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18 Collaboration and Collegiality: The Fuel For Growth in Sports Medicine RAZIB KHAUND, MD GUEST EDITOR

R. Khaund, MD

19 Preparticipation Physical Exams: The Rhode Island Perspective, A Call for Standardization PETER K. KRIZ, MD,FAAP, FACSM AILIS CLYNE, MD, MPH, FAAP SARA R. FORD, MD, FAAP On the cover P. Kriz, MD A. Clyne, MD S. Ford, MD Photos: CDC, Public Health Image 23 Current Concepts in Library/Amanda Mills Sports-related Concussion http://phil.cdc.gov/phil/home.asp JEFFREY P. FEDEN, MD

J. Feden, MD

27 Diagnosis and Management of Meniscal Injury JACOB BABU, MD, MHA ROBERT M. SHALVOY, MD STEVE B. BEHRENS, MD

J. Babu, MD R. Shalvoy, MD S. Behrens, MD

31 Understanding Athletic Pubalgia: A Review BRIAN COHEN, MD DOMINIC KLEINHENZ, MD JONATHAN SCHILLER, MD RAMIN TABADDOR, MD B. Cohen, MD D. Kleinhenz, MD

J. Schiller, MD R. Tabaddor, MD RHODE ISLAND M EDICAL J OURNAL

8 COMMENTARY The Not-So-Near Death of Autopsies in the U.S. JOSEPH H. FRIEDMAN, MD Medical Decision-Making for Unrepresented Patients HERBERT RAKATANSKY, MD

The Rio 2016 Polyclinic – An Athlete-Centered Experience in the Olympic Village CLIVE W. BRIDGHAM, MA, DC

9 LETTER TO THE EDITOR Changes in the Maintenance of Certification (MOC) process have not gone far enough LISA FRAPPIER, DO

16 RIMJ AROUND THE WORLD Accra, Ghana Mountain View, California Stykkishólmur, Iceland

62 RIMS NEWS Are you reading RIMS Notes? Vote Yes on Question 7 Working for You New officers inaugurated Special Event: Demystifying the Legislature Why You Should Join RIMS

87 HERITAGE Daughters of Asclepius: Early women physicians in Rhode Island MARY KORR RHODE ISLAND M EDICAL J OURNAL

IN THE NEWS

DEPT. OF HEALTH, AG OFFICE 71 76 STUDY ON SMARTPHONE APP give conditional approval to LMW Healthcare to teach sexual health (Westerly Hospital)/ Yale-New Haven affiliation to adolescent girls

DANA-FARBER, LIFESPAN 71 77 RESEARCH EVALUATES sign MOU risk factors for postpartum depression in mothers of preterm infants BROWN LAUNCHES 72 MD/MPA program 77 WOMEN & INFANTS participating in National Pelvic EPIVAX AWARDED 72 Floor Disorders Network $600,000 NIH grant to improve H7N9 avian influenza vaccine 79 ENROLLMENT 100% in Prescription Drug Monitoring Program DRS. VIREN D’SA, BARRY LESTER 74 awarded $11.1M NIH grant to study 79 HEALTH CENTER FOR WEIGHT LOSS environmental influences on child health at Charlton earns national accreditation

HASBRO 76 79 DR. LINDA J. RESNIK receives $1.8M from NIH to study at Providence VA awarded $2.5M for environmental influences on child health multi-center amputation care study

PEOPLE

F. DENNIS MCCOOL, MD 81 84 STEPHANIE CURRY, MD patient travels from joins CharterCARE Thailand to Memorial Medical Associates for a good night’s sleep 84 EDWARD HURLEY, MD ALAN MORRISON, MD 83 named President-elect research project at VA funded of Pediatric Research to study heart valve disease Society, Junior Section

PATRICK SWEENEY, MD 83 receives ACCME’s 2016 Rutledge W. Howard, MD, award OCTOBER 2016 VOLUME 99 • NUMBER 10 RHODE ISLAND Rhode Island Medical Society R I Med J (2013) 2327-2228 M EDICAL J OURNAL 99 PUBLISHER RHODE ISLAND MEDICAL SOCIETY 10 PRESIDENT 2016 SARAH J. FESSLER, MD

October PRESIDENT-ELECT 4 BRADLEY J. COLLINS, MD VICE PRESIDENT PETER A. HOLLMANN, MD CONTRIBUTIONS SECRETARY CHRISTINE BROUSSEAU, MD 35 The Decline of the Autopsy in Rhode Island and Nationwide:

TREASURER Past Trends and Future Directions JOSE R. POLANCO, MD ALEX BAUMGARTNER, MD IMMEDIATE PAST PRESIDENT DOUGLAS ANTHONY MD, PhD RUSSELL A. SETTIPANE, MD

EXECUTIVE DIRECTOR 37 Fluid Choice Matters in Critically-ill Patients with Acute Pancreatitis: NEWELL E. WARDE, PhD Lactated Ringer’s vs. Isotonic Saline MOHAMMED M. ABOELSOUD, MD EDITOR-IN-CHIEF OSAMA SIDDIQUE, MD JOSEPH H. FRIEDMAN, MD ALEXANDER MORALES, MD ASSOCIATE EDITOR YOUNG SEOL, ScB SUN HO AHN, MD MAZEN O. AL-QADI, MD PUBLICATION STAFF MANAGING EDITOR 42 A Five-Year Evolution of a Student-led Elective on Health Disparities MARY KORR at The Alpert Medical School [email protected] LUCINDA B. LEUNG, MD, MPH GRAPHIC DESIGNER JAMES E. SIMMONS, MD MARIANNE MIGLIORI JULIUS HO, BS ADVERTISING STEVEN DETOY EMMA ANSELIN, BA SARAH STEVENS RIAN YALAMANCHILI, BA [email protected] JOSEPH S. RABATIN, MD

EDITORIAL BOARD 47 Medical School Ranking and Student Research Opportunities JOHN J. CRONAN, MD JAMES P. CROWLEY, MD ANNIKA G. HAVNAER EDWARD R. FELLER, MD PAUL B. GREENBERG, MD JOHN P. FULTON, PhD PETER A. HOLLMANN, MD KENNETH S. KORR, MD MARGUERITE A. NEILL, MD CASE REPORT FRANK J. SCHABERG, JR., MD 53 Systemic Amyloidosis Masquerading as Intractable Cardiomyopathy LAWRENCE W. VERNAGLIA, JD, MPH LINDSEY CILIA, MD NEWELL E. WARDE, PhD LESLIE PARIKH, MD MADHU M. OUSEPH, MD, PhD EDWARD STOPA, MD RHODE ISLAND MEDICAL JOURNAL (USPS 464-820), a monthly publication, is MICHAEL K. ATALAY, MD, PhD owned and published by the Rhode Island Medical Society, 405 Promenade Street, Suite A, Providence RI 02908, 401-331-3207. All rights reserved. ISSN 2327-2228. Published PUBLIC HEALTH articles represent opinions of the authors and do not necessarily reflect the official policy 56 HEALTH BY NUMBERS of the Rhode Island Medical Society, unless Community Health Teams: clearly specified. Advertisements do not im- ply sponsorship or endorsement by the Rhode A Healthcare Provider’s System Transformation Opportunity Island Medical Society. JAMES C. RAJOTTE, MS Advertisers contact: Sarah Stevens, RI Medical DEBORAH GARNEAU, MA Society, 401-331-3207, fax 401-751-8050, [email protected]. NANCY SUTTON, MS, RD, LDN AILIS CLYNE, MD, MPH

© COPYRIGHT JANUARY 2013, RHODE ISLAND 60 Vital Statistics MEDICAL SOCIETY, ALL RIGHTS RESERVED. ROSEANN GIORGIANNI, DEPUTY STATE REGISTRAR With the right tools, you can do more than insure against risk.

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ProSelect Insurance Company 800.225.6168 www.coverys.com COMMENTARY

The Not-So-Near Death of Autopsies in the U.S.

JOSEPH H. FRIEDMAN, MD [email protected] 8 9 EN

N eurological d i s - of Alzheimer’s disease, parkinsonism, which, despite being only orders are the most dif- and not what they were a general term for a syndrome, adequate ficult to diagnose. While expected to be. Occa- enough to understand the disease pro- imaging and genetic test- sional cases of Alzhei- cess, possibly do a Google search, etc. ing has advanced tremen- mer’s masquerades as My local colleagues learn as well, but dously over the past three other, rare disorders. In a only an occasional brain autopsy will decades, and our ability few years we will see that merit a case report. to diagnose has advanced much of what we believe Getting autopsies is not very easy, with it, the truth of the about Parkinson’s disease despite the extremely generous and matter is that we’re not so will be reframed based on hospitable nature of the neuropathology good at identifying most pathological and genetic group at Rhode Island Hospital, which is neurodegenerative disor- findings. Thirty percent where all brain autopsies are performed. ders in life that do not fit a clear pattern. of people diagnosed with Alzheimer’s It turns out that they do more than I Complicating the matter is the fact disease by dementia experts are proven thought, although less than they should. that it is not uncommon for different wrong at autopsy. We Parkinson’s dis- Autopsies, in general, are dwindling. disorders to have identical clinical ease experts even misdiagnose Parkin- In the U.S., in-hospital deaths were presentations. Probably the most com- son’s disease about 10–20% of the time, autopsied over half the time 50 years mon example is the problem of diag- especially during the early years. The ago, but now only about 5%. Obviously, nosing dementia with Lewy bodies. point of these references to esoterica is out-patient death autopsies are much This is quite simple if the patient with to establish that neurologists are unable less common, partly because the family dementia also has clear-cut features of to make diagnoses in a fair number of rarely knows how to proceed, and if they Parkinson’s disease. But, if the demen- cases, that we know a lot about what contact the attending physician, that tia precedes the motor dysfunction the we don’t know, but, like everyone else, person usually does not know how to diagnosis is made correctly in only don’t know what we don’t know, which proceed. And, even if the doctor is me, about half the cases if seen by a demen- is why autopsies are crucial if we are to the logistics are challenging and the tia specialist, and mostly diagnosed as make advances. family has to pay the funeral home to Alzheimer’s by other doctors, including I am not very good at getting autop- transport the body. Many funeral homes neurologists. sies. I do get some, particularly when I discourage the practice. I am not sure Much rarer is the newly re-named think we may learn something of rele- why in-patient autopsies are so uncom- disorder, “corticobasal syndrome,” vance to the family. I am less assiduous mon, but I have a lot of thoughts on which had been called, “corticobasal when the motivation is largely for me to why outpatient post-mortems are rare. ganglia degeneration,” after initially be the primary recipient of the knowl- In UK, a recent medical article spoke of being labeled as “cortico-striatal-pallidal edge. Oftentimes I am more interested autopsies as being near extinct. degeneration with neuronal achromasia. in knowing the true diagnosis than the I think that one reason in-hospital “The first change was made for brevity’s family. It is meaningful to me to learn autopsies are uncommon is that there is sake. The recent change was made when which of the several atypical parkinson- a fear of unwittingly revealing a deficit autopsies made clear that one third of isms was the pathology, whereas the in medical care. Yet, it turns out that the cases were actually unusual cases family finds the diagnosis of atypical medical-legal data have shown that

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autopsies generally aid the physicians in closure. Perhaps most important is the The autopsy “completes” the physical cases of alleged malpractice, even when common belief that little is to be gained exam. Neither has yet become outdated, the autopsy demonstrated an unrecog- from the autopsy, that with the current despite what some of our colleagues nized, yet treatable condition. Decisions battery of highly sophisticated tests we might think. v were based on standard of care for what know all we need to know, so why go were thought to be the problems at the to the bother and expense of a formal Author time of treatment. In a recent article autopsy? This is remarkably incorrect, Joseph H. Friedman, MD, is Editor-in-chief looking at this by the American Asso- in general. For neurological cases, this is of the Rhode Island Medical Journal, ciation of Anesthesiology, over 50% of even more likely to be incorrect. Professor and the Chief of the Division the autopsies were thought to help the Complicating any attempts to of Movement Disorders, Department of plaintiff while only 28% supported the increase autopsy rates is the absence of Neurology at the Alpert Medical School of malpractice allegations. I believe that reimbursement for the pathology depart- Brown University, chief of Butler Hospital’s another reason is that requesting an ment for autopsies, a rather expensive Movement Disorders Program and first autopsy requires asking something from undertaking, especially for brain dis- recipient of the Stanley Aronson Chair in the bereaved relatives, which is always orders which often require extensive Neurodegenerative Disorders. a difficult thing to do unless the illness testing and large amounts of time as was a great mystery that the family special stains get ordered to perform Disclosures on website wants to understand better to achieve increasingly sophisticated testing.

