RESidENcy PROGRAM Scholarly and Community Medicine Projects

Madison Family Medicine 

Residency Program 

Scholarly and Community 

Medicine Projects 

from the Class of 2011

David Beckmann, MD 

PROJECTS COMPLETED 

DURING RESIDENCY: 

Scholarly Project: 

Self-Directed Learning Modules relating to 

Care of the Hospitalized Aging Medical Patient 

(CHAMP) 

Community Medicine Project: 

Over the course of the last year, with the help of 

many faculty and support staff at Wingra clinic, we 

were able to begin to offer diabetic group visits to our 

Spanish-speaking patients at Wingra. As many people 

will probably mention tonight, group visits allow 

patients and physicians to discuss chronic disease in a 

larger setting that becomes more patient-centered and 

patient-driven. I decided to focus on Spanish-speaking 

diabetic patients initially as many free clinics and 

available resources are not multilingual in the area. We 

recruited patients with invitation letters and follow-up 

phone calls. During the course of the diabetic group 

visits, patients are given the opportunity to discuss their 

diagnosis, their challenges, and what they’ve learned. 

The patients are able to help each other through 

personal experiences, challenges, and questions. Each 

patient’s history is reviewed during the course of the 

visit with an opportunity for all patients to discuss 

medications, laboratory studies, and monitoring of 

their blood glucose. The hope is to expand this to all 

diabetic patients and eventually to other conditions such 

as smoking cessation. I am hopeful that we can soon 

involve pharmacists, our behavioral health psychologists, 

and nutritionists in delivering a group-centered model of 

care that can focus more time on patient education. 

I would personally like to thank Dr. Patricia Tellez-Giron and Dr. 

Brian Arndt. Dr. Arndt gave me the blueprint for developing group 

visits at Wingra and provided access to helpful documents and tips on 

how to structure the visit. Patricia was instrumental in helping with 

the translation of letters into Spanish and has always been supportive 

of developing different and innovative ways to deliver better care to 

the Latino community. I would also like to thank my lovely wife, 

Stefanie. She is a constant source of happiness for me and without 

her, I would have likely lost my sanity by now! 

– Dave 

David Beckman 

grew up in Chicago 

and earned his B.A. 

in Biology from 

the University of 

Illinois at Urbana- 

Champaign. A fan of 

international travel, 

he has worked as 

a camp counselor 

for impoverished children in Spain, 

volunteered in a French hospital, and 

delivered medical supplies to remote 

villages in Peru. He is a graduate of 

the University of Chicago Pritzker 

School of Medicine and brings to 

his practice a strong commitment 

to helping the underserved. During 

medical school he established a 

University of Chicago night at the 

Community Health Clinic, which takes 

care of primarily uninsured Spanish 

and Polish-speaking patients on the 

west side of Chicago. He has also 

been involved in several research 

studies, including an investigation 

of why patients with regular primary 

care physicians choose the emergency 

room for non-urgent complaints. He 

enjoys reading fi ction and writing 

poems, short stories, and song lyrics. 

He also loves athletics, including 

soccer, ultimate Frisbee, basketball, 

and dance. David is fl uent in both 

Spanish and French. 

CONTACT INFORMATION: 

dbeckmann82@gmail.com 

630 . 212 . 1604

Curriculum for the Hospitalized Aging Medical Patient (CHAMP) 

Delirium Dementia Depression Falls Identifying Frail Elders 

Systems of Care/QI 

Deconditioning Foley Catheter Use Palliative Care Wound Care Nausea 

OSTE 

Drugs and Aging Pain Control Advance Directives Nursing Home Care Ideal Discharge Plans 

Teaching Techniques 

Overview 

Geriatric Topics & Objectives 

+ Teaching on Today's Wards 

+ Evaluation Forms 

Dissemination 

Educational Resources 

CHAMP Faculty 

+ Reynolds' Links 

Speaker’s Bureau 

Contact Us 

http://champ.bsd.uchicago.edu/ 

This is the official website for CHAMP at the University of Chicago. CHAMP is an 

educational program designed to train non-geriatrician clinical educators to become more 

adept at teaching geriatric topics and covering the ACGME core competencies in the 

inpatient setting. Adaptable to doctors, doctors in training, advanced practice nurses and 

others who care for hospitalized older adults, the CHAMP faculty development course at the 

University of Chicago resulted in increased geriatric teaching and improved clinical health 

outcomes during its implementation from 2003 - 2007. 

ADDITIONAL CHAMP HAPPENINGS: 

CHAMP Publication: The Curriculum for the Hospitalized Aging Medical Patient program: A 

collaborative faculty development program for hospitalists, general internists, and geriatricians. 

Journal of Hospital Medicine. 2008;3(5):384-393. 

Inpatient teaching curriculum - Checklist for covering CHAMP topics during inpatient teachingrounds 

CHAMP 2-day Workshops. Train-the-trainer or Clinical care models. 

Parnterships with several Reynolds grant recipients (Cohort 4) to develop sustainable CHAMP-inspired 

faculty development programs in-house. 

Mini-CHAMP at the University of Chicago and on online 

Geriatric Curricula for Medical Students 

How to use this site: Teaching materials on geriatric topics are easy to spot along the top 

menu. Programmatic materials, including overview and evaluation instruments, can be 

found on the menu along the left. 

© 2007 Department of Medicine ® The University of Chicago 

5801 South Ellis, Chicago, IL 60637 773-702-1234 

Page 1 of 1 

5/13/2011

“It Burns!” Assessment and Treatment of Neuropathic 

Pain 

Introduction: 

This self-directed learning exercise explores the assessment and 

management of neuropathic pain. Through a case presentation and related 

readings, the student will identify appropriate strategies for assessing and 

treating common sources of neuropathic pain. 

Learning objectives: 

After completion of this module the student should be able to: 

1) Recognize common presentations and symptoms of neuropathic 

pain 

2) Understand basic pathophysiologic mechanisms of neuropathic pain 

3) Identify chronic medical diagnoses associated with neuropathic pain 

4) Discuss the most effective therapies available for this type of pain 

ACGME Competencies: 

Practice-based learning and Improvement, Medical knowledge, Patient care 

What you need to complete the module: 

1) Download and print the workbook 

2) Read case presentation 

3) Read the following: 

a) Jackson KC. Pharmacotherapy for neuropathic pain. Pain Practice 

2006;6(1):27-33. 

b) American Medical Association “Pathophysiology of Nociceptive and 

Neuropathic Pain”. 

Accessed on-line at: 

http://www.ama-cmeonline.com/pain_mgmt/module01/03patho/index.htm 

4) Answer questions in workbook 

5) Bring completed module to the Palliative Medicine Workshop for 

discussion 

Case Presentation: 

David Beckmann M.D. and Stacie Levine M.D. 

Self-Directed Learning Exercises 

1

Mr. Smith is a 39 year-old male with who presents to the outpatient clinic 

with 3 weeks of intermittent shooting and burning pain in his lower 

extremities. The symptoms occur mainly at night, are not associated with 

physical exertion and usually come on suddenly. The pain is usually 4/10 

in severity but increases to an 8/10 when he feels “shooting pains”. He 

has been poorly sleeping at night as it “burns terribly” when the bedsheet 

lightly touches his skin. 

Past medical history: 

� HIV - diagnosed 5 years ago with last CD4 count of 250 1 year ago. 

His counts have been stable on his current HAART regimen over the 

last 10 months. 

� Depression - well-controlled on sertraline (Zoloft) 200 mg daily. 

Family history: sister with juvenile diabetes. 

Social history: non-smoker, denies alcohol, occasionally smokes 

marijuana which he feels helps the pain. He contracted HIV through a 

blood transfusion as a child. 

Review of systems: as above, otherwise negative. 



2

Questions: 

1) What could be the cause of Mr. Smith’s pain? (circle all that apply) 

a) Undertreated depression 

b) Undiagnosed diabetes 

c) Medication side effect 

d) HIV neuropathy 

e) Postherpetic neuralgia 

2) How do you define the symptom he is experiencing at night? 

a) Allodynia 

b) Hyperalgesia 

c) Hyperpathia 

d) Nociceptive pain 

3) Which of the following medications would you start to treat his 

symptoms? (circle any that may apply) 

a) Start gabapentin at 300 mg at night 

b) Apply Lidocaine patches 5%, 3 on each foot, at night 

c) Start amitriptyline 10 mg at night 

d) Start tramadol 100 mg four times a day 

4) Which of the following statements is true regarding medications 

used to treat neuropathic pain? 

a) Amitriptyline is a tertiary amine that has a more favorable side 

effect profile than secondary amines (e.g. nortriptyline) 

b) Tramadol is a peripherally acting agent with a strong affinity 

for mu-opioid receptors and reuptake inhibition of 

norepinephrine and serotonin 

c) The most common side effect of gabapentin is dry mouth 

d) Most studies have focused on postherpetic neuralgia, diabetic 

peripheral neuropathy, and trigeminal neuralgia 



3

Meaghan Combs, MD 




Presentation at the 44th STFM Annual 

Spring Conference, April 28, 2011, in New 

Orleans: “Does a Micropractice Lead to 

Macrosatisfaction?” 


ImPACT Testing at Belleville High School -- 

Continuing the project of a previous resident, 

ImPACT testing was provided to an expanded 

group of students at the Belleville High school. 

Timed to coincide with starting fall sports, students 

on the Soccer and Football teams were provided 

with pre-participation ImPACT testing. This testing 

program is an evidence-based, abbreviated type of 

neuro-psychiatric testing. The pre-participation 

test provides a baseline to be used for the student 

in the event they should suffer a concussion. If 

the student does suffer a concussion, the preparticipation 

baseline is then compared to postconcussion 

test scores. The student is considered 

cleared to return to play with minimal harm once 

the post-concussion test score is comprable to 

the pre-participation test. We do not offer postconcussion 

testing at this time at the Belleville 

Clinic. Thus families of injured students had to 

take the student into Madison for follow-up testing. 

Families and teachers were very appreciative of 

this project, which was co-funded by the Belleville 

High School Athletic Fund and the Belleville Family 

Medicine Clinic. 

I would like to thank my husband Neal who has been a constant 

source of love, support, delicious meals, exercise inspiration, and 

belly laughs throughout my residency. It is thanks to him that I 

survived with my heart, soul, and body intact. Thanks also to my 

parents and siblings for their love, guidance, and free emotional 

counseling sessions; to Kathy Oriel for her excellent leadership and 

inspiration throughout residency; and to the Residency Staff for 

their friendship, support, and smiles. 

– Meaghan 

Meaghan Combs 

graduated from Case 

Western Reserve 

University with a B.A. in 

Medical Anthropology. 

She served as a Peace 

Corps volunteer in 

Burkina Faso before 

pursuing an M.D. 

and M.P.H. at Tulane 

University School of 

Medicine. During her 

time in New Orleans, 

she co-founded and coordinated the 

Fleur De Vie Clinic, a holistic, no-cost, 

student-led clinic to address the post- 

Katrina needs of the community. Since 

moving to Madison, Meaghan has been 

grateful for the chance to work at the 

Belleville Family Medicine Clinic. There 

she has had the good fortune to care for 

patients in the surrounding community, 

learn from astounding faculty members, 

and volunteer in the community. She 

has helped the clinic to organize fl oats in 

the annual UFO Day parade, worked with 

the local police department on Senior 

Health topics, has been invited to teach 

various topics at the high school, and 

worked with the Sports Trainer at the 

high school on an ImPACT concussion 

screening program. During residency 

Meaghan has had the opportunity to 

pursue her interests in maternal and 

newborn care, breastfeeding medicine, 

and comprehensive reproductive health 

care through her completion of the 

Maternal Health Pathway. In addition to 

clinical duties, Meaghan has made a name 

for herself in the Mad Rollin’ Dolls roller 

derby league, voted Most Valuable Rookie 

in 2010 and breaking the record for most 

points scored in a Rookie season. She 

loves her husband, Neal Goldenberg, very 

much and is thrilled to be expecting the 

birth of their fi rst child in September of 

this year. She will join the Integrative 

Medicine Fellowship after graduation. 


meaghanita.combs@gmail.com 

440 . 669 . 1252

Does Micropractice Lead to Macrosatisfaction? 

Meaghan Combs, MD, MPH; Elizabeth Paddock, MD; Melissa Stiles, MD, Ron Prince, MS 

University of Wisconsin, Department of Family Medicine, Madison, WI 

ABSTRACT RESULTS RESULTS OUTCOMES: SATISFACTION 

Physician quality of work life is a well recognized 

key factor in career choice and retention. No 

comparison exists between traditional practices and 

p y p y p y 

by the University of Wisconsin Department of 

Family Medicine in community and residency 

clinics and physicians working in micropractice 

clinics across the USA. Micropractice clinics are 

defined as those which are independent, with low 

overhead, and extended visit time with patients. 

•Micropractice physicians reported: 

• greater satisfaction with opportunities to fully 

utilize skills in practice, (mean score of 4.38 compared to 

Community and Residency clinic mean scores of 3.55 and 3.58, respectively, 

(Krusal-Wallis = 13.779, p=0.001).) 

• more satisfaction with amount of time spent with 

family, (mean score of 4.09 compared to Residency and Community 

clinic mean scores of 2.97 and 2.30, respectively, (K-W = 25.794, p=0.000).) 

• working under time pressure only occasionally, (mean 

score of 2.50, compared to often by Community and Residency clinics, mean 

scores of 4.07 and 4.08, respectively (K-W = 4.839, p=0.00).) 

• more likely to agree: able to match time spent with 

patients to the level of complexity of the patient’s 

care, (mean score of 4.63 compared to Community and Residency 

physicians, mean scores of 3.29 and 3.00, respectively (K-W test of 39.277, 

p=0.00).) 

• they were not planning to leave the work group in 

the h near ffuture, 

(K-W test of 10.94, p=0.004.) 

•Residency clinic physicians reported: 

• greater satisfaction with current income, (mean score 

of 3.25, compared to Community and Micropractice clinic mean 

scores of 2.76 and 2.32, respectively. (K-W = 6.549, p=0.38).) 

micropractices. We surveyed physicians employed ( ,p )) 

Methods Community Clinic: 

• “The dissatisfaction with income arises because of the lack of valuing 

• Validated survey assessed physician satisfaction with current 

employment 

• Survey invitation emailed to University of Wisconsin, Department of 

Family Medicine residency clinic and community clinic physicians and 

a national sample of self-identified micropractice physicians 

• Surveys were completed through online survey tool 

(http.//survey.wisc.edu) 

• Responses were all anonymous 

• Data was analyzed y using gSPSS and the online survey y tool 

• Krusal-Wallis or chi-square tests were used to assess data for 

statistically significant differences to questions in regards to 

Satisfaction, Practice Issues, Outcomes, and Scope of Practice amongst 

the three identified employment models: community clinic, 

micropractice, and residency clinic. 

• 92 total respondents 

GENDER 

AGE 

CLINIC TYPE 

RESEARCH POSTER PRESENTATION DESIGN © 2011 

www.PosterPresentations.com 

Demographics g p 

51% male 

N=46 

47% 25-45 yrs 

N=43 

32% Community 

N=29 

49% female 

N=44 

52% 45-65 yrs 

N=47 

24% Microclinic 

N=22 

1% >65 yrs 

N=1 

44% Residency 

N=40 

primary care relative to specialist medicine.” 

• “I get discouraged with all the uncompensated time--phone calls, dictations, 

Mychart, and I am often working from home or on my days off to complete 

these things.” 

Microclinic: 

• “I would not trade this model for anything short of bankruptcy” 

• “My hospital recredentialling is coming up and I will have to give up 

privileges. In the last 2 years I have only had 2 patients hospitalized” 

Residency Clinic: 

• “We'd W nearly yall enjoy j y more time with our families!” 

Community Clinic: 

• “I don't enjoy jymy ywork 

as much as I could if I were to have more time to 

learn and to teach patients...this is the difficulty of trying to be 'efficient' while 

being 'thorough'” 

Microclinic: 

• “I am not able to perform some of the procedures that I previously was able 

to perform...I cannot afford this equipment, would not have the number to 

support their purchase, do not have staff for it, do not have room for it.” 


• “you left out the effects of ancillary support staff. In small group practice 

models the MD's have much more control over who they work with in clinic 

setting. Now that seems controlled more by the "big organization" , unless 

you have a very dedicated clinic manager committed to the continuity of 

patient care” 

Microclinic: 

• “30-40 hours is PATIENT time, another 10 hours on paper work drivel” 

Residency: 

• “Patient care is 40-55 hours, with 12 additional hours of 

administrative/teaching time, which is often encroached by the patient care 

time” 


• “My My happiness/satisfaction is integrally tied to the quality of my 

support staff. I didn't see any questions about these individuals. When 

they support my practice and are efficient, we act as a team and can 

provide good care. If I don't have that support,then my satisfaction really 

plummets.” 

Microclinic: 

• “I would NEVER go back to being employed or on the hamster wheel 

again” 

OUTCOMES: 

SCOPE OF PRACTICE 

•84% Community & 90% Residency clinic physicians 

DO practice inpatient medicine 

• 86% Microclinic physicians 

DO NOT practice inpatient medicine 

• 44% Community & 65% Residency physicians 

DO practice OB 

• 91% Microclinic physicians 

DO NOT practice ti OB 

• Microclinic physicians have been in their current model of 

practice 

for no more than 10 years 

• Community Clinic physicians reported most hours of patient care 

per week 

REFERENCES 

Beasley et. al. Quality of Work life of Independent vs Employed Family 

Physicians in Wisconsin: A WReN study. Annals of Family Medicine. Vol 

3,No 6. Nov/Dec 2005 

Linzer, M, et. al. Physician stress: results from the physician work life study. 

Stress health. 2002; 8:37-42 

Moore LG. Going solo: one doc, one room, one year later. Fam Pract 

Manag. March2002:25–29. 

Moore LG. The Ideal Medical Practice Model: Improving Efficiency, Quality 

and the Doctor-Patient Relationship. Fam Pract Manag. 2007 Sep;14(8):20- 

24 

5/13/2011 

1

Jessica Dalby, MD 




Clinical Quality Improvement: Adding Fluoride 

Prophylaxis to Well Child Care 


Schrager S, Paddock E, Dalby J, Knudsen L. 

Contraception in Wisconsin: a review. WMJ. 2010 

Dec;109(6):326-31 -- Collaborated on an article 

for the Wisconsin Medical Journal focused on 

a contraceptive update following the Wisconsin 

state legislative contraceptive equality mandate. 

The Contraceptive Equality Mandate took effect 

in Wisconsin on January 1, 2010. This mandate 

from the Wisconsin Offi ce of the Commissioner 

of Insurance requires all insurance companies 

in the state of Wisconsin to cover all types of 

contraception, making Wisconsin the 28th state to 

do so. I reviewed the literature on Implanon use, 

safety, effi cacy and side effects for this article. 

A heartfelt bear-hug and thank you to all my fellow residents, 

faculty mentors, residency and clinic staff who made my training 

experience downright bearable and often rather enjoyable (even 

at 3am) with your warmth, laughter and willingness to help. I 

cannot imagine a more supportive residency family. And for my 

friends and family, who let me pour out my sorrows when the 

bucket got too full . . . thank you for lending ears and shoulders 

to carry me through. 

