh
(a) Cause of death statistics were derived from the underlying cause of death reported by physicians on death certificates.
(b) rates per 100,000 estimated population of 1,055,173 (www.census.gov)
(c) Years of potential Life Lost (YpLL).
noTe: Totals represent vital events, which occurred in rhode island for the reporting periods listed above.
Monthly provisional totals should be analyzed with caution because the numbers may be small and subject to seasonal variation.
* rates per 1,000 estimated population
# rates per 1,000 live births
viTal sTaTisTics niCoLe e. aLexander-sCoTT, Md, Mph direCTor, rhode isLand deparTMenT oF heaLTh CoMpiLed BY roseann GiorGianni, depUTY sTaTe reGisTrar
Rhode Island Monthly Vital Statistics Report Provisional Occurrence Data from the Division of Vital Records
REPORTING PERIOD
VITAL EVENTSJANUARY 2016 12 MONTHS ENDING WITH JANUARY 2016
Number Number Rates
Live Births 918 11,539 10.9*
deaths 887 10,266 9.7*
infant deaths 7 72 6.2#
neonatal deaths 5 57 4.9#
Marriages 241 6,665 6.3*
divorces 251 3,112 2.9*
induced Terminations 209 2,459 213.1#
spontaneous Fetal deaths 46 597 51.7#
Under 20 weeks gestation 41 547 53.3#
20+ weeks gestation 5 50 4.3#
REPORTING PERIOD
Underlying Cause of Death CategoryJULY 2015 12 MONTHS ENDING WITH JULY 2015
Number (a) Number (a) Rates (b) YPLL (c)
diseases of the heart 212 2,449 232.1 3,586.5
Malignant neoplasms 195 2,259 214.1 5,177.5
Cerebrovascular disease 41 451 42.7 550.0
injuries (accident/suicide/homicide) 70 852 80.7 13,064.0
Copd 33 546 51.7 582.5.
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 R h o d e I s l a n d m e d I c a l j o u R n a l 32
The Rhode Island Medical Society now endorses Coverys.
It’s a new day.
Coverys, the leading medical liability insurer
in Rhode Island, has joined forces with RIMS
to target new levels of patient safety and
physician security while maintaining competitive
rates. Call to learn how our alliance means a
bright new day for your practice.
401-331-3207
The Rhode Island Medical Society now endorses Coverys.
rhodE islaNd MEdical sociETy
savE ThE daTE
sEpTEMBEr 23
The new tradition continues.
Members and guests are
invited to schmooze, graze,
and relax with colleagues
while enjoying live music
and watching the sun set
over narragansett Bay.
EaT, driNK, BE chuMMy
nosh and mingle waterside
at the squantum association.
entertainment by alpert Medical
school’s own Chords of Bilroth.
6:30pm
Convivi um
205Th aNNual MEETiNg
inauguration of officers and
award presentations:
dr. Charles L. hill award
dr. herbert rakatansky award
dr. John Clarke award
Third aNNual riMs MEMBErs
waTch for your iNviTaTioN laTEr This suMMEr!
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 34R h o d e I s l a n d m e d I c a l j o u R n a l
rhodE islaNd MEdical sociETy
Working for You: RIMS advocacy activitiesWorking for You: RIMS advocacy activities
June 1, WednesdayMeeting with Chairman Miller, Senate Health and Human Services Committee, at RI Urological Society: Mark Sigman, MD
Legislative Hearings
Meeting to discuss legislation: Michael Migliori, MD
June 2, ThursdayWarren Alpert Medical School Dual Degree Program Seminar: Josiah Rich, MD; Thomas Bledsoe, MD; Steve DeToy, staff
Rhode Island Diabetes Council: Newell Warde, RIMS staff
June 3, FridayMeeting with PhRMA regarding opioid issues, Washington, DC
June 6, MondayRIMS Council Meeting
June 7, TuesdayRIMS Physician Health Committee: Herbert Rakatansky, MD, Chair
Legislative hearings
Senator Kettle fundraiser
June 8, 2016, WednesdayBoard of Medical Licensure and Discipline meeting
Governor’s Opioid Taskforce: Gary Bubly, MD, Past President, Taskforce member
Legislative hearings
June 9, ThursdaySIM Steering Committee: Peter Hollmann, MD
June 10–15, Fri–WedAMA House of Delegates Meeting, Chicago: Peter Hollmann, MD; Alyn Adrain, MD; Sarah Fessler, MD; RIMS staff
June 14, TuesdayLegislative Hearings
RIMS member special event: Grilled Pizza Class
June 15, WednesdayPrimary Care Physician Advisory Committee
Reach Out and Read RI, Board of Directors: Steven R. DeToy, Board Member
Legislative Hearings
June 16, Thursday Legislative Hearings
June 17, FridayDiabetes Prevention Stakeholder Network: Newell Warde, RIMS staff
Legislative Hearings
June 18, SaturdayLegislature Adjourns
June 20, MondayBlue Cross Blue Shield of RI; meeting with new President, Kim Keck
June 21, TuesdayConference call AMA, Department of Health, and Department of Behavioral Health, Developmental Disabilities and Hospitals regarding SAMSHA opioid grant
OHIC Health Insurance Advisory Committee meeting
June 22, WednesdayRhode Island Medical Journal: centennial planning
June 23, ThursdayLifespan Resident Orientation: Presentation by Herbert Rakatansky, MD, and Kathleen Boyd, MSW, LICSW, Physician Health Program; new member recruitment, Diane R. Siedlecki, MD, Co-chair, Membership Committee
June 27, MondayUS Department of Labor, Women’s Bureau Roundtable on Temporary Caregivers’ Insurance
Grilled Pizza Class riMs hosted this special event
for members at the easy
entertaining Café on June 14.
Members and riMs staff en-
joyed an evening of culinary
fun, learning to throw dough
and grill pizza to perfection.
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 35R h o d e I s l a n d m e d I c a l j o u R n a l
THE RHODE ISLAND MEDICAL SOCIETY HOSTS DATA BREACH AND YOUR PRACTICE:
NEW REGULATIONS AND THEIR IMPLICATIONS
WEDNESDAY, AUGUST 31, 2016 RHODE ISLAND MEDICAL SOCIETY 405 PROMENADE STREET, SUITE A
PROVIDENCE, RI 02908
AGENDA
7:30 am—8:00 am: Continental Breakfast
8:00 am—9:00 am: Expert Panel Presentations I) 2016 regulations and some of the latest breaches Jeffrey F. Chase-Lubitz, Esq., Donoghue Barrett & Singal, PC
II) A case study and compliance audit for a medical practice Chris Sheehan, Compliance Agent, Shred-it
III) Insurance options for your practice David White, Partner, Butler & Messier Insurance Robert Anderson, Jr., President, RIMS Insurance Brokerage Corporation
9:00 am—9:30 am: Question & Answer
This Event is Free to the Members of the RI Medical Society and their staff. Please visit www.rimed.org for further registration information.