Changes in the Maintenance of Certification (MOC) process have not gone far enough

9 To the Editor and my RI colleagues: I am writing to seek your interest and support in asking the With a formal resolution like Massachusetts, we could then 9 Rhode Island Medical Society to follow in the steps of the Mas- seek “Right to Care” legislation to prevent what has become EN sachusetts Medical Society1 and many others in creating a for- mandatory participation in MOC for many doctors in RI. It is mal resolution against the Maintenance of Certification (MOC) complicated with the many hospitals and insurers and will not process being promulgated by the American Board of Medical happen overnight, but if we join together with physicians and Specialties. Grassroots efforts across the country have pressured medical societies nationwide, our voices do have power. Help the specialty boards into making concessions, but these changes ensure that MOC will never be linked to licensure, reimburse- have not gone far enough. ment, hospital privileges or employment. The time to act is now. In the last two years, we have seen a group of well-respected Please take a look at our petition and add your name if you physicians2 create an alternative to the American Board of Med- haven’t previously: ical Specialties, The National Board of Physicians and Surgeons, https://www.change.org/p/rhode-island-medical-society- which has so far been accepted into 40 hospitals in the US.3 create-a-resolution-against-the-abms-moc Oklahoma has enacted the first ever “Right to Care” legisla- tion4 which states that MOC cannot be linked to licensure, re- Sincerely, imbursement, hospital privileges or employment. Michigan and Lisa Frappier, DO Missouri are now considering their own similar legislation. The [email protected] AMA has called for an immediate end to any mandatory, secure RI Physicians for Quality Care recertifying examinations5 which is a major step, although it has also previously endorsed the idea of more intense Mainte- nance of Licensure to be enforced by the states6, a process which References looked exactly like MOC with its self-assessment, assessment 1. http://aapsonline.org/resolutions/a-10-20-MA-no-moc.pdf of knowledge and skills, and performance in practice.7 2. https://nbpas.org/board/ Though making a resolution against MOC is a small step, it 3. https://nbpas.org/hospitals-accepting-nbpas-diplomats/ is one brick in a much larger foundation, which has made the 4. http://www.medscape.com/viewarticle/862331 current progress we have seen possible. Most doctors who are 5. http://rebel.md/new-ama-policy-opposes-moc-exams/ required to complete MOC feel this is an important issue, and I 6. http://www.policymed.com/2016/01/ama-house-of-delegate-recom- have yet to talk to one who has not complained about this bur- mendations-on-maintenance-of-certification-and-licensure.html densome process. I believe this would be an issue where our med- 7. https://www.fsmb.org/Media/Default/PDF/FSMB/Foundation/ ical society could be a strong advocate and voice for its doctors. jmr-mol.pdf

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Medical Decision-Making for Unrepresented Patients

HERBERT RAKATANSKY, MD

11 12 EN

A s i x t y - i s h - y e a r - o l d we designate close family a law. Three states (New York, Texas, homeless man is admitted or friends who may know Iowa) have laws establishing extra-in- to the hospital with pneu- the patient’s values and stitutional committees that may serve monia and found to have will be able to use the as proxies. In Florida, the “ultimate COPD and cancer of the criterion of “substituted surrogate” is a clinical social worker lung. Radiation and sur- judgment” to make med- and in Texas “a member of the clergy.” gery are under consider- ical decisions. But there Currently our largest RI health care ation. He is forgetful and are no such persons for system instructs attending physicians is unaware of any family. our patient. faced with caring for an unrepresented He has no friends and A proxy who could patient to call “risk management.” We this is his first encounter apply the “reasonable need an approach in RI that will better with the medical system. person” standard is the serve these unfortunate folk. He is confused and lacks capacity to default option. But who is that person? A new law (effective August 2016) in make decisions about his treatment. In emergency situations it is clear Colorado (CO) offers guidance. The law A diligent search fails to discover any that treatment should be given. But in works as follows: friends or relatives and did not reveal our case, where the treatment is urgent Lack of capacity must be confirmed any cultural, religious or other values but not emergent, the only legal option by an independent examiner. that might influence medical decisions. is to seek a court-appointed guardian. Such cases are not common but pose This is not a realistic solution as that A doctor (other than a doctor involved in the care of the patient) may be difficult dilemmas when they occur. process is very time consuming (up appointed proxy with the consensus Without family, friends or a prior knowl- to several months) and expensive (est. of the ethics committee. edge of their views on medical treat- $5000–$8000). And often a willing ment, such persons are “unrepresented guardian who can make timely informed For routine treatment (formal patients.” They have no advocates. decisions cannot be found. informed consent not required) The literature suggests that 5% of the The attending physician generally the proxy may act independently. 500,000 patients who die annually in should not be the default proxy of For treatments requiring formal ICU’s and 3–4% of patients in nursing record. In some states, including RI, informed consent both the proxy homes are unrepresented. the attending physician is prohibited and the ethics committee must sign Forty-three states have laws designat- by law from being an appointed proxy. the informed consent. ing who can make medical decisions However, 12 states allow the attending For end-of-life treatment involving for patients who lack capacity and have doctor to be the legal proxy although 7 of withholding or withdrawing treat- not designated a proxy. Rhode Island those impose significant limitations on ment, a second independent medical (RI) is not one of these. RI has a statute them. A multi-disciplinary committee opinion from a physician (not the designating a hierarchy of persons who such as an ethics committee could serve proxy) and the consensus of the ethics can consent for an autopsy, but we in this role. Only 5 states, however, committee must be obtained. do not have such a legal hierarchy for have laws that specifically empower decision-making for live patients when such committees to make decisions This law applies to all medical insti- there is no designated proxy. Generally about treatment. RI does not have such tutions in CO, including nursing homes,

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assisted living facilities and communi- institutions. A protocol based on the CO in multiple institutions would always ty-based health services. If the desig- law, incorporated into the policy struc- know the rules as would the institutions, nated doctor proxy is willing, he/she ture of hospitals, would be inexpensive and the designated proxy (if willing to may continue as a proxy in all of the and effective in dealing with this signif- do so) and the ethics committee could other care facilities and systems. If the icant issue. Acting in concordance with continue to serve in their roles in other consensus of the ethics committee is hospital policy, the doctors caring for an institutions or settings, further bene- required and there is no such commit- unrepresented patient could enhance fiting both patients and institutions. tee in the other facilities, the hospital timely medical decision-making. And Finally, if a single agreed-upon policy committee may continue in its role to by acting in accordance with official to protect unrepresented patients were support the patient. hospital policy doctors may receive adopted by the various medical institu- Since there is no law in RI that addresses significant legal protection. This would tions and endorsed by the RI Hospital these issues, we have several options. be a benefit for patients, and would Association and the RI Medical Society, We could try to get a law passed as result in significant financial savings. the legislature then might be convinced the initial effort. Such legislation would Patients would get prompt, medically to create legislation incorporating these likely address the issue of the hierarchy appropriate treatment and the admin- already effective policies and thus of medical proxies when family and istrative costs of dealing with the legal ensure the legal protection of these most friends are available as well as the pro- issues of unrepresented patients would vulnerable members of our society. cess to assist unrepresented patients. be reduced. And that, after all, is our real goal. v Such an effort is likely to be lengthy, Our small size and relatively few expensive and afflicted with unintended hospitals offer a unique opportunity for Author legislative consequences. the competing medical systems in RI to Herbert Rakatansky, MD, FACP, FACG, However, we could more easily incor- cooperate on a non-controversial issue is Clinical Professor of Medicine Emeritus, porate processes to protect the unrepre- and establish a uniform policy for all RI The Warren Alpert Medical School of sented patients into the policies of our medical institutions. Doctors working Brown University.

Errata R I Med J (2013). 2016 Sep 1;99(9):27-30. ERRATUM Sex Trafficking Assessment and Resources (STAR) for Pediatric Attendings in Rhode Island. Moore JL1, Baird G2, Goldberg AP3. Author information 1Hasbro Children’s Hospital, Providence, Rhode Island. 2Lifespan Biostatistics Core, Rhode Island Hospital. 3The Warren Alpert Medical School of Brown University, Department of Pediatrics, Hasbro Children’s Hospital, Providence, Rhode Island. ERRATUM IN: R I Med J (2013). 2016 Oct 4;99(10):12 CORRECTED TO: Barron CE,1,3 Moore JL1, Baird G2, Goldberg AP3 (first author added) Abstract BACKGROUND: Domestic minor sex trafficking (DMST) victims have unique medical and mental health needs and present frequently for medical attention. Little is known about the reported training, screening, comfort and knowledge of DMST among pediatricians in Rhode Island who likely encounter these patient victims without knowing. METHODS: An anonymous electronic survey sent to Rhode Island Hospital staff physicians from November 2014 through January 2015. RESULTS: Of the 109 participants, the majority reported no training, screened no patients for DMST in the past year, did not know any resources available and had limited knowledge and comfort with this pediatric patient population. CONCLUSIONS: Rhode Island pediatricians of various specialties do not feel adequately prepared to identify and respond to a DMST patient population. These findings inform the need for increased training and education on DMST in our medical community. [Full article available at http://rimed.org/rimedicaljournal-2016-09.asp, free with no login]. KEYWORDS: commercial sexual exploitation of children; domestic minor sex trafficking; training; victim PMID: 27579947

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M COMMENTARY

The Rio 2016 Polyclinic – An Athlete-Centered Experience in the Olympic Village

CLIVE W. BRIDGHAM, MA, DC, DACBSP, ICSSD 14 15 EN

At first, being a mem- we found an entrance, then toured the clinic, which included ber of the sports med- but the security guards many specialties: dentistry, ophthalmol- icine team at the Rio wouldn’t let the taxi into ogy, emergency room, orthopedic sports 2016 Olympic Games the restricted area. We medicine, podiatry, osteopathy, massage was like being a mouse were stopped with a huge therapy, and of course chiropractic. in a huge maze of cor- bus honking behind us. I The complex also included two state- ridors, offices, entries got out of the taxi and for- of-the-art MRIs, one digital x-ray, a cryo and exits – not to men- tunately one of the guards pool room, a rehab room with an anti- tion protocols. It quickly spoke enough English and gravity treadmill, conference, storage became an athlete-cen- let me get on the bus, and IT rooms, as well as lounges and tered, check your ego at which was authorized to reception areas. the door experience. go into the outer perime- There was a room for orthotics and Arriving on my first assignment ter of the village. I walked toward some support braces for ankles to shoulders, a day was a transportation maze. I was volunteers and asked for directions to chiropractic table room, an osteopathic living with friends in Logoa, where the the Polyclinic. Passing though security table room, and our main area for phys- rowing and kayak events took place. with credential check, metal detector, ical medicine: the physio room with 12 I opted to take a taxi, as I had no idea and x-ray examination of my official treatment tables and state-of-the-art of the public transportation logistics volunteer carry bag, they pointed me in physio machines for ultrasound, ems, of walking to buses which took you to the right direction. laser, cryo/compression, and hot moist subways which took you to more buses After a fast walk/jog, which seemed packs. There was also a Swiss machine and more walking. My taxi arrived 15 like an eternity, I arrived at the Poly- for intense pulsed ultrasound. The one minutes late and the driver didn’t know clinic, where we had our introductions exception was that no acupuncture was where the Olympic Village (OLV) was. and meetings of the physical therapies allowed in the clinic. The physios were After 50 minutes and driving in circles, team of physios, chiros, and osteos. We allowed to perform mobilization but

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only the chiros and osteopaths were Our teams were divided into two exposed to chiropractic services for the allowed to perform manipulation. shifts. On my first day there were only first time. Many new friendships were During the first few days, the early about 2,500 people housed in the OLV, formed and old acquaintances renewed. morning hours were relatively quiet by midway through my rotation the OLV It is amazing what happens when you with only an easy flow of returning ath- swelled to at least 11,000 occupants. have a dedicated team of professionals letes, so it was watch and learn and Athletes accompanied by their team who are athlete-centered treating the figure out what specialty we each were doctor or team physio were allowed finest athletes in the world. This has as we were all dressed the same and direct access and could either work with been a dream for my entire chiropractic our credentials made no differentiation us or independently. career, and was 30 years in the making. as to our degrees. It was an adaptive I found many team physios and some It is the highest level of sport, and a total process on all sides, learning the subspe- team MDs were very interested in refer- honor to be a part of the sports medicine cialties of each provider. Watching the ring and watching chiropractic services. staff. It was truly a world-class experi- team develop understanding and work Pleased athletes spread the word about ence, well worth the time to learn how together was a great experience. The the clinic and soon the volume increased to navigate the mazes I encountered. v chiropractic team provided treatment exponentially. Once the athlete was to all athletes requesting their services, in the physio treatment area interdis- Author from any country’s team in any sport. ciplinary referrals were allowed and Dr. Clive W. Bridgham, a chiropractic sports We saw a wide variety of treatment encouraged, providing the athletes with medicine specialist and director of the Bar- needs, with many athletes being referred a world-class experience. My first day rington Chiropractic and Sports Medicine to us for neck, low back and extremity shift ended at 3 p.m. with a debriefing Clinic, was one of the 17 chiropractors from conditions. It was great being able to and a team Rio cheer. eight countries chosen by the Rio 2016 Or- make a difference in these athletes’ There are so many people to thank ganizing Committee to serve in the host lives. We helped them achieve their for their years of work in making the medical services during the Olympics and goals by getting them back into play Rio 2016 Polyclinic the success that Paralympics. For three weeks, from July 29 after an injury, or helping them per- it was. Of special note are Dr. Marcelo to August 11, Dr. Bridgham and colleagues form at their optimum level by making Botelho, the lead chiropractic physician worked in a multidisciplinary polyclinic sure that their body was functioning and Felipe Tadiello, coordinator of phys- open to all athletes, coaches and officials. at 100%. ical therapy services. Many people were

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We are read everywhere

ACCRA, GHANA Joseph H. Friedman, MD, visiting professor in the Department of Medicine for the house staff training program at 37 Military Hospital in Accra, Ghana, pauses to consult the September issue of the journal. It was Dr. Friedman’s first return to Ghana after teaching there in 1969-1971 as a Peace Corps Volunteer prior to attending medical school. Dr. Friedman is editor-in-chief of RIMJ, Professor and Chief of the Division of Movement Disorders, Department of Neurology at the Alpert Medical School of Brown University, chief of Butler Hospital’s Movement Disorders Program and Stanley Aronson Chair in Neurodegenerative Disorders.