– Jess 

Jessica Dalby 

completed her B.S. 

at the University of 

Texas in Austin and 

attended medical 

school at Baylor 

College of Medicine in 

Houston. She brings 

to family medicine 

a passion for social 

justice and a deep 

love for other cultures. She has 

taught ESL in a number of settings, 

including a year-long teaching 

position in Japan and Hispanic 

community centers in Austin and 

Houston. Her medical and research 

interests have taken her to Mexico, 

Chile, Puerto Rico, and Honduras, 

where she fi ne-tuned her fl uency 

in the Spanish language. She also 

has a strong interest in women’s 

health. During medical school she cofounded 

Baylor’s fi rst-ever Women’s 

Health Elective, a series of lectures 

designed to expose students to topics 

in women’s health not covered in 

the standard curriculum. She was 

also president of the Baylor chapter 

of the American Medical Women’s 

Association and a student leader for 

Medical Students for Choice. Jessica 

grew up in the Pacifi c Northwest, 

where the beauty of the natural 

environment inspired a deep love 

of nature. She spends most of her 

free time outside, hiking, biking, 

swimming, or playing a friendly game 

of ultimate frisbee. She is well known 

for great hugs. 


jessiedalby@gmail.com

Jessica Dalby, MD 

Family Medicine Resident 

University of Wisconsin 

Department of Family Medicine 

Community Medicine Project 

April 2011 

Project: Fluoride Varnish for Prevention of Early Childhood Caries 

Background: Early childhood caries are a serious cause of childhood morbidity, leading to pain, 

infection, missed school and/or work for their caregivers and even surgical intervention requiring 

general anesthesia. Children under the age of three rarely see a dentist, but will make many visits 

to their primary care clinic during those first important years. Children on Medicaid in our 

community are a high-risk group for dental caries and have additional difficulty accessing dental 

care. Fluoride varnish applied in the primary care office at routine well child checks has been 

shown to reduce the incidence of childhood caries in high-risk populations. 

Intervention: I invited our colleagues from the Dane County Public Health Department to 

Wingra during one of our Well Child Check extravaganzas. They provided fluoride varnish and 

dental care supplies to children seen that day, but more importantly they instructed some of the 

medical assistants on how to apply the varnish. I then visited the Southside Access clinic, where 

this intervention is part of their routine, to learn how to incorporate this service into our clinic 

flow. Working with clinic staff, fluoride varnish was ordered. I presented to MA and nursing 

staff the technical aspects and purpose of this intervention. Voila! We now offer fluoride varnish 

routinely at WCC at Wingra, fighting cavities one tooth at a time!

Bridget DeLong, MD 




Family Practice Inquiry Network (FPIN) Help 

Desk Answer: What is the differential diagnosis 

for an elevated monocyte count in a patient 

with an acute febrile illness? 

Quality Improvement Project: 

Quality Improvement Project: Cardiac Risk 

Assessment by Primary Care Providers (with Dan 

Sutton) -- The goal of the quality improvement 

project was to inform PCPs and their patients as to 

an individual patient’s hard cardiac risk. 

We calculated this risk score for patients prior 

to upcoming appointments with PCPs. This 

information was presented to the patients during 

their visit with PCP. Post-interview phone 

questionnaires revealed that patients were slightly 

more likely to make lifestyle changes than to change 

medication adherence following this intervention. 

Most patients thought the intervention was helpful. 

Pre- and post-intervention surveys of PCPs 

revealed that there was an increase in the number 

of physicians who reported using cardiac risk 

assessment tools, the number who relayed this 

information to patients, and in the number of 

providers who thought that this improved patient 

care. 

Bridget Delong 

grew up in Clinton, 

Wisconsin, and she 

completed both her 

undergraduate and 

medical degrees at 

UW-Madison. She 

has a strong interest 

in rural medicine, 

as evidenced by 

her leadership role 

throughout medical school in the 

Rural Health Interest Group. She 

fi rst discovered her passion for rural 

medicine as a student researcher for 

the Wisconsin Offi ce of Rural Health, 

where she focused her work on mental 

health issues among the elderly in two 

Wisconsin counties. She then went on 

to complete a summer externship in 

Clinton, WI, and a longitudinal rural 

rotation in Black River Falls, WI. In 

addition, during her fi rst two years in 

medical school Bridget volunteered 

regularly at the Salvation Army Clinic 

for Women and Children. Working with a 

variety of family doctors in these varied 

settings led Bridget to choose Family 

Medicine as her specialty, and she joins 

the residency program as part of the 

Baraboo Rural Training Track. In her 

spare time, Bridget enjoys camping, 

hiking, hunting, and participating in 

a variety of sports. Her other hobbies 

include refi nishing furniture, reading, 

listening to music, and following UW 

athletics. Bridget is married to Mark 

Wozniak. She will be working for 

Medical Associates Clinic of Baraboo (a 

Dean affi liate) in Baraboo and will be 

a faculty member of the Baraboo Rural 

Training Track. 


bridget.delong@gmail.com 

608 . 290 . 8844

HDA 45051 

Title: 

What is the differential diagnosis for an elevated monocyte count in a patient with an 

acute febrile illness? 

Author: 

Bridget DeLong, MD (resident) 

Stuart Hannah, MD (faculty co-author) 

Melissa Stiles, MD (faculty co-author) 

Affiliation: University of Wisconsin Department of Family Medicine, Madison, WI 

Question: 

What is the differential diagnosis for an elevated monocyte count in a patient with an 

acute febrile illness? 

Evidence-Based Answer: 

There are many causes of moncytosis in a febrile patient with an acute illness. The causes 

can be broadly grouped into hematologic disorders, infections, inflammatory causes, and 

miscellaneous causes. (SOR: C, based on multiple case series reports.) History and 

physical should guide the clinician in developing a diagnosis in evaluation of patients 

with fever and monocytosis. (SOR: C, based on review of case series.) 

Evidence Summary 

An acute febrile illness with monocytosis noted on complete blood count can be broadly 

categorized by cause. These categories include hematologic disorders and malignancies, 

infections, inflammatory causes, and miscellaneous causes. 1 The differential diagnosis is 

broad but can usually be narrowed through careful history and exam. 2 

Hematologic disorders include various forms of leukemia, Hodgkin and non-Hodgkin 

lymphoma, and chronic or congenital neutropenia. 1 Myelodysplastic disorders can exhibit 

monocytosis in up to 25% of cases. 1 Profound monocytosis is more likely to represent a 

hematologic disorder or malignancy than other causes. Non-hematologic malignancies 

can also cause monocytosis. 1,5 The relative immunosuppression present with some 

malignancies can lead to infections, and hence a presentation with acute fever. 

Infections do not typically cause isolated monocytosis. 1 Bacterial infections that could 

cause monocytosis and fever include tuberculosis 1-5 , syphilis 1,3,5 , subacute bacterial 

endocarditis 1-5 , erlichiosis/anaplasmosis 1 , Rocky Mountain Spotted Fever 1-4 , and 

brucellosis. 1-4 The resolution of an acute bacterial infection can also result in 

monocytosis. 1 Viral causes of monocytosis and acute fever include dengue hemorrhagic 

fever, cytomegalovirus infection, and varicella-zoster infection. Malaria and 

leishmaniasis are protozoan illnesses that can also result in monocytosis. 2,3,4 

Inflammatory and rheumatologic causes of monocytosis and fever include subacute lupus 

erythematous 1,2,3,5 , rheumatoid arthritis 1,2,3,5 , temporal arteritis 2,3,5 , sarcoidosis 1,2,3,5 and 

inflammatory bowel disease 1,3,5 as well as celiac disease. 1

Miscellaneous causes of fever and monocytosis include Kawasaki disease 1 , postsplenectomy 

state 1,3,5 and drug reactions. 3 

The combination of a non-specific diagnostic test finding (monocytosis) and a nonspecific 

physical exam finding (fever) should be taken into account with the focused but 

detailed history and physical exam. Subsequent evaluation, including further diagnostic 

testing, should be based on this initial impression. 2 

References: 

1. Lichtman MA. Monocytosis and monocytopenia. In: Lichtman MA, Kipps TJ, 

Seligsohn Uri, Kaushansky K, and Prchal JT. Williams 

Hematology. 8 th ed. New York, NY: McGraw-Hill Professional; 2010. 

http://www.accessmedicine.com.ezproxy.library.wisc.edu/content. Accessed March 9, 

2011. (LOE 5) 

2. Cunha BA. Fever of unknown origin: focused diagnostic approach based of 

clinical clues from the history, physical examination, and laboratory tests. Infect Dis Clin 

N Am. 2007; 21(4): 1137-1187. (LOE 5) 

3. Boxer, LA. Leukocytosis. In: Kliegman RM, Behrman RE, Jenson HB, and Stanton B. 

Nelson Textbook of Pediatrics. 18 th ed. Philadelphia, PA: Saunders Elsevier; 2007. 

http://www.mdconsult.com.ezproxy.library.wisc.edu/books. Accessed March 9, 2011. 

(LOE 5) 

4. Holland SM, Gallin JI. Disorders of granulocytes and monocytes. In: Fauci AS, 

Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J. Harrison's 

Principles of Internal Medicine. 17 th ed. New York, NY: McGraw Hill Professional; 

2008. http://www.accessmedicine.com.ezproxy.library.wisc.edu/content. Accessed 

March 9, 2011. (LOE 5) 

5. Dinauer MC and Coates TD. Disorders of phagocyte function and number. In: 

Hoffman R, Furie B, Benz EJ Jr, McGlave P, Silberstein LE, and Shattil SJ. Hematology: 

Basic Principles and Practice. 5 th ed. Philadelphia, PA: Churchill Livingston Elsevier; 

2008. http://www.mdconsult.com.ezproxy.library.wisc.edu/books. Accessed March 9, 

2011. (LOE 5) 

Continuing Education Question 

In any patient presenting with an acute febrile illness and monocytosis, the differential 

diagnosis includes illnesses from all of the following categories EXCEPT: 

A. inflammatory conditions 

B. primary hematologic malignancies 

C. endocrinopathies 

D. non-hematologic malignancies

JACQUELINE GERHART, md 




Co-authored an article with Amer Kalaaji, MD 

in the Journal of the American Academy of 

Dermatology: “Development of Pneumocystis 

Carinii Pneumonia in Patients with 

Immunobullous and Connective Tissue” (June 

2010) 


Women in Science and Engineering (WISE) Health 

Panel and Lecture Series -- For my community 

medicine project, I worked with a UW-Madison 

program called WISE (Women in Science and 

Engineering), which provides mentorship, service, 

and cultural opportunities to a group of 100 college 

students interested in science. I worked with faculty 

members to set up a lecture and panel series for the 

college students focused on healthcare careers. I 

organized two dinner panels with female healthcare 

providers, including physicians (MDs and DOs from 

both medical and surgical specialties), pharmacists, 

physician assistants, nurse practitioners, medical 

assistants, and a radiology technician. A total of 

twelve panelists have participated, and over 80 

college students have been to the panels. Many of 

the panelists (including myself) continue to mentor 

students on an individual basis. Since starting the 

panel program, a greater percentage of women 

involved in the WISE program have explored 

healthcare careers and have been accepted into preprofessional 

healthcare programs. 

Thank you to my family and friends who supported me with 

their love and guidance. Thank you to the Madison Family 

Medicine Residency Program faculty and staff for their teaching 

and mentorship. And finally, thank you to my co-residents for 

welcoming me as a 2nd year resident and for their continued 

friendship. 

– Jackie 

Jackie Gerhart is a 

Wisconsin native 

who completed 

undergraduate 

degrees in Biomedical 

Engineering and 

Neuroscience at 

UW-Madison. While 

in college, she was 

the president of the 

engineering student 

council, and worked 

at Kimberly-Clark Medical Systems 

designing medical and surgical devices. 

She was on the executive committee 

for the Wisconsin Alumni Student Board 

and organized the UW Homecoming 

Parade. She won an Iron Cross Award 

for community service and a Wisconsin 

Idea Fellowship for analyzing care 

practices at local MEDiC clinics. She 

attended medical school at Mayo 

Medical School in Rochester, MN, where 

she developed a strong commitment 

to service and teaching. She worked 

as a teen educator through the 

Rochester Teen Council, mentoring and 

teaching teens about substance abuse, 

pregnancy and mental health. She 

co-chaired the Primary Care Interest 

Group and co-founded the Integrative 

Medicine Interest Group. She also cochaired 

the Harvest Classic, a 5K/10K 

race which promoted family physical 

fi tness and raised over $10,000 for a 

local food pantry. Her passion for global 

health has taken her to Guatemala 

and Argentina, and she is traveling to 

Ecuador this spring to provide rural 

healthcare. In residency, she cochaired 

the recruitment committee, and 

taught PDS. Outside of medicine, she 

enjoys running, tennis, and trying new 

restaurants. 


jacquelinegerhart@yahoo.com 

480 . 287 . 3309

Development of Pneumocystis carinii pneumonia in 

patients with immunobullous and connective tissue 

disease receiving immunosuppressive medications 

Jacqueline L. Gerhart, BS, a and Amer N. Kalaaji, MD b 

Rochester, Minnesota 

Background: Pneumocystis carinii pneumonia (PCP) causes morbidity and mortality in immunocompromised 

hosts. Data describing use of PCP prophylaxis in immunosuppressed dermatologic patients are 

lacking. 

Objective: We sought to describe the frequency of PCP among dermatologic patients receiving 

immunosuppression for immunobullous disease or connective tissue disease. 

Methods: We retrospectively reviewed the cases of patients with immunobullous and connective tissue 

disease at our department of dermatology between 1980 and 2006 who received immunosuppression and 

had subsequent development of pneumonia. We recorded patient characteristics, use of PCP prophylaxis, 

whether PCP developed, and if so, their morbidity and mortality. 

Results: Of 334 patients identified, 7 (2.1%) were given the diagnosis of PCP during immunosuppressive 

treatment. Of these 7 patients, 3 (43%) died within 1 month of diagnosis, and none received PCP 

prophylaxis. 

Limitations: Retrospective study design and limited patient group are limitations. 

Conclusions: PCP prophylaxis may improve outcomes for some patients with immunobullous or 

connective tissue disease receiving immunosuppressive therapy. ( J Am Acad Dermatol 2010;62:957-61.) 

Key words: connective tissue disease; immunobullous disease; immunosuppression; Pneumocystis carinii; 

pneumonia. 

Pneumocystis carinii is a fungal pathogen that 

causes pneumonia (P carinii pneumonia 

[PCP]) in immunocompromised patients, 

and it occasionally disseminates in patients with 

advanced AIDS. 1-7 Clinically relevant diagnostic 

sources include sputum, bronchoalveolar lavage, or 

lung tissue. 8,9 PCP affects not only patients with AIDS 

but also those with hematologic malignant disorders 

From the Mayo Medical School, College of Medicine, a and 

Department of Dermatology, Mayo Clinic. b 

Funding sources: None. 

Conflicts of interest: None declared. 

Accepted for publication July 27, 2009. 

Reprint requests: Amer N. Kalaaji, MD, Department of 

Dermatology, Mayo Clinic, 200 First St SW, Rochester, MN 

55905. E-mail: kalaaji.amer@mayo.edu. 

Published online October 14, 2009. 

0190-9622/$36.00 

ª 2009 by the American Academy of Dermatology, Inc. 

doi:10.1016/j.jaad.2009.07.042 

or solid malignant lesions, organ transplant recipients, 

and those receiving long-term immunosuppressive 

therapy, especially with corticosteroids. 10 The 

mortality among patients who have PCP without 

AIDS is 30% to 60%, with greater risk of death in 

patients with cancer than in patients undergoing 

transplantation or with connective tissue disease. 6,10 

In addition, mortality is substantially higher for 

patients with PCP who have a concomitant pulmonary 

infection, have an underlying disorder, are 

supported with mechanical ventilation, have had 

chemotherapy, have used corticosteroids, or are 

receiving cyclophosphamide therapy. 1,3,8,10 

Given the morbidity and mortality related to P 

carinii infection, many clinicians choose to prescribe 

PCP prophylactic medications when starting highdose 

immunosuppressive therapy in patients. 11-15 

However, the favored prophylactic medications, 

such as trimethoprim-sulfamethoxazole, have potential 

adverse effects such as erythema multiforme, 

957

958 Gerhart and Kalaaji 

Stevens-Johnson syndrome, and toxic epidermal necrolysis. 

Given these adverse effects, many dermatologists 

are reluctant to give prophylaxis to patients 

who are on long-term immunosuppressive therapy 

for immunobullous and connective tissue diseases. 

No apparent standard of care exists among dermatologists 

regarding PCP prophylaxis. Therefore, the 

aim of this study was to iden- 

tify the frequency of PCP development 

in patients with 

immunobullous and connective 

tissue disease receiving 

immunosuppressive therapy. 

METHODS 

This study was approved 

by our institutional review 

board. We performed a retrospective 

review of patients 

receiving long-term immunosuppressive 

therapy for 

connective tissue disease or 

a bullous disorder at our institution 

from 1980 through 

2006, in whom pneumonia 

developed. We used our institutional 

medical record 

registry, cross-index system, 

and paper chart archives to 

CAPSULE SUMMARY 

identify patients. Patients were excluded from analysis 

if their diagnosis of immunobullous or connective 

tissue disease was not supported by biopsy 

specimen, immunofluorescence, or serum test results 

or if there was no record of a systemic immunosuppressive 

drug used for treatment of the 

disease. Immunosuppressive drugs (prednisone, 

azathioprine, methotrexate, mycophenolate mofetil, 

hydroxychloroquine, dapsone, intravenous immunoglobulin, 

sulfasalazine, sulfapyridine, methylprednisolone, 

and cyclophosphamide) were 

defined as being used for the dermatologic disease 

if they were given systemically within 1 month of the 

diagnosis. Patients with AIDS were not excluded. 

Clinical data collected included age, other comorbid 

diseases, and date of death and autopsy findings, 

if applicable. Dermatologic data included date and 

type of dermatologic diagnosis, method of diagnosis 

(biopsy specimen, immunofluorescence staining, 

serum tests), and immunosuppressive drug regimen 

(dosage, start date, and stop date). In addition, date 

and type of pneumonia diagnosis, method of diagnosis 

(from sputum, bronchoalveolar lavage, biopsy 

specimen, or other), and presenting symptoms were 

recorded. If the patient received PCP prophylaxis, 

the medication, duration, and dose were recorded. 

d Although only 2.1% of patients with 

immunobullous or connective tissue 

disease had development of 

Pneumocystis carinii pneumonia (PCP) in 

our study, the mortality in those with 

PCP was high (43%). 

d The risk of PCP developing in these 

patients is not necessarily related to 

high-dose prednisone but to presence of 

several risk factors, including pulmonary 

fibrosis, organ transplantation, and 

malignancy. 

d Dermatologists must individually assess 

each patient for risk factors for PCP when 

weighing the risks and benefits of PCP 

prophylaxis. 

JAM ACAD DERMATOL 

JUNE 2010 

Finally, if PCP did develop, we recorded the duration 

of immunosuppression before PCP diagnosis, length 

of hospital stay, and time from PCP diagnosis to 

death, if applicable. 

RESULTS 

Of the patients identified who had a diagnosis of 

immunobullous or connective 

tissue disease and were 

on long-term immunosup- 

pression, 334 had pneumonia 

at some point during their 

immunosuppressive treatment 

and were included in 

our review. Of the 334 patients, 

241 (72.2%) had connective 

tissue disease and 93 

(27.8%) had immunobullous 

disease. Immunosuppressive 

medications used in the 

group included prednisone 

alone in 148 (44.3%), steroid-sparing 

drugs alone in 

69 (20.7%), and a combination 

of prednisone and a steroid-sparing 

drug in 117 

(35.0%). 