Senior Physicians: Addressing Age, Ability and Acumen … exploring challenges and opportunities for senior physicians as well as implications for healthcare systems, regulatory agencies, and medical practices
Friday, September 30, 2016 8:00am to 4:00pm
Crowne Plaza, Warwick, RI This conference is made possible through an educational grant from the Coverys Community Healthcare Founda-tion. Program agenda and registration details may be found here or at www.rimed.org
R I M S Special E V E N T
MILE AND A QUARTER
334 South Water Street, Providence
ESCAPE RHODE ISLAND
385 South Main Street, 2nd Floor, Providence
THURSDAY, SEPTEMBER 8 , 20165:00–6:30 pm Mingle at Mile and a Quarter6:50–8:30 pm Teams participate in one of three games The Study 21% success rate, record time 34:22The Gallery 15% success rate, record time 39:10
Ex Machina 12% success rate, record time 45:29
FOR RIMS MEMBERS AND THEIR GUESTS$60 per person Limited space availability, RSVP by September 1Reserve via the Member Portal on www.rimed.org or contact Megan Turcotte at 401-331-3207
P U Z Z L E C H A L L E N G EMingle with your colleagues over a bite to eat at the Mile and a Quarter, then walk to Escape Rhode Island where your team will try to escape a mysterious room by solving a series of puzzles.
r i m s c o r p o r a t e a f f i l i a t e s
Care New England was founded in 1996 and is the parent organization of Butler, Kent, Memorial and Women & Infants hospitals, the VNA of Care New England, The Providence Center, CNE Wellness Center and Integra, a certified Accountable Care Organization. Care New England includes 970 licensed beds and 216 infant bassinets. Through Butler, Memorial and Women & Infants, Care New England has a teaching and research affiliation with The Warren Alpert Medical School of Brown University. Kent is a teaching affiliate of the University of New England College of Osteopathic Medicine.
Established in 1817, Claflin has been supplying medical equipment to physicians, clinics, and hospitals in the New England Region for nearly 200 years. Claflin is a leading medical equipment specialist, and now nationwide and abroad through our secure website. Claflin is a full-line distributor of medical and surgical products sourced from over 500 regional, national and international suppliers. We specialize in advanced logistics programs which are custom designed to fit the needs of all healthcare providers throughout the continuum of care.
www.claflin.com
The Rhode Island Medical Society continues to drive forward into the future with the implementation of various new programs. As such, RIMS is expanded its Affinity Program to allow for more of our colleagues in healthcare and related
business to work with our membership. RIMS thanks these participants for their support of our membership.
Contact Megan Turcotte for more information: 401-331-3207 or [email protected]
Neighborhood Health Plan of Rhode Island is a non-profit HMO founded in 1993 in partnership with Rhode Island’s Community Health Centers. Serving over 185,000 members, Neighborhood has doubled in membership, revenue and staff since November 2013. In January 2014, Neighborhood extended its service, benefits and value through the HealthSource RI health insurance ex-change, serving 49% the RI exchange market. Neighborhood has been rated by National Committee for Quality Assurance (NCQA) as one of the Top 10 Med-icaid health plans in America, every year since ratings began twelve years ago.
www.nhpri.org
www.ripcpc.com
www.carenewengland.org
Doctor’s Choice provides no cost Medicare consultations. Doctor’s Choice was founded by Dr. John Luo, a graduate of the Alpert Medical School at Brown University to provide patient education and guidance when it comes to choosing a Medicare Supplemental, Advantage, or Part D prescription plan. Doctor’s Choice works with individuals in RI, MA, as well as CT and helps compare across a wide variety of Medicare plans including Blue Cross, United Health, Humana, and Harvard Pilgrim.
RIPCPC is an independent practice association (IPA) of primary care phy-sicians located throughout the state of Rhode Island. The IPA, originally formed in 1994, represent 150 physicians from Family Practice, Internal Medicine and Pediatrics. RIPCPC also has an affiliation with over 200 specialty-care member physicians. Our PCP’s act as primary care providers for over 340,000 patients throughout the state of Rhode Island. The IPA was formed to provide a venue for the smaller independent practices to work together with the ultimate goal of improving quality of care for our patients.
RHODE ISLAND MEDICAL SOCIETY
A. LOUIS MARIORENZI, M.D. ARTHROSCOPIC SURGERY*
LOUIS J. MARIORENZI, M.D. JOINT REPLACEMENT SURGERY
GREGORY J. AUSTIN, M.D. HAND SURGERY
MICHAEL P. MARIORENZI, M.D. SPORTS MEDICINE
CHRISTOPHER N. CHIHLAS, M.D. ORTHOPAEDIC SURGERY
KENNETH R. CATALLOZZI, M.D. GENERAL ORTHOPAEDICS
725 Reservoir Avenue, Suite 101 Cranston, RI 02910 • (401) 944-3800
Orthopaedic Associates, Inc.
Orthopaedic Medicine and Surgery with subspecialty expertise*
IRA J. SINGER, M.D. RECONSTRUCTIVE SURGERY AND SPORTS MEDICINE
SIDNEY P. MIGLIORI, M.D. RECONSTRUCTIVE SURGERY AND SPORTS MEDICINE
JOSEPH T. LIFRAK, M.D. GENERAL ORTHOPAEDICS AND SPORTS MEDICINE
LISA K. HARRINGTON, M.D. ADULT RHEUMATOLOGY
ROBERT J. FORTUNA, M.D. GENERAL ORTHOPAEDICS
NATHALIA C. DOOBAY, D.P.M. MEDICINE AND SURGERY OF THE FOOT AND ANKLE
2138 Mendon Road, Suite 302 Cumberland, RI 02864 • (401) 334-1060
RIMS gratefully acknowledges the practices who participate in our discounted Group Membership Program
For more information about group rates, please contact Megan Turcotte, RIMS Director of Member Services
rhodE islaNd MEdical sociETy
apply for MEMBErship oNliNE
The Rhode Island Medical Society delivers valuable member
benefits that help physicians, residents, medical students,
physican-assistants, and retired practitioners every single
day. As a member, you can take an active role in shaping a
better health care future.
RIMS offers discounts for group membership, spouses, mil-
itary, and those beginning their practices. Medical students
can join for free.
Why You Should Join the Rhode Island Medical Society
riMs MEMBErship BENEfiTs iNcludE:
Career management resourcesInsurance, medical banking, document shredding, collections, real estate services, and financial planning
Powerful advocacy at every levelAdvantages include representation, advocacy, leadership opportunities, and referrals
Complimentary subscriptionsPublications include Rhode Island Medical Journal, Rhode Island Medical News, annual Directory of Members; RIMS members have library privileges at Brown University
Member Portal on www.rimed.orgPassword access to pay dues, access contact information for colleagues and RIMS leadership, RSVP to RIMS events, and share your thoughts with colleagues and RIMS
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 R h o d e I s l a n d m e d I c a l j o u R n a l 39
M E D I C A L P R O F E S S I O N A L L I A B I L I T Y I N S U R A N C E
COMMITTED TO RHODE ISLANDTrusted Guide, Guard and Advocate to
Rhode Island Physicians for Over 20 Years
Learn more about NORCAL Mutual today. Call us at 401.824.7550
© 2016 NORCAL Mutual Insurance Company. nm0681
NORCAL Mutual has a legacy of serving Rhode Island physicians and health care professionals, and our
commitment to you remains steadfast. Rhode Island is important to us and we’re here to stay.