MOUNTAIN VIEW, CALIFORNIA Kelly Grimes, RN, high-risk obstetrics coordinator at Lucille Packard Children’s Hospital at Stanford and Kevin Grimes, MD, (Brown ‘79, MD ‘82) Director, Spark Translational Research Program, and Associate Professor of Chemical and Systems Biology, both at Stanford University School of Medicine, peruse the September issue at their home in Mountain View.

Wherever your travels take you, be sure to check the latest edition of RIMJ on your mobile device and send us a photo: [email protected].

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We are read everywhere

STYKKISHÓLMUR, ICELAND M. Jean-Jacques Joly, Dr.-Ing., of Lyon, France, discovered that he could access the September 2016 edition of the Rhode Island Medical Journal from the summit of Súgandisey Island above the town of Stykkishólmur on the Snæfellsnes Peninsula in western Iceland. In the background are the bay and islands of Breiðafjördur.

Spirited, small, and hardy, Icelandic horses are descendants of ponies It is believed that 60% of the world’s Atlantic taken to Iceland by the Norse as puffins form their breeding colonies in Iceland early as the 9th century. They are in spring and summer. The plentiful lundi, the capable of two additional, distinctive Icelandic name for their national bird, are also gaits called the tölt and skeið, found on Icelandic menus. Smoked, or boiled compared to the typical three gaits in milk, puffin is now considered a delicacy, (walk, trot, gallop) of other breeds. but had been a dietary staple in centuries past.

Wherever your travels take you, be sure to check the latest edition of RIMJ on your mobile device and send us a photo: [email protected].

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Collaboration and Collegiality: The Fuel For Growth in Sports Medicine

RAZIB KHAUND, MD GUEST EDITOR

18 18 EN This month’s Rhode Island Medical Journal has dedicated sports, climate of competition, the athlete, and medicine; the issue to sports medicine. It is my honor to be the guest and how they all relate to one another. editor, as over the past 25 years, from my days as a medi- Sports medicine as a specialty is relatively young; however, cal resident at Brown to my return from fellowship to start its roots are very deep. It represents the best in medicine; a practice in Rhode Island, I have seen tremendous growth in collaboration of various specialties to provide education and the field locally and nationally. The acceptance of sports care to the patient. It is also susceptible to outside demands. medicine amongst physicians and the public is parallel to its An important tenet to remember: when treating an athlete, acceptance by the American Board of Medical Specialties. they are a patient first and athlete second. Education of the Fellowship training and board certification have helped to athlete, parents, coaches, administrators, general public, and set modern standards of practice. colleagues is the best tool we have to temper expectations. Truth be told, sports medicine can be traced back to Herod- This issue of the Rhode Island Medical Journal includes icus 5th century BCE with regards to fundamental theories articles addressing current “hot” topics in the field.PETER on the use of therapeutic exercise for the maintenance of KRIZ, MD, and colleagues write about the need for standard- health and treatment of disease. The dawn of the modern ization of pre-participation physical exams. Pre-participation sports medicine era is ascribed by some to Harvard Medical exams are part of the foundation of sports medicine. The School in 1890. It was there that significant injuries were ability to screen and counsel athletes is an important oppor- recognized and thus a program was instituted to educate tunity not to be wasted. JEFFREY FEDEN, MD, provides players of the need for personal fitness, use of proper gear, insight and perspective regarding concussions in sports. Over need for treatment of all injuries and the importance of reha- the past few years, there has been significant media coverage bilitation. Most people consider the true genesis of modern of concussions. Improving the awareness of the public has sports medicine to have begun in the 1950s. Don O’Dono- been a benefit. Unfortunately, some media coverage has per- ghue, MD, from the University of Oklahoma, wrote the petuated misperception. ROBERT SHALVOY, MD, and STEVE textbook “Treatment of Injuries to Athletes” which became BEHRENS, MD, address meniscal injuries in the knee. The the bible for sports medicine physicians. At the same time article helps to review a common diagnosis seen in athletes in Columbus, Georgia, Jack Hughston, MD, was starting as well as the general public. It also highlights arthroscopy sideline coverage of football/athletic events. His foresight to and its role in revolutionizing orthopedic sports medicine. merge clinical practice, research, and education is legendary. Finally, RAMIN TABADDOR, MD, and colleagues take on Sports as a part of life, be it recreational, therapeutic, com- a difficult topic in Athletic Pubalgia. In the past, athletic petitive, or professional, continues to take on more signif- groin pain was considered a black-box diagnosis. In the past icance as time moves on. Be it the billion-dollar industry few years, however, there have been advances in the under- of professional sports or the patient recovering from heart standing of athletic groin pain. Dr. Tabaddor’s article high- surgery who is participating in cardiac rehabilitation, people lights these developments and outlines treatment options. from all walks of life can benefit from sports medicine. Physi- Sports medicine is a relatively young vibrant field that is cians are commonly prescribing exercise to help with overall in the midst of a growth spurt. As I head into the second half health, and with this rise in the number of athletes comes a of my career, I am anxious to see the future unfold. concomitant rise in problems and injuries specific to a sport. The field of sports medicine can best be defined as medicine meant to include all of the subspecialties of medicine Author as well as nutrition, physiology, and preventative health Razib Khaund, MD, Clinical Assistant Professor of Medicine, care. It involves the education, treatment, and care not just Alpert Medical School of Brown University; Director of Sports of injuries, but of athletes. It involves the understanding of Medicine, Care New England Health Systems

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Preparticipation Physical Exams: The Rhode Island Perspective, A Call for Standardization

PETER K. KRIZ, MD, FAAP, FACSM; AILIS CLYNE, MD, MPH, FAAP; SARA R. FORD, MD, FAAP

18 22 EN ABSTRACT athletes for risk factors associated with sudden cardiac death As of 2015, 98% of U.S. states require preparticipation (SCD)3; 3) the PPE has little effect on the overall morbidity exams (PPE) before participating in scholastic sports. and mortality of athletes.4 Proponents of the PPE cite that Despite widespread availability of a PPE monograph en- 1) ≥75% of medical and orthopedic conditions which may dorsed by six medical societies, a lack of uniformity ex- require sports participation restriction are detected by his- ists regarding implementation of the PPE among Rhode tory alone5; 2) it allows for establishment of a medical home, Island health care providers (HCPs). Consequently, sig- updating of immunizations, identification and management nificant variability exists regarding how comprehensive a of chronic health conditions related to sports and other life- history and physical exam screening is conducted for ado- style risk factors. lescent athletes looking for sports participation clearance. In Rhode Island, wide variability exists regarding the The purpose of this document is to: 1) establish a uniform implementation of the PPE. In many health care settings, screening process in Rhode Island for the PPE utilizing a the PPE is combined with the annual wellness visit, due peer-reviewed history and physical exam; 2) familiarize to a variety of factors. Insurance companies restrict reim- HCPs with the 2010 PPE monograph, with emphasis on bursement for adolescent physical examinations to annual the cardiovascular and musculoskeletal (MSK) systems; wellness visits only. As a result, HCPs cannot bill insurance 3) encourage HCPs to treat the PPE as a separate enti- for dedicated sports physical/PPE. Nationally, the PPE sub- ty from the annual wellness visit; 4) engage HCPs and stitutes for the annual comprehensive health evaluation in sports medicine providers in Rhode Island to improve the 30-88% of adolescents.6,7 Time restrictions (e.g., timely need quality and process of evaluating adolescent athletes for for physical forms for sports, camps, school enrollment) sports participation. and appointment availability often impact the feasibility KEYWORDS: preparticipation exam, adolescent, athlete, of scheduling separate annual wellness visits and PPE vis- screening its in most clinical practices. As a result, most HCPs utilize a state-issued School Physical Form (http://www.health. ri.gov/forms/school/Physical.pdf) which can be used for multiple purposes, including school-sponsored physical activity/ BACKGROUND sports participation and non-scholastic sports participation. In 2010, the fourth edition of the Preparticipation Physical With the development of the 2010 PPE monograph Evaluation monograph was published by 6 medical societ- comes new momentum to develop a standardized, uniform ies, including the American Academy of Family Physicians, approach to the PPE. Currently, each state determines the American Academy of Pediatrics (AAP), American College content, comprehensiveness, and length of its respective of Sports Medicine, American Medical Society for Sports PPE form, as well as the type of HCP licensed to perform Medicine, American Orthopedic Society for Sports Medi- the PPE.1,8,9 A 2015 study found that only 19 U.S. states cine, and American Osteopathic Academy of Sports Medi- (37%) required or recommended use of the 2010 PPE mono- cine. This comprehensive, peer-reviewed document was the graph.9 By adopting the 2010 PPE monograph, Rhode Island culmination of an extensive review of the literature includ- could assist in the establishment of a national, standardized ing position, policy, and consensus statements pertaining to approach to the PPE that would allow for meaningful data provision of health care in the adolescent population. The collection, with future editions transitioning from predom- objective of the authoring societies was to promote the PPE inantly expert opinion-based content to evidence and out- as an effective tool in identifying medical and orthopedic come-driven content. Aside from the authoring societies of conditions that may affect an athlete’s ability to participate the 2010 PPE monograph, other organizations have recently safely in sports, particularly when performed thoroughly and joined in efforts to standardize the approach to PPE perfor- consistently by qualified, licensed supervising physicians.1 mance, including the Campaign and Coalition for Youth Critics of the PPE have questioned its utility, as 1) <2% of Sports Health and Safety.8 Ninety-five percent (95%) of high school athletes are ultimately disqualified from sports Americans believe that PPE screenings must be conducted participation2; 2) the PPE lacks capacity to effectively screen in a consistent manner across the country.10

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MAKING THE TRANSITION Figures 1a and 1b. 2010 PPE monograph history and physical Physician-reported obstacles to the delivery of the PPE examination forms. include time and scheduling limitations, lack of familiarity with the medical history and physical examination portions of the PPE, uncertainty regarding relative importance of each PPE component, length of the PPE form, time spent covering non-PPE topics, and lack of a standard approach.11 When evaluating a patient for sports participation clearance, HCPs are responsible for conducting a detailed history and physical examination that screens an athlete for cardiovascular and MSK conditions that may ultimately predispose to a life-threatening event, disabling injury or illness during training or competition. A critical element for determining athletic participation is a targeted, albeit detailed PPE history and physical examination. PPEs were never intended to take the place of an annual wellness visit; conversely, the standard history and physical examination of an annual physical can effectively be integrated into the annual physical by utilizing the PPE monograph. The authoring societies of the 2010 PPE monograph acknowledge that the athlete’s personal physician’s office is the ideal setting for the PPE given the established physician-patient relationship, accessibility to the complete medical record, and comfortable environment to discuss confidential issues. This endorsement assumes clinical comfort and competency in performing the PPE. Alternative arrangements for PPE administration, such as group-based assessments by a coordinated medical team, should be available to student-athletes if a comprehensive PPE cannot be accomplished in the medical home. One of the overall purposes of the 2010 PPE monograph was to provide a resource for primary care physicians to improve the quality of the PPE performed in the medical home and to close the knowledge gap regarding the various components of the PPE.1 Clinicians interested in familiariz- ing themselves with the various components of the screening examination (e.g., general MSK screening examination) should consider purchasing the 180-page 2010 PPE monograph in its entirety. For those clinicians who have access to the current or previous editions of the PPE monograph, detailed figures provide valuable information pertaining to screening examination assessments. The authoring societies of the 2010 PPE monograph provide the history, physical exam, and clearance forms free of charge (available at AAP Council on Sports Medicine and Fitness website). Clinicians can download these forms for use in their practice settings (Figures 1A–B).

THE CARDIOVASCULAR AND MUSCULOSKELETAL EVALUATIONS: WHAT YOU SHOULD KNOW While a comprehensive review of the history and physical exam sections of the PPE is beyond the scope of this article, specific attention to key elements of the cardiovascular and MSK evaluations is warranted.