Seven patients had a diagnosis 

of PCP (Table I); none 

of the 7 had received PCP prophylaxis. Of these 7, 

one had a bullous disorder (1.0% of all patients with 

immunobullous disease) and 6 had connective tissue 

diseases (2.5% of all patients with connective tissue 

disease), which included systemic lupus erythematosus 

in two patients and dermatomyositis in 4. Of 

the 327 patients without PCP, 96 received prophylaxis 

and 231 did not. 

The mean age of all 334 patients was 57.6 years; 

mean age was 62.7 years for the 7 patients with 

PCP. Smoking history, defined as at least 5 years of 

smoking, was reported in 48.3% of the total group 

and in 57% (4 of 7) of the patients with PCP. 

History of chronic obstructive pulmonary disease 

was reported in 11.8% of study patients and in 29% 

(2 of 7) of the patients with PCP. We did not assess 

age, smoking, or chronic obstructive pulmonary 

disease in the general population during the same 

period. 

The mean (SD) number of significant comorbid 

conditions for the 327 patients without PCP was 2.3 

(1.0), whereas for the 7 patients with PCP the mean 

(SD) number of comorbid conditions was 4.0 (2.2). 

All 7 patients with PCP had multiple comorbid 

conditions: two patients had malignancies, two had 

undergone renal transplantation, and 3 had


VOLUME 62, NUMBER 6 

Table I. Clinical data for the 7 patients with a diagnosis of Pneumocystis carinii pneumonia 

Patient Diagnosis 

1 BP Prednisone, 40 mg/d; 

methotrexate, 

Immunosuppressive 

regimen Duration, d* 

2.5-12.5 mg/wk 

pulmonary disease (two with interstitial fibrosis and 

one with pneumonia) (Table I). 

Five of the 7 were taking at least 30 mg/d of 

prednisone at some point during immunosuppressive 

treatment, and prednisone dosage ranged from 

15 to 60 mg/d. The time from beginning immunosuppressive 

medication to PCP diagnosis ranged 

from 48 to 253 days, and 5 patients had PCP 

development within 3 months of starting immunosuppressive 

treatment. Six of 7 patients were admitted 

to the hospital for hypoxia or respiratory 

failure resulting from PCP. Five patients died; survival 

in these 5 varied from 8 days to 12 years after 

PCP diagnosis. Three (43%) of the 7 patients died 

within 1 month of the PCP diagnosis: two from 

respiratory arrest caused by PCP and one from 

respiratory failure caused by a combination of PCP, 

pulmonary embolism, and disseminated intravascular 

coagulation. 

Dermatologic data PCP data 

Comorbid 

conditions 

253 Bladder cancer, HTN, AS, 

Paget disease, macular 

degeneration, MAC 

2 SLE Prednisone, 60 mg/d 62 Lupus nephritis after 

renal transplantation, 

HTN, CAD, 

hyperlipidemia, 

3 SLE Methylprednisolone, 

16 mg/d; MM, 

750 mg, 23/d 

cataracts, obesity 

124 Lupus nephritis after 

renal transplantation, 

HTN, hyperlipidemia, 

myogenic bladder, 

splenectomy, 

congential 

hydronephrosis, EBV, 

Listeria septicemia 

4 D Prednisone, 15 mg/d 50 Acute tubular necrosis, 

interstitial pulmonary 

fibrosis 

5 D Prednisone, 20-30 mg/d 63 Renal cell carcinoma, 

interstitial pulmonary 

fibrosis 

6 D Prednisone, 25-40 mg/d; 48 Hypothyroidism, 

azathioprine, 75 mg/d 

7 D Prednisone, 60 mg/d; 

azathioprine, 200 mg/d 

glaucoma 

75 Hypothyroidism, HSV 

pneumonia, arrhythmia 

Gerhart and Kalaaji 959 

Reason for 

hospitalization/ 

duration, d Survival Prophylaxis 

PCP/17 3 y None 

PCP/26 12 y None 

EBV/31 Living None 

PCP/24 20 d None 



PCP, HSV/8 Living None 

AS, Aortic stenosis; BP, bullous pemphigoid; CAD, coronary artery disease; D, dermatomyositis; EBV, Epstein-Barr virus; HSV, herpes simplex 

virus; HTN, hypertension; MAC, Mycobacterium avium complex; MM, mycophenolate mofetil; PCP, Pneumocystis carinii pneumonia; SLE, 

systemic lupus erythematosus. 

*Duration of immunosuppression before PCP diagnosis. 

DISCUSSION 

PCP is a major cause of morbidity and mortality in 

immunocompromised hosts. Dermatologists are often 

reluctant to use sulfa-based medications for PCP 

prophylaxis for fear of severe drug reactions such as 

erythema multiforme, Stevens-Johnson syndrome, 

and toxic epidermal necrolysis. Data describing how 

often PCP prophylaxis is used for dermatologic 

patients are lacking. 

In this study, we reviewed the cases of patients 

who had an immunobullous or connective tissue 

disease and were started on immunosuppressive 

therapy who also had development of pneumonia. 

Six of the 7 patients in whom PCP developed were 

receiving immunosuppressive medication for connective 

tissue disease, and only one patient had a 

diagnosis of immunobullous disease. Although the 

majority of the patients in this study had connective 

tissue disease, the percentage of these patients who

960 Gerhart and Kalaaji 

eventually had PCP appears to be disproportionate to 

that in patients with immunobullous disease (2.5% vs 

1.0%). In addition, it does not appear that a high dose 

of prednisone is needed for development of PCP; one 

patient was receiving a dosage of only 15 mg/d. 

Furthermore, none of the patients in whom PCP 

developed had received PCP prophylaxis. However, 

these patients also had other comorbid conditions, 

which suggests that they may have been at higher 

risk for the development of PCP. In contrast, our 

patients who were on chronic immunosuppression 

and did not have development of PCP had fewer 

comorbid conditions overall. 

From our patients, it appears that the greatest risk 

for developing PCP is in patients with connective 

tissue disease who have comorbid malignancies or 

associated pulmonary disease or are transplant recipients. 

In contrast, patients on immunosuppressive 

medication without comorbid malignancies or transplantation 

appear to have a much lower risk of PCP 

development. The study of Raychaudhuri and Siu 13 

reviewed the cases of 86 immunocompromised patients 

without HIV infection who had a diagnosis of 

PCP. Approximately 70% of the patients had an 

underlying malignancy. The authors reported 4 dermatology 

patientseone with pemphigus, two with 

cutaneous necrotizing vasculitis, and one with 

Behçet diseaseein whom PCP developed after taking 

immunosuppressive medication. The patient 

with pemphigus initially received treatment with 

prednisone, and azathioprine was added after 6 

months. Cyclophosphamide also was eventually 

added, and PCP developed in the 3 months after it 

was administered. However, the patient recovered 

and trimethoprim-sulfamethoxazole was subsequently 

started without recurrence of PCP. 

Interestingly, Sowden and Carmichael 16 reported 

that PCP risk factors include Wegener granulomatosis, 

corticosteroid use, lymphopenia, and low CD4 1 

lymphocyte count. They propose that PCP prophylaxis 

in autoimmune inflammatory disorders be 

considered if patients receiving corticosteroids 

have a CD4 1 cell count of less than 200 cells/mm 3 . 

LIMITATIONS 

In addition to the limitations of a retrospective 

study design, our study was limited by several factors. 

We only reviewed cases of patients with immunobullous 

or connective tissue disease in whom pneumonia 

developed. A total of 3921 of our patients had 

immunobullous or connective tissue disease between 

1980 and 2005. A future study is needed to validate the 

diagnosis in these patients and to determine how 

many received long-term immunosuppression and 

PCP prophylaxis. This would allow for risk analysis of 


JUNE 2010 

PCP development while on immunosuppressive therapy 

for immunobullous or connective tissue disease. 

Another limitation of our study is the lack of a 

control group in which pneumonia did not develop, 

and selection bias that may result from a referral 

population of patients with more complicated disease 

courses. Furthermore, because many patients 

did not have long-term follow-up at our institution, 

we do not know whether pneumonia developed in 

any of these patients after returning home. Thus, the 

number of patients in whom PCP is diagnosed while 

on immunosuppression may actually be higher than 

that reported in this study. 

CONCLUSION 

In summary, PCP developed in 7 of 334 patients 

with immunobullous or connective tissue disorders 

who were receiving immunosuppressive medications. 

None of these 7 patients had received PCP 

prophylaxis. Our study’s design did not allow us to 

perform a risk analysis for PCP development while 

on immunosuppressive therapy. Therefore, we cannot 

make specific recommendations regarding PCP 

prophylaxis for our patient population at this time. 

However, because none of the 7 patients had 

received PCP prophylaxis and because of the infrequency 

with which dermatologists prescribe PCP 

prophylaxis, this topic requires further study. A 

retrospective study with long-term follow-up of 

patients may provide dermatologists with important 

information regarding the relative risks and benefits 

of PCP prophylaxis in patients receiving immunosuppressive 

medications. 

REFERENCES 

1. Arend SM, Kroon FP, van’t Wout JW. Pneumocystis carinii 

pneumonia in patients without AIDS, 1980 through 1993: an 

analysis of 78 cases. Arch Intern Med 1995;155:2436-41. 

2. Bartlett MS, Smith JW. Pneumocystis carinii, an opportunist in 

immunocompromised patients. Clin Microbiol Rev 1991;4: 

137-49. 

3. Ognibene FP, Shelhamer JH, Hoffman GS, Kerr GS, Reda D, 

Fauci AS, et al. Pneumocystis carinii pneumonia: a major 

complication of immunosuppressive therapy in patients with 

Wegener’s granulomatosis. Am J Respir Crit Care Med 1995; 

151:795-9. 

4. Saito K, Nakayamada S, Nakano K, Tokunaga M, Tsujimura S, 

Nakatsuka K, et al. Detection of Pneumocystis carinii by DNA 

amplification in patients with connective tissue diseases: reevaluation 

of clinical features of P. carinii pneumonia in 

rheumatic diseases. Rheumatology (Oxford) 2004;43:479-85. 

5. Sepkowitz KA. Pneumocystis carinii pneumonia in patients 

without AIDS. Clin Infect Dis 1993;17:S416-22. 

6. Thomas CF Jr, Limper AH. Pneumocystis pneumonia. N Engl J 

Med 2004;350:2487-98. 

7. Roblot F, Godet C, Le Moal G, Garo B, Faouzi Souala M, Dary M, 

et al. Analysis of underlying diseases and prognosis factors 

associated with Pneumocystis carinii pneumonia in


VOLUME 62, NUMBER 6 

immunocompromised HIV-negative patients. Eur J Clin Microbiol 

Infect Dis 2002;21:523-31. 

8. van der Lelie J, Venema D, Kuijper EJ, van Steenwijk RP, van 

Oers MH, Thomas LL, et al. Pneumocystis carinii pneumonia in 

HIV-negative patients with hematologic disease. Infection 

1997;25:78-81. 

9. Vassallo R, Thomas CF Jr, Vuk-Pavlovic Z, Limper AH. Mechanisms 

of defense in the lung: lessons from Pneumocystis 

carinii pneumonia. Sarcoidosis Vasc Diffuse Lung Dis 2000;17: 

130-9. 

10. Limper AH. Diagnosis of Pneumocystis carinii pneumonia: does 

use of only bronchoalveolar lavage suffice? Mayo Clin Proc 

1996;71:1121-3. 

11. Hahn PY, Limper AH. The role of inflammation in respiratory 

impairment during Pneumocystis carinii pneumonia. Semin 

Respir Infect 2003;18:40-7. 

12. Ogawa J, Harigai M, Nagasaka K, Nakamura T, Miyasaka N. 

Prediction of and prophylaxis against Pneumocystis pneumo- 

Gerhart and Kalaaji 961 

nia in patients with connective tissue diseases undergoing 

medium- or high-dose corticosteroid therapy. Mod Rheumatol 

2005;15:91-6. 

13. Raychaudhuri SP, Siu S. Pneumocystis carinii pneumonia in 

patients receiving immunosuppressive drugs for dermatological 

diseases. Br J Dermatol 1999;141:528-30. 

14. Sato T, Inokuma S, Maezawa R, Nakayama H, Hamasaki K, 

Miwa Y, et al. Clinical characteristics of Pneumocystis carinii 

pneumonia in patients with connective tissue diseases. Mod 

Rheumatol 2005;15:191-7. 

15. Yale SH, Limper AH. Pneumocystis carinii pneumonia in 

patients without acquired immunodeficiency syndrome: associated 

illness and prior corticosteroid therapy. Mayo Clin Proc 

1996;71:5-13. 

16. Sowden E, Carmichael AJ. Autoimmune inflammatory 

disorders, systemic corticosteroids and Pneumocystis 

pneumonia: a strategy for prevention. BMC Infect Dis 

2004;4:42.

Ronni Hayon, MD 




The T in LGBT Health 


Currently working on a HelpDesk Answer 

(HDA) with Dr. Jennifer Edgoose on “What 

antihypertensives are least likely to cause erectile 

dysfunction (impotence)?” HDAs are brief, 

structured evidence-based answers to clinical 

questions written by physicians for physicians, 

based on the best available recent evidence. HDAs 

are peer reviewed and published in Evidence-Based 

Practice, a monthly journal produced by the Family 

Physicians Inquiries Network (FPIN). 

Thanks go out to my mentors who have helped support my 

interests and shape my role as a physician, including Kathy 

Oriel, Jeff Patterson, Lou Sanner, and Teri Kulie. My deepest 

thanks, of course, to my partner Kathleen who has been an 

unwavering source of support. 

– Ronni 

Ronni Hayon 

graduated from UW 

Madison with a B.A. 

in Zoology before 

heading west to 

California. While 

living in the Bay 

area she worked 

as a Reproductive 

Healthcare Specialist 

at Planned Parenthood, where 

she provided pregnancy options 

counseling and HIV counseling to a 

diverse patient population. She also 

volunteered as an HIV counselor at 

the Haight-Ashbury Free Clinic and 

served as an outreach worker at a 

weekly street-based needle exchange 

program. Medical school then called 

her to the other coast, and she 

earned her medical degree from 

Drexel University in Philadelphia. As 

a medical student she continued to 

be active in volunteer work for atrisk 

populations. She was a student 

coordinator for the Streetside Health 

Project, and she worked as an 

Intimate Partner Violence Prevention 

Educator with area teens. She also 

served as a student coordinator 

for her campus chapter of Medical 

Students for Choice. In her off hours, 

Ronni enjoys music/performance, and 

she was the lead singer of a 10-piece 

band in San Francisco. She also loves 

bread-making. 


rhayon@gmail.com 

415 . 516 . 3247

Th The T in i LGBT Healthcare H lth 

Ground Rules 

� Please participate! Ask 

questions, make comments, 

express confusion, etc. 

� Please be respectful in your 

participation. ti i ti 

� It’s OK to be confused and 

make mistakes 

Sex 

Ronni Hayon, MD 

� Biological or anatomical characteristics 

used to determine if a person is male or 

female or intersex intersex. 

� The best known attributes include the sex 

determining genes, the sex chromosomes, 

the gonads, sex hormones, internal and 

external genitalia, and secondary sex 

characteristics 

PGY-3 

Objectives 

� Gain a better understanding of terminology/language 

used in discussions of gender and gender identity 

� Gain tools that will improve your ability to provide 

culturally y competent p care to the transgender g patient p 

� Discuss hormone regimens for gender transition of the 

adult patient 

Terms and Definitions 

Gender 

� Traditional behavioral differences between men 

and women as defined by a particular culture and 

historical period 

� Used to refer to behaviors, attitudes, and 

personality traits that designates someone as 

masculine or feminine 

� Masculine/feminine means: more “appropriate” to, 

or typical of, the social role as men or as women. 

5/13/2011 

1

Gender Identity 

� A person’s sense of their own gender. 

� “Do I feel I am male or female?” 

� “Do Do I feel I am something else other than 

male or female?” 

Sexual Orientation 

� Sexual orientation is not the same as sexual identity, 

nor is it the same as gender identity 

� For example: a person may be predominantly aroused 

by homoerotic stimuli, yet not regard himself or herself 

to be gay or lesbian 

Gender Identity Disorder 

� GID is a DSM (psychiatric) diagnosis. 

� A strong and persistent cross-gender 

identification—not just a desire for social or 

cultural advantages afforded to the other sex 

� Combined with a persistent discomfort with 

one’s sex or sense of inappropriateness in the 

gender role of that sex, causes clinically 

significant distress. 

10 

Sexual Orientation 

� A person’s relative responsiveness to sexual stimuli. 

� W We usually ll take t k this thi t to mean: what h t i is th the sex of f th the 

person to whom one is attracted sexually? 

Gender Identity Disorder 

(cont’d) 

� Distress: preoccupation with getting rid of primary or 

secondary sex characteristics, or belief that one was 

born the wrong sex. 

� Condition is NOT concurrent with a physical intersex 

condition 

� Condition causes significant distress or impairment in 

social, occupational or other important areas of 

functioning. 

5/13/2011 

2

� Umbrella term 

Transgender 

� Comprises anyone who does not conform to 

gender norms/traditional gender roles 

Types of Transgender Patients 

You Might Encounter 

Outside the Binary 

� Those who define their gender outside the 

binary construct of male/female 

� Terms: Genderqueer, queer, gender fluid 

Transgender 

� Transgender also can mean anyone who transcends 

the conventional definitions of 'man' and 'woman'. 

� This can include Butch Lesbians, Drag Queens, Drag 

Kings, cross-dressers, androgynous people, Two- 

Spirit people, people many gender variant people who use 

a variety of terms to self-identify, as well as people 

who do not identify with any labels. 

Within the Binary 

� Those who identify/express their gender as opposite of 

their birth sex 

� Often referred to as transsexuals, though this term does 

not accurately y describe all transgendered g ppeople p and 

can be perceived as stigmatizing 

� Surgery is not a requirement to fall into this group 

� Terms: MTF, FTM, transwoman, transman, transsexual, 

gender-affirmed female, gender-affirmed male, genderaffirmed 

person, pre-op, post-op, no-ho (cis-gendered) 

Cross Dressing 

� Those who for various reasons reflect the 

outward manifestations of different gender 

roles and cross-dress to varying extents 

� PPeople l in i thi this category, t generally ll h have no 

intention or desire to change their sex 

� Terms: Cross-dressing, cross-dresser, 

transvestite (pejorative) 

5/13/2011 

3

The Process of Gender 

Transition 

The Basic Roadmap 

Born as 

biologic male 

or female 

� Harry Benjamin (1885-1986): 

German endocrinologist 

Life happens 

� 1979 

� Harry Benjamin International 

Gender Dysphoria Association 

(HBIGDA) was formed and 

named after Dr. Benjamin 

� First publication of standards 

of care which are consensus 

guidelines about the 

psychiatric, py ,py psychological, g , 

medical, and surgical 

management of gender identity 

disorders 

� Now called World Professional 

Association for Transgender 

Health (WPATH) 

� 2001: 6 th edition published. 

New edition currently being 

revised. 

“Real Life 

Experience” 

+/psychotherapy 

What is the Goal? 