As one of the nation’s leading providers of medical professional liability insurance, NORCAL Mutual
combines the benefits of local resources with the financial strength and stability of a national carrier:
• A dedicated Rhode Island office since 1995
• Peace of mind from being insured by a company with an A.M. Best “A” (Excellent) rating for 32 consecutive years
• A new, enhanced Health Care Professional policy with increased limits for administrative defense and cyber liability
• Industry-leading risk prevention and claims handling services with 24/7 urgent live phone support
NORCALMUTUAL.COM/RHODEISLAND
RI Foundation awards $480,000 for medical research
proVidenCe – The Rhode Island Foundation has awarded more than $480,000 in seed funding for 20 promising medical research projects ranging from reducing heart failure among people who are overweight to developing stress-reduction techniques to prevent pre-term births.
The grants are intended to help early-career researchers advance projects to the point where they can compete for national funding.
A review panel made up of scientists and physicians assisted the Foundation in reviewing the medical research proposals. The grants are:
• $25,000 to Brown University Department of Neuroscience for the research project entitled “Multiple functions of the cell adhesion molecule TAG-1 in motor circuit development” led by alExaNdEr JaworsKi, phd.
• $25,000 to Brown University Department of Cognitive, Linguis-tic, and Psychological Sciences for the research project entitled “Exam-ining How Autism Spectrum Disor-ders Affect Social Causal Learning” led by JosEph ausTErwEil, phd.
• $25,000 to Brown University School of Engineering for the research proj-ect entitled “Temporal Geometric Control of Stem Cell Chondrogene-sis for Osteoarthritis Therapy” led by aNiTa shuKla, phd.
• $25,000 to Brown University for the research project entitled “Regulation of human neural stem cell function by the pro-longevity FOXO transcription factors” led by ashlEy wEBB, phd.
• $25,000 to Brown University School of Engineering for the research project entitled “Micro-scopic in vivo imaging of cerebral dynamics in ischemic stroke” led by JoNghwaN lEE, phd.
• $25,000 to Miriam Hospital for the research project entitled “Address-ing sexual networks and the burden of sexually transmitted diseases in Providence, Rhode Island” led by philip chaN, Md, Ms.
• $25,000 to Rhode Island Hospital for the research project entitled “miR-146a prevents cartilage degeneration in mouse osteoarthritis model” led by yiNgJiE guaN, Md, phd.
• $22,222 to Rhode Island Hospital for the research project entitled “Home Blood Pressure Monitoring to Track Post-Discharge Blood Pres-sures In At Risk Individuals” led by EliZaBETh goldBErg, Md.
• $22,000 to Rhode Island Hospital for the research project entitled “Caenorhabditis elegans as a host model to study multi-drug resis-tance in Candida glabrata” led by diMiTrios farMaKioTis, Md.
• $15,000 to Rhode Island Hospital for the research project entitled “Merging a National Hospital Trauma Registry with Post-Acute Care Data in Older Adults with TBI” led by MarK ZoNfrillo,
Md, MscE.
• $24,947 to URI Foundation for the research project entitled “Improving influenza vaccine efficacy in the elderly with a novel physical adju-vant” led by xiNyuaN chEN, phd.
• $23,695 to URI Foundation for the research project entitled “Use of Gold Nanoparticles to Enhance the Effect of Radiation on Cancer” led by MichaEl aNTosh, phd.
• $24,598 to Women & Infants Hospi-tal for the research project entitled “Initiating metformin after delivery in post-partum women at high risk for diabetes mellitus: A Pilot Study” led by EriKa wErNEr, Md. v
• $25,000 to Miriam Hospital for the research project entitled “Fecal Microbiota Transplant by Enema in Severe Clostridium difficile Infec-tion” led by collEEN KElly, Md.
• $24,334 to Miriam Hospital for the research project entitled “Mind-fulness-based Stress Reduction to Prevent Preterm Birth” led by MargarET BuBliTZ, phd.
• $24,758 to Ocean State Research Institute, Inc. for the research proj-ect entitled “Magnesium Supple-mentation for Primary Prevention of Heart Failure in Obesity” led by siddiquE aBBasi, Md.
• $25,000 to Rhode Island Hospital for the research project entitled “Targeting aspartate-beta hydrox-ylase as a chemoprevention for cholangiocarcinoma” led by chiuNg-KuEi huaNg, phd.
• $25,000 to Rhode Island Hospital for the research project entitled “BKCa activation and metabolic syndrome- induced vasomotor dysfunction” ledby richard clEMENTs, Bs, Ms, phd.
• $25,000 to Rhode Island Hospital for the research project entitled “IRE1 branch of the unfolded pro-tein response and arrhythmias” led by MaN liu, phd.
• $25,000 to Rhode Island Hospital for the research project entitled “Elu-cidating How Matrilin-3 Prevents Accelerated Osteoarthritis” led by chaThuraKa Jayasuriya, phd.
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 41R h o d e I s l a n d m e d I c a l j o u R n a l
iN ThE NEws
RECOVERING YOUR MONEY WITHOUT ALIENATING YOUR PATIENTS
WE CARE BECAUSE YOU CARE
••••
24/7 Online Client Management System
For a free consultation call Carmella Beroth at 508-553-1916 or visit www.debtmanagementinc.com
While National Companies are sending their collection calls overseas, all our calls to your patients are made from our
local office.
Exclusive Collection Agency for:
“Collecting the Uncollectible”
Your passion is to help people be and stay well, but at the end of the day, you are running a business. Let Debt Management, Inc. help recover the funds to keep your business running!!
New day, new adventuresAetna is proud to support the members of the Rhode Island Medical Society.
Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna).
©2016 Aetna Inc. 2016021
Quality health plans & benefitsHealthier livingFinancial well-beingIntelligent solutions
PROFESSIONAL OFFICE SPACE FOR LEASE
serving Barrington’s small business and professional community for
over 36 years, and providing high visibility, convenient rental space
in an ideal location to meet the demands of a growing business.
We see a great fit for health care professionals in this 1,680 sq. ft.
multi-unit ground level unit. it is conveniently located in the bustling
center of Barrington with high visibility, plenty of off street parking.
Contact us to find out more: 401-440-1725, fcmd1974@gmail.
com, or https://sites.google.com/site/cpob147
Pediatric Anxiety Research Center moves to Bradley campusClinical and research branches united in one collaborative setting
easT proVidenCe – Bradley Hospital’s Pediatric Anxiety Research Center (PARC) has relocated its clinical and research services to the hospital’s main campus in East Prov-idence. The move unifies and expands its pediatric obses-sive-compulsive disorder and anxiety treatment programs, leading research and education/training in one central loca-tion. PARC’s services – previously located at the Coro West Building – are offered in Bradley’s newly expanded outpa-tient building in a patient- and family-centered environment optimized for milieu-based therapy.