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Preparticipation cardiovascular screening in athletes this article, but numerous articles17-19 illustrate the ongoing entails a detailed personal and family history and physi- debate in sports medicine and cardiology communities. cal exam. Cardiovascular disorders are the leading cause of Regarding the musculoskeletal evaluation, a focused sudden death in young athletes, accounting for ~ 75% of all history is the most important first step in the PPE2: sudden death in athletes.12 In the United States, hypertro- • Athletes with unresolved musculoskeletal pain require phic cardiomyopathy (HCM) and congenital coronary artery additional evaluation prior to sports clearance. anomalies are the most common etiologies of sudden cardiac death (SCD), with HCM accounting for one-third of • Stress fractures may be associated with inadequate SCD deaths in US athletes younger than 30 years.13 The caloric, calcium, and vitamin D intake. prevalence of HCM is 1:500 in the general population, and ~ • Fractures or dislocated joints represent more serious 1:1000-1500 in competitive athletes.14 Because HCM is the orthopedic injuries, and often accompany each other. most common genetic cardiovascular disease,15 a targeted Neurologic deficits can be associated with such injuries. family history may trigger a referral to cardiology for addi- Referral to sports medicine specialists may be indicated tional screening and increase the yield of detection of this prior to clearance. high-risk condition. Most athletes with HCM are asymptomatic, with SCD often the sentinel event of their disease. While the overall yield of the MSK examination in detect- Only 25% of patients with HCM have a murmur,16 which ing significant injuries in asymptomatic athletes with no characteristically is a harsh systolic ejection murmur, best history of injury is typically low (in contrast, history alone heard at the left sternal border that increases in intensity is 92% sensitive in detecting significant MSK injuries20), with maneuvers decreasing venous return (e.g., Valsalva, a general MSK screening examination is recommended1: moving from squat to stand) and diminishes with maneuvers • Inspection: athlete faces examiner. Assess symmetry increasing venous return (e.g., supine position, transitioning of trunk, upper and lower extremities, upper-to-lower 1 from stand to squat). Coronary artery anomalies are the sec- segment ratio, arm span-to-height (should be < 1.05), ond-leading cause of SCD, accounting for ~ 17% of cases in general body habitus athletes.13 Abnormal origin of the left coronary artery is the • Assess cervical ROM (flexion, extension, lateral most common anomaly. <50% of SCD cases from coronary rotation, lateral flexion) anomalies have prodromal symptoms identifiable by preparticipation history. The American Heart Association (AHA)13 • Assess shoulder function (resisted shoulder shrug recommends the PPE include: for trapezius strength, resisted abduction to 90° for deltoid strength, internal and external rotation for 1. Auscultation for heart murmurs: should be performed in glenohumeral joint ROM) both supine and standing positions (or with Valsalva) to identify dynamic LV outflow tract obstruction murmurs. • Assess upper extremity function (flexion/extension Standing is preferred to sitting because the diagnostic of elbows for ROM, pronation/supination of forearms HCM murmur becomes louder when the patient stands for ROM, clench fist and spread fingers for ROM). due to decreased venous return. • Assess back/spine: athlete faces away from examiner. 2. Palpation of the femoral pulses: delayed femoral artery Assess forward flexion, extension, perform Adams pulses compared to radial artery pulses (radiofemoral forward bend testing to evaluate for scoliosis. delay) may indicate the presence of coarctation of the • Perform “duck walk” for 4 steps (hip, knee, and aorta and warrant further diagnostic assessment. ankle ROM; strength and balance testing). 3. Examination for physical stigmata of Marfan syndrome: • Perform toe and heel walk kyphoscoliosis, high-arched palate, pectus carinatum or (calf symmetry and strength, balance). excavatum, arachnodactyly (long, slender fingers), arm Clinicians should augment the general screening exam- span greater than height (ratio > 1.05), mitral valve pro- ination with a thorough joint-specific examination as lapse, aortic insufficiency murmur, myopia, and general- indicated by historical or general screening findings (e.g., ized hyperlaxity are clinical findings. glenohumeral joint instability), and referral to an orthope- 4. Brachial artery blood pressure: should be obtained on a dic specialist should be considered if diagnosis, clearance, bare upper arm supported at heart level, measured with an or further treatment decisions are uncertain. Sport-specific appropriate cuff size, with the patient in the sitting posi- examinations may be considered in addition to the gen- tion with back supported. eral screening examination to assess strength, endurance, Currently, noninvasive cardiovascular screening tests and flexibility testing in joints or segments under particu- such as ECG or echocardiography are not recommended lar stress in a given sport (e.g., shoulders in swimmers and in the preparticipation screening of athletes. A discussion baseball pitchers).1 regarding this controversial topic is beyond the scope of

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SUMMARY AND RECOMMENDATIONS 8. Seto CK. The preparticipation physical examination: an update. Clin Sports Med. 2011 Jul;30(3):491-501. Despite controversy regarding the effectiveness of the PPE 9. Caswell SV, Cortes N, Chabolla M, et al. State-specific differ- as a screening tool for potentially life-threatening or dis- ences in school sports preparticipation physical evaluation poli- abling medical/MSK conditions, PPEs continue to be widely cies. Pediatrics. 2015 Jan;135(1):26-32. 10. PR Newswire. Athletes, physicians urge adoption of new medi- performed and a necessary requirement for scholastic sport cal screening tool. 2010. http://www.prnewswire.com/news-re- participation. Currently in Rhode Island, there is no uniform leases/athletes-physicians-urge-adoption-of-new-medical- screening-tool-93681639.html. Accessed July 24, 2016. or standardized process for conducting a PPE. Additionally, 11. Madsen NL, Drezner JA, Salerno JC. The preparticipation physi- annual wellness visits and PPEs are commonly combined cal evaluation: an analysis of clinical practice. Clin J Sport Med. by HCPs out of convenience and necessity. Potential to 2014 Mar;24(2):142-9. 12. Maron BJ, Doerer JJ, Haas TS, et al. Profile and frequency of sud- miss the opportunity to identify conditions that may be den death in 1463 young competitive athletes: from a 25 year US life-threatening or disabling may occur if pertinent histori- national registry: 1980-2005. Circulation. 2006;114:II(18):830. 13. Maron BJ, Thompson PD, Ackerman MJ, et al. Recommenda- cal information is not gathered and a systems-based physical tions and considerations related to preparticipation screening examination is not performed. for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement form the American Heart Associ- The 2010 PPE monograph is a comprehensive tool that ation Council on Nutrition, Physical Activity, and Metabolism: is gaining traction nationally as a standard for all 50 states endorsed by the American College of Cardiology Foundation. to utilize for preparticipation physical evaluation of ado- Circulation. 2007;115(12):1643-1455. 14. Basavarajaiah S, Wilson M, Whyte G, et al. Prevalence of hy- lescent athletes. The current Rhode Island School Physical pertrophic cardiomyopathy in highly trained athletes: rel- Form includes a section to indicate any physical activity evance to pre-participation screening. J Am Coll Cardiol. 2008;51(10):1033-1039. restrictions, but the form does not specifically require doc- 15. Marron BJ. Hypertrophic cardiomyopathy: a systematic review. umentation that life-threatening or disabling medical and JAMA. 2002;287:1308-1320. musculoskeletal conditions in athletes were screened for. 16. Maron BJ. Hypertrophic cardiomyopathy. Lancet. 1997;350(9071):127-133. Rhode Island physicians and affiliated health care providers 17. Sharma S, Millar L. Yes: Screening ECG is cost-effective. Am can ensure a more comprehensive and consistent approach Fam Physician. 2015 Sep 1;92(5):338-340. to the PPE by adopting the screening recommendations in 18. Wexler R, Estes NA 3rd. Should preparticipation cardiovascular screening of athletes include ECG? No: there is not enough ev- the 2010 PPE monograph for the performance of PPEs in idence to support including ECG in the preparticipation sports their respective clinical settings. It is not the charge of the evaluation. Am Fam Physician. 2015 Sep 1;92(5):343-4. 19. Roberts WO, Asplund CA, O’Connor FG, et al. Cardiac clinician to find the one “needle in a haystack” diagnosis preparticipation screening for the young athlete: why the rou- that will prevent a sports-related adverse event, but rather tine use of ECG is not necessary. J Electrocardiol. 2015 May- to provide a more uniform, systematic screening process. Jun;48(3):311-5. 20. Gomez JE, Landry GL, Bernhardt DT. Critical evaluation of Adopting and implementing the 2010 PPE monograph his- the 2-minute orthopedic screening examination. Am J Dis tory, physical examination, and clearance forms could assist Child.1993;147(10):1109-1113. in development of a national, standardized approach to the Authors PPE. By utilizing the 2010 PPE monograph, clinicians can Peter K. Kriz, MD, FAAP, FACSM, is the chief of primary care improve the quality of their PPE data collection, physical sports medicine at University Orthopedics. He is an Assistant examination skills, and ultimately contribute to an evi- Professor (Clinical) of Orthopedics and Pediatrics at the Warren Alpert Medical School of Brown University. Dr. Kriz is also a dence-based approach and expanding scientific basis for the member of the Rhode Island Interscholastic League’s Sports preparticipation physical evaluation. Medicine Advisory Committee. Ailis Clyne, MD, MPH, FAAP, is a board-certified pediatrician and immediate past president of the Rhode Island chapter of the References American Academy of Pediatrics. Dr. Clyne contributed to this article in her personal capacity. The opinions expressed 1. American Academy of Family Physicians, American Academy of in this article do not represent the views of the Rhode Island Pediatrics, American College of Sports Medicine. Preparticipa- tion Physical Evaluation, 4th ed, Bernhardt D, Roberts W (Eds), Department of Health. American Academy of Pediatrics, Elk Grove Village, IL 2010. Sara R. Ford, MD, FAAP, is a pediatric cardiologist at Hasbro 2. Smith J, Laskowski ER. The preparticipation physical examina- Children’s Hospital. She is an Associate Professor of Pediatrics tion: Mayo Clinic experience with 2,739 examinations. Mayo (Clinical) at the Warren Alpert Medical School of Brown Clin Proc. 1998;73:419–429. University. Dr. Ford is also secretary on the board of directors 3. Magalski A, McCoy M, Zabel M, et al. Cardiovascular screen- of the Rhode Island chapter of the American Academy of ing with electrocardiography and echocardiography in collegiate Pediatrics. athletes. Am J Med. 2011;124:511–518. 4. Best TM. The preparticipation evaluation: an opportunity for Disclosures change and consensus. Clin J Sport Med. 2004;14:107-108. The authors and/or their spouses/significant others have no 5. Koester MC, Amundson CI. Preparticipation screening of high financial interests to disclose. school athletes: are recommendations enough? Phys Sportsmed. 2003;31(8):35-38. 6. Goldberg B, Saraniti A, Witman P, et al. Pre-participation sports Correspondence assessment--an objective evaluation. Pediatrics. 1980;66:736. Peter Kriz, MD, FAAP, FACSM 7. Risser WL, Hoffman HM, Bellah GG. Frequency of preparticipa- 2 Dudley St., Suite 200, Providence, RI 02905 tion sports examinations in secondary school athletes: are the University Interscholastic League guidelines appropriate? Tex 401-457-2188; Fax 401-457-2187 Med.1985;81(7):35–39. [email protected]

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Current Concepts in Sports-related Concussion

JEFFREY P. FEDEN, MD

23 26 EN ABSTRACT Table 1. Symptoms of Concussion Increasing concern over the acute and long-term con- Physical Cognitive Behavioral sequences of sports-related concussion has generated Headache Memory problems Increased emotions widespread interest and attention. This article provides an overview of concussion in athletes, including diagnos- Nausea/Vomiting Difficulty concentrating Sadness tic and management considerations, and highlights the Visual disturbance Fogginess Depression clinical challenges associated with repeated minor head Dizziness/Vertigo Feeling slowed down Anxiety trauma in sports. Impaired balance Confusion Irritability KEYWORDS: sports-related concussion, mild traumatic Sensitivity to light/noise brain injury, athletes Fatigue Sleep disturbance

INTRODUCTION headache and “fogginess” to irritability (Table 1). Diagnosis Sports-related concussion has become a growing concern is made when an athlete presents with the typical constel- in recent years and has generated considerable discussion lation of findings following either direct or indirect trauma. within the scientific and athletic communities. Perhaps no The focus of initial care is on the evaluation for cervical other issue in sports medicine has received as much atten- spine injury or neurosurgical emergency. The next step in tion in the media as the potential long-term consequences of evaluating and managing concussion involves recognition of concussion in athletes. An estimated 1.6 million to 3.8 mil- the injury and removal from play. A systematic neurologic lion concussions occur annually in the United States (1), but exam and assessment of symptoms, cognition, and balance many more may go unrecognized or unreported. Although will often lead to the correct diagnosis. However, sports-re- significant advances have been made over the last decade, lated concussion is not always easy to identify. While novel the assessment and management of concussion remains a technologies are being developed to measure biomechanical challenging endeavor. forces, the magnitude of head impact does not necessarily predict clinical injury. Furthermore, the various symptoms of concussion are nonspecific, sometimes resulting in a diag- PATHOPHYSIOLOGY nostic dilemma. This is complicated by the fact that athletes Concussion is defined as a complex pathophysiologic pro- may not recognize the significance of their symptoms or will cess resulting in transient neurologic dysfunction following conceal symptoms in an effort to continue playing. Symptom a biomechanical insult to the brain, with or without loss of checklists, such as the Sideline Concussion Assessment Tool consciousness (2). It falls on the mild end of the traumatic (version 3, aka SCAT3) (2), are useful in the sideline evalua- brain injury (TBI) spectrum. There is considerable evidence tion after injury and have been adapted to assist in the office- to implicate linear and rotational acceleration forces at the based evaluation of concussion. Unless there is concern for moment of impact, causing deformation of neuronal mem- structural brain injury, CT or MRI is often unnecessary. branes and axonal stretching. The resulting neurometabolic Traditional neuroimaging is expected to be normal in con- cascade involves ionic imbalances and local metabolic dys- cussion, reflecting the more functional nature of the injury. function (3). These physiologic disturbances are transient but Same-day return to play should not be allowed at any level render the brain more vulnerable to repeat injury, possibly of sport for an athlete with diagnosed or suspected concus- with longer lasting effects. sion. Following the Zackery Lystedt Law in Washington State in 2009, all fifty states have now enacted some form of EVALUATION AND RETURNING TO PLAY concussion legislation in an effort to increase awareness and The acute clinical effects of concussion result from neuro- improve athlete safety. Rhode Island’s School and Youth Pro- nal dysfunction. They include balance and cognitive impair- grams Concussion Act (Chapter 16–91) mandates education ment, and any of more than 20 symptoms ranging from for all coaches and volunteers involved with interscholastic