Increasing quality of life by bringing 

a patient’s body bod into better 

congruence with their gender 

identity 

The Basic Roadmap 

Hormone 

therapy 

Surgery 

Phenotypically 

“pass” as chosen 

gender and legal 

changes (birth 

certificate, driver’s 

license, passport, 

etc) 

Evaluating for Hormone 

RReadiness di 

5/13/2011 

4

Summary of Minimum 

Requirements 

Eligibility Criteria Readiness Criteria 

1. At least 18 yo 

2. Informed of anticipated effects 

and risks 

3. Recommended completion of 

th three months th “ “real-life l lif 

experience” or have been in 

psychotherapy for duration 

specified by a mental health 

professional (usually minimum 

of 3 mos): may be waived to 

prevent unsupervised hormone 

use 

1. Consolidation of Gender 

identity through real life 

experience or therapy 

2. Improved or continuing mental 

stability t bilit 

3. Pt is likely to take hormones in 

a responsible manner 

Subsequent Appointments 

� Complete Physical 

� Informed Consent 

� Phenotype 

�� Reversible/irreversible effects of hormones 

� Risks/benefits 

� Time frame 

Psychological Assessment 

WPATH recommends evaluation by y a mental 

health professional who has experience, 

training and ongoing education in 

transgender care 

Initial Appointment 

� Get to know your patient 

and their gender journey 

� Complete Hx: medical, 

family, psychiatric, social 

supports, t AODA/t AODA/tobacco, b 

sexual hx 

� Order screening labs 

Nuts & Bolts 

� Money 

� Managing expectations 

� How things g work at this clinic 

� Psychological assessment requirements (ie 

will they need a therapist’s letter) 

� What’s going to happen today, and what 

you can expect at upcoming appointments 

� Who is managing what 

� Prescriptions 

Psychological Assessment cont’d 

Letter from MHP to clinician should include (WPATH): 

1. Patient’s general characteristics 

2. Diagnoses related to gender, sexuality, other concerns 

3. Duration of therapeutic relationship 

4. Eligibility criteria which pt has met 

5. Rationale for hormones (why is it appropriate) 

6. Degree to which WPATH SOC have been followed, and 

likelihood that it will continue 

7. Explanation of assessor’s relationship to others involved in 

pt’s care 

8. Statement that assessor welcomes contact to verify 

information in the letter 

5/13/2011 

5

Psychological Assessment cont’d 

I need a letter which provides psychological clearance for @FNAME@ to 

start hormonal therapy for gender transition. This letter should 

include the following: 

� Confirmation of diagnosis of gender identity disorder 

� Assessment of pt's mental health (i.e. is it stable or improving) 

� Assessment of pt's ability to take hormones in a stable manner 

� Assessment/discussion of pt's expectations regarding hormone 

therapy 

� Assessment of any other pschological comorbidities 

If *** is not able to provide a letter of clearance, pt will be referred to 

Pathways Counselling center in Milwaukee. 

Male to Female 

Medications 

Hormone Therapy 

Estrogen: 17B 17B-estradiol estradiol 

Transdermal Oral 

use if if >40 >40 yrs, yrs, or or at at risk risk If If < < 40 40 yo yo and and lo lo risk risk 

for for DVT DVT 

for for DVT DVT 

BBrand dNName Climara Climara, Vivelle Vivelle, Estradot Estrace 

Preorchiectomy 

Postorchiectomy 

Start 0.1mg/24hrs, twice 

weekly; gradually increase 

to max 0.2mg/24 hrs twice 

weekly 

0.375-0.1mg/24 hours, 

Applied twice weekly 

Start 1-2mg daily, 

increase to maximum 

4mg daily 

1-2mg daily 

Monthly Cost $31-60/month generic $11-$18/month generic 

Overview 

Responsibilities of prescribing clinician (per WPATH): 

1. Perform an initial evaluation (H&P, labs) 

2. Explain what the hormones do and possible side effects/health risks 

3. Confirm the pt has the capacity to understand risks/benefits and 

make an informed decision 

4. Inform pt of WPATH SOC and eligibility/readiness requirements 

5. Provide ongoing medical monitoring, including regular physical 

exams and monitoring labs 


Timeline 

� 1-6 mos: body fat redistribution, decreased muscle 

mass, softer skin, decreased libido, anorgasmia, 

decreased ejaculate, decreased erections, testicular 

atrophy 

� 1-2 mos: breast buds 

� Years: hair is finer and grows more slowly 


Medications (cont’d) 

Spironolactone Finasteride 

Brand Name Aldactone Proscar 

Pre- 

orchiectomy hi t 

Postorchiectomy 

Monthly Cost 

Start 50-100 daily, 2.5-5.0 mg daily for 

increase by 100mg each 

month to maximum 

systemic anti-androgen 

effects 

300mg/day (some say 500 2.5 mg every other day if 

mg max) 

Modify if risk factors 

solely for alopecia 

androgenetica 

0-50 mg daily 2.5 mg daily 

200mg daily = $70/month 

25mg tabs are on the $4 list 

5mg daily-$70/month 

5mg tabs are on the $4 list 

5/13/2011 

6

Male to Female Regimen (cont’d) 

Progesterone: 

� Use is controversial 

� Some think it is necessary for nipple/breast 

development 

� Potential adverse effects 

� Micronized progesterone 100mg BID or 

� Medroxyprogesterone 10mg a day 


Labs—New Recommendations 

Monitoring Labs 

Baseline •Fasting lipids, K+, Cr 

•LFTs if on oral estrogen 

1 month, 3 months, 6 months •Serum K+ if on spironolactone 

follow-upp 

1-2 years after initiation of •Screening prolactin 

hormones 

•+/- PSA beginning at age 50, 

taking into consideration family 

and personal history and risk 

factors 

Female to Male 

Medication 

Intramuscular injection 

Agent Testosterone cypionate 

Brand name Depo-Testosterone 

Pre-oophorectomy 25-40mg every week (or 50-80 mg 

every 2 wks); gradually increase 

until serum testosterone is within 

normal male range or there are 

visible changes (typically 50-100 

mg weekly or 100-200 every 2 

weeks) 

Maintenance 

Reduce to level needed to keep 

(after 2 yrs) 

serum free testosterone within the 

lower-middle end of the male 

reference interval. 

Cost $30-100/mo 


Labs—Older Recommendations 


Baseline •Free testosterone, lipids, CMP, 

prolactin, CBC, UA 

1 week after starting or changing •Serum K+ BUN/Cr 

spironolactone p 

dose 

1 month after starting/changing •CMP, lipids 

dose of estrogen 

3 months after starting estrogen •Free testosterone: repeat every 3 

mos until

Female to Male 

Labs—Newer Recommendations 


Baseline •Lipids, Hgb 

1 month, 3 months follow-up •None 

6 month follow up •Consider checking testosterone 

level if difficulty virilizing or 

stopping menses 

Annually •lipids only for patients over 30 or 

who have hyperlipidemia before or 

after starting testosterone 

•TSH every year or two or as 

needed. 

•Pap screening every 2-3 years 

based on current 

recommendations (strongly 

recommended, but not required). 

Chest/Breast 

Surgery (“Top 

Surgery”) 

Genital 

Surgery/Hystere 

ctomy (“Bottom 

Surgery”) 

Eligibility 

Criteria 

1) Able to give informed 

consent 

2) Informed of 

anticipated effects and 

risks 

3) Completion of 3 

months of “real life 

experience” OR have 

been in psychotherapy 

for duration specified 

by a mental health 

professional (usually 

minimum of 3 months) 

1) Able to give informed 

consent 

2) On hormones for > 12 

months 

3) At least 1 year “real 

life experience” 

4) Completion of any 

psychotherapy required 

by the mental health 

professional 

5) Informed of cost, 

hospitalization, 

complications, 

aftercare, and surgeon 

options 

Feminizing Surgery 

� Breast augmentation 

� Orchiectomy 

Readiness 

Criteria 

1) Consolidation of 

gender identity 

2) Improved or 

continuing mental 

stability 

1) Consolidation of 

gender identity 

2) Improved or 

continuing mental 

stability 

� Vaginoplasty 

� Goal is to create a functional vagina and clitoris 

Minimum 

Timeline 

FTM chest surgery may 

be done as first step, 

alone or with hormones 

MTF breast 

augmentation may be 

done after 18 months on 

hormones (to allow time 

for hormonal breast 

development 

At least one year of 

“real life experience” 

� Facial surgeries 

� Chondrolaryngoplasty (thyroid cartilage shaved, aka “trach 

shave”) 

� Jaw reshaping 

� Hair removal 

� Etc 

Surgery 

Masculinizing Surgery 

� Chest reconstruction 

� Metoidioplasty 

� Clitoral release (lengthening) by cutting suspensory 

ligaments lga e ts +/- urethral uet al “hook-up” oo up 

� Cost $4K to $40K 

� Phalloplasty 

� Extensive surgery with grafting 

� Scrotoplasty 

� Silicone implants inserted into labia majora 

Cultural Competency p y 

5/13/2011 

8

Cultural and linguistic competence is a set of 

congruent behaviors, attitudes, and policies that 

come together in a system, agency, or among 

professionals that enables effective work in crosscultural 

situations. 'Culture' refers to integrated 

patterns of human behavior that include the 

language, thoughts, communications, actions, 

customs customs, beliefs beliefs, values values, and institutions of racial racial, 

ethnic, religious, or social groups. 'Competence' 

implies having the capacity to function effectively 

as an individual and an organization within the 

context of the cultural beliefs, behaviors, and 

needs presented by consumers and their 

communities. (US DHHS) 

Linguistic Anxiety 

� Name (given vs. chosen) 

� Pronouns 

�� Gender definitions 


� Sample verbiage: 

� “What name do you go by?” “Do you have a chosen name?” 

� “What pronouns do you use?” 

� “How do you identify?” “Do you identify as transgender, or 

i is there h another h term you prefer?” f ?” 

Cultural Competency 

� Transgender patients are a medically underserved 

population 

� Lack of access, transphobia/discrimination in the health 

care setting g is common 

� The National Transgender Discrimination Survey Report 

� Like all people, transgender patients deserve respectful 

medical care 


� Sample verbiage: 

� “Because so many people are impacted by 

gender issues, I have begun to ask everyone 

about it. Anything you do say about gender 

issues will be kept confidential. If this topic isn’t 

relevant to you, tell me and I’ll move on.” 

� “Out of respect for my clients’ right to selfidentify, 

I ask all clients what gender pronoun 

they prefer I use for them. What pronoun would 

you like me to use for you?” 

5/13/2011 

9

Clinic Environment 

� Post a non-discrimination statement. 

� This statement should also be provided, in writing, to every 

client and staff member. 

�� Provide training for staff 

� Participate in social service provider referral programs 

through LGBT organizations. 

� Display LGBT supportive images and include LGBT friendly 

magazines, newsletters, etc. in the waiting room and various 

appropriate areas 

� Hire LGBT staff 

General Safety 

� Adopt and enforce LGBTQ-inclusive nondiscrimination 

policies, and make it clear that anti-LGBTQ harassment 

and discrimination will not be tolerated and there will 

consequences as a result of non-adherence. 

� Sexual minority patients are at increased risk for both 

suicide and abuse, pay special attention to the mental 

health of this patient. Ask about the patient's access to 

support. Isolation from peers and rejection by family 

are very real risk factors for some sexual minority 

patients. 

Physical Exam of the 

Transgender Patient 

Intake Process 

� Use intake forms that include optional questions about sexual 

orientation/gender identity. 

� Do not ask questions that assume sexual orientation or gender 

identity. 

� Call patients by their preferred name and pronoun in 

accordance with the person’s gender identity or expression. 

Clearly indicate this information on their chart in a manner 

that allows you to easily reference it. 

� When talking with transgender clients, ask questions 

necessary to assess the issue, but avoid unrelated probing. 

Know Your Community and 

Resources 

� Develop Agency/Clinic Connections to LGBT 

Organizations and the LGBT Community 

� Get involved with local networks of 

organizations that are concerned with the 

welfare of LGBT people. 

General Tips 

� Physical exams should be structured based on the organs 

present rather than the perceived gender of the patient 

� Example: if a FTM patient has any significant breast 

tissue, , they y need appropriate pp p exams/screenings g 

� Example: the prostate remains intact even after 

vaginoplasty, so prostate exams should be performed 

per screening guidelines 

5/13/2011 

10

General Tips 

� Be sensitive and kind 

� GU and breast exams can be very uncomfortable for 

transgender patients 

� Unless absolutely necessary, consider deferring these 

examinations until rapport and trust are developed 

Possible Physical Exam Findings 

MTF patients 

� Feminine breast shape/size, +/- underdeveloped nipples 

� Fibrocystic changes from silicone injections 

� Galactorrhea 

� Variable hair 

� Testicular atrophy 

� Defects or hernias at inguinal ring due to “tucking” 

� www.lgbtoutreach.org 

� Madison’s LGBT center (located in Gateway Mall, 600 

Williamson Street) 

� Various support groups for LGBT people 

� http://www.wpath.org/ 

� http://transhealth.vch.ca/resources/library/ 

� Vancouver Coastal Health Transgender Health Program 

� Excellent website with many free resources for providers as 

well as patients 

� http://www.transhealth.ucsf.edu/trans?page=protocol- 

00-00 

� New primary care protocols as of 04/2011 

Possible Physical Exam Findings 

FTM patients 

� Androgenized hair pattern (beard, chest hair, 

androgenic alopecia) 

� Clitoromegaly 

� Acne 

� Intertriginous yeast from breast binding 

� Surgical scars from chest reconstruction 

� http://www.glma.org/ 

Resources 

� http://transequality.org/ 

� Social justice organization dedicated to advancing the 

equality of transgender people through advocacy, 

collaboration and empowerment 

� http://www.checkitoutguys.ca 

� Canadian action campaign geared towards educating trans 

men about pap smears 

� Pamphlet: Tips for Providing Paps to Trans Men 

� www.tsroadmap.com 

� Extensive website created by a transwoman to help others 

navigate the journey of transition 

5/13/2011 

11

References 

� Hembree, et al. Guidelines on the Endocrine Treatment of Transsexuals, J 

Clin Endocrinol Metab, September 2009, 94(9):3132–3154. 

� Gender Education & Advocacy, Inc. www.gender.org, Gender Variance: A 

Primer. 2001. 

� www.Fenway.org 

F 

� Dahl, M., Feldman, J., Goldberg, J. M., Jaberi, A., Bockting, W.O., & 

Knudson, G. (2006). Endocrine therapy for transgender adults in British 

Columbia: Suggested guidelines. Vancouver, BC: Vancouver Coastal Health 

Authority. 

� Feldman, J, Goldberg, J. Transgender Primary Medical Care: Suggested 

Guidelines for Clinicians in British Columbia. (2006). Vancouver, BC: 

Vancouver Coastal Health Authority. 

References 

� van Kesteren, P. J. M., et al. Mortality and morbidity in transsexual subjects 

treated with cross-sex hormones. Clinical Endocrinology, 47, 337-342. 

� http://www.kingcounty.gov/healthservices/health/personal/glbt/CulturalCo 

mpetency.aspx 

� Th The Harry H Benjamin B j i IInternational t ti l GGender d DDysphoria h i AAssociation’s i ti ’ St Standards d d 

Of Care For Gender Identity Disorders, Sixth Version, February, 2001 

� Screening for HIV, Topic Page. April 2007. U.S. Preventive Services Task 

Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspshivi.htm 

� Primary Care Protocol for Transgender Patient Care , Center of Excellence 

for Transgender Health, University of California, San Francisco, Department 

of Family and Community Medicine, April 2011 

5/13/2011 

12

Sam Heiks, MD 



�� Project: 

The Verona Clinic Resident Newsletter 

�� Project: 

Diagnostic Criteria for Diabetes Mellitus -- My 

scholarly project involved working with Brian 

Arndt to write a help desk answer. The topic 

was updating the diagnostic criteria of diabetes 

mellitus to include a hemoglobin A1c of 6.5 or 

greater. This was in response to a change in the 

guidelines published by the ADA. Our article was 

featured as the lead article in the July 2010 edition 

of Evidence-Based Practice. 

Sam discovered an 

interest in medicine 

while working as a 

teacher in Kansas 

with children with 

special needs. At the 

Prairie View Special 

Purpose School in 

Newton, Kansas, he 

worked with students 

with severe behavioral problems, 

learning disabilities, and psychiatric 

illnesses that prevented them from 

attending public schools. Later, he 

served as a mental health worker on 

the child and adolescent inpatient 

units at the mental health hospital 

adjacent to this school. Graduating 

with a degree in History, he went 

back to obtain the science required of 

medical school, and attended the UW 

School of Medicine and Public Health. 

In medical school, he discovered 

interests beyond child psychiatry, and 

decided to pursue Family Medicine. At 

present, he lives with his wife, Rachel, 

and two daughters, Adeline and Ella, 

at the Village Cohousing Community 

in Madison. Outside of medicine, 

Sam enjoys chasing his children and 

throwing balls at them, swimming, 

canoeing, hockey, frisbee, soccer, 

and classical guitar. Most of all, he 

enjoys sitting quietly in the sun with 

Rachel, drinking a cup of coffee while 

his daughters play quietly in the yard 

(yeah right)! 


4175 Jackson St 

Bluffton, OH 45817

Volume 1, Issue 3 

UW Health Verona Winter 2010 

Resident Newsletter 

INSIDE THIS ISSUE: 

Resistance Exercises 1 

Reflection of a Newbie 2 

Benefits of Joining a CSA 3 

Recipe: Veggie Chili 3 

Pantoum for the Heart 3 

What is a Pantoum? 3 

Add resistance to your workout – especially if you have diabetes! 

By Sam Heiks, MD 

Exercise is one of the best 

therapies for people who are at 

risk for developing diabetes, a 

condition known as impaired 

fasting glucose (or sometimes 

called “pre-diabetes”). This 

condition is diagnosed when 

the fasting blood sugar is 

elevated, but not as high as in 

diabetes. It is important to 

know about because simple 

lifestyle changes can make a 

big difference. In one of the 

largest studies comparing a 

lifestyle program that included 

physical activity for at least 150 

minutes per week with diabetes 

medication (Metformin), 

lifestyle intervention was found 

to be TWICE as effective as 

medication in preventing 

diabetes over the next 3 years. 

A new study adds to the 

growing body of evidence 

suggesting that exercise is also 

helpful for people who already 

carry the diagnosis of diabetes. 

This study found that 

combining resistance training 

with aerobic activity was more 

effective than either activity 

alone. Over the nine months 

that the patients were followed, 

only the group that added a 

resistance routine to their 

aerobic activity had significant 

reductions in the hemoglobin 

A1c level (which indicates 

blood sugar levels over the 

past three months). While the 

results were modest, the 

effects were likely larger than 

reported because this group 

required less medication 

increases to control their 

diabetes over this time. To put 

it a different way, this group 

achieved greater reductions in 

their blood sugar while at the 

same time requiring less 

medication to do so. So, if you 

or someone you know has 

diabetes, encourage them to 

add a resistance program to 

their exercise. The group that 

did the best walked for 40 

minutes three times a week 

and did 1 set of 9 different 

resistance exercises two times 

a week. 

Sam Heiks is in his third and 

final year of residency. 

“Reduction in the Incidence of 

Type 2 Diabetes with Lifestyle 

Intervention or Metformin. NEJM, 

2002. 

“Effects of Aerobic and Resistance 

Training on Hemoglobin A1c 

Levels in Patients With Type 2 

Diabetes.” JAMA, Nov. 2010.