PARC treats children ages five to 18 who experience significant impairment in their daily lives due to anxiety and obsessive-compulsive (OC) spectrum disorders. It is home to the Intensive Program for Obsessive Compulsive Disor-der, one of many nationally-recognized programs that brings families to Bradley Hospital. PARC is led by a team of child behavioral experts who specialize in the assessment and treat-ment of OCD and anxiety disorders, including social anxiety, phobias, panic disorder, illness anxiety and OC spectrum disorders, such as Tourette syndrome, tic disorders, body dysmorphic disorder , skin-picking, and trichotillomania (hair-pulling).
“Centralizing our services in one convenient, modern facility allows us to easily access the latest treatment options and various levels of care to help children with complex anx-iety disorders,” said JENNifEr frEEMaN, phd, director of research and training. Freeman leads the program with aBBE
garcia, phd, clinical director, and Brady casE, Md, medical director.
PARC is a nationally recognized, leading research group in pediatric OCD and anxiety, continually receiving National Institute of Mental Health research funding since 1998. The center focuses on developing and evaluating treatment pro-tocols; improving understanding of psychological and biolog-ical factors in pediatric OCD, anxiety, and tic disorders; and training providers in the community to deliver evidence-based treatment. PARC was one of three sites in the U.S. for the Pedi-atric OCD Treatment Studies, the largest federally-funded
treatment outcome studies for youth with OCD. “Approximately one in eight children is affected by an
anxiety disorder, which if left untreated can lead to school avoidance, withdrawal from family and friends, loss of inter-est in activities, substance abuse and problems eating and sleeping,” Freeman added.
PARC’s patients benefit from the center’s research by receiving the latest, proven treatments and therapies. Patients with OCD or anxiety participate in exposure and response prevention (ERP), a specific form of cognitive behavioral therapy (CBT) proven to be the most effective form of treatment for anxiety.
The move to Bradley’s campus and expansion of PARC’s services enabled the program to grow its research opportu-nities and clinical services for children and adolescents with tics – sudden, uncontrollable body sounds or movements. Tics occur in approximately one out of five school-age chil-dren and may persist into adolescence and adulthood. Tic Talk is PARC’s 8-week group program that utilizes Compre-hensive Behavioral Intervention for Tics (CBIT), a research-based therapy aimed to help reduce tics and improve overall functioning for youth. v
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 R h o d e I s l a n d m e d I c a l j o u R n a l 43
iN ThE NEws
Patients deserve a healthcare experience they can trust. Keep private information private with Shred-it. We protect what matters.
Call 800-697-4733 or visit shredit.com
Document Destruction | Hard Drive Destruction | Workplace Security Policies | Online Compliance Training
We protect patient privacyWe protect patient privacy
RIMJ_Ad_8.5x11.indd 1 2016-03-14 10:10 PM
NIH awards Brown $11.5M for computational biology researchBrown University will launch a Center for Biomedical Research Excellence in Computational Biology of Human Disease to expand its research using sophisticated computer analyses to understand and fight human diseases.
proVidenCe — With a new five-year, $11.5 million grant from the National Institutes of Health, Brown Univer-sity will expand its research in com-putational biology and launch a new Center of Biomedical Research Excel-lence (COBRE), which will support five early career faculty members as they tackle the genomics underlying diseases such cancer, preeclampsia and severe lung infections.
“There’s data and then there’s information,” said david raNd, director of the new center and chair of the Department of Ecology and Evolutionary Biology (EEB). “Turning data into information you can use for something is what computational biology is all about.”
The new center will bring together diverse teams of researchers to gen-erate new insights to advance medi-cine and health, said david saviTZ, Brown’s vice president for research.
“Brown scientists and students from a number of departments around the University – from com-puter science and applied mathemat-ics to biology, medicine and public health – have been working collabo-ratively to understand and realize the benefits of advanced genomics,” said Savitz, who is also a professor in the School of Public Health. “This new COBRE will expand those programs to help move Brown to the forefront of this exciting, promising field of research.” v
South County Health opens Medical & Wellness Center in WesterlyWesTerLY – After three years in planning and construction, the South County Health Medical & Wellness Center in Westerly welcomed its first patients May 23.
The 32,000 square foot Center, located at 268 Post Rd. (Rt. 1) in Westerly, is home to more than a dozen medical services, including primary care physicians, OB/GYNs, dermatologists, orthopedic surgeons, cardiologists, podiatrists, a gen-eral surgeon, diabetes management, urgent/walk-in care, lab, x-ray, ultrasound, and 3-D mammography among the array of services available.
The urgent/walk-in center is open seven days a week. v
Fatima opens Long-Term Behavioral Health UnitWill assist with state waiting list
proVidenCe – CharterCARE Health Partners and Our Lady of Fatima Hospital re-cently opened a Long-Term Behavioral Health Unit, where beds will be immediately available to patients on the waiting lists for long-term psychiatric care at the state’s Eleanor Slater Hospital.
The new 20-bed unit offers the following:
• Dedicated open community spaces;
• Several acres of outdoor space for walking;
• An evidence-based care model that offers a variety of individual, family, and group modules, and that incorporates principles of rehabilitation and recovery;
• The opportunity for patients to develop positive coping and daily living skills that will enhance patient autonomy and individual decision-making;
• A multi-disciplinary team with Psychiatry, Nursing, CNAs, Licensed clinicians, Milieu Therapists, and Occupational Therapists who routinely receive training for best practices in the treatment of patients on the new long-term unit.
rEBEcca ploNsKy, licsw, CharterCARE Vice President of Integrated Behav-ioral Health, worked in partnership with the Rhode Island Executive Office of Health and Human Services, the Department of Behavioral Healthcare, Disabilities and Hos-pitals, and the Rhode Island Department of Health to reach the agreement to create the dedicated long-term unit. v
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 45R h o d e I s l a n d m e d I c a l j o u R n a l
iN ThE NEws
Elizabeth Messier800.886.1775
Preferred Real Estate Company of
Celebrating 35 Years of Proven Results
CE
LE
BR
AT I N G
View the Video at 15Bayside.com
For the past 35 years, we have been Rhode Island’s first choice for real estate. Whatever your needs may be, we’ve got you covered, including:
• Selling Your House - We utilize innovative technology and marketing tools to gain maximum exposure for our listings around the globe.
• Finding Your Next Home - Downsizing? Looking for a vacation home? We’ll help you find your next home locally, nationally, or anywhere around the world.
• Recruiting - The FREE services offered by our award-winning Relocation Department will help you attract top talent to Rhode Island. Let us show your recruits why our state is such a special place to work and live!
Peter Snyder, PhD, to Head Statewide Committee on Neuroscience Research
Panel will guild partnership of Lifespan, Brown, URI, Care New England and Providence VA
pETEr J. sNydEr, phd, senior vice president and chief research officer at Lifespan, has been named the inaugural chairman of the Rhode Island Neurosciences Leadership and Steering Commit-tee, the panel responsible for lead-
ing a collaboration of Rhode Island’s most prominent research institutions engaged in the brain sciences.
sTEvEN rasMussEN, Md, chair of the department of psychiatry and human behavior at the Alpert Medical School of Brown University, and representing Care New England on the committee, will serve as vice chair.