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athletics; it requires immediate removal from play for sus- to the classroom. The American Academy of Pediatrics pected concussion, and written clearance for return to sports emphasizes the importance of this and provides strategies must be provided by a licensed physician (4). for a productive transition back into the academic setting After eliminating life-threatening injury and diagnosing following concussion (7). concussion, safely returning an athlete to sports is a critical piece of the management paradigm. Grading systems were popular in the diagnosis and management of sports-related NEUROPSYCHOLOGICAL TESTING concussion in the early 1990s (5). However, these systems Neuropsychological assessment first entered the scene in were flawed and have been abandoned as the focus shifted the late 1980s when it was discovered that sports-related from categorizing injury severity to making individual rec- concussion results in an acute decline in neurocognitive ommendations based on several factors. Although most function. Traditional paper and pencil testing was cumber- concussions will resolve within 7–10 days (6), recovery some and gave way to computerized neurocognitive testing can be unpredictable and some may take significantly lon- in the 1990s as a tool to more objectively evaluate concus- ger to improve. The return-to-play decision is complex and sion. Neuropsychological testing adds diagnostic value over requires a very individualized plan. It is well understood symptom reporting alone (8), and computerized neurocogni- that returning an athlete to sports assumes complete res- tive testing is now an important piece in the evaluation and olution of symptoms at rest and with physical activity, in management of concussion. Formal testing examines mem- addition to full recovery of cognitive function. Physical rest ory, attention, reaction time and other executive functions eliminates the risk of another head injury and allows recov- commonly affected by mild TBI. It allows for detection of ery, though the degree and duration of rest are debatable. subtle cognitive deficits, which can persist beyond symptom The widely used protocol published by the Concussion in resolution. It is most useful to have a baseline evaluation for Sport group is a consensus approach that outlines a progres- comparison following injury, but testing can be beneficial in sion of activity from light aerobic exercise to full contact the athlete without pre-injury data as well. Computerized activity (2). Introduction of exercise occurs once the athlete neurocognitive testing is inexpensive, widely available, and is asymptomatic, and each step identifies a 24-hour period has demonstrated reliability and validity (9). Nevertheless, with suggested activity (Table 2). Successful completion of it must be understood that such testing is only a single tool each step requires that symptoms are not exacerbated during in the comprehensive evaluation of concussion and should or after exertion. not stand alone or be considered mandatory.

Table 2. Graded Return to Play Protocol FEARED CONSEQUENCES Stage Activity Functional Exercise Objective Although the neurometabolic disturbances and 1 No activity Complete physical and cognitive rest Recovery symptoms of concussion are often short-lived, Low-intensity aerobic exercise 2 Light activity Increase heart rate there are acute and long-term consequences Walk, swim, stationary bike related to unrecognized or recurrent injury. A Simple sport-related exercise 3 Sport-specific Add movement very conservative approach to managing concus- Skating, running sion has evolved based on our knowledge of three Noncontact sport-related training drills Coordination and 4 Training major (and often controversial) clinical concerns: Resistance training cognitive load second impact syndrome, post-concussion syn- Full contact Restore confidence 5 Resume normal activity/practice drome, and chronic traumatic encephalopathy. practice & Assess function 6 Return to play Resume competitive game play Second Impact Syndrome Adapted from Consensus Statement on Concussion in Sport (2). The phenomenon of second impact syndrome, first popularized in the mid-1980s, remains a In addition to physical rest, cognitive rest is recommended frequently cited concern when returning athletes to play. It as a cornerstone of concussion management and is also refers to a second impact that occurs prior to recovery from consensus-based (2). Cognitive rest entails limiting activi- an initial concussive injury, leading to loss of cerebral auto- ties of attention and concentration, including schoolwork regulation, diffuse cerebral edema, and permanent neuro- and video games, which may exacerbate symptoms and logic disability or death. However, there is little evidence to delay recovery. It often involves varying levels of academic support its existence and it is, at most, an exceedingly rare accommodations (and sometimes removal from school) entity (10). Participation in contact and collision sports will in an effort to allow recovery and preserve school perfor- always present a risk for catastrophic head trauma, but the mance. Although guidelines for “returning to learn” lack reference to second impact syndrome as a reason for caution a strong evidence base, there is increasing attention to the is debatable. need for a student-athlete’s gradual and structured return

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Post-concussion Syndrome cognitive, and behavioral changes is not well established. Post-concussion syndrome (PCS) is another major concern Some research supports a decline in neurocognitive function and represents the most practical clinical challenge fol- with multiple concussions, but other studies have failed to lowing sports-related concussion. The definition of PCS in demonstrate cumulative adverse effects (14). Chronic trau- the medical literature is inconsistent, but it is generally matic encephalopathy (CTE) was first described in boxers as understood to be the persistence of cognitive, physical, or dementia pugilistica in the 1930s, referring to boxer’s demen- emotional symptoms well beyond the expected time frame tia. CTE is a neurodegenerative disease found in individu- for recovery (11). Post-concussion syndrome is considered als with a history of repetitive mild traumatic brain injury. when concussion symptoms last more than six to twelve It shares clinical similarities with Alzheimer’s dementia weeks following injury, and some experts argue that PCS and parkinsonism, but diagnosis is made only by distinct is the manifestation or unmasking of psychiatric illness changes on post-mortem neuropathologic examination. rather than the neurological injury itself. Severity of injury Although the risks of developing neurodegenerative dis- does not always correlate with symptoms, but a large symp- ease from boxing have been recognized for decades, research- tom burden might predict a prolonged course. Pre-existing ers and the media have more recently brought attention to migraine headaches and learning difficulties may also her- this risk in football following several high-profile cases and ald a lengthy recovery. There is evidence to suggest a period tragic deaths. CTE generally occurs later in life, long after of vulnerability following concussion, and repeated injury retirement from sports, and is characterized by an insid- during this period can exacerbate symptoms and complicate ious-onset of cognitive decline and behavioral changes. recovery (3). A protracted course following a second concus- Deterioration of mental health has also been highlighted as sion before complete recovery is perhaps more concerning a concern. Clinical diagnosis is complicated by the lack of than the unlikely second impact syndrome. standard criteria, the requirement for autopsy confirmation, Regardless of the underlying pathophysiology, a multidis- and confounders such as substance abuse. Additionally, the ciplinary and symptom-targeted approach is best for manag- exact relationship between sports-related concussion and ing PCS. Education of the athlete, family, coaching staff and CTE remains unclear (15). Risk factors within sport are others in the recovery process is universally important as largely unknown, including the significance of repetitive well. While there are various medical treatments available, subconcussive head trauma or even a single lifetime concus- evidence is limited, and many therapies remain anecdotal sion. Nonetheless, concerns about the cumulative effects or opinion-based. Pharmacologic therapy is directed toward of both concussive and subconcussive impacts are growing, alleviating symptoms but should not be expected to speed and certain thresholds may predict later-life depression and recovery and may cause cognitive or behavioral side effects. cognitive impairment (16). Examples include melatonin for sleep disturbance, amitrip- Based on the subacute and chronic consequences of con- tyline for headache, selective serotonin reuptake inhibitors cussion mentioned above, the question of retiring athletes for depression, and amantadine for cognitive impairment from contact or collision sports is frequently encountered (12). Unfortunately, because there is little supportive evi- in clinical practice. There are no specific data or criteria on dence for the use of medications for PCS in athletes, these which to base retirement decisions, and each decision is strategies should be considered only by experienced providers highly individualized. Despite a lack of strict guidelines, it is after failure of more conservative measures. generally understood that several variables will prompt this Rehabilitation techniques play an increasing role in the discussion: decreasing time intervals between concussions, management of prolonged concussion recovery. Cognitive relatively minor impacts causing or exacerbating symp- behavioral therapy may be helpful in managing emotional toms, and increasing symptom burden or duration with each and sleep disturbances, as well as other physical symptoms successive injury. such as posttraumatic headache. Neurocognitive rehabilitation may enhance memory, attention and general cognitive performance. Vestibular rehabilitation may help relieve diz- FUTURE DIRECTIONS ziness and improve gait and balance. It has been postulated Concussion will always be an inherent risk of contact and that prolonged rest may actually be detrimental to recovery. collision sports. Present and future efforts toward miti- Some experts advocate a supervised and controlled aerobic gating this risk are focused on prevention, diagnosis, and exercise rehabilitation program for athletes with symptoms improved understanding of long-term sequelae. Primary pre- lasting beyond three weeks. Gradual progression of exercise vention includes enforcement of existing rules and careful at a subsymptom threshold can aid in recovery (13). consideration of further rule changes. Equipment use and modification is important for injury prevention, but despite Chronic Traumatic Encephalopathy manufacturers’ claims, there is no conclusive scientific evi- The third major concern surrounding sports-related con- dence that protective equipment prevents or reduces risk of cussion involves the cumulative effects of repeated head concussion. Continued efforts toward educating the athletic trauma. The investigation into long-term neuropathologic, community about injury recognition and significance, and

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the importance of safe return to competition, is essential in References limiting adverse outcomes. 1. Langlois JA, Rutland-Brown W, Wald MM. The epidemiology Presently, sports-related concussion is a clinical diagnosis. and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil. 2006;21(5):375-8. Advances in areas like biomarker research and functional 2. McCrory P, Meeuwisse W, Aubry M, et al. Consensus state- magnetic resonance imaging may someday offer a more ment on concussion in sport: the 4th International Conference objective view of this injury. Development of other tech- on Concussion in Sport held in Zurich, November 2012. Clin J Sport Med. 2013;23(2):89-117. nologies, such as force-measuring accelerometers in foot- 3. Giza CG, Hovda DA. The neurometabolic cascade of concus- ball helmets, may also change our understanding of head sion. J Athl Train. 2001;36(3):228-35. trauma, as may further research into the roles of age, gender, 4. Chapter 16-91: School and Youth Programs Concussion Act. and genetic predisposition as risk factors for injury or long- Retrieved September 6, 2016, http://webserver.rilin.state.ri.us/ term complications. Statutes/TITLE16/16-91/INDEX.HTM 5. Collins MW, Lovell MR, McKeag DB. Current issues in managing sports-related concussion. JAMA. 1999;282(24):2283-5. 6. McCrea M, Guskiewicz KM, Marshall SW, et al. Acute effects and CONCLUSIONS recovery time following concussion in collegiate football play- Our knowledge of sports-related concussion has grown ers: the NCAA Concussion Study. JAMA. 2003;290(19):2556-63. exponentially in the past decade, but it is clear that we have 7. Halstead ME, McAvoy K, Devore CD, et al. Returning to learning following a concussion. Pediatrics. 2013;132(5):948-57. only scratched the surface. Dissemination of information by 8. Van Kampen DA, Lovell MR, Pardini JE, et al. The “value add- media outlets has outpaced our true scientific understand- ed” of neurocognitive testing after sports-related concussion. ing of concussion. This has been productive in educating Am J Sports Med. 2006;34(10):1630-5. the public about its significance, and education is integral 9. Johnson EW, Kegel NE, Collins MW. Neuropsychological assessment of sport-related concussion. Clin Sports Med. in mitigating risk. However, it has arguably created unsub- 2011;30(1):73-88. stantiated concern in the absence of sound evidence for poor 10. McCrory P, Davis G, Makdissi M. Second impact syndrome or long-term outcomes. The management of sports-related cerebral swelling after sporting head injury. Curr Sports Med concussion has evolved from grading systems to consen- Rep. 2012;11(1):21-3. 11. Jotwanu V, Harmon KG. Post-concussion syndrome in athletes. sus-based recommendations with a limited base of evidence. Curr Sports Med Rep. 2010;9(1):21-6. Currently, the standard for management incorporates a con- 12. Meehan WP 3rd. Medical therapies for concussion. Clin Sports servative, individualized approach guided by the principles Med. 2011;30(1):115-24. of physical and cognitive rest, though the role of strict or 13. Leddy JJ, Willer B. Use of graded exercise testing in concus- prolonged rest is being challenged. Complex cases often sion and return-to-activity management. Curr Sports Med Rep. 2013;12(6):370-6. require a multidisciplinary team consisting of primary care 14. Belanger HG, Spiegel E, Vanderploeg RD. Neuropsycholog- providers, sports medicine specialists, neurologists, men- ical performance following a history of multiple self-reported tal health professionals, neuropsychologists, and physical concussions: a meta-analysis. J Int Neuropsychol Soc. 2010; 16(2)262-7. therapists. 15. Stern RA, Riley DO, Daneshvar DH, et al. Long-term consequences of repetitive brain trauma: chronic traumatic encephalopathy. PM R. 2011:3(10 Suppl 2):S460-7. 16. Montenigro PH, Alosco ML, Martin B. Cumulative head impact exposure predicts later-life depression, apathy, executive dysfunction, and cognitive impairment in former high school and college football players [published online March 30, 2016]. J Neurotrauma. 2016.

