RESidENcy PROGRAM Scholarly and Community Medicine Projects

fammed.wisc.edu

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.

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

Self-Directed Learning Exercises

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

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

Self-Directed Learning Exercises

3


Meaghan Combs, MD

PROJECTS COMPLETED

DURING RESIDENCY:

Scholarly Project:

Presentation at the 44th STFM Annual

Spring Conference, April 28, 2011, in New

Orleans: “Does a Micropractice Lead to

Macrosatisfaction?”

Community Medicine Project:

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.

CONTACT INFORMATION:

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.”

Community Clinic:

• “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”

Community Clinic:

• “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

PROJECTS COMPLETED

DURING RESIDENCY:

Community Medicine Project:

Clinical Quality Improvement: Adding Fluoride

Prophylaxis to Well Child Care

Scholarly Project:

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.

CONTACT INFORMATION:

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

PROJECTS COMPLETED

DURING RESIDENCY:

Scholarly Project:

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.

CONTACT INFORMATION:

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

PROJECTS COMPLETED

DURING RESIDENCY:

Scholarly Project:

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)

Community Medicine Project:

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.

CONTACT INFORMATION:

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


JAM ACAD DERMATOL

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/19 8 d None

PCP/19 18 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

JAM ACAD DERMATOL

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


JAM ACAD DERMATOL

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

PROJECTS COMPLETED

DURING RESIDENCY:

Community Medicine Project:

The T in LGBT Health

Scholarly Project:

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.

CONTACT INFORMATION:

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

Male to Female

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

Male to Female

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

Male to Female

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

Male to Female

Labs—Older Recommendations

Monitoring Labs

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

Monitoring Labs

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

Linguistic Anxiety

� 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

Linguistic Anxiety

� 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

PROJECTS COMPLETED

DURING RESIDENCY:

������������������ 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)!

CONTACT INFORMATION:

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,

Resident Newsletter

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.


Resident Newsletter

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

PROJECTS COMPLETED

DURING RESIDENCY:

Community Medicine Project:

Healthy Habits for Preschoolers (with Kate

Porter)

Scholarly Project:

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.

CONTACT INFORMATION:

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

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

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

PROJECTS COMPLETED

DURING RESIDENCY:

Community Medicine Project:

Bringing the Advanced Life Support in

Obstetrics (ALSO) training to Uganda

Scholarly Project:

“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.

CONTACT INFORMATION:

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

PROJECTS COMPLETED

DURING RESIDENCY:

Community Medicine Project:

Building a Clinic Wiki -- A Collaborative

Website

Scholarly Project:

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.

CONTACT INFORMATION:

gleydon@gmail.com


Patrick McKenna, MD

PROJECTS COMPLETED

DURING RESIDENCY:

Community Medicine Project:

The Verona Clinic Community Garden

Scholarly Project:

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.

CONTACT INFORMATION:

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

PROJECTS COMPLETED

DURING RESIDENCY:

Community Medicine Project:

Ongoing series of articles on a variety of

health topics published in the Belleville

local paper.

Scholarly Project:

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.

CONTACT INFORMATION:

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

PROJECTS COMPLETED

DURING RESIDENCY:

Community Medicine Project:

Healthy Habits for Preschoolers (with Jill

Klemin)

Scholarly Project:

“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.

CONTACT INFORMATION:

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

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

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

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

PROJECTS COMPLETED

DURING RESIDENCY:

Community Medicine Project:

Initiating Diabetes Group Visits at Northeast

Clinic

Scholarly Project:

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.

CONTACT INFORMATION:

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

PROJECTS COMPLETED

DURING RESIDENCY:

Scholarly Project:

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”

Community Medicine Project:

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.

CONTACT INFORMATION:

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

PROJECTS COMPLETED

DURING RESIDENCY:

Scholarly Project:

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.

CONTACT INFORMATION:

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

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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


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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


Management and follow-up based on predischarge

TSB/TcB, GA, and other risk factors

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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

Management and follow-up based on predischarge

TSB/TcB, GA, and other risk factors

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

Phototherapy (cont'd)

● 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

Phototherapy (cont'd)

● 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

Phototherapy (cont'd)

● 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

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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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