The new 10-member committee also announced at its first meeting last month that the collaboration has $200,000 in seed money. The committee is working on a thorough as-sessment of the organizations’ resources and capabilities, and identifying shared interests in the neurosciences.
A memorandum of understanding was signed last year by leadership from Lifespan, Brown University, the University of Rhode Island, Care New England and the Providence VA Medical Center.
The five institutions will focus on identifying causes and potential treatments for a wide range of diseases and disorders, including Alzheimer’s disease, epilepsy, stroke, traumatic brain injury and autism.
“The neurosciences are a broad area of study, one in which we have the potential to effect some real advancements in our lifetime,” said Snyder. “It is not commonplace for academic and medical institutions to collaborate, rather than compete. The sharing of mutual goals by these institutions will allow us to maximize our resources, in terms of personnel, physical research space, and, of course, funding. I am honored to have been chosen as the first leader of this exciting endeavor.”
Along with creating a critical mass in attracting large grants, Snyder says the partnership has started exploring ini-tiatives like research opportunities for students of the neuro-sciences and planning a statewide research conference around brain sciences. v
Dr. Albert Woo Named Chief of Pediatric Plastic Surgery at Hasbro Children’s HospitalproVidenCe– Hasbro Children’s Hospital has appointed alBErT
s. woo, Md, as chief of pediat-ric plastic surgery and director of its Cleft and Craniofacial Center. Woo is a board-certified plastic
and reconstructive surgeon who treats children and adults af-fected by a variety of facial and body malformations. He also serves as a faculty member in the department of surgery at the Warren Alpert Medical School of Brown University.
Woo most recently served as chief of pediatric plastic surgery at St. Louis Children’s Hospital.
“Dr. Woo has more than a decade of clinical experience and is nationally recognized for his skills in complex craniofacial reconstruction,” said paul liu, Md, chief of plastic surgery at Rhode Island Hospital and its pediatric division, Hasbro Children’s Hospital. “Because pediatric plastic surgery can be an understandably emotional process for families, we are for-tunate to have Dr. Woo who is not only innovative and tech-nically skilled but brings compassionate care to his patients and their families.”
Woo’s clinical interests include craniofacial surgery, cleft lip and palate, facial reconstruction, cosmetic procedures, treatment of moles and vascular malformations, hand surgery, trauma reconstruction and facial paralysis. He is an expert in the field of endoscopic craniosynostosis surgery and cranio-facial reconstruction. He has pioneered a new technique for cleft palate repair that improves speech outcomes in both primary and secondary operations.
Published in more than 40 peer-reviewed publications, Woo’s research interests include cleft lip and palate, velopha-ryngeal insufficiency, craniosynostosis (endoscopic and open), robotic plastic surgery and 3D printing technology.
He earned his medical degree at the Warren Alpert Medical School of Brown University and completed his residency in plastic surgery at Rhode Island Hospital. He also completed a fellowship in craniofacial surgery at the University of Wash-ington School of Medicine in Seattle.
Woo currently is a member of the American College of Sur-geons, the American Society of Maxillofacial Surgeons, the American Cleft Palate-Craniofacial Association and the Amer-ican Society of Plastic Surgeons. He is the recipient of numer-ous awards including Best Doctors in America since 2011. v
people
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 47R h o d e I s l a n d m e d I c a l j o u R n a l
Appointments
Signature 3-story v Newly Remodeled Office building on Providence’s East Side (between Angell Street & Waterman Avenue)
Available Summer of 2016 Brokers Protected
CONTACTDR. MICHAEL FOLLICK
(401) 527-7527
FOR LEASE285 GOVERNOR STREET PROVIDENCE, RI 2,000 to 8,000 sq. ft.
v New HVACv Gas heatv Voice/Data linesv 55 Parking Spaces
v Fire alarmv Sprinklersv Handicap accessible
with elevator
Southcoast Health President & CEO Keith Hovan to Chair Massachusetts Hospital Association Board of Trustees
KEiTh hovaN, President & CEO of Southcoast Health in Southeastern Massachusetts was recently named the 76th Chair of the Massachusetts Hospital Association Board of Trustees. In his inaugural address, Hovan noted the unique responsibilities of healthcare institution and organization leaders.
“As executives, we have a special role within health-care,” Hovan said. “We do not diagnose disease. But we ensure that our hospitals and clinics are staffed with the highly skilled clinicians who can. We do not remove tumors or set bones. But we help provide the operating rooms and high-tech equipment for those who do. And we do not deliver infants. But we help provide the best set-tings for our obstetrics professionals to usher in new life. We work every day to make sure that our hospitals, clinics and health centers deliver safe, high quality care at a cost that patients, businesses and, indeed, society can bear.” v
Dr. Donald Coustan appointed to committee of American Diabetes AssociationproVidenCe – doNald r. cous-
TaN, Md, of Jamestown, director of the Division of Maternal-Fetal Med-icine’s Diabetes in Pregnancy Pro-gram at Women & Infants Hospital of Rhode Island and a professor of ob-stetrics and gynecology at The Warren Alpert Medical School of Brown Uni-
versity, has been appointed to serve a two-year term of the Profes-sional Practice Committee of the American Diabetes Association.
Dr. Coustan was chairman of the Department of Obstetrics and Gynecology at Women & Infants and the Alpert Medical School from 1991 to 2008. He is a past president of the Society for Mater-nal-Fetal Medicine, past board member of the American Diabetes Association, and has held numerous other national positions. v
people
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 48R h o d e I s l a n d m e d I c a l j o u R n a l
Appointments
Rhode Island’s Medical Staffing Experts!As a Valued Sponsor of the Rhode Island Medical Society, Favorite Healthcare Staffingprovides a comprehensive range of staffing services at preferred pricing to RIMS members.
Serving the Rhode Island healthcare community since 1981, Favorite sets the standardfor quality, service, & integrity in medical staffing. Call today and let us show you why weare The Favorite Choice of Physician Practices and Healthcare Professionals across the US!
One Call Does It All!Phone: 401-354-7115Email: [email protected]
Joint Commission Health CareStaffing Services Certification
AA / EOE / M / F / V / D
One Call Does It All!401-354-7115
Favorite Healthcare Staffing is a ValuedSponsor of the Rhode Island Medical Society
Recognition
Kent, Memorial Recognized for Quality Stroke Care by American Heart/ American Stroke Association
proVidenCe – Kent and Memorial hospitals have been recognized by the American Heart Association/American Stroke Association for their commitment to quality stroke care.
Kent Hospital has received the American Heart Association/American Stroke Asso-ciation’s Get With The Guidelines®-Stroke Gold Plus Quality Achievement Award with Target: StrokeSM Honor Roll. Memorial Hos-pital has received the American Heart Asso-ciation/American Stroke Association’s Get With The Guidelines®-Stroke Gold Plus Quality Achievement Award. These awards recognize the hospitals’ commitment and success in ensuring stroke patients receive the most appropriate treatment according to nationally recognized, research-based guide-lines based on the latest scientific evidence.