Author Jeffrey P. Feden, MD, Associate Professor (Clinical), Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI.

Disclosures None

Correspondence Jeffrey P. Feden, MD Department of Emergency Medicine 593 Eddy Street, Claverick 2 Providence, Rhode Island 02903 401-444-5826 Fax 401-444-5166 [email protected]

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Diagnosis and Management of Meniscal Injury

JACOB BABU, MD, MHA; ROBERT M. SHALVOY, MD; STEVE B. BEHRENS, MD

27 30 EN ABSTRACT PRESENTATION Meniscal injury is a common cause for presentation to Knee pain can be the result of numerous possible intra- and the emergency department or primary care physician’s extra-articular diagnoses, all of which must be kept in the office. Meniscal injuries can be the result of a forceful, differential when evaluating a patient. Meniscal tears can twisting event in a young athlete’s knee or it can insid- be identified by asking a few focused questions during the iously present in the older patient. Many patients with patient evaluation. The mechanism of injury is important as meniscal pathology appropriately undergo conservative are the presence of specific symptoms after injury. management with a primary care physician while some Acute meniscal tears are most often associated with a may need referral to an orthopedist for operative inter- twisting mechanism to the knee while the foot is planted, vention. Arthroscopic surgery to address the menisci is providing an axial load. The joint swelling with a meniscus the most frequently performed procedure on the knee tear is more likely to present in a delayed fashion (> 24 hours). and one of the most regularly performed surgeries in or- Atraumatic, degenerative meniscal pathology more fre- thopedic surgery.1 The purpose of this paper is to help quently presents with an insidious onset of pain. This diag- elucidate the diagnosis and management of meniscal nosis can be difficult to distinguish from osteoarthritis in pathology resulting in knee pain. the older patient. Mechanical symptoms are relatively com- KEYWORDS: meniscal injury, knee pain, osteoarthritis, mon, with patients often describing the sensation of ‘lock- arthroscopy, orthopedic referral ing,’ ‘clicking,’ ‘popping,’ and sometimes even a feeling of ‘giving way’ of the knee. Symptoms tend to wax and wane with activity levels. On physical examination, joint line tenderness is often INTRODUCTION described as the most sensitive finding for diagnosing a The frequency in which meniscal tears occur makes it an meniscal tear; however, it is not very specific.7 Blocks to important injury to identify by the medical practitioner. active and passive range of motion, especially to deep flex- Acute, traumatic tears in the young patient and atraumatic, ion, are associated with more complex meniscal tears. A degenerative tears in the older patient represent a contin- few provocative examination maneuvers for meniscal pain uum of pathology, often presenting with their own diffi- include the Apley Compression, McMurray, Steinman and culties in diagnosis and management. The prevalence of Thessaly tests, demonstrated in Figures 1 and 2.7,8 The basic meniscal tears in the general population has been challeng- premise of these tests involves applying an axial force through ing to identify due to the high frequency of asymptomatic or the knee joint to simulate weight-bearing while providing undiagnosed lesions. In some Northern European countries, a rotational moment about the leg to try to elicit clicking, the estimated incidence of meniscal tears is 2 per 1000 per- popping or pain. Kocabey et al. evaluated the effectiveness son-years.2 A study by Englund et al., focusing on degenera- of various physical examination maneuvers in diagnosing tive tears, found that 35% of enrolled patients older than 50 meniscal pathology and found the combination of joint years old had imaging evidence of a meniscal tear, with ⅔ line tenderness, positive McMurray, Steinmann and Apley of these being asymptomatic.3 Risk factors associated with tests to have an 80% sensitivity for medial meniscal pathol- the development of a symptomatic meniscal tear have been ogy and a 92% sensitivity for lateral meniscal pathology.8 identified to be a BMI > 25 kg/m², male sex, and occupa- tions requiring kneeling, squatting or stair-climbing.2-4 A military study looking at more acute, traumatic meniscal ANATOMY tears estimated the incidence in active duty personnel to be The menisci are fibrocartilaginous structures which impor- 8.27 per 1000 person-years.5 In this study, age was found to tantly serve as load-sharing components of the knee joint. be a variable associated with elevated rates of injury, with By increasing the surface area of contact between the femur tears occurring 4 times as often in those over 40 compared to and tibia, they can significantly decrease contact stresses those less than 20 years of age.5 Arthroscopic meniscectomy experienced by articular cartilage. Menisci also function is estimated to occur 400,000-700,000 times annually.1,6 as secondary restraints to anterior/posterior translation of

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Figure 1. The Thessaly test consists of internal and external rotation of the Figure 2. The McMurray Test is performed with the patient in the supine body with the knee flexed at 5 and 20 degrees. The examiner can offer position. The examiner places one hand on the heel, which will provide assistance by holding the patient’s hands for stabilization. Reproduction internal and external rotation moments on the tibia. The other hand is free of symptoms/pain is a positive finding. to palpate the medial/lateral knee joint line and serve as a lever for val- gus/varus forces. Reproduction of pain or ‘clicking’ is considered positive.

the tibia with the primary restraint being provided by the test available, albeit with a high false positive rate. MRI is cruciate ligaments. The menisci are triangular in cross-sec- often not necessary when osteoarthritis is recognized on tion, and predominantly comprised of water, proteoglycans plain films or there is a high clinical suspicion for menis- and Type 1 collagen.6 The medial meniscus is c-shaped with cal pathology. On MRI, a linear hyperintensity that extends multiple capsular attachments including the medial collat- to the superior or inferior joint surface is diagnostic of a eral ligament, making it much less mobile than the lateral meniscal tear, most sensitively identified on T1 sagittal and meniscus which is more circular and devoid of ligamen- coronal slices.10 Parameniscal cysts visualized on MRI are tous constraint. This disparity in motion contributes to the most often seen in the presence of meniscal tears, so images frequency in which each meniscus is injured. The medial must be carefully scrutinized when cysts are present. A meniscus is injured much more often than the lateral menis- study performed by Zanetti et al. utilized MRI to evaluate cus, with the posterior horn being the most afflicted com- 100 patients that had unilateral symptoms consistent with ponent. The lateral meniscus is more commonly injured a meniscal tear.11 MRIs were performed on the symptom- in association with ACL tears. In ACL-deficient knees, the atic and asymptomatic contralateral knee. Meniscal tears menisci become increasingly important restraints to anterior were found in 57 of the symptomatic knees and 36 of the translation of the tibia, predisposing it to injury. The medial asymptomatic knees. 11 Symptoms correlated most with and lateral inferior genicular arteries provide blood supply radial, vertical and complex, displaced types of meniscal to the peripheral ¼ to ⅓ of the menisci, with the remaining tears.11 Another study showed that MRI had a sensitivity of central portion of the meniscus receiving its nutrition via 91.4 percent and specificity of 81.1 percent for identifying diffusion from the synovial fluid.6 The poor vascularity of medial meniscus tears and a sensitivity and specificity of 76 the central meniscus accounts for its very limited inherent and 93.3 percent, respectively, for identifying lateral-sided capacity to heal. The menisci have been found to have noci- tears.12 The management of meniscal tears is centered on ceptor/mechanoreceptor innervation at the peripheral ⅔ and the presence of symptoms; this study recognizes that a large at the anterior and posterior horns from histologic study.9 percentage of meniscal tears are asymptomatic.

IMAGING TEAR CONFIGURATION Plain radiographs of the knee provide little information Vertical or longitudinal tears in the sagittal plane, as seen about meniscal pathology. However, they are still valuable in Figure 3, are the most common type of meniscal tear initial tests and provide information about bony anatomy and can be repaired when present in the peripheral third and alignment. MRI is the most sensitive diagnostic imaging of the meniscus.6 Radial tears are tears that initiate in the

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central portion of the meniscus and propagate to the Figure 3. Meniscal tear patterns periphery; they are usually not repairable due to the Image Courtesy of Michaela Procaccini poor vascularity of this area of the meniscus. When these tears are symptomatic, a partial meniscectomy is indicated. Bucket-handle tears are vertical tears with displacement that can cause mechanical blocks to flexion/extension. Flap and parrot-beak tears are tears that initiate centrally and continue in a circumferential manner.6

MANAGEMENT Meniscal tears require treatment when pain is unmanageable or function is impaired. Some meniscal tears are managed successfully without operative intervention. This is typically consistent with small radial tears and stable, nondisplaced longitudinal tears. ACL-deficient knees with no plan for ACL reconstruction and degenerative tears in patients with osteoarthritis are usually not candidates for arthroscopic treatment.6 Several studies have shown good results from managing certain meniscal tears conservatively with a protocol of ice, NSAIDs, and physical therapy.13-16 Physical therapy for these injuries focuses on strengthening the muscles of the injured extremity, especially surrounding the knee, as well as maintaining range of motion of the knee and hip.17-18 Supervised therapy sessions emphasizing exercises such as quadri- ceps sets, hamstring curls, straight-leg raises, and heel raises have been shown to produce statistically significant improvements in knee pain and functional outcome scores.17-18 Patients should be encouraged to avoid deep-knee flexion activities that exacerbate their pain such as squatting and kneeling.17-18 Intra-articular steroid injections can be useful adjuncts to minimize inflammation and suppress symptoms in patients with osteoarthritis. Several studies have shown statistically significant, short-term improvement in pain following an intra-articular surgery for patients with symptoms consistent with a degen- steroid injection lasting 2–4 weeks or longer.13 erative medial meniscus tear without osteoarthritis.16 There Katz et al. performed a randomized controlled trial comparing were no significant differences in change from baseline to 12 arthroscopic meniscectomy to a standardized physical therapy months in any of the primary outcome scores, regardless of regimen in 351 patients 45 years and older with MRI-confirmed intervention.16 The effect of various biases, crossover from meniscal tear and osteoarthritis.14 This study showed no signif- treatment groups, and the external validity of these trials icant differences in magnitude of improvement in functional have recently brought some of these data into question.19 status evaluated by Western Ontario and McMaster Arthritis These studies demonstrate the difficulty practitioners have Index (WOMAC) as well as pain at 6 and 12 months after inter- deciphering whether knee pain is the result of osteoarthritis vention.14 Moseley et al. compared outcomes after randomiza- or a symptomatic meniscal injury, and subsequently deter- tion of 180 patients with osteoarthritis and meniscal tears to mining the appropriate management. However, they do an arthroscopic debridement, arthroscopic lavage, or placebo reinforce the importance of attempting conservative man- surgery group and reported no significant differences in the agement, especially for the older patient with a degenerative Knee-Specific Pain Scale at one- and two-year follow-up.15 Sih- tear. Some clues that can help identify the source of pain are vonen et al. evaluated outcomes after random assignment to the mechanism of injury, radiographic findings consistent either arthroscopic partial-meniscectomy or a sham-controlled with osteoarthritis, and patient demographics.