Page 2 

“The truly tough part 

about being a 

physician is making 

difficult, weighty 

decisions in the face 

uncertainty, and in 

many ways intern 

year is all about 

becoming somewhat 

comfortable with 

this. “ 

Reflections of a Newbie 

By Benji Scherschligt, MD 

As the weather turns cold 

and the holiday season 

approaches, I find myself 

looking back on the first 

half of my first year of 

residency (also called 

intern year). I think back 

to when my residency 

mates and I first arrived at 

orientation in mid-June, 

the rigorous months that 

followed, and how we’ve 

all changed so much since 

then. 

Most physicians begin 

residency with emotions 

typical of any major life 

change… amplified by a 

million. Any newly minted 

M.D. would surely admit to 

feeling a mix of 

excitement, anxiety, 

anticipation, and 

downright fear when 

describing the beginning 

of residency. While I have 

experienced all of these at 

some point over the last 

six months, I’ve only 

recently begun to realize 

that not only is this 

expected, but it is 

necessary in order to 

become a truly competent 

doctor. The truly tough 

part about being a 

physician is making 

difficult, weighty decisions 

in the face uncertainty, 

and in many ways intern 

year is all about becoming 

somewhat comfortable 

with this. 

As family medicine 

interns, we change every 

month to a different 

experience, or “rotation”, 

as we like to call it. For 

instance, I am spending 

this month in Fort 

Atkinson doing a rotation 

in general surgery. While 

most family doctors will 

never actually do surgery 

as part of their practice, 

this rotation provides 

valuable experience with 

stitching up wounds, using 

tools involved in office 

procedures, and seeing 

complications that can 

arise from surgery. Next 

month I will switch to 

obstetrics, then intensive 

care after that, and on and 

on throughout the year. 

By the time intern year is 

over, we will have had a 

broad overview of 

everything that 

encompasses being a 

family doctor (even though 

the constant switching can 

be nerve-wracking at 

times!). The only real 

constant is that we spend 

one to two days every 

week seeing patients in 

our designated clinic, 


regardless of our current 

rotation. Because of the 

familiarity, the friendly 

faces (I’m talking about 

you, Verona clinic 

patients!), and our love for 

office-based medicine, 

many residents come to 

view the clinic as a 

sanctuary as the hectic 

year progresses. 

All in all, intern year has 

been a great experience 

so far. I have learned 

more than I ever thought 

possible both about 

medicine and about 

myself. While the work is 

difficult and the learning 

curve is steep, being able 

to care for the people of 

Verona and the 

surrounding communities 

is the ultimate reward.


Benefits of Joining a CSA 

By: James Bigham, MD 

Eating fruits and vegetables is 

an important part of any healthy 

diet…but it can be really hard to 

do. What if you had a weekly 

supply of fresh produce 

delivered directly from a local 

farm to your door? Consider 

becoming a sponsor of 

Community Supported 

Agriculture (CSA). When you 

join a CSA, you support a local 

Pantoum for the Heart 

By Kristen Prewitt, DO 

Something in my heart died 

tonight 

As I wandered the wards, lost. 

Feeling my selfish, amplified 

pain: 

Cannot ignore the reality of 

another’s life. 

As I wandered the wards, lost, 

My patient’s heart struggled. 

Cannot ignore the reality of 

another’s life 

Etched in blood on EKG paper: 

terminal. 

My patient’s heart struggled, 

farm of your choice; in return 

you receive a share of the 

produce harvested over the 

course of the growing season 

(typically May to October). Your 

weekly or biweekly produce 

boxes will contain everything 

from asparagus to eggs and lots 

of things in between. Best of all, 

many insurance providers 

reimburse their members for all 

or part of the cost of joining the 

CSA. Below are listed resources 

for several of the larger area 

insurance providers. If your 

insurance company is not listed 

below, give them a call to 

inquire about their wellness 

benefits. 

If you would like to learn more 

about this great, healthy 

resource, please check out the 

Madison Area Community 

While mine merely broke into 

pieces. 

Etched in blood on EKG paper: 

“terminal,” 

We say too casually. 

While mine merely broke into 

pieces, 

Attempts were made to rescue the 

patient’s. 

We say too casually, “Time heals 

all wounds.” 

Attempts were made to rescue the 

patient’s 

Life, heart, tissue, cells. 

Time heals all wounds 

Supported Agriculture Coalition 

(MACSAC) at www.macsac.org. 

Even better, why not meet the 

actual farmers? MACSAC offers a 

CSA Open House every March 

which provides you an opportunity 

to meet the farmers while learning 

more about the over 40 farms 

available. Happy eating! 

Dean: CSA benefit through: 

Wellness Incentives Now Program 

($100 per member, $200 per family 

per year) 

GHC: CSA benefit each year 

through Wellness reimbursement 

(https://ghcscw.com/csa.asp) 

Unity: CSA benefit: $50 per 

member per year, $100 per family 

per year 

http://www.unityhealth.com/Health 

Wellness/Rewards/CSAFarm/index 

.htm 

Of the soul, perhaps, but not the flesh. 

Life, heart, tissue, cells: 

Feeling my selfish, amplified pain 

Of the soul, perhaps, but not the flesh: 

Something in my heart died tonight. 

Vegetarian Chili: 

Page 3 

Ingredients 

1 tablespoon olive oil 

1/2 medium onion, chopped 

2 bay leaves 

1 teaspoon ground cumin 

2 tablespoons dried oregano 

1 tablespoon salt 

2 stalks celery, chopped 

2 green bell peppers, chopped 

2 jalapeno peppers, chopped 

3 cloves garlic, chopped 

2 (4 ounce) cans chopped green chiles 

2 (12 ounce) packages vegetarian 

burger crumbles 

3 (28 ounce) cans tomatoes, crushed 

1/4 cup chili powder 

1 tablespoon ground black pepper 

1 (15 ounce) can kidney beans, drain 

1 (15 ounce) can garbanzo beans, 

drain 

1 (15 ounce) can black beans 

1 (15 ounce) can whole kernel corn 

Directions: Heat the olive oil in a 

large pot over medium heat. Stir in the 

onion, and season with bay leaves, 

cumin, oregano, and salt. Cook until 

onion is tender, then mix in the celery, 

green bell peppers, jalapeno peppers, 

garlic, and green chiles. When 

vegetables are heated through, mix in 

the vegetarian burger crumbles. 

Reduce heat to low, cover pot, and 

simmer 5 minutes. Mix the tomatoes 

into the pot. Season chili with chili 

powder and pepper. Stir in the kidney 

beans, garbanzo beans, and black 

beans. Bring to a boil, reduce heat to 

low, and simmer 45 minutes. Stir in the 

corn, and continue cooking 5 minutes 

before serving. 

What is a Pantoum? 

A pantoum is composed of a series 

of quatrains; the second and fourth 

lines of each stanza are repeated 

as the first and third lines of the 

next. This pattern continues for any 

number of stanzas, except for the 

final stanza, which differs in the 

repeating pattern. The first and third 

lines of the last stanza are the 

second and fourth of the 

penultimate; the first line of the 

poem is the last line of the final 

stanza, and the third line of the first 

stanza is the second of the final. 

Ideally, the meaning of lines shifts 

when they are repeated although 

the words remain exactly the same: 

this can be done by shifting 

punctuation, punning, or simply recontextualizing.

Jill Klemin, MD 




Healthy Habits for Preschoolers (with Kate 

Porter) 


FPIN Maternity Topic: Magnesium Sulfate used 

for Fetal Neuroprotection in Preterm Birth -- Over 

the past 20 years, there have been great strides made 

in the survivability of fragile, preterm infants with 

advances in obstetric and neonatal care, but with 

this, the number of children with cerebral palsy 

has increased. There has been strong interest in 

the scientifi c and medical communities regarding 

neuroprotection in the preterm infant. Lex W 

Doyle recently published a Cochrane review which 

included 5 RCTs and a total of 6,145 infants, 

and concluded that there remains little doubt 

that antenatal magnesium sulfate therapy given 

to women at risk of preterm birth substantially 

reduced the risk of CP and substantial gross motor 

dysfunction in their children. He also found that 

the number needed to treat to prevent one case of 

cerebral palsy was 63 (5). The American College 

of Obstetrics and Gynecology (ACOG) released a 

Committee Opinion in March 2010 that supports 

the use of magnesium sulfate to reduce the risk of 

CP in preterm infants. 

I’d like to thank my husband, Pete, and my children Addison 

and Logan for helping me laugh and enjoy life during residency- 

-they always remind me that it is the little, simple things in life 

that are most important! I also want to let my residency colleagues 

and staff know how important they are to me and how much I’ve 

enjoyed my time here in Madison because of them. 

– Jill 

Jill Klemin grew up in 

several small towns 

in North Dakota, 

where she was able 

to see fi rst hand the 

impact good family 

physicians can have 

on rural communities. 

She graduated 

from Creighton 

University in Nebraska with degrees 

in Biology and Philosophy and then 

went on to complete her medical 

degree at the University of North 

Dakota School of Medicine. She loves 

working with children and originally 

envisioned herself as a pediatrician. 

She has volunteered in elementary 

classrooms through the Great Books 

Program, Doctor’s Ought to Care, Mad 

Science Youth Program, and most 

recently teaching Health Habits to 

preschoolers. She has also taught 

Sunday School and Summer Bible 

School for many years at her church 

in North Dakota. In addition to her 

love of pediatrics, though, Jill also 

has a strong interest in women’s 

health and geriatrics. Thus, she has 

ultimately chosen Family Medicine 

as the one unique specialty that can 

encompass the full spectrum of her 

medical interests. Jill spends as much 

of her free time as she can with her 

husband Peter, who is a resident 

in the OB/Gyn program, and their 

children Addison and Logan. She 

also enjoys reading, journaling, and 

spending time outdoors. 


Medcenter One Hospital & 

Clinics - Bismarck, ND

Community Medicine Project: Healthy Habits for Preschool Children 

Jill Klemin and Kate Porter worked on a project to bring health education to preschool children. Our goal 

was to introduce them to concepts of healthy living. No child is too young to learn about eating right and 

being active. The earlier a child forms healthy habits, the easier it will be to maintain a healthy lifestyle. 

We contacted area preschool education centers to see if they would be interested in the program we 

designed. The response was excellent. The preschools that we visited included Kids Express Learning 

Center and La Petite Academy. We also have plans to visit other area preschools in the near future. 

Prior to our educational meeting, we prepared reward charts for the children to take home and share 

with their families. The charts included healthy food options, hygiene, and exercises. This was done in 

hopes that the parents would see healthy eating and living as behaviors that deserve rewards. We also 

purchased the book, “Oh The Things You Can Do That Are Good For You,” by Dr. Seuss. At the end of 

our meeting, this book was donated to the classroom. 

We met with the children at their school. We began the encounter by asking them if they could name 

any foods they thought were healthy. This was followed by asking them what they like to do for 

exercise. We read them the Dr. Seuss book “Oh The Thing You Can Do That Are Good For You.” This was 

followed by a poster presentation of children their age doing healthy habits. We talked through each 

poster and asked the children for their thoughts or ideas to expand on the concepts displayed in the 

posters. The presentation ended with some fun with fruit stickers. Each child was sent home with the 

reward charts and a sheet of star stickers. Each child was also given 2 healthy recipes that are kidfriendly 

to make and fun to eat! The handout also included goal setting for each family to consider, in 

hopes that each family could take steps forward in health living.

Exercise 

Limit Screen 

Time (TV) 

Healthy Food 

Choices 

Brush Teeth 

(twice!!) 

Be Safe!! 

(seat belt, 

helmets…) 

Sleep 10+ hours 

nightly 

Keep Clean 

The Things You Can Do To Take Care of You!!! 

Monday Tuesday Wednesday Thursday Friday Weekend 

**Use Stickers on the Chart to Reward Health Habits!!**

Frozen Yogurt Pops 


Fun, Healthy Recipies!! 

*Pour favorite flavor of yogurt into multiple small paper cups—fill almost to the top! Then, stretch a small piece of plastic wrap across the top of each cup. Next, poke a wooden popsicle 

stick into the plastic wrap and into the center of the cup of yogurt. Put the cups in the freezer until frozen, then remove plastic wrap and remove the frozen pop from the paper cup— 

Enjoy! This is also fun to layer multiple flavors of yogurt for a rainbow pop! 

Incredible, Edible Veggie Bowls 

*Cut a Green or Red Pepper in half (from side to side). Clean out the insides. These pieces can be your bowls. Then, cut carrots, celery, peppers, cucumbers, etc into skinny sticks. Put 

either ranch dressing or hummus into the bottom of your ‘bowls.’ Last, put the veggie slices into the bowl—Enjoy! 

_____________________________________________________________________________________________________ 

My Healthy Family 

Healthy habits that my family already does are: ____________________________________________________ 

New healthy habits that we can try are: ________________________________________________________

lara knudsen, MD 




Bringing the Advanced Life Support in 

Obstetrics (ALSO) training to Uganda 


“Contraception in Wisconsin: A Review” -- 

Along with faculty member Sarina Schrager and 

residents Jessica Dalby and Elizabeth Paddock, 

I wrote an article titled “Contraception in 

Wisconsin: A Review,” which was published in 

the Wisconsin Medical Journal in 2010. This 

article reviewed literature related to several types 

of contraception including Implanon (a newly 

available implantable contraceptive), drospirenonecontaining 

oral contraceptive pills, and intrauterine 

devices. We also reviewed evidence regarding 

depot medroxyprogesterone acetate and bone 

mineral density, and new cycling regimens for oral 

contraceptive pills. 

Many thanks to the awesome staff, faculty, and residents who 

make this program one of the best. I’ve learned so much from you 

all. Thank you to my family and friends, especially Chris, Jena, 

Ernesto, Mom, Dad, and Beth, Robert, and Jonathan Jones. 

– Lara 

After earning her 

B.A. from Marlboro 

College in Vermont, 

Lara completed her 

M.D. and M.P.H. at 

George Washington 

University School of 

Medicine. She has 

a strong interest 

in women’s health 

issues, especially in a global context. 

As an undergraduate, she spent 

eight months in Uganda conducting 

research and working in a maternity 

ward of a rural hospital. Then, 

before entering medical school, she 

traveled to Peru to continue her 

research and to volunteer as an ob/ 

gyn assistant at a local hospital. 

On the home front, she also spent 

six years working on-and-off at a 

women’s health clinic in Oregon that 

specializes in abortion services. She is 

the author of Reproductive Rights in a 

Global Context, which won the ALA’s 

Outstanding Academic Book of 2007 

Award. Lara also has a keen interest 

in integrative medicine and was cofounder 

and co-president of GWU’s 

Integrative Medicine Club. In her free 

time, she enjoys hiking, biking, and 

spending time with her husband. She 

is a fl uent Spanish speaker. 


Laraknudsen@gmail.com 

608 . 514 . 3979

Lara Knudsen, MD MPH 

Family Medicine Resident 

University of Wisconsin 

Department of Family Medicine 

Community Medicine Project 

April 2011 

Introducing Advanced Life Support in Obstetrics (ALSO) Training in Uganda 

My community medicine project has been laying the framework for introducing the 

Advanced Life Support in Obstetrics (ALSO) training to medical students and physicians in 

Kampala, Uganda. The training will likely take place in 2012. 

Developed in 1991 by a group of family physicians at the University of Wisconsin, the 

Advanced Life Support in Obstetrics (ALSO) program provides health care professionals with 

information and skills to manage emergencies that arise during pregnancy and childbirth. The 

program covers a variety of topics over the two-day training, including managing post-partum 

hemorrhage, breech deliveries, shoulder dystocia, and forceps or vacuum deliveries. Managed by 

the American Academy of Family Physicians (AAFP) since 1993, the program has trained nearly 

55,000 health professionals in 47 countries. 1, 2 Though ALSO first spread to other industrialized 

countries, including Canada and the United Kingdom, in recent years the program has also been 

implemented in developing countries in all regions of the world. 3 A modified Global ALSO 

curriculum was developed in 2005 to ensure the relevance of the curriculum in the setting of 

more impoverished nations, and to further address issues more specific to such a setting, 

including unsafe abortion, infections (like malaria, tuberculosis, and HIV/AIDS), malnutrition, 

obstetric fistula, and female genital mutilation. The Global ALSO curriculum also includes 

recommendations on collaboration with midwives and traditional birth attendants. 

Multiple studies have demonstrated that the ALSO course is effective in increasing the 

confidence of maternity care providers in dealing with obstetric emergencies. 1 Surveys have also 

shown that health professionals who have completed the ALSO course state they are more likely 

to provide maternity care. Though specific data on the impact of the ALSO course on maternal 

mortality is difficult to collect given the multitude of factors that affect such a measurement, 

other outcomes data relating to the management of pregnancy and labor complications has been 

encouraging. One survey in Honduras found that the episiotomy rate decreased from 60% before 

the training to 20% within the first two months after ALSO was introduced. 4 A recent study in 

Tanzania showed that the rate of postpartum hemorrhage (>500ml blood loss) dropped from 33% 

before ALSO training to 18% after the training. 5 

Using a teach-the-teacher model, the ALSO program is usually introduced to a country 

through a week-long series of courses. First, a group of health professionals in the country who 

are interested in being leaders of ALSO training undergo the two-day ALSO course, taught by a 

team of foreign health providers. Next the same group completes a one-day provider course, 

again taught by the foreign team. Then the new ALSO instructors from the host country teach a 

two-day ALSO course to another group of local health providers, with the foreign team present 

for assistance as needed. This model has served well in creating self-sustaining ALSO programs 

in roughly 25 countries (see Table 1). 2

Table 1 Countries With Self-sustaining Advanced Life Support in Obstetrics (ALSO) Programs 3 

Year Countries Providers Instructors 

introduced 

trained trained 

1996 United Kingdom 10,937 300 

1997 Canada 4,842 115 

2000 Brazil 1,998 129 

2001 Asia/Pacific, Hong Kong, New Zealand 2,177 159 

2002 Greece, Scandinavia, Greenland, People’s Republic of 

China, Qatar 

2,415 138 

2003 Ecuador, Kenya, Palestine, Pakistan 671 98 

2004 Guatemala, Nigeria, Norway, Sudan, United Arab 

Emirates 

777 61 

2005 Honduras 73 41 

2006 Mexico, Moldova 187 31 

2006-2007 Saudi Arabia, Bahrain, Colombia, Peru, Argentina New New 

programs programs 

Why Uganda? 

Over the past decade, I have been to Uganda three times to work in the health care field: 

first for a year in college, then as a fourth-year medical student, and most recently for a month as 

a second-year resident. Many of the patients I saw there were profoundly anemic from malaria 

during pregnancy, but were unable to get blood transfusions and were thus at higher risk of death 

from hemorrhage during their delivery. The vast majority of the deliveries are not attended by 

skilled health personnel, and even those women who do deliver in hospitals are often delivered 

by residents or recently graduated physicians who do not always have adequate skills for 

emergency obstetric care. I also saw women in clinic who suffered from vesico-vaginal and 

recto-vaginal fistulas as a result of the inadequate maternity care they had available to them for 

previous deliveries. Despite recent advances in reproductive health, Uganda still has one of the 

highest maternal mortality rates in the world, reporting 435 deaths per 100,000 live births. 6 

Coupled with a total fertility rate of 6.7 children per woman, the risk to any individual woman of 

mortality or serious morbidity related to pregnancy and childbirth is staggering. 6 Introducing the 

ALSO training course may bolster local health providers’ confidence and skills in dealing with 

the obstetric emergencies most responsible for both maternal and infant mortality and morbidity. 