Hospitals must achieve 85 percent or higher adherence to all Get With The Guide-lines-Stroke achievement indicators for two or more consecutive 12-month periods and achieve 75 percent or higher compliance with five of eight Get With The Guidelines-Stroke Quality measures to receive the Gold Plus Quality Achievement Award.
To qualify for the Target: Stroke Honor Roll, hospitals must meet quality measures developed to reduce the time between the pa-tient’s arrival at the hospital and treatment with the clot-buster tissue plasminogen acti-vator, or tPA, the only drug approved by the U.S. Food and Drug Administration to treat ischemic stroke. If given intravenously in the first three hours after the start of stroke symptoms, tPA has been shown to signifi-cantly reduce the effects of stroke and less-en the chance of permanent disability. Kent Hospital earned the award by meeting specif-ic quality achievement measures for the diag-nosis and treatment of stroke patients at a set level for a designated period. v
Lynn E. Taylor, MD, accepts certificate honoring the program she created, rhode island
defeats hepatitis C, from Karen B. desalvo, Md, acting assistant secretary for health, U.s.
department of health and human services (hhs), at a White house event in May, the first
time hhs presented awards for hepatitis testing. The 12 non-profit organizations honored
were selected based on their success in reaching out to underserved populations and getting
people tested and linked into care. dr. Taylor developed and directs Miriam hospital’s hiV/
Viral hepatitis Coinfection program.
Lianna Karp, Md ’16, shown with herbert rakatansky, Md, received the herbert rakatansky
prize at the alpert Medical school in May. The award was endowed by the rhode island
Medical society in 2012 and is given to the graduating senior medical student who has done
the most to promote the well-being of her/his fellow medical students.
people
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 50R h o d e I s l a n d m e d I c a l j o u R n a l
Recognition
dr. susan MacKenzie, director of the providence Va Medical Center, dr. satish sharma, chief of
staff, far left, and dr. paul pirraglia, chief of primary Care, second from left, present dr. Monty
VanBeber with the Va secretary’s hands and heart award Monday, June 13, 2016. The award
recognizes Va employees whose dedication to Veterans is marked by the highest standards in
patient care. dr. VanBeber oversees primary care at all of the providence VaMC’s communi-
ty outpatient clinics. in addition to his administrative duties, dr. VanBeber works tirelessly to
personally deliver care to Veterans as the primary care physician for many clinic patients in
hyannis and new Bedford, Mass., and Middletown, r.i., as well as on Martha’s Vineyard and
nantucket islands.
Providence VA Dialysis Unit Wins ICARE Award
proVidenCe – dr. MichaEl Mayo-
sMiTh, director of the VA New England Healthcare System, visited the Provi-dence VA Medical Center June 15th and presented an ICARE award to the Prov-idence VAMC’s Dialysis Unit for their exceptional service to veterans.
For the past two years, the unit was one of a select group of recipients of a National VA Renal Disease and Dialysis Office of Specialty Care Award.
Dialysis at the Providence VAMC has also achieved an infection rate of zero for several years, and implemented a Ticket to Ride program to seamlessly transition patients from their hospital bed to hemo-dialysis treatment.
ICARE awards are presented to a VA employee, or group of VA employees, who through their outstanding service, exemplify VA’s core values of integri-ty, commitment, advocacy, respect and excellence. v
dr. andrew Cohen, Chief of nephrology at the
providence Va Medical Center, right, gives a
tour of the new dialysis facility’s state -of-the-
art water treatment plant to dr. Michael Mayo-
smith, director of the Va new england health-
care system, Wednesday, June 15, 2016.
Members of the providence Va Medical Center’s dialysis Unit show-off their iCare awards after a
presentation by dr. Michael Mayo-smith.
pr
oV
ide
nC
e V
aM
C p
ho
To
BY
Win
Fie
Ld
da
nie
Ls
on
people
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 51R h o d e I s l a n d m e d I c a l j o u R n a l
S tay i n g c o m p e t i t i v e in today’s changing healthcare environment can be a challenge. It may require investing in
new technologies, expanding services, even merging with another practice.
For the specialized financing you need to help keep your practice successful, contact Dev Singh
at 401.688.3314 or [email protected].
for a successful practice.
All credit products, pricing and overdraft protection are subject to the normal credit approval process. Some applications may require further consideration and/or supplemental information. Certain terms and conditions may apply. SBA guaranteed products may also be subject to additional terms, conditions and fees. All loans/lines of credit require a Webster business checking account which must be opened prior to loan closing and which must be used for auto-deduct of payment. The Webster Symbol and Webster Bank are registered in the U.S. Patent and Trademark Office.
Specialized financing
Webster Bank is the affinity banking partner for the members of
Specialized Financing - Singh Studio Number: 23422016Ad Code: WFC-AFF-TBD
1/25/16GD: JessieRIMJ
Size: Full Page (8.5” x 11”)Color: 4CMM: Joanne Renna
Blood and Marrow Transplant Program reaccredited by FACT
proVidenCe – The Roger Williams Medi-cal Center Blood and Marrow Transplant program, the only unit of its kind in the state, has been awarded renewed ac-creditation from the Foundation for the Accreditation of Cellular Therapy (FACT) for demonstrating compliance with the
FACT-JACIE International Standards for the full scope of bone marrow transplant programming. The accredita-tion is effective January 2016 for a period of three years.
“Patients with leukemia, lymphoma or other life-threat-ening disease or other blood disorders need the most ef-fective care to improve and prolong their lives,” said dr.
Todd f. roBErTs, Program Director of the Blood and Marrow Transplant Unit and Section of Hematologic Ma-lignancies. “FACT reaccreditation for the program at Rog-er Williams confirms the excellent care and treatment we are delivering to patients in need of transplant services.”
The FACT accreditation process involved an on-site inspection, which took place in December 2015 and was conducted by inspectors qualified by training and experi-ence in cellular therapy. FACT accreditation is embraced by the overwhelming majority of transplant programs. More than 90% in the United States are FACT accredited.
A dedicated unit located in the hospital is supplied with high-efficiency particulate air-filtration systems that provide protection to patients who cannot resist in-fection. Patients are monitored through a centralized in-tensive care patient monitoring system, which includes highly skilled nurses who have expertise in high-dose, an-ti-tumor chemotherapy administration and management of transplant-related side effects.
The unit is a full-service program, which provides compassionate care to patients diagnosed with acute and chronic leukemia, lymphoma, multiple myeloma, aplas-tic anemia, and myelopdysoplastic syndrome.
This voluntary accreditation is based upon compliance with the most comprehensive standards in the field, veri-fied by rigorous peer-reviewed inspections. FACT-accred-ited organizations voluntarily seek and maintain FACT accreditation through a rigorous process, demonstrating their belief that patient needs are paramount.
The accreditation includes adult allogeneic and au-tologous transplantation, hematopoietic progenitor cell transplantation, marrow and peripheral blood cellular therapy product processing with minimal manipulation, and cellular therapy product processing with minimal manipulation. v
Southcoast Centers for Cancer Care earns national seal of accreditation from the American College of Radiology
neW BedFord, Mass. — The Southcoast Centers for Cancer Care, part of Southcoast Health, has been awarded a three-year term of accreditation in radiation oncology as the result of a recent review by the American College of Radiology (ACR). The ACR seal of ac-creditation represents the highest level of quality and patient safety.