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Patients with large or complex tears, a traumatic mecha- 7. Fowler PJ, Lubliner JA. The predictive value of five clinical nism, or a large joint effusion are likely candidates for oper- signs in the evaluation of meniscal pathology. Arthroscopy, 1989;5:184-6. ative intervention. Severe pain with provocative maneuvers 8. Kocabey Y, Tetik O, Isbell W, Atay O, Johnson D. (2004). The such as the McMurray, Apley, and Steinman tests or any value of clinical examination versus magnetic resonance imag- patient with a locked knee are also likely surgical candi- ing in the diagnosis of meniscal tears and anterior cruciate liga- Arthroscopy 20 dates.6, 20 Patients with persistent symptoms after a period of ment rupture. , (7), 696-700 9. McMurray T. The semilunar cartilages. Br J Surg, 1942;29:407-14. conservative management should receive orthopedic consul- 10. Sanders T, Miller M. (2005). A Systematic Approach to Magnetic 6, tation for either arthroscopy or arthroplasty as appropriate. Resonance Imaging Interpretation of Sports Medicine Injuries of 20 Operative options include partial meniscectomy, total the Knee. Am J Sports Med, 33(1), 131-148. meniscectomy, meniscal repair, and meniscal transplanta- 11. Zanetti M, Pfirrmann C, Schmid M, Romero J, Seifert B, Hodler J. (2003). Patients with suspected meniscal tears: Prevalence of tion. A partial meniscectomy is by far the most common abnormalities seen on MRI of 100 symptomatic and 100 con- procedure preferred for centrally located radial tears, com- tralateral asymptomatic knees. AJR Am J Roentgenol, 181(3), plex tears away from the periphery, and degenerative tears.20 635-641 Peripheral tears that have good vascularity and subse- 12. Crawford R, Walley G, Bridgman S, Maffulli N. (2007). Magnetic resonance imaging versus arthroscopy in the diagnosis of knee quently a greater likelihood of healing are often better pathology, concentrating on meniscal lesions and ACL tears: A targeted by meniscal repair procedures. 6, 20 This includes systematic review. British Medical Bulletin. longitudinal tears located peripherally, especially in young 13. Bellamy N, Campbell J, Robinson V, Gee T, Bourne R, Wells patients, and tears associated with ACL injury when repaired G. (2006). Intraarticular corticosteroid for treatment of osteoarthritis of the knee. Cochrane Database Syst Rev, (2), CD005328 20 concomitantly. 14. Katz J, Brophy R, Chaisson C, Chaves L, Cole B, Dahm D, Don- Total meniscectomies are rarely performed considering nell-Fink L, et al. (2013). Surgery versus physical therapy for a the implication of increased stresses experienced by artic- meniscal tear and osteoarthritis. N Engl J Med, 368(18), 1675-84. ular cartilage as well as early degenerative changes.6 Menis- 15. Moseley J, OʼMalley K, Petersen N, Menke T, Brody B, Kuyken- dall D, Hollingsworth J, et al. (2002). A Controlled Trial of Ar- cal transplantation is usually considered after partial or throscopic Surgery for Osteoarthritis of the Knee. N Engl J Med, total meniscectomy with persistent symptoms in younger 347(2):81-8 patients that have reached skeletal maturity without 16. Sihvonen R, Paavola M, Malmivaara A, Itälä A, Joukainen A, arthritic changes of the knee. Nurmi H, Kalske J, et al. (2013). Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med, 369(26), 2515-24. 17. Stensrud S. (2012). A 12-Week Exercise Therapy Program in Mid- CONCLUSION dle-Aged Patients With Degenerative Meniscus Tears: A Case Series With 1 Year Follow Up. J Orthop Sports Phys Ther, 42(11), Meniscal injury is one of the more common musculoskeletal 919-931. conditions and a frequent cause of knee pain. It is important 18. Yim J, Seon J, Song E, Choi J, Kim M, Lee K, Seo H. (2013). A for physicians to recognize meniscal pathology as a source of comparative study of meniscectomy and nonoperative treat- knee pain and not solely an MRI finding. Painful tears can be ment for degenerative horizontal tears of the medial meniscus. Am J Sports Medicine, 41:1565–1570. managed conservatively in certain circumstances as well as 19. Ha A, Shalvoy R, Voisinet A, Racine J, Aaron R. (2016). Con- surgically with success. troversial Role of Arthroscopic Meniscectomy of the Knee: A Review. WJO, 7(5):287-92. 20. Mordecai S, Al-Hadithy N, Ware H, Gupte C. (2014). Treatment References of meniscal tears: An evidence based approach. WJO, 5(3), 233-41. 1. Kim S, Bosque J, Meehan J. P, Jamali A, Marder R. (2011). In- crease in outpatient knee arthroscopy in the United States: a Authors comparison of National Surveys of Ambulatory Surgery, 1996 Jacob Babu, MD, MHA, Resident, Department of Orthopaedics, and 2006. The JBJS. American volume, 93(11), 994-1000. Alpert Medical School of Brown University, Providence, RI. 2. Bhattacharyya T, Gale D, Dewire P, Totterman S, Gale M. E, Mc- Robert M. Shalvoy, MD, Executive Chief of Orthopedic Surgery & Laughlin S, Einhorn T, et al. (2003). The clinical importance of Sports Medicine, Care New England Health System, Assistant meniscal tears demonstrated by magnetic resonance imaging in osteoarthritis of the knee. The JBJS. American volume, 85-A, 4-9. Professor of Orthopedic Surgery, Alpert Medical School of Brown University, Providence, RI. 3. Englund M, Guermazi A, Gale D, Hunter D.J, Aliabadi P, Clan- cy M, Felson D. (2008). Incidental meniscal findings on knee Steve B. Behrens, MD, Attending Orthopedic Surgeon, Care New MRI in middle-aged and elderly persons. N Engl J Med, 359(11), England Health System, Providence, RI. 1108-1115. 4. Snoeker B, Bakker E, Kegel C, Lucas C. (2013). Risk factors for Correspondence meniscal tears: a systematic review including meta-analysis. J Jacob Babu, MD Orthop Sports Phys Ther, 43(6), 352-67. Department of Orthopaedics 5. Jones J.C, Burks R, Owens B, Sturdivant R, Svoboda S, Cameron Rhode Island Hospital K. (2012). Incidence and risk factors associated with meniscal 593 Eddy Street injuries among active-duty US Military service members. J Athl Train, 47(1), 67-73. Providence, RI 02903 6. Boyer M. (2014). AAOS Comprehensive Orthopedic Review. 401-444-4030 Rosemont, IL: American Academy of Orthopedic Surgeons, 2, [email protected] 1397-1402.

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Understanding Athletic Pubalgia: A Review

BRIAN COHEN, MD; DOMINIC KLEINHENZ, MD; JONATHAN SCHILLER, MD; RAMIN TABADDOR, MD

31 35 EN ABSTRACT longus which are confluent and form a sheath anterior to Athletic Pubalgia, more commonly known as sports the pubis. The confluence of the rectus abdominus, the con- hernia, is defined as chronic lower abdominal and groin joint tendon (formed by the internal oblique and transversus pain without the presence of a true hernia. It is increas- abdominus) and external oblique form the pubic aponeu- ingly recognized in athletes as a source of groin pain and rosis, which is also confluent with the adductor and graci- is often associated with other pathology. A comprehen- lis. The rectus abdominus flexes the trunk, compresses the sive approach to the physical exam and a strong under- abdominal viscera, and stabilizes the pelvis for motion at standing of hip and pelvic anatomy are critical in making the hip while the adductors stabilize the anterior pelvis. the appropriate diagnosis. Various management options During athletics, a large amount of force occurs at the ante- are available. We review the basic anatomy, patholophys- rior pelvis in which the pubic symphysis is its center. The iology, diagnostic approach and treatment of athletic opposing forces of the adductor longus directly against the pubalgia as well as discuss associated conditions such as rectus abdominus at the pubic symphysis fulcrum point are femoroacetabular impingement. thought to be implicated as the origin mechanism of ath- KEYWORDS: athletic pubalgia, groin pain, sports hernia, letic pubalgia. Therefore, when the rectus is weakened, the impingement adductor longus pulls in an unopposed fashion. Typically this is from chronic or acute intense muscle contractions by the athlete while hyperextending and/or twisting the trunk. The inequality of forces acting on the anterior pelvis leads to tearing at the inser- INTRODUCTION tion point of the rectus Hip and groin pain has long been a diagnostic dilemma in abdominus. (Figure 1) athletes given the complexity of the anatomy and the mul- Athletic pubalgia is tiple sources of pathology. Athletic pubalgia is increasingly more common in males identified as a source of pain in athletes as it is becoming due to a narrower pel- more recognized and better understood. Originally termed vis that cause greater “Gilmore’s groin” over 40 years ago, it has also been known shifts in force and as sportsmen’s hernia, groin disruption injury, sports hernia less stability than the and, most recently, core muscle injury (CMI).1,2,3,4 The evo- wider female pelvis.7 lution from “hernia” to CMI/athletic pubalgia stems from our developed understanding that there is no true hernia Figure 1. Pathoanatomy of or deficiency from the posterior wall of the inguinal canal Athletic Pubalgia 7 but rather an injury to the various structures that com- The rectus abdominus and prise the pubic aponeurosis.4,5,6 Athletic pubalgia can occur adductor longus muscles pull in isolation but often occurs in the setting of other hip and in the opposite direction. pelvic pathology which can make its diagnosis challenging. With injury to the rectus an Although this is much more common in athletes, it can be imbalance in muscle forces seen in non-athletes and is referred to simply as pubalgia in occurs causing groin pain. this population.

PATIENT HISTORY ANATOMY AND PATHOPHYSIOLOGY Chronic lower abdominal and groin pain is increasingly more The pubic symphysis is believed to act as a fulcrum for recognized in high-level athletes. Forces across the pelvis the anterior pelvis and, according to Meyers, a majority of increase as muscle strength increases, which may explain pathology stems from this fulcrum point.7 It is a common why athletes are commonly affected. Activities that can attachment site for the rectus abdominus and adductor lead to athletic pubalgia involve running, kicking, cutting

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and twisting movements, and explosive Table 1. Examination for Groin and Hip turns and changes in direction. In the United Athletic Pubalgia Test Maneuver Interpretation States, soccer, ice hockey, and American football players are most commonly affected.1,8,9 Resisted Sit up Patient supine, stabilizes the A positive test is when the patient’s feet. Arms straight ahead pain at rectus insertion is Athletes usually present with the com- and sit up is performed. Hold for 5 reproduced plaint of exercise-related unilateral lower seconds. . abdomen and anterior groin pain that may Single or Bilateral Patient supine, flex leg to 30°. A positive test is when this radiate to the perineum, inner thigh, and Resisted Leg Places hands on the medial aspect reproduces the patient’s scrotum. Pain is mostly relieved with rest. Adduction of the patient’s heel and instructs pain However, even with resolution of symp- the patient to resist abduction . toms after a period of rest, the pain often This can be done with isolated returns with return to play. Pain can occur leg or simultaneously with contralateral leg gradually, but 71% of athletes will relate the recurrence to a specific event.1,9 This event Hip Test Maneuver Interpretation can include trunk hyperextension and/or hip FADIR (Flexion, Patient supine, raises leg with hip Positive if pain, suggest hyperabduction leading to increased tension Adduction, Internal flexed to 90 degrees and knee femoral acetabular in the pubic region. Kachingwe and Grech Rotation) flexed to 90 degrees, adduct and impingement, labral tear explained 5 signs and symptoms that they internally rotates the hip felt encompassed athletic pubalgia: “(1) a FABER (Flexion, Patient supine, flexknee to 90 Positive if pain, suggest subjective complaint of deep groin/lower Abduction, external degrees, foot placed on opposite sacroiliac disorder is pain abdominal pain, (2) pain that is exacerbated rotation) (also know knee places one hand on opposite posterior, if pain in groin as Patrick test) iliac crest to stabilizes pelvis suggest femoral acetabular with sport-specific activities such as sprint- against table, other hand placed impingement, labral tear, ing, kicking, cutting, and/or sit-ups and is on knee and externally rotates hip iliopsoas tendinits relieved with rest, (3) palpable tenderness Scour Patient supine , passively flex Positive is pain/catching/ over the pubic ramus at the insertion of the and adducts the hip and places clicking must note where rectus abdominus and/or conjoined tendon, the knee in full flexion, then in motion the symptom (4) pain with resisted hip adduction at 0, 45 downward force along the shaft occur, suggest hip labrum, and/or 90 degrees of hip flexion, and (5) pain of the femur is applied while capsulitis, osteochondral with resisted abdominal curl-up.” 9 passively adducting/abducting defects, acetabular defects, and externally/internally rotating osteoarthritis, avascular the hip necrosisand femoral acetabular impingment PHYSICAL EXAM syndrome One should start palpation laterally at the DEXRIT (Dynamic Patient supine with contralateral Positive if pain, suggest inguinal ligament and work centrally to the External Rotatory hip flexed 90 degrees, affected femoral acetabular pubic tubercle. It is important to include the Impingement Test) hip flexed and brought through a impingement, labral tear pubic symphysis as osteitis pubis can often wide arc of external rotation and be present with athletic pubalgia. Exam find- abduction, and extension ings include tenderness at or just above the DIRIT (Dynamic Patient supine with the Positive if pain, suggest pubic tubercle near the rectus insertion or Internal Rotatory contralateral hip flexed 90 femoral acetabular hip adductor origin on the affected side. Pain Impingement Test) degrees, affected hip flexed and impingement, labral tear brought through a wide arc of can also be elicited with resisted sit-up and internal rotation and hip flexion. There is no a bulge at the exter- adduction, and extension nal inguinal ring, or palpable true hernia. Valsalva maneuvers can occasionally repro- duce symptoms. One should evaluate the adductor longus findings of intra and extra-articular pathology that can coex- as a source of isolated pain by resisted leg adduction in both ist with athletic pubalgia. (Table 1) flexion and extension. This can also exacerbate the rectus abdominus symptoms. Adductor tenderness can be found in as many as 36% of athletes with athletic pubalgia.1 A sen- FEMOROACETABULAR IMPINGEMENT (FAI) sory exam should be performed as sensory disturbances and AND OTHER ASSOCIATED CONDITIONS dysethesias in the lower abdomen, inguinal region, antero- Many disorders around the hip and pelvis can coexist with medial thigh, and genitals can be present with occasional athletic pubalgia making diagnosis difficult. These include entrapment of the iliohypogastric, ilioinguinal, and geni- acetabular labral tears, adductor injuries, snapping hip syn- tofemoral nerves.19 Both hips must be examined for range dromes, iliopsoas tendonitis, osteitis pubis, and femoroace- of motion and provocative maneuvers to rule out isolated tabular impingement. (Figure 2) One must rule out a true

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Figure 2. Demonstration of a Pincer and Cam lesion that attach to them predisposing patients to athletic pubalgia.14 Therefore, treatment of FAI may normalize hip motion which can restore core and pelvic mechanics.15 Multiple studies have shown that the treatment of athletic pubalgia alone may lead to poorer results and inability to return to play. Larson showed that pubalgia surgery alone allowed only 25% of patients to return to the previous level of sport, whereas arthroscopic treatment of FAI alone resulted in a 50% return to the previous level. However, when both conditions were surgically treated, 89% returned to sports.13 Hammound reported similar findings with no patients returning to sport after athletic pubalgia surgery alone.15 Proximal adductor tendonopathy is often associated with athletic pubalgia and FAI. One study showed that 94% of (Reproduced with permission from the American Academy of Orthopedic Surgeons) athletes with adductor-related pain had radiographic signs of FAI.10 Patients may also develop osteitis pubis, a stress injury Figure 3. Common X-ray findings Associated with Athletic Pubalgia to the perisymphyseal pubic bones secondary to increased Anteroposterior pelvic radiograph in a collegiate hockey player with clin- strain on the anterior pelvis, and internal snapping hip syn- ical examination consistent with intra-articular hip and athletic pubalgia drome, an iliopsoas tendinitis resulting from irritation of a symptoms reveals bilateral cam type de-formities (solid arrow), acetab- tight iliopsoas tendon snapping over the iliopectineal emi- ular retroversion (dashed curved line), and osteitis pubis (dashed arrow). nence as the hip moves from flexion to extension.1 Intra- articular hip pathology that may produce similar symptoms to athletic pubalgia include synovitis, loose bodies, osteoarthritis, avascular necrosis and torn acetabular labrum.