While in Uganda in January/February 2010, I met with key members of Makerere 

University’s Department of Family Medicine and Learning for Life Africa (a non-profit 

organization) to assemble a team of Ugandan organizers interested in this training. I also gave a 

presentation to the DFM faculty and residents at Makerere University about what the ALSO 

training includes and why it may be useful in Uganda. Originally scheduled for January 2011, 

the course was postponed due to concerns about political instability leading up to the February 

2011 elections. We have submitted our proposal to the AAFP’s ALSO Advisory Board for 

consideration. We are hoping to hold the training in early 2012, though we still face financial 

barriers as well as ongoing concern about political stability. 

I would like to thank Dr. Lee Dresang and Dr. Cindy Haq from our own faculty, as well 

as Dr. Samuel Luboga of Learning for Life Africa, for their support in moving this project 

forward and for their dedication to women’s health in Uganda.

References 

1. Beasley JW, LT Dresang, DB Winslow, JR Damos. The Advanced Life Support in Obstetrics 

(ALSO) program: fourteen years of progress. Prehospital Disaster Med 2005;20:271-5. 

2. American Academy of Family Physicians. ALSO International. 

www.aafp.org/online/en/home/cme/aafpcourses/clinicalcourses/also/intlactivities.html Accessed 

January 11, 2009. 

3. Deutchman M, L Dresang, D Winslow. Advanced Life Support in Obstetrics (ALSO) 

International Development. Fam Med 2007;39(9):618-22. 

4. Bustillo C. Preliminary impact report of ALSO in Honduras: decreased use of episiotomy. 

Presented at the 2007 ALSO International Advisory Board Meeting. Cabo San Lucas, Mexico. 

5. Sorensen BL, V Rasch, S Massawe et al. Advanced Life Support in Obstetrics (ALSO) and 

post-partum hemorrhage: a prospective intervention study in Tanzania. Acta Obstetricia et 

Gynecologica Scandinavica, February 19, 2011. 

6. Macro International, Uganda Bureau of Statistics. Uganda Demographic and Health Survey 

2006.

George Leydon, DO 




Building a Clinic Wiki -- A Collaborative 

Website 


FPIN Article: “Are Waddell’s Signs Helpful in 

Predicting Patients Who Are Malingering?”-- 

Waddell’s signs are historically used to help 

distinguish between patients who have organic 

low back pain and those that are malingering, 

using pack pain for secondary gain, or those who 

have other psychosocial aspects to their pain. This 

review looks at the studies and articles to see if 

using Waddell’s signs is helpful for this distinction. 

Thanks to my wife Charlotte who has made surviving residency 

possible, to my wonderful sons Henry and Grant, and to all 

the folks at the DFM who helped us out. 

– George 

George Leydon 

earned a B.S. in 

Biology from Boston 

College and a M.A. in 

Medical Sciences from 

Boston University. 

He then went on 

to complete his 

medical degree at 

Kirksville College of 

Osteopathic Medicine 

in Kirksville, Missouri. Throughout 

his life, George has spent much of 

his time in service to others, through 

both work and volunteerism. As a 

high school student he spent most of 

his Saturday mornings volunteering at 

a local nursing home, and throughout 

college he dedicated time each 

week to work at the Pine Street Inn, 

Boston’s largest homeless shelter. He 

also started a new Cub Scout Pack at 

a Boston housing development and 

organized spring break service trips 

with Habitat for Humanity. Then, 

following his undergraduate studies, 

George spent a year as a Jesuit 

Volunteer, serving as a homeless 

outreach worker and case manager 

at an agency that provided services 

to HIV positive men. Needless to say, 

George’s commitment to service and 

advocacy make Family Medicine the 

perfect specialty for him. When he’s 

not working or volunteering, George 

enjoys playing guitar (both regular 

and air), camping, skiing, cooking, 

and spending time with his wife 

Charlotte and their two sons Henry 

and Grant. 


gleydon@gmail.com

Patrick McKenna, MD 




The Verona Clinic Community Garden 


Communicating Benefi ts and Risks of Screening for 

Prostate, Colon and Breast Cancer -- This paper, 

co-authored with Bruce Barrett, MD, outlines 

several strategies for effective communication of 

complex statistical information regarding screening 

for cancer. The article introduces and encourages 

“natural frequency presentation,” a relatively 

new method for portraying benefi ts and harms, that 

recent evidence suggests is better understood and 

more concordant with patients’ values than other 

methods. The paper was published in the April 

2011 issue of Family Medicine. 

Thanks to my family, my wife Tonya, and my kids, Evie and 

Egan, for their day-to-day support through Residency. Thanks 

to my parents, Anne and Joseph, for their work in instilling 

the values that have carried me through my life: service and 

education, respect for others. 

– Patrick 

Patrick McKenna grew 

up in the northern 

Wisconsin town of 

Antigo. After earning 

his bachelor’s degree 

in biochemistry from 

UW-Madison, he took 

an untraditional path 

to medicine by fi rst 

pursuing an MBA in 

Chicago and a Masters in Fine Arts at 

the University of Alaska. Ultimately, 

though, his Wisconsin roots lured him 

back to The Dairy State to attend 

medical school at the UW-Madison 

School of Medicine and Public Health. 

Patrick’s leadership and commitment 

to public service are evidenced by 

his work during medical school as a 

LOCUS Fellow and with the MEDIC 

free clinics in Madison. He served 

as MEDIC Council president during 

his second year and received the 

2006 McGovern-Tracy Scholar award, 

which recognizes medical students 

who exemplify values of community 

service and leadership while in 

training. He also has a passion for 

global health and served as both 

a member and co-chair of the UW 

Global Health Interest Group. In his 

spare time, Patrick enjoys athletics 

of all kinds, including basketball, 

broomball, running, bicycling, 

canoeing, and skiing. He also enjoys 

gardening, cooking, baking, and 

sewing, and he has strong interests 

in politics, rural policy, sustainability, 

and creative writing. 


pamckenn@gmail.com 

608 . 469 . 0219

Verona Community Clinic Garden 

Mission Statement: To improve the health and happiness of patients, community, and staff through 

the planting, tending and harvesting of a community garden. 

Values: health, well-being, local autonomy, appreciation of Verona's farming heritage, community 

collaboration and involvement. 

Key Stakeholders: Verona community, patients, long-term staff and faculty, residents, local food 

growers and gardeners. 

Long Term Vision: 

The town of Verona has a long tradition of being fed and nurtured by the surrounding landscape, 

with a diverse array of farms and farmers, growers of food, living in this community. The Verona 

garden would be serve as a bridge between these deep traditions and the contemporary interests of 

sustainable, local, organic food. 

That the Verona Garden would exist as a sustaining and varied garden tended by a wide variety of 

people. That the physical act of caring for the garden would make people happier, and healthier. That 

the fruits of those labors would be shared with community members, patients, staff, not only through 

what is grown there, but also by teaching others how to grow food and prepare food. 

More clearly: the Verona Garden would allow people to work, to put their hands in the dirt, and to 

be outside a little more than they might otherwise be outside, in the sunlight and weather. It will allow 

us to better appreciate the passage of time, and the natural course that a growing season takes. It will 

allow one to taste food that they have tended to, and watched grow. These are not small things, as they 

add to the satisfaction of living, and being alive. 

Short-term goals: 

1. Approval of a garden by clinic and broader organizational leadership. 

2. Approval by local government to plant a garden on business property. 

3. Draft a working proposal for the community garden. 

4. Promote/advertise the garden in the clinic, to staff and patients to build excitement/enlist support. 

Mid-range goals: 

1. Invite key stakeholders to participate in planning and . This includes personally contacting patients 

recommended by other clinicians, staff members interested in participating. This may also include the local 4H 

program/high school program/students interested in participating. 

2. Talk with local area businesses/farms regarding donation of basic supplies/time (a couple shovels, rakes, 

some seeds). 

3. Start working on a tentative site, approximate planting time for the spring of 2010. 

4. build and support a core of committed volunteers to work in the garden. 

5. Provide a small but real harvest of food by the first autumn frost of 2010. 

Long-term goals: 

1. Establish a leadership and support structure that makes the garden a sustainable and recurring project. 

2. That the garden provide nourishing food to patients, staff, community. 

3. Increase understanding and awareness of the local food ecosystem. 

4. Contribute meaningfully to the overall health and happiness of the Verona community. 

5. Serve as a model for other clinic and community gardens in the state.

A moment in the sun: 

The Verona Community Clinic Garden 

The purpose of the garden: 

To improve the health and happiness of 

patients, patients patients, community, community community, and staff 

staff th through rough 

the planting, tending and harvesting of 

a community garden 

Preparation 

Ok from the clinic 

Permission from the city 

Digger’s ’ hotline h l 

Designing and planting the 

garden 

Verona Clinic Community 

Garden 

The garden was the idea of James 

Bigham and Patrick McKenna 

Getting Started: 

Planning 

We had great support from the 

clinic staff and from Mark 

Shapley, Sh Shapley, l our clinic li i manager, 

who has been instrumental in 

our efforts. 

5/13/2011 

1

Principles 

�� The garden has no individual plots, it is an open 

community space. 

�� Patients, , staff, , residents, , faculty, y, community y 

members: the garden space would be available to all 

to help tend and to enjoy. 

�� Food harvested would be shared with patients, 

staff, community members. 

We cut and 

rolled the sod, 

and placed it on 

the corner. It 

was gone by the 

end of the day. 

"Where you have a plot of land, however small, plant a 

garden. Staying close to the soil is good for the soul." ~ 

Spencer W. Kimball 

Preparing the plot 

“Gardening is a kind of selfprescribed 

preventative 

medicine, good for all ills.” 

Sheryl London 

We used a tiller for the initial turning of the soil. 

5/13/2011 

2

The garden was inaugurated in early May. 

Members of Jame’s church helped with the initial 

planting. 

We used hay to serve as a mulch and ground 

cover for the garden. 

“Every child is born a 

naturalist. His eyes are, by 

nature, open to the glories of 

the stars stars, the beauty of the 

flowers, and the mystery of 

life.”   

- R. Search 

"This time, like all times, is a very good one if we but know what to do 

with it." ~ Ralph Waldo Emerson 

Growing season 

We had lettuce, onions, swiss chard, tomatoes, asparagus, 

peppers potatoes, herbs and much else that grew in the 

garden. 

5/13/2011 

3

Harvest 

"How How fair is a garden amid the trials and passions of 

existence." - Benjamin Disraeli 

The hope of the garden 

�� To allow us to put our hands in the dirt, out in the 

sunlight and weather, 

�� To enjoy j y fresh air in the company p y of our friends. 

�� To allow us a better appreciation of time’s passage, 

and the natural course of a growing season. 

�� To enjoy the food which we have tended, to watch it 

grow, to take satisfaction in living, and to bear 

witness to time’s passage. 

“Anyone who has a library and a garden wants for nothing.” 

“Show me your garden and I shall tell you what you are.” 

Alfred Austin 

Th Thanks k to t all ll who h hhelped l d 

with the Verona Garden! 

Cicero 

5/13/2011 

4

Elizabeth Paddock, MD 




Ongoing series of articles on a variety of 

health topics published in the Belleville 

local paper. 


Schrager S, Paddock E, Dalby J, Knudsen 

L. Contraception in Wisconsin: a review. 

WMJ. 2010 Dec;109(6):326-31 -- This article 

discussed the new Contraception Equality 

Mandate in Wisconsin. It also specifi cally 

reviewed Implanon, drosperione containing oral 

contraceptives, and IUDs, and discussed the 

evidence regarding DMPA and bone density, 

and extended cycling regimens for OCPs. 

I really feel lucky and glad to be a part of this residency 

program. It has been a fine 3 years. 

– Elizabeth 

A longtime native 

of New York State, 

Elizabeth Paddock 

earned her bachelor’s 

degree from Cornell 

University and 

completed her 

medical degree 

at Albany Medical 

College. Her strong 

interest in social justice drew 

her to family medicine, and she 

comes to the residency with a long 

history of action on the behalf of 

the underserved. Before entering 

medical school, she worked at 

Crossroads Rhode Island, a clinic 

that provides free primary care to 

the homeless. As a medical student, 

she volunteered with Care from 

the Start, a longitudinal program 

focusing on health care issues of the 

underserved, and she traveled to 

Uganda to participate in a medical 

mission that provided free care 

to communities in need. She was 

also the vice president of her local 

AMSA chapter, a coordinator for 

Medical Students for Choice, and the 

editor of Student Perspectives and 

Activism, a student-run bimonthly 

publication. Elizabeth’s outside 

interests include environmentally 

friendly living, swimming, biking, 

canoe racing, and cross-country 

skiing. She is also an accomplished 

runner, with multiple marathons and 

triathlons under her belt. 


elizabeth.paddock@fammed.wisc.edu

Elizabeth Paddock 

Community Medicine Project: Health education article series. Published in the Post 

Messenger Record. 

Excerpts from the series: 

March 2010: Joint Wear and Tear 

Your knees ache. It has come on slowly but now after a walk or long day on your feet, or after 

playing pick-up basketball with co-workers you notice knee pain. Maybe it has even progressed 

beyond that- you feel stiff first thing in the morning and it takes 30 minutes to really get going. 

You've blamed it on age, but it keeps getting worse. Or maybe its not you, but you've seen your 

older family members struggle with worsening knee or hip or back or shoulder pain- could this 

happen to you? 

What is this? This slow insidious ache is osteoarthritis which is also known as degenerative joint 

disease. If it occurs in the back it is called degenerative disc disease. It is the most common joint 

disorder; affecting 12.1% of the adult population. Onset is generally in middle age, with the 

majority of the population having symptoms by age 70. The degree of discomfort a person 

experiences varies wildly. 

December 2010: S.A.D and Other Melancholy States 

Winter time is upon us, and it seems that with the shorter days, I am seeing more and more 

people coming in to clinic feeling down, blue, sad, depressed, helpless, overwhelmed and 

hopeless. Depression is a very common illness- in fact 1 in 20 people will develop depression 

every year. Suffering from depression is NOT a sign of personal weakness or suggestive that 

someone has character flaws. Depression is a diagnosable medical illness that affects thoughts, 

feelings, health and behaviors. Depression is effectively treated in most patients, and most 

patients start feeling better within several weeks of treatment. 

Often people do not realize that they are depressed, they just know they do not feel like 

themselves. Common symptoms of depression include:… 

Aug 2010: Fatigue Fizzle. 

Fatigue, also known as weariness, exhaustion, tiredness and lack of energy is a very common 

complaint heard in the doctor’s office. In fact about 20% of the population will complain of 

fatigue intense enough to interfere with their lives. 

The list of causes of fatigue is extensive, and it can be challenging to determine a cause. The 

goal of this article will be to review some of the more common causes of fatigue and go over 

what you can do to try and feel less exhausted. 

Summer 2010: Insomnia: Another Night Awake in Bed. 

Not being able to sleep has happened to all of us: Those nights where we lay tossing and turning, 

unable to drift in to sleep. For the majority of people this only happens a few times each year, 

but many people do suffer nightly from insomnia, or the inability to sleep through the night. 

Some people have difficulty falling asleep while others fall asleep but then wake up and are 

unable to get back to sleep.

The average adult needs 7-8 hours of sleep daily. With age, sleep patterns change, an older adult 

may sleep less at night, but nap during the day, still getting a total of 7+ hours of sleep. Not 

getting an adequate amount of sleep leads to feeling tired, depressed and grumpy, in addition to 

making it difficult to concentrate. People who are too tired have increased motor vehicle 

accidents, are more easily aroused to anger and are less productive. There are lots of things that 

can cause insomnia. Stress, too much caffeine, depression, shift work, medications and pain are 

common triggers. 

March 2010: Revisiting Resolutions for the New Year: Smoking and Tobacco Use. 

Spring is coming-as the warmer weather and longer days approach many people get the itch to 

spend more time outside, start to exercise more and change a few other bad habits. Now is a 

great time to look back on New Year’s resolutions and re-assess. Is 2010 the year you finally 

quit smoking or chewing tobacco? 

Spring is a time of re-awakening and renewal- change is in the air as the trees begin to bud, the 

grass greens and the sun regains warmth- now is a great time to renew your resolutions to live a 

healthier life. 

January 2010: Resolutions for the NewYear: A Healthier You. Shaking Those Bad Habits! Part 

1. Diet and Exercise 

As we move into the cold days of January many of us are tempted to curl up in a blanket with 

some warm, delicious comfort foods... yet the little voice in the back of our head can be heard, 

reminding of our New Years resolutions to live a healthier life, lose weight and start exercising! 

In this article, the first of a two part series, I will spend time reviewing weight loss and the role 

of diet and exercise (those dreaded “lifestyle changes”). The second article will discuss shaking 

some of those other bad habits including smoking, drinking and chewing tobacco. 

To begin, I’d like to remind you that change is hard, and lifestyle changes may be the hardest of 

all. We all have our routines and habits and these are hard to break. Don’t expect to see instant 

results and while you should aim for success, try not to be overly discouraged if things are slow 

going. 

November 2009: New PAP and Mammogram Guidelines 

This month, the United States Preventative Services Task Force (USPSTF) issued new 

guidelines for breast cancer screening with mammography and a few days later the American 

College of Obstetricians and Gynecologists (ACOG) presented new guidelines for cervical 

cancer screening. Since then numerous voices have been heard, many strongly in disagreement 

with the new guidelines especially regarding mammograms. For women who have been 

diligently getting their annual Pap smears and mammograms the recent announcements probably 

seem very confusing and contradictory to everything you’ve been told about preventative 

healthcare. Below hopefully I can lay help lay out the new guidelines, and explain why the 

changes were recommended, and then discuss how the new guidelines might be applied. 

September 2009: The ABCs and 123s of H1N1 

School has started, fall is coming and flu season is just around the corner. How does the H1N1 

virus, also known as the Swine flu fit into the winter cold and flu season? Below hopefully you 

can find answers to your questions. In addition at the bottom please find resources with further 

information.

Spring 2009: You, Your health and Aging: A Prescription for a Healthy, Long Life. 

In 2000 average life expectancy was 76.9 years. Wow! However, you know that at 70 you will 

look and feel much different than you did when you were 30. What is normal aging, and what 

things can you expect as you age, and what things can you modify in order to maximize your 

health and wellbeing? 

Spring 2009: Sun: As with Everything Great in Life, Enjoy It in Moderation! 

The sun has come back. It brings warmth, an uplifted mood, flowers and longer days with it. We 

all spend countless hours happily running around in it- gardening, biking, running, sunbathing. It 

feels so nice! 

Unfortunately with all the brightness surrounding sunlight there is a darker side – sun damage. 

December 2008: So You Have the Sniffles: At Home Remedies and When to See the Doctor. 

Winter is here and for many of us so are those cold weather colds. We’re congested, coughing, 

sneezing, and suffering from sore throats and headaches. When are these symptoms concerning 

and when is the doctor going to send you away with a diagnosis of “Viral URI (upper respiratory 

infection)”. URI’s include infections of the ears, sinuses and throat. 

September 2008: A Healthy and Fit You. A Guide to Preventing, Diagnosing and Treating 

Common Running and Walking Injuries. 

I’m sure you hear it all the time, being fit and healthy is beneficial to your health. And it is true: 

Increased fitness has been linked to decreased cardiovascular disease (heart attacks, strokes, 

peripheral vascular disease), reduced risk of osteoporosis and obesity (along with the sequelae of 

obesity: high blood pressure, diabetes, high cholesterol) and has been to show to boost mental 

health. And what is the quickest, easiest, most convenient way to become fit? Walking and, 

especially running of course! 