“American College of Radiology certification for radiation oncolo-gy has been the gold standard in our field for quite some time, yet has historically not been achievable by many institutions – even some of the most renowned,” said Sheri Weintraub, MS, DABR, Director and Chief Physicist of Radiation Oncology for Southcoast Centers for Cancer Care. “Certification requires an organized, systematic, and well-documented adherence to published best practices. As simple and reasonable as this sounds, there are many ways to follow best practices and it took a lot of focused teamwork to develop standard operating procedures that utilized the best of what each of us brought to the table. Developing those procedures was one thing, and holding ourselves accountable was another. We spent countless hours track-ing and evaluating data to determine where our weak areas were and what was being done effectively to improve not only quality, but the patient experience.” v
Obituarydr. louis viNcENT sorrENTiNo died on June 12, 2016. Born February 19, 1923 in Providence, he
was predeceased by his wife, Rosemary Pierrel Sorrentino. Surviving are his brother, Stanley Sorrentino, daugh-ter, Kathy Lytle (Rev. Bern) of Fishers, IN, son, Rev. Dr. Paul Sorrentino (Kar-en) of S. Deerfield, MA. He also leaves behind four grandchildren and eight great-grandchildren.
Military service in World War II short-ened his Princeton studies. After the war, he graduated from Boston Univer-sity Medical School. After his residency, he served for five years as a medical missionary in Japan. Upon returning from Japan, he completed his psychiatric training at Boston State Hospital.
His psychiatric practice began in Rhode Island in 1960. He was a member and Past President of the RI Psychiatric Soci-ety, the American Medical Association and the RI Medical So-ciety. He was active for many years on the RI Medical Society Physician Health Committee and the RI Group Psychotherapy Society of which he was a founder. He was on the staff of RI Hospital and Butler Hospital and a Clinical Assistant Professor of Psychiatry at the Brown University Medical School.
In lieu of flowers, please contribute to the Dean of Pembroke College Endowed Visiting Professorship (Brown University, Gift Cashier, Box 1877, Providence, RI 02912, Butler Hospital (Foundation Office, Butler Hospital, 345 Blackstone Boulevard, Providence, RI 02906) or the charity of your choice. v
people
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 53R h o d e I s l a n d m e d I c a l j o u R n a l
Recognition
The Eleanor Slater Hospital (ESH), with campuses in Cranston and Burrillville, Rhode Island, is seek-ing physicians either board certified or board eligible in Internal Medicine or Family Practice interest-ed in working with our patient population who suffer from acute and long term medical illnesses.
The hospital provides care to patients with both medical and psychiatric disorders. At ESH physicians serving the psychiatric and medical populations work together in a collegial environment. Applicants must be licensed by the State of Rhode Island Department of Health.
Competitive salary and excellent benefits including malpractice insurance coverage, medical, dental/vision, long term disability, paid vacation, 401 K retirement plan, strongly supported continuing medi-cal education with funding provided, and paid physician license renewal fees. Send C.V. to Elinore McCance-Katz, MD, PhD, Medical Director, Eleanor Slater Hospital, 111 Howard Ave., Cranston, RI, 02920; fax 401-462-5242, Email: [email protected]
The american College of obstetrics and
Gynecology (aCoG) recently award-
ed the arnold p. Gold Foundation hu-
manism in Medicine award to Corne-
lius “Skip” Granai III, MD, director of
the program in Women’s oncology at
Women & infants hospital. he was
presented the award at aCoG’s recent
annual meeting.
Dr. Jennifer Gass serves as international breast cancer resourceproVidenCe – JENNifEr s. gass, Md, surgeon-in-chief and co-director of the Breast Health Center at Women & Infants Hospital of Rhode Island, a Care New England hospi-tal, continues to be recognized as an international resource in the field of oncoplastic breast cancer surgery and cancer survivorship issues and was recently invited to participate in two key groups.
Dr. Gass completed a one-month sabbatical at the Paris Breast Center in 2011 in the novel surgical procedure that combines the best techniques from plastic surgery with oncologic surgery to re-move breast cancer, and then brought oncoplastic surgery to Wom-en & Infants, making it the first facility in New England to use it.
Dr. Gass – who has also served as a surveyor for the National Accreditation for Breast Centers, directs the breast fellowship at Women & Infants, and serves as a clinical associate professor at The Warren Alpert Medical School of Brown University – was recently invited faculty to the Internationale Senologic Society in Warsaw, Poland. There, she presented on onco-plastic surgery and served on the Global Breast Health Initiative working group.
“As we gain a greater appreciation of the cancer survivorship journey, we better cata-logue patient reported outcomes in survivorship. Oncoplastic surgery is one technique sur-geons can provide that may empower women who want to preserve and reconstruct their breasts in the most natural looking way at the time the cancer is removed,” Dr. Gass says.
In addition, she was the invited co-chair of the American Society of Breast Surgeon’s survivorship pre-conference course at the group’s recent annual meeting. As such, she was asked to submit a manuscript for the course offering. v
people
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 54R h o d e I s l a n d m e d I c a l j o u R n a l
Recognition
一漀琀 洀愀渀礀 猀洀愀氀氀 戀甀猀椀渀攀猀猀攀猀 愀爀攀 爀攀愀搀礀 琀漀 搀攀愀氀 眀椀琀栀 琀栀攀 挀栀愀渀最攀猀 琀漀 栀攀愀氀琀栀 椀渀猀甀爀愀渀挀攀Ⰰ 挀漀洀瀀氀椀愀渀挀攀Ⰰ 愀渀搀 栀甀洀愀渀 爀攀猀漀甀爀挀攀猀⸀ 圀栀攀琀栀攀爀 椀琀 猀ᤠ 昀椀渀搀椀渀最 琀栀攀 戀攀猀琀 搀攀愀氀 漀渀 栀攀愀氀琀栀 椀渀猀甀爀愀渀挀攀Ⰰ 愀猀猀椀猀琀椀渀最 礀漀甀爀 挀漀洀瀀愀渀礀 眀椀琀栀 戀甀猀椀渀攀猀猀 愀渀搀 䠀䤀倀䄀䄀 挀漀洀瀀氀椀愀渀挀攀Ⰰ 漀爀 欀攀攀瀀椀渀最 甀瀀 眀椀琀栀 琀栀攀 洀漀猀琀 爀攀挀攀渀琀 栀甀洀愀渀 爀攀猀漀甀爀挀攀 爀攀焀甀椀爀攀洀攀渀琀猀Ⰰ 䠀一䤀 椀猀 爀攀愀搀礀 琀漀 栀攀氀瀀 礀漀甀 眀椀琀栀 琀栀攀 猀甀瀀瀀漀爀琀 礀漀甀 渀攀攀搀 琀漀 昀漀挀甀猀 漀渀 眀栀愀琀 爀攀愀氀氀礀 洀愀琀琀攀爀猀 ጠ 礀漀甀爀 瀀愀琀椀攀渀琀猀⸀ 圀椀琀栀 漀瘀攀爀 ㈀ 礀攀愀爀猀 漀昀 挀漀洀戀椀渀攀搀 攀砀瀀攀爀椀攀渀挀攀 椀渀 最爀漀甀瀀 戀攀渀攀昀椀琀猀Ⰰ 䠀一䤀 栀愀猀 琀栀攀 攀砀瀀攀爀琀椀猀攀 琀漀 愀搀瘀椀猀攀 漀渀 琀栀攀 洀漀猀琀 挀漀洀瀀氀攀砀 戀攀渀攀昀椀琀猀 洀愀琀琀攀爀猀Ⰰ 礀攀琀 眀攀 愀爀攀 猀洀愀氀氀 攀渀漀甀最栀 琀漀 欀攀攀瀀 愀 瀀攀爀猀漀渀愀氀 琀漀甀挀栀⸀
䴀愀欀攀 猀甀爀攀 礀漀甀ᤠ爀攀 挀漀瘀攀爀攀搀⸀ 䌀愀氀氀 甀猀 琀漀搀愀礀 㐀 ⴀ㈀㈀㠀ⴀ㠀㤀㔀 漀爀 瘀椀猀椀琀 甀猀
漀渀氀椀渀攀 䠀一䤀椀渀猀⸀挀漀洀
internal Medicine graduates, pictured left to right, were omair Tahir, Md, Umama Gorsi, Md, ameya hodarkar, Md, rachana sedhai, Md, Jae Young
Lee, Md, nicole Yang, Md, Muhammad shafi, Md, anum saeed, Md, arman Uzunyan, Md, Mervat saleh, Md and Fady Marmoush, Md.
Graduation day exercises were held on Friday, June 17, 2016, for residents and fellows completing their training at Memorial hospital of rhode island.
Family Medicine graduates, pictured left to right, were: kneeling front row, Jeremy stricsek, Md, Jeffrey sorokin, Md, samantha Greenberg, Md, sarah
phillips, Md and susan Boisvert, Md. standing, back row, left to right, david dick, do, rachel Trippett, Md, Gabriel pleasants, Md, Katherine Jarrell,
Md, Jessica heney, Md, Laurie Garabedian, do, Bridget Marvinsmith, Md and Michael Chen-illamos, Md.
people
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 56R h o d e I s l a n d m e d I c a l j o u R n a l
RIMS-IBC 405 PROMENADE STREET, SUITE B, PROVIDENCE RI 02908-4811
MEDICAL PROFESSIONAL/CYBER LIABILITY PROPERTY/CASUALTY LIFE/HEALTH/DISABILITY
Some things have not.
Since 1988, physicians have trusted us to meet
their professional and personal insurance needs.
Working with multiple insurers allows us to
offer choice, competitive rates, and the benefit
of one-stop shopping. Call us.
800-559-6711
Some things have changed in the past 27 years.
1915: Poison Pies on the Fourth of July Create Panic in Westerly & Stonington, CT.MarY Korr
riMJ ManaGinG ediTor
Francis T. Brightman, 72, and his wife, Geor-giana, 68, were returning home from the First Baptist Church in Westerly on Sunday, July 4th, 1915 when they stopped for lunch at Alex-ander Ray Gavitt’s restaurant. Known for its homemade pies, the restaurant was located on the bridge spanning the Pawcatuck River between Westerly, RI, and Pawcatuck, CT. For dessert, they each had a slice of pie.
Three days later, the Civil War veteran and his wife were dead. The holiday weekend proved deadly for two others who had also consumed the restaurant’s pies. Timothy J. Sullivan, 49, was the first fatality. He exhibited symptoms of severe food poisoning seven hours after eating
• On Sunday, July 4th, second pastry cook Fred Steiger made two custard and four cocoanut-custard pies.
dr. M.N. scaNloN, medical examiner for Washington County, which includes Westerly, later testified to attending to several patients about midnight on July 4, all of whom had eaten the custard pie at Gavitt’s.
On the morning of July 5th, Alexander Gavitt himself came to Dr. Scanlon’s office with gastroenteritis and leg cramps.
Later that day, Dr. Scanlon went to Gavitt’s restaurant and ordered him to stop selling the pies. He took samples of everything used for cooking in the restaurant and sent them to Providence for analysis by bacteriologists.
At first, Dr. Scanlon and area physicians thought that arse-nic or mercury had gotten into the pies or that ptomaine poisoning had resulted from bacteria present in one or more of the pie ingredients. The food samples were initially tested for heavy metals and alkaloids, with negative results.
the pie and died 36 hours later. Two family members who had eaten the pie became very ill; his young daughter was in a coma for several days, while four other family members who had not eaten the pies were fine.
The fourth victim, Horace Rodman, lingered for three weeks before succumbing. In addition, more than 60 people in southern Rhode Island and border-ing Connecticut, all suffering from acute gastroenteri-tis, violent vomiting and nausea, and severe stomach pain, kept area physicians busy making house calls.
It didn’t take long for the pie panic to spread throughout southern Rhode Island and over the bor-der. Physicians called it an epidemic and sprung into action to determine the cause.
Investigators, both medical and legal, stated the following facts which local newspapers reported:
• Gavitt’s pastry chef, Thomas Fantano, mixed the dough for the holiday pies on Friday, July 2.
• On Saturday, July 3rd, he made 11 coconut pies, six custard, six squash, four lemon, three blueberry, four chocolate and eight apple pies.
A court inquiry was held in Connecticut, where many of the victims, as well as Gavitt himself, lived. As physicians and those who had recovered sufficiently to testify, a star-tling fact emerged – those who ate only the pie filling did not become sick. But those who ate the pie and crust did.
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 R h o d e I s l a n d m e d I c a l j o u R n a l 58
hEriTagE
Pathologists harry s. BErNsTEiN, Md, and EZra s.
fish, Md, of the Rhode Island Board of Health, conducted the investigation which ultimately concluded the outbreak was due to the organism bacillus paratyphosus B which their lab isolated from the pie crust and from samples pro-vided from an autopsy of one of the victims, as well as a dozen blood serums provided by physicians tending those seriously ill who had eaten the pies.
In a report published in JAMA the following January, Drs. Bernstein and Fish noted striking similarities in a food epi-demic resulting from pork pies which occurred in 1910 in Wexham, England: 107 persons in 56 families became seri-ously after eating pork pies; five of them died. The pork pies
all came from the same bakery. Health authorities were able to detect bacillus paratyphosus B in two of the specimens of the pies eaten, and it was also found in the “agglutins for the organism in five persons who had eaten the pies in question.”
The Rhode Island doctors concurred with their English colleagues that “parathyphoid carriers may cause infection not only directly but also by contaminating sound food.”
They emphasized the importance of protecting public food supplies from “disease carriers.”
In the Westerly pie epidemic, the disease carrier was not identified in the medical literature or general press of the day, nor were there any reports of the restaurant staff being tested. v
W W W. r i M e d . o r G | r i M J a r C h i V e s | J U LY W e B p a G e J U LY 2 0 1 6 R h o d e I s l a n d m e d I c a l j o u R n a l 59
hEriTagE