However, walking and running are not risk free, in fact about 40% of runners will suffer some 

type of running related injury every year, mostly of the lower legs. In this article I offer some 

tips and suggestions for preventing injury as well as describing some of the more common 

injuries associated with walking and running and offer basic treatment advice for those ailments.

Kate Porter, do 




Healthy Habits for Preschoolers (with Jill 

Klemin) 


“What is the Expected Antibody Titer Response 

to Prenatal Rhogam?” -- Anti-D Ab titers after 

the IM administration of 300 micrograms of Rh 

immune globulin are usually detected fi rst in the 

serum 4 hours after injection and reach maximum 

levels at 48 hours. The IM administration of 

300 micrograms of Rh immune globulin usually 

results in anti-D titer of 1:4 after a standard dose of Rh Ig require further 

investigation. A critical titer is that titer associated 

with signifi cant risk for severe erythroblastosis 

fetalis and hydrops, and in most centers is between 

1:8 and 1:32. The mean residual anti-D IgG at 12 

weeks (using some calculation assumptions) would 

be 4-10 micrograms; this would be suffi cient to 

neutralize up to 0.5 ml of fetal RBCs. 

Thank you Mom, Dad, and sibs for all of your support over 

the last 30 years! 

– Kate 

A Madison native, 

Kate Porter earned her 

B.S. in Biopsychology 

from the University of 

Michigan – Ann Arbor, 

and she completed 

her medical degree 

at Michigan State 

University College 

of Osteopathic 

Medicine. Throughout medical school, 

Kate was an active volunteer with 

the Friendship Clinic and the Cristo 

Rey Clinic, both of which serve the 

underinsured population of Lansing. 

Her commitment to the underserved 

has also taken her as far away as 

Andhra Pradesh, India, and Blantyre, 

Malawi, where she helped provide 

compassionate and effective health 

care to local populations in need. 

Kate has taken on leadership roles in 

numerous organizations, including the 

International Health Project and her 

local chapter of the American College 

of Osteopathic Family Physicians. She 

also has special interests in teaching: 

she tutored medical students in the 

class beneath her during their Anatomy 

Lab. Kate enjoys traveling, hiking, 

biking, fi shing, swimming, reading, and 

spending time with her family. 


608 . 358 . 5833

Community Medicine Project: Healthy Habits for Preschool Children 

Jill Klemin and Kate Porter worked on a project to bring health education to preschool children. Our goal 

was to introduce them to concepts of healthy living. No child is too young to learn about eating right and 

being active. The earlier a child forms healthy habits, the easier it will be to maintain a healthy lifestyle. 

We contacted area preschool education centers to see if they would be interested in the program we 

designed. The response was excellent. The preschools that we visited included Kids Express Learning 

Center and La Petite Academy. We also have plans to visit other area preschools in the near future. 

Prior to our educational meeting, we prepared reward charts for the children to take home and share 

with their families. The charts included healthy food options, hygiene, and exercises. This was done in 

hopes that the parents would see healthy eating and living as behaviors that deserve rewards. We also 

purchased the book, “Oh The Things You Can Do That Are Good For You,” by Dr. Seuss. At the end of 

our meeting, this book was donated to the classroom. 

We met with the children at their school. We began the encounter by asking them if they could name 

any foods they thought were healthy. This was followed by asking them what they like to do for 

exercise. We read them the Dr. Seuss book “Oh The Thing You Can Do That Are Good For You.” This was 

followed by a poster presentation of children their age doing healthy habits. We talked through each 

poster and asked the children for their thoughts or ideas to expand on the concepts displayed in the 

posters. The presentation ended with some fun with fruit stickers. Each child was sent home with the 

reward charts and a sheet of star stickers. Each child was also given 2 healthy recipes that are kidfriendly 

to make and fun to eat! The handout also included goal setting for each family to consider, in 

hopes that each family could take steps forward in health living.

Exercise 

Limit Screen 

Time (TV) 

Healthy Food 

Choices 

Brush Teeth 

(twice!!) 

Be Safe!! 

(seat belt, 

helmets…) 

Sleep 10+ hours 

nightly 

Keep Clean 


Monday Tuesday Wednesday Thursday Friday Weekend 

**Use Stickers on the Chart to Reward Health Habits!!**

Frozen Yogurt Pops 


Fun, Healthy Recipies!! 

*Pour favorite flavor of yogurt into multiple small paper cups—fill almost to the top! Then, stretch a small piece of plastic wrap across the top of each cup. Next, poke a wooden popsicle 

stick into the plastic wrap and into the center of the cup of yogurt. Put the cups in the freezer until frozen, then remove plastic wrap and remove the frozen pop from the paper cup— 

Enjoy! This is also fun to layer multiple flavors of yogurt for a rainbow pop! 

Incredible, Edible Veggie Bowls 

*Cut a Green or Red Pepper in half (from side to side). Clean out the insides. These pieces can be your bowls. Then, cut carrots, celery, peppers, cucumbers, etc into skinny sticks. Put 

either ranch dressing or hummus into the bottom of your ‘bowls.’ Last, put the veggie slices into the bowl—Enjoy! 

_____________________________________________________________________________________________________ 

My Healthy Family 

Healthy habits that my family already does are: ____________________________________________________ 

New healthy habits that we can try are: ________________________________________________________

Jacqueline Redmer, MD 




Initiating Diabetes Group Visits at Northeast 

Clinic 


Systematic Weight Loss Screening, Referral and Ongoing 

Support for Overweight and Obese Patients 

in a Primary Care Clinic -- An important barrier to 

the delivery of obesity management in primary care 

settings is the lack of an integrated screening and 

intervention approach that could help clinicians and 

patients to address this process in an effi cient and 

productive manner. In this project we examined the 

feasibility and logistics of systematically screening 

patients for their motivation to lose weight and then 

offering them support and referrals outside of the 

physician encounter. Patients were fi rst screened 

for interest in weight loss prior to their visits at 

Northeast Clinic in June of 2008 using a modifi ed 

WIPHL (Wisconsin Initiative to Promote Healthy 

Lifestyle) survey. Participants in the study received 

two motivational interviews by telephone as well as 

a mail survey to assess readiness for change and to 

assist with goal setting and support. Results from 

this study show that systematic screening appears 

to capture patients with a BMI>25 and at various 

stages of behavior change. This intervention shows 

some promise assisting patients with weight loss as 

well as increasing their follow-up with their primary 

care provider (PCP) and/or a dietary counselor. 

There are also many missed opportunities, however, 

since only one-half of those who intended to 

discuss weight loss with their PCP were able to 

follow-through with this interest at 6 months. 

A native of Manitowoc, 

WI, Jackie Redmer fi rst 

explored her interest 

in science as a UW 

undergraduate through 

the study of forestry 

and insects. After 

serving as a Public 

Heath Educator with 

the Peace Corps in 

Kazakhstan, however, 

she saw medicine as 

the fi eld which would best engage her 

values of social justice, compassion, 

and community. Following medical 

school, she worked as a research fellow 

with the UW DFM. During this time she 

completed the UW Masters in Public 

Health Program and conducted a research 

study evaluating a clinic wide weight 

loss intervention for obese patients. 

Throughout medical school and residency 

she has continued to combine medicine 

and public health through international 

health work in rural Guatemala, Lesotho, 

and Honduras. As a medical student 

at UW-Madison, Jackie volunteered at 

the MEDIC free clinics, and served as 

the MEDIC Council President. She has 

continued to volunteer as a resident 

physician and plans to work with 

underserved communities in the future. 

Jackie is also committed to the practice of 

Integrative Medicine. She co-founded the 

UW Integrative Medicine Interest Group 

during medical school and looks forward 

to incorporating a holistic approach to 

healing in her future practice. For the 

next 2 years she will be participating in 

the UW Integrative Medicine Fellowship. 

In her free time, Jackie enjoys staying 

active with outdoor recreation including 

skiing, biking, running, canoeing, and 

planning backcountry wilderness trips. 


jackie.redmer@fammed.wisc.edu 

608.658.1614

Initiating Diabetes Group 

Visits at Northeast Clinic 

Jacqueline Redmer MD,MPH 

Senior Night UW Family Medicine Residency Program 

May 25 th , 2011 

A History of Diabetes Group Visits 

Model emerged 1990s with Kaiser 

Permanente's efforts to serve a growing 

number of chronic chronic-disease disease patients 

receiving less face time with physicians 

Rationale: patients patients with chronic disease 

need more support and education because 

they deliver most healthcare at home 

Kaiser presented group visits with 20 20-25 25 

patients, other models now include 3-15 3 15 

patients varying in clinical services and 

discussion format 

RWJF Diabetes Initiative 2003 

Evidence for Group DM Visits 

Studies have shown improvement in A1C, BMI, 

Lipids as well as increased adherence to ADA 

guidelines (lab monitoring, ASA, foot exams), 

evidence of cost containment, patient/provider 

satisfaction, and education 

Interventions vary in composition of providers, 

group size, time length 

Most significant improvements in metrics with 

intensive behavioral health interventions 

Riley et. al 2010, Trento et. al 2002, 2004, Bray 2005, Clancy 2007, 

Sadur 1999, Pi-Sunyer X et. al 2007, Kirsh 2007, Davis 2008 

Prevalence of Diabetes 2011 

Diabetes affects 25.8 

million people, or 8.3% of 

the US population 

Diagnosed 18.8 million, 

undiagnosed undiagnosed 7 7.0 0 million 

million 

Risk of death 2 times that 

of people similar age and 

no diabetes 

Total costs $174 billion, 

direct medical $116 

billion, indirect $58 billion 

CDC National Diabetes Fact Sheet 2011 

Group Visit Rationale 

Innovative way to help diabetic patients 

reach their goals, not the same as DE 

Interactive education with components of 

an individual patient p office visit 

Stresses the importance of diabetes self- 

management 

Group visits more than lectures lectures-draw draw on 

patient experience and emotion 

Providers bill the same medical- 

management codes 

Creating a Group DM Visit at 

Northeast Clinic 

NE residents visited Verona Clinic and 

used their group diabetes visit as template 

Scheduling: All clinic schedules, EPIC 

templates, templates templates, 90 90 minute minute visits 

visits 

Recruiting patients: Signs, diabetes 

registry 

Understanding pre-visit pre visit logistics 

Coordinating follow-up: follow up: Labs, referrals 

5/13/2011 

1

Elements of a Group Diabetes Visit 

All patients sign HIPAA forms 

Patients’ diabetes control reviewed 

Visits can include ordering labs, refilling DM 

medications, changing doses of 

medications, immunizations, referrals 

All patients devise a self self-management management goal 

and share this with the group 

Additional diabetes/nutritional education as 

time permits 

Brief physical exam if indicated 

What it takes for diabetes group 

visits to work? 

Administrative Support 

Customized patient 

groups 

Creative scheduling 

Motivated patients 

(education, support) 

Committed and prepared 

physicians and clinical 

staff 

Patient no no-shows shows 

Clinical staff turnover 

and difficulty 

assigning g g nursing g 

responsibility 

Pre Pre-visit visit input higher 

than routine patient 

care 

Challenges 

Diabetes Summary (Mary) 

Measurement Goal Time 1 Date Time 2 Date Current Date 

A1c (Glucose/Sugar) < 7.0 % 8.2 % 2/1/10 8.5 % 01/20/11 7.0 % 3/28/11 

LDL (Cholesterol) < 100 38 2/1/10 93 01/20/11 

ALT (Liver) < 80 25 2/1/10 29 01/20/11 

Blood Pressure (Heart) 130/80 145 / 60 2/11/10 170 / 80 02/15/11 126 / 60 3/28/11 

Urine MACr (Protein) < 30 24.0 01/20/11 

Creatinine (Kidney) 0.8 ‐ 1.3 0.64 2/1/10 0.79 01/20/11 

TSH (Thyroid) 0.5‐5.0 3.69 2/1/10 3.51 01/01/11 

BMI (Body fat) 18‐24 32.0 2/11/10 32.0 02/15/11 32.0 3/28/11 

Pneumonia shot One time 

Due 

Flu shot Once per year 2008 2009 

10/21/10 

Eye Exam Once per year 

05/10/11 

Foot Exam Once per year 

02/15/11 

What has worked well? 

NE high patient volume, >1000 diabetics 

Patient recruitment from providers and 

clinical staff inviting patients from the DM 

registry 

registry 

Patient and provider satisfaction 

Improved education and health literacy for 

patients 

Group visits as a part of larger clinic clinic-wide wide 

diabetes care initiative 

Financially Feasible? 

�� Diabetes Group Visits billed at 99213: 

$130/0.97, 99214: $194/1.50 

�� Group DM Visits at NE Clinic with two 2 nd or 

3 rd year y residents as leaders 

�� Typical 3 rd year resident schedule: 88-10 

10 

patients in a half day (30-40% (30 40% of office visits 

level IV) 

�� On days with DM Group Visits: 10 patients 

including 6 Group DM patient split with other 

resident (70-80% (70 80% of office visits level IV) 

5/13/2011 

2

New Directions 

Patient satisfaction survey mailed to 

previous attendees 

Develop outcome measures (HgbA1C, 

LDL, , Immunizations, , etc) ) 

Mandatory resident participation as 

training in practice management? 

Organizing curriculum, transitioning from 

resident project to clinic wide initiative 

Invest time in educational modules 

Acknowledgements 

Residents: Srivani Sridhar, Nicole Bonk, 

Amy Bauman 

Faculty: Brian Arndt, Jennifer Edgoose, 

Lou Sanner 

Northeast Admin and Clinical Staff 

5/13/2011 

3

Srivani Sridhar, MD 




Co-authored an article with David Rakel, MD, 

published in the February 2010 issue of Evidence- 

Based Practice: “Peppermint Oil as a Therapeutic 

Agent for Irritable Bowel Syndrome” 


Group Diabetes Visits at Northeast Clinic -- 

Group diabetes visits are an innovative way to 

help diabetic patients reach their goals. They 

provide interactive education along with 

components of an individual patient offi ce visit. 

In a group setting, patients are able to draw on 

their experiences to provide each other with tools 

in diabetes management. The group visits are 

90 minutes long and consist of approximately 6 

patients lead by two residents. One group visit is 

held monthly and patients are expected to attend 

once every 3 to 6 months. Prior to the visit, 

patients fi ll out a questionnaire that is translated 

into the subjective portion of the visit. At the visit, 

each patient receives a summary of their health 

in a spreadsheet containing recent labs, blood 

pressures, BMIs, and vaccinations which is reviewed 

with the group. Visits can include ordering labs, 

refi lling medications or adjusting doses, and making 

referrals. All patients devise a self-management 

goal and share this with the group. Finally, a 

brief physical exam is performed and additional 

education is provided as time permits. 

Thank you to my parents for all their support throughout my schooling 

and my career choice as a Family Physician. I am grateful that they 

allowed me to come all the way to Madison, Wisconsin to complete an 

excellent residency program. My family has been with me every step 

of the way and I could not have done it without their blessings. Last 

but not least, thank you to all my friends in the residency, supervising 

physicians, DFM staff, clinic staff, and Kathy Oriel, MD, my 

spectacular program director, for making me part of the DFM family. 

– Srivani 

Srivani Sridhar was 

born in Salem, India, 

and carries into her 

medical practice the 

Hindu belief that 

the family bears 

great importance 

in shaping both the 

body and the mind. 

She completed her 

B.S. in Biology at The College of New 

Jersey and then went on to medical 

school at the University of Medicine 

and Dentistry of New Jersey. As a 

medical student, Srivani was an active 

volunteer for the underserved in and 

around Newark. She worked regularly 

at the Student Health and Family 

Care Clinic, which provides free 

medical care to the uninsured. She 

also enjoyed mentoring high school 

students interested in the medical 

fi eld through the Mini-Med Program. 

Srivani was president of her medical 

school’s Family Medicine Interest 

Group, and she remains an active 

member of the American Association 

of Physicians of Indian Origin. In her 

free time, she likes to travel, read, 

and work out. 


srivani.sridhar@fammed.wisc.edu

CME 

Evidence-Based Practice 

Answering clinical questions with the best sources VOLUME 13 NUMBER 2 FEBRUARY 2010 

INTEGRATIVE MEDICINE IN DEPTH 

3 Is saw palmetto helpful for benign 

prostatic hyperplasia? 

HELPDESK ANSWERS 

4 What methods are effective for reducing 

the incidence of dental caries? 

5 What common food additives can cause acute, 

nonallergic symptoms? 

6 Are group visits effective for the treatment 

of obesity? 

7 What are appropriate treatment goals 

for hypertension in the very elderly 

(≥80 years)? 

8 What are the risks of overtreating 

hyperlipidemia with statins? 

9 Do you need to use heparin when initiating 

warfarin therapy in a patient with atrial 

fibrillation? 

10 Should you treat an upper extremity deep 

venous thrombosis with anticoagulation? 

10 Should you use anticoagulation in an elderly 

patient with atrial fibrillation? 

11 Are inhaled corticosteroids effective for patients 

with chronic obstructive pulmonary disease? 

BEHAVIORAL HEALTH MATTERS 

13 Which symptoms best distinguish unipolar 

and bipolar depression? 

SPOTLIGHT ON PHARMACY 

14 Do inhaled beta-agonists control cough 

in acute bronchitis? 

CME TEST 

15 February 2010 

Peppermint oil as a therapeutic agent 

for irritable bowel syndrome 

Bottom line 

Peppermint oil is a safe and effective therapeutic agent for pain and 

abdominal discomfort in patients with irritable bowel syndrome (IBS). 

It should be considered as an adjunct in IBS management, however, as 

pain is only one component of the clinical picture. 

Background 

IBS is a chronic, relapsing gastrointestinal disorder without a known 

structural or anatomical explanation. Mechanisms of altered gastrointestinal 

motility, smooth muscle spasm, visceral hypersensitivity, 

and abnormalities of central pain processing have all been implicated. 

Many modalities have been used to control IBS symptoms, including 

bulk-forming agents, prokinetics, antispasmodics, antidepressants, 

exercise, yoga, stress relief, and diet changes, but evidence supporting 

many of these methods is limited by relatively poor methodology 

and inconclusive findings. Generally, a holistic approach is required to 

improve the overall management of this condition, because no individual 

intervention has a high success rate. 

The use of peppermint oil is a nontraditional therapy that has been 

studied as an inexpensive and easily attainable adjunct for IBS symptoms. 

Bench research shows its major constituent, menthol, blocks Ca 2+ channels 

in the gut and decreases smooth muscle spasm. Peppermint oil also has a 

relaxing effect on the gall bladder and slows orocecal transit time. 1 

Summary of Evidence 

Meta-analysis 

A review of fiber, antispasmodics, and peppermint oil showed that all 3 of 

these agents are more effective than placebo in the treatment of IBS. Four 

studies compared peppermint oil with placebo in 392 adults. Only 26% 

of the patients randomized to peppermint oil had persistent symptoms 

compared with 65% receiving placebo (relative risk [RR]=0.43; 95% confidence 

interval [CI], 0.32–0.59; number needed to treat [NNT]=2.5). 2 

When the 3 studies with the highest methodological quality were 

considered, the relative risk of persistent symptoms was of a similar magnitude 

(RR=0.40; 95% CI, 0.29–0.55). Adverse events were reported in 

Evidence-Based Practice / Vol. 13, No. 2 1

In Depth 

2 

3% of the patients receiving peppermint oil and none in 

those receiving placebo, but the types of adverse events 

were not discussed. The NNTs to prevent 1 patient from 

having persistent IBS symptoms were higher for the 

other agents considered (11 for fiber and 5 for antispasmodics). 

Only 2 of the 4 studies with peppermint oil 

used Rome II criteria to define the presence of IBS. 2 

Other randomized controlled trials (RCTs) 

A subsequent double-blind RCT was conducted on 90 

adults with IBS who took 1 enteric-coated capsule containing 

187 mg delayed-release peppermint oil (Colpermin ® ) 

or placebo 3 times daily for 8 weeks. Their symptoms and 

quality of life (QOL) were evaluated at 1, 4, and 8 weeks. 

An IBS symptoms scale was used in which patients rated 

the intensity of various symptoms from 0 to 3, with 3 being 

the worst. Additionally, a standardized QOL assessment 

was completed by the researcher at weeks 1 and 8. 3 

By week 8, 42.5% of subjects were free from 

abdominal pain or discomfort in the treatment group, 

compared with 22.2% in the placebo group (P

Daniel Sutton, MD 




Literature review and update -- Neonatal 

Hyperbilirubinemia Screening, Diagnosis, and 

Management 

Quality Improvement Project: 

Quality Improvement Project: Cardiac Risk 

Assessment by Primary Care Providers (with Dan 

Sutton) -- The goal of the quality improvement 

project was to inform PCPs and their patients as to 

an individual patient’s hard cardiac risk. 

We calculated this risk score for patients prior 

to upcoming appointments with PCPs. This 

information was presented to the patients during 

their visit with PCP. Post-interview phone 

questionnaires revealed that patients were slightly 

more likely to make lifestyle changes than to change 

medication adherence following this intervention. 

Most patients thought the intervention was helpful. 

Pre- and post-intervention surveys of PCPs 

revealed that there was an increase in the number 

of physicians who reported using cardiac risk 

assessment tools, the number who relayed this 

information to patients, and in the number of 

providers who thought that this improved patient 

care. 

I really want all of the physicians in Baraboo (FPs, general surgeons, 

Kansas Dubray, Joe Fok) to know how much I appreciate your 

contribution to my education. While I know that you are not looking 

for recognition, it is important to me that you know what a powerful 

infl uence you have had on my development as a doctor. If I had to do 

residency all over, I would choose Baraboo again in a heartbeat! 

Tina - Thanks for supporting me through all the call nights, OB nights, 

etc during my intern year and the pages at home during my 2nd and 3rd 

years. Thanks for putting up with my getting called into the hospital 

interrupting dinners, hikes, movies, visit with friends, and so on. 

– Dan 

Dan Sutton hails 

from the small 

town of Barton, WI. 

He earned a B.S. 

in Physics from 

the University of 

Wisconsin – LaCrosse 

and then went on 

to medical school 

at UW Madison. 

His love of smalltown 

life, as well as his interest in 

preventative medicine, led him to 

family medicine, and he joins the 

residency as part of the Baraboo 

Rural Training Track. During medical 

school, he volunteered with Fit Kids 

Challenge and Doctors Ought to Care, 

two organizations that encourage 

children to lead healthier, more active 

lives. In addition, he completed a 

summer externship with a family 

medicine doctor in West Bend, WI, 

and he volunteered with the Madison 

MEDIC clinics, which provide free 

medical care to underserved members 

of the community. Dan is also an 

elite runner. He qualifi ed for the 

U.S. Olympic Trials for the marathon 

and was featured in the November 

2007 issue of Runners World. He 

describes himself as a running addict 

and typically runs 95-100 miles each 

week. He also loves hiking, camping, 

fi shing, cooking, and spending 

time with friends and family. Dan is 

engaged to be married this summer 

to Tina Pike. After residency, he will 

be joining a practice in Waupaca, 

WI with ThedaCare providing fullspectrum 

family medicine. 


202 E. Lake St 

Waupaca, WI 54981

Newborn Bilirubin Screening 

Daniel Sutton, MD 

PGY-3 

Causes of elevated bilirubin in newborns: 

● ↑ RBC destruction (↓ life span, ↑ Hct), ↓ albumin, 

low UGT activity (~1% of adult level; not to adult 

levels until 14 weeks), ↓ hepatic blood flow, 

increased enterohepatic uptake (undeveloped GI 

flora, slow colonic transport, bilirubin 

unconjugation) 

Jaundice 

● Common – 60% of term and 80% of preterm in 1 st week of 

life 1 

● Mean peak TB occurs 48-96 hours of age and is 7 to 9 

mg/dL 

● Primary neonatal jaundice resolves w/in 1 st 1-2 weeks 

● Significance correlates to timing 

● Jaundice usually spreads caudally 

The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. 

Bilirubin pathophysiology 

● Formed from breakdown of RBCs (90%) and other 

heme containing compounds (10%) 

● 2 types of bilirubin: 

● Unconjugated (indirect) – unmetabolized by liver, 

fat soluble, poorly excreted, primary form seen in 

neonatal jaundice 

● Conjugated (direct) – metabolized, water soluble, 

excreted in stool and urine 

Timing of jaundice 

● Early onset (day 1-2) - uncommon 

● Usually hemolytic (Rh, ABO, hereditary spherocytosis, G6PD 

deficiency) 

● Normal onset (days 3-10) – Very common 

● Breast feeding jaundice 

● Galactosemia 

● Sepsis 

● Late Onset (>14 days) – Common 

● Breast milk jaundice - common 

● Conjugated hyperbilirubinemia – uncommon 

● Inherited deficiency of UGT – very rare 

1

● Usually in 1 st week 

Breast Feeding Jaundice 

● Maternal factors, such as engorgement, cracked nipples, and fatigue, 

and neonatal factors, such as ineffective suck, may result in ineffective 

breastfeeding. 

● Prevention 

● Identify/address breast feeding issues prior to discharge 

● Mothers should nurse whenever infant shows signs of hunger or 4 

hours since the last feeding; usually results in 8-12 feedings/24 

hours 

● supplement with banked human milk or formula when weight loss 

>7 percent of birth weight, or signs of dehydration (eg, decr. 

UOP), stool output


ABE 

Maximum possible score is 9. Scores of 4-6 usually indicate 

reversible ABE. Progression to higher scores indicates 

worsening BIND. 4 

Screening 

● USPTF – insufficient evidence to recommend for or against 

universal bilirubin screening (І rating) 5 

● lack of evidence that universal bilirubin screening prevents 

bilirubin encephalopathy, insufficient evidence regarding risks and 

efficacy of phototherapy 

● AAP Practice Guideline (updated 10/2009) 6 

● universal predischarge bilirubin screening using total serum 

bilirubin (TSB) or transcutaneous bilirubin (TcB) 

● structured approach to management and follow-up according to 

predischarge TSB/TcB, GA, and other risk factors for 

hyperbilirubinemia 

Nomogram of hour-specific total serum 

bilirubin (TSB) concentration in healthy term 

and near-term newborns 

BIND (cont'd) 

● Kernicterus - chronic and permanent sequelae of BIND 4 

● Develops during first year after birth 

● Cognitive function usually relatively spared 

● Major features: 

– Choreoathetoid cerebral palsy (chorea, ballismus, tremor and 

dystonia) 

– Sensorineural hearing loss 

– Gaze abnormalities, especially limited upward gaze 

– Dental enamel dysplasia 

AAP Predischarge Risk Assessment 

● TSB – can be measured from blood draw for newborn 

screen 

● For nomogram, use total bilirubin (do not subtract direct 

bilirubin) 

● Assess GA and other risk factors: 

● Exclusive breastfeeding, esp if nursing not going well and/or 

weight loss is excessive (>8 –10%) 

● Isoimmune or other hemolytic disease (eg, G6PD deficiency, 

hereditary spherocytosis) 

● Previous sibling with jaundice 

● Cephalohematoma or significant bruising 

● East Asian race 

Management and follow-up based on predischarge 

TSB/TcB, GA, and other risk factors 

3




Follow Up (If low risk for 

hyperbilirubinemia) 

Cost-effectiveness of screening 

● General cost-effectiveness of screening is poor 

● Cost/case kernicterus prevented ranges from $5-10 million 18 

● Due to low incidence of condition – 1:100,000-1:500,000 

● TSB vs TcB 

● Studies lacking 

● ↑ cost of TcB device offset by ↓ number of TSB measurements 10,19 

● ↓ cost from hospital readmission offset by ↑ usage of phototherapy 

with net slight increase in cost seen after instituting TcB 13 



Transcutaneous bilurubin (TcB) 

Pediatrics. 2011 

Jan;127(1):e126-31. 

● Non-invasive, instantaneous method to estimate TSB level; 

reliable across multiple ethnic backgrounds 11,12 

● Relatively correlate with TSB13 mg/dL 9 

4

TcB Nomogram for Newborns >35 weeks GA 10 

TcB - Benefits 

● ↓ hospital readmission – prospective trial by Petersen et al – 

6603 newborns; readmission rates/1000 newborns for 

significant hyperbili ↓ from 4.5 to 1.8 13 

● ↓ painful lab draws – 20-50% decrease in TSB draws in 

preterm babies >34 weeks14 p 

● Accurate - National Academy of Clinical Biochemistry 

Laboratory Medicine practice guidelines concluded TcB 

meters currently available in US provide results comparable 

to laboratory TSB15 Simultaneous Tcb vs TSB measurements 12 

TcB - Limitations 

● Affected by wide variety of factors - 

● Sun or phototherapy exposure 

– Studies in adults indicate that possible to have accurate TcB 

measurements in sun-exposed pts16 – Variability reduced by using sternal measurments17 ● Dermal thickness 

● Hgb Concentration – drops by 10% in 1 st week 

● Location of application 

Management of Hyperbilirubinemia 

● Primary prevention 6 

● Advise mothers to nurse 8-12 times per day 

● AAP recommends AGAINST supplementing with 

water or dextrose water in non-dehydrated non dehydrated breast 

fed infants 

5

Management of Hyperbilirubinemia 

● Secondary prevention 6 

● Test all mothers for ABO and Rh type + Ab screen 

● If no typing done on mother, perform direct Coombs' 

test, and ABO/Rh on infant cord blood 

● Obtain direct bilirubin for sick infants and those 

jaundiced > 3weeks 

● If direct (conjugated) bilirubin elevated, obtain UA and 

urine cx. Further lab testing for sepsis if H&P suggests 

sepsis; also evaluate for cholestasis 

● GP6D testing for infants receiving phototherapy AND 

family Hx or geographic origin suggests ↑ risk OR poor 

response to phototherapy 

Treatment 

● Dictated by hour-specific bilirubin levels plotted on appropriate 

nomogram (based on GA, risk factors). 

● Use TOTAL bilirubin levels 

● TSB at level for exchange transfusion or >25mg/dL – 

MEDICAL EMERGENCY → transfer f di directly l to hhospital i lwith i h 

pediatric specialist21 ● If TSB does not fall (or continues to rise) despite phototherapy, 

hemolysis is likely 

● Consider IV γ-globulin (0.5-1 g/kg over 2 hrs, may repeat x1 

in 12 hours) 22 

● Serum albumin 

Treatment (cont'd) 

● Consider measuring and if < 3g/dL, use as risk factor in 

determining phototherapy threshold 

● Exchange transfusion – calculate bilirubin/albumin (B/A) 

ratio 

6

● Rate of decline in bilirubin 

Phototherapy (cont'd) 

● Varies based on factors slide 38 

● Intensive phototherapy can produce ↓ of 30-40% in 

initial bilirubin level by y 24 hours after initiation (6-20% ( 

with standard phototherapy) 

● Most significant decline will occur in 1 st 4-6 hours 

● Phototherapy may be interrupted during feeding or brief 

parental visits (unless approaching transfusion zone) 

Treatment - phototherapy 

● No standardized method for delivering 

● Efficacy depends on dose and several other factors (next slide) 

● TSB above treatment treshold → intensive phototherapy - irradiance 

in the 430- to 490-nm band (usually 30 W/cm2 per nm or higher) 

delivered to as much of the infant infant’ss surface area as possible 

● Irradiance should be measured periodically 

– Radiometers clinically available 

– Take single measurement across a band of wavelengths, 

typically 425 to 475 or 400 to 480 nm 

– Use average of measurements at multiple sites under area 

illuminated (60x30 cm is standard surface area) 

Treatment – phototherapy (cont'd) 

● Multiple devices – fluorescent tubes, tungsten-halogen lamps, 

fiber optic blankets, high-intensity gallium nitride LEDs 

● When bilirubin levels approach intensive phototherapy level, 

maximal phototherapy efficiency must be sought 

● Most effective light sources currently commercially available 

use special blue fluorescent tubes (labeled F20T12/BB 

(General Electric, Westinghouse, Sylvania) or TL52/20W 

(Phillips, Eindhoven, The Netherlands)) or a specially 

designed LED light (Natus Inc, San Carlos, CA) 

● fluorescent tubes should be placed as close to the infant as 

possible – place in bassinet, not incubator 

● When to stop 


● Depends on the age at which phototherapy is initiated and the 

cause of the hyperbilirubinemia 23 

● Usually may be discontinued when the serum bilirubin level 

fll falls below bl 1314 13-14 mg/dL /dL 

● D/c need NOT be delayed to observe the infant for rebound 23- 

25 

● Phototherapy used for infants with hemolytic diseases or 

initiated early and discontinued before infant is 3-4 days old 

→ follow-up bilirubin level within 24 hours after d/c 

recommended 23 

7

● Home phototherapy 


● Should be used only in infants whose bilirubin levels are 

in “optional phototherapy” range 

● Essential that TSB be monitored regularly 

References 

1. Jaundice and hyperbilirubinemia in the newborn. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of pediatrics. 16th ed. 

Philadelphia: Saunders, 2000:511–28. 

2. Bhutani VK, Johnson L, Sivieri EM. Predictive ability of a predischarge hour-specific serum bilirubin for subsequent significant 

hyperbilirubinemia in healthy term and near-term newborns. Pediatrics 1999; 103:6. 

3. Burke BL, Robbins JM, Bird TM, et al. Trends in hospitalizations for neonatal jaundice and kernicterus in the United States, 1988-2005. 

Pediatrics 2009; 123:524. 

4. Volpe, JJ. Neurology of the Newborn, 4th ed, WB Saunders, Philadelphia, 2001, p. 521. 

5. US Preventive Services Task Force. Screening of infants for hyperbilirubinemia to prevent chronic bilirubin encephalopathy: 

recommendation statement. Pediatrics. 2009;124 (4):1172 –1177. 

6. Maisels MJ, Bhutani VK, Bogen D, Newman TB, Stark AR, Watchko JF. Management of hyperbilirubinemia in the newborn infant ≥35 

weeks' gestation: an update with clarifications. Pediatrics. 2009;124 (4):1193 –1198 

7. Ebbesen F, Rasmussen LM, Wimberley PD. A new transcutaneous bilirubinometer, BiliCheck, used in the neonatal intensive care unit and 

the maternity ward. Acta Paediatr. 2002;91 (2):203 –211. 

8. Maisels MJ, Kring E. Transcutaneous bilirubin levels in the first 96 hours in a normal newborn population of ≥35 weeks’ of gestation. 

Pediatrics. 2006;117 (4):1169 –1173. 

9. Engle W, Jackson GC, Stehel EK, Sendelbach D, Manning MD. Evaluation of a transcutaneous jaundice meter following hospital discharge 

in term and near-term neonates. J Perinatol. 2005;25 (7):486 –490. 

10. Maisels MJ, Kring E. Transcutaneous bilirubin level in the first 96 hours in a normal newborn population of 35 weeks’ gestation. Pediatrics 

2006;117:1169 –73. 

11. Slusher TM, Angyo IA, Bode-Thomas F, Akor F,Pam SD, Adetunji AA, et al. Transcutaneous bilirubin measurements and serum total 

bilirubin levels in indigenous African infants. Pediatrics 2004;113:1636–41. 

● Complications 


● Separation of mother and infant 

● Bronze infant syndrome in babies with cholestatic 

jaundice j 

● Rarely, purpura and bullous eruptions have been 

described in infants with severe cholestatic jaundice 

● Severe blistering and photosensitivity during 

phototherapy have occurred in infants with congenital 

erythropoietic porphyria 

Discharge and follow-up 

● http://www.aap.org/family/jaundicefaq.htm 

● Follow up assessment should include: 

● Weight and % change from birth 

● Intake and voiding 

● Assessment of jaundice – if there is ANY doubt, obtain 

TSB or TcB 

References (cont'd) 

12. SN El-Beshbishi, KE Shattuck, AA Mohammad, JR Petersen. Hyperbilirubinemia and Transcutaneous Bilirubinometry. Clinical Chemistry 

55:71280–1287 (2009). 

13. Petersen JR, Okorodudu AO, Mohammad AA,Fernando A, Shattuck KE. Association of transcutaneous bilirubin testing in hospital with 

decreased readmission rate for hyperbilirubinemia.Clin Chem 2005;51:540–4. 

14. Stevenson DK, Wong RJ, Vreman HJ, McDonagh AF, Maisels MJ, Lightner DA. NICHD conference on kernicterus: research on prevention 

of bilirubin-induced brain injury and kernicterus: bench-to-bedside: diagnostic methods and prevention and treatment strategies. J Perinatol 

2004;24:521–5. 

15. Nichols JH, Christenson RH, Clarke W, Gronowski A, Hammett-Stabler CA, Jacobs E, et al. Executive summary. The National Academy of 

Clinical Biochemistry Laboratory Medicine Practice Guideline: evidence-based practice for point-of-care testing. Clin Chim Acta 

2007;379:14–28. 

16. Harbrecht BG, Rosengart MR, Bukauskas K, Zenati MS, Marsh JW Jr, Geller DA. Assessment of transcutaneous bilirubinometry in 

hospitalized adults. J Am Coll Surg 2008;206:1129 –36. 

17. Maisels MJ, Ostrea EM Jr, Touch S, Clune SE, Cepeda E, Kring E, et al. Evaluation of a new transcutaneous bilirubinometer. Pediatrics 

2004; 113:1628 –35. 

18. Suresh GK, Clark RE. Cost-effectiveness of strategies that are intended to prevent kernicterus in newborn infants.Pediatrics. 

2004;114(4):917–924 

19. Maisels MJ. Transcutaneous bilirubinometry. NeoReviews 2006;7:e217–25. 

20. Gonçalves A, Costa S, Lopes A, Rocha G, Guedes MB, Centeno MJ, Silva J, Silva MG, Severo M, Guimarães H. Prospective validation of a 

novel strategy for assessing risk of significant hyperbilirubinemia. Pediatrics. 2011 Jan;127(1):e126-31. 

21. Garland JS, Alex C, Deacon JS, Raab K. Treatment of infants with indirect hyperbilirubinemia. Readmission to birth hospital vs nonbirth 

hospital. Arch Pediatr Adolesc Med. 1994;148:1317–1321 

8

22. Gottstein R, Cooke R. Systematic review of intravenous immunoglobulin in haemolytic disease of the newborn. Arch Dis Child 

Fetal Neonatal Ed. 2003;88:F6–F10. 

23. Maisels MJ, Kring E. Bilirubin rebound following intensive phototherapy. Arch Pediatr Adolesc Med. 2002;156:669–672. 

24. Yetman RJ, Parks DK, Huseby V, Mistry K, Garcia J. Rebound bilirubin levels in infants receiving phototherapy. J Pediatr. 

1998;133:705–707. 

25. Lazar L, Litwin A, Merlob P. Phototherapy for neonatal nonhemolytic hyperbilirubinemia. Analysis of rebound and indications for 

discontinuing therapy. Clin Pediatr (Phila). 1993;32:264–267 

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