DIAGNOSTIC IMAGING AND DIAGNOSTIC INJECTIONS Radiographic evaluation includes a standing anteroposterior (AP) pelvis and lateral hip radiographs. One should look for intra-articular disorders including FAI, arthritis, loose bodies and acetabular dysplasia. Extra-articular pathology that may be visible on radiographs includes osteitis pubis, acute or chronic pelvic avulsion fractures/apophyseal injuries and fractures. Magnetic resonance imaging (MRI) of the pelvis is important to obtain for suspicion of athletic pubalgia and

Reprinted with permission from SAGE Publications, Thousands Oaks, CA. All other already discussed pathology, although a dedicated hip permission requests for this image shoulder be made to copyright holder. MR arthrogram should be performed if there is specific concern for hip pathology such as FAI and labral tears. Concern groin hernia, genitourinary and gynecological disorders, and for athletic pubalgia should be specified in the history. Tears intra-abdominal sources of pain that can mimic athletic of the rectus abdominus on MRI are uncommon. When a pubalgia symptoms. tear is seen, it is essentially pathognomonic for athletic pub- Recent literature has suggested a strong relationship algia. Zoga found MRI to be 68% sensitive and 100% spe- between athletic pubalgia and FAI. Addressing one or the cific for rectus abdominus pathology when compared with other independently may not resolve symptoms completely. findings at surgery. Rectus disruptions are seen as a cleft Femoroacetabular impingement is defined as an abnormal sign with increased signal on T2-weighted images at the rec- contact between the femoral neck and the acetabular rim tus abdominus/adductor aponeurosis. (Figure 4) Also, MRI is during terminal motion of the hip due to excessive bone 86% sensitive and 89% specific for adductor pathology and on the acetabular rim, the femoral neck or both. 12 (Figure 100% sensitive for osteitis pubis.16 2 and 3) Limited range of motion associated with FAI can Diagnostic intra- and extra-articular injections of local lead to compensatory patterns of movement around the pel- anesthetic and/or corticosteroid can be helpful to make vis and trunk.13 In a cadaveric study, Birmingham showed a diagnosis. This can be done either fluoroscopically or that cam morphology restricts hip motion and results in ultrasound guided. Injection of the hip joint followed by increased stress and motion on the pubic symphysis. This provocative maneuvers can be used to distinguish hip causes excessive strain at these joints and on the muscles from pelvic pain. Continued pain in the lower abdominal/

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Figure 4. MRI of Pelvis adductor regions, despite an intra-articular injection, can Magnetic resonance imaging of the hip and pelvis in 22-year-old help diagnose athletic pubalgia. Pubic symphysis injections Division 1 football player with left sided lower abdominal and proximal can be performed when osteitis pubis is suspected. Pubic adductor related pain reveals a disruption of the distal rectus abdomi- cleft and psoas bursal injections can also be performed for nus/adductor aponeurosis on the left (solid arrow). adductor and psoas-related pain, respectively.

CONSERVATIVE TREATMENT Rehabilitation with physical therapy is first-line treatment for most patients with athletic pubalgia. However, treatment should be individualized based on the level of the athlete, the length of time before the athlete is expected to return to play, and timing of sport season. (Figure 5) Physical therapy should include core strengthening and stabilization, resto- ration of pelvic tilt and postural training. Increasing range- of-motion of the hip should be done with caution in patients with underlying hip pathology/FAI as changes in the pelvic motion may increase the patient’s symptoms. Generally, conservative treatment should be attempted for 3 months before considering surgery. In-season athletes can trial a 4-week period of rest. Pharmacological treatments include nonsteroidal anti-inflammatories and oral steroid taper. Injections include selective corticosteroid or platelet-rich plasma injections into the rectus abdominus and/or adductor longus origin. After this rest period, return to sport can be trialed. If pain continues, it is up to the athlete whether or not to return to play. Return to play is not believed to 17 Reprinted with permission from SAGE Publications, Thousands Oaks, CA. All per- worsen the tear or the surgical results of repair. Paajanen mission requests for this image shoulder be made to copyright holder. compared nonsurgical treatment consisting of physical therapy and corticosteroid injec- Figure 5. Algorthrim for Treatment of Athletic Pubalgia tions with surgical treatment for athletes with chronic groin pain. Twenty-three percent of patients in the nonsurgical group crossed over into the surgical arm due to continued pain. Only 50% of the nonsurgical patients returned to sport at 1-year. At 1-year follow-up, 97% of patients in the surgical group were pain free and returned to full sport.18

SURGICAL TREATMENT If the athlete has continued pain despite a trial of nonsurgical management, surgery may be warranted. Athletes should be referred for evaluation to an orthopedic or general surgeon who is familiar with the recognition, treatment and management of athletic pubalgia. Multiple operations and

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techniques including laparoscopic and open procedures exist 6. Malycha P, Lovell G. Inguinal surgery in athletes with chron- which make it difficult to compare outcomes. Most tech- ic groin pain: the “sportsman’s” hernia. Aust N Z J Surg. 1992 Feb;62(2):123–5. niques have satisfactory results reported in the literature. 7. Meyers W, Greenleaf R, Saad A. Anatomic basis for evaluation Principles of operative management include reinforcement of abdominal and groin pain in athletes. Oper Tech Sports Med. of the posterior wall and fixation of the rectus abdominus or 2005 Jan;13(1):55–61. conjoint tendon. Most also recommend adductor tenotomy 8. Nam A, Brody F. Management and therapy for sports hernia. J when adductor pain and dysfunction is present. Femoroac- Am Coll Surg. 2008 Jan;206(1):154–64. etabular surgery should also be considered accordingly if 9. Kachingwe A, Grech S. Proposed algorithm for the management of athletes with athletic pubalgia (sports hernia): a case series. J recognized as a contributing issue, as previously discussed. Orthop Sports Phys Ther. 2008 Dec;38(12):768–81. A full return to sport is expected at about 6–8 weeks if an 10. Weir A, de Vos R, Moen M, Hölmich P, Tol J. Prevalence of ra- isolated athletic pubalgia repair is performed and 4 months diological signs of femoroacetabular impingement in patients 17 presenting with long-standing adductor-related groin pain. Br J if FAI surgery is concomitantly done. Sports Med. 2011 Jan;45(1):6–9. 11. Meyers W, Lanfranco A, Castellanos A. Surgical management of chronic lower abdominal and groin pain in high-performance SUMMARY athletes. Curr Sports Med Rep. 2002 Oct;1(5):301–5. Though referred to as many names in the literature, chronic 12. Beck M, Kalhor M, Leunig M, Ganz R. Hip morphology influences the pattern of damage to the acetabular cartilage: femoro- lower abdominal and groin pain without a true hernia is acetabular impingement as a cause of early osteoarthritis of the known as athletic pubalgia. It is most commonly seen in hip. J Bone Joint Surg Br. 2005 Jul;87(7):1012–8. male athletes. The pathophysiology is based on weakening 13. Larson C, Pierce B, Giveans M. Treatment of athletes with symptomatic intra-articular hip pathology and athletic pub- or tearing of the lower abdominal or adductor muscles and algia/sports hernia: a case series. Arthrosc J Arthrosc Relat their opposing forces on the pubic bone. Symptoms include Surg Off Publ Arthrosc Assoc N Am Int Arthrosc Assoc. 2011 exercise-related unilateral lower abdominal and anterior Jun;27(6):768–75. groin pain that is relieved with rest. Examination shows 14. Birmingham P, Kelly B, Jacobs R, McGrady L, Wang M. The effect of dynamic femoroacetabular impingement on pubic tenderness at or just above the pubic tubercle near the rec- symphysis motion: a cadaveric study. Am J Sports Med. 2012 tus insertion and pain with a resisted sit-up. Intra-articular May;40(5):1113–8. hip, genitourinary, and intra-abdominal pathology, as well as 15. Hammoud S, Bedi A, Magennis E, Meyers W, Kelly B. High in- gynecological sources of pain in women, must be ruled out. cidence of athletic pubalgia symptoms in professional athletes with symptomatic femoroacetabular impingement. Arthrosc J FAI has been shown to be associated with athletic pubalgia Arthrosc Relat Surg Off Publ Arthrosc Assoc N Am Int Arthrosc and addressing both pathologies may be necessary for com- Assoc. 2012 Oct;28(10):1388–95. plete relief. Plain radiographs, pelvic MRI, and diagnostic 16. Zoga A, Kavanagh E, Omar I, Morrison W, Koulouris G, Lopez H, et al. Athletic pubalgia and the “sports hernia”: MR imaging injection should used to help make a diagnosis. Conserva- findings.Radiology. 2008 Jun;247(3):797–807. tive treatment is the mainstay and physical therapy should 17. Litwin D, Sneider E, McEnaney P, Busconi B. Athletic Pubalgia be tried prior to any surgery. However, the timing and length (Sports Hernia). Clin Sports Med. 2011 Apr;30(2):417–34. of therapy should be individualized to the athlete. With fail- 18. Paajanen H, Brinck T, Hermunen H, Airo I. Laparoscopic sur- ure of conservative treatment, referral to a specialist should gery for chronic groin pain in athletes is more effective than nonoperative treatment: a randomized clinical trial with mag- be made for repair. Results of surgical treatment allow most netic resonance imaging of 60 patients with sportsman’s hernia athletes to return to play at 6 weeks. (athletic pubalgia). Surgery. 2011 Jul;150(1):99–107. 19. Larson C. Sports hernia/athletic pubalgia: evaluation and management. Sports Health. 2014 Mar;6(2):139–44.

Authors References Brian Cohen, MD, Department of Orthopedics, The Warren Alpert 1. Meyers C, Foley D, Garrett W, Lohnes J, Mandlebaum B. Man- Medical School of Brown University. agement of severe lower abdominal or inguinal pain in high-performance athletes. PAIN (Performing Athletes with Abdominal Dominic Kleinhenz, MD, Department of Orthopedics, The Warren or Inguinal Neuromuscular Pain Study Group). Am J Sports Alpert Medical School of Brown University. Med. 2000 Feb;28(1):2–8. Jonathan Schiller, MD, Department of Orthopedics, The Warren 2. Gilmore J. Groin pain in the soccer athlete: fact, fiction, and Alpert Medical School of Brown University. treatment. Clin Sports Med. 1998 Oct;17(4):787–793, vii. Ramin Tabaddor, MD, Ortho Rhode Island, 1567 South County 3. Garvey J, Hazard H. Sports hernia or groin disruption injury? Trail, East Greenwich, RI 02818. Chronic athletic groin pain: a retrospective study of 100 patients with long-term follow-up. Hernia J Hernias Abdom Wall Surg. Correspondence 2014;18(6):815–23. Brian Cohen, MD 4. Taylor D, Meyers W, Moylan J, Lohnes J, Bassett F, Garrett W. Department of Orthopedics Abdominal musculature abnormalities as a cause of groin pain Rhode Island Hospital in athletes. Inguinal hernias and pubalgia. Am J Sports Med. 1991 Jun;19(3):239–42. 593 Eddy Street 5. Polglase A, Frydman G, Farmer K. Inguinal surgery for debil- Providence, RI 02903 itating chronic groin pain in athletes. Med J Aust. 1991 Nov [email protected] 18;155(10):674–7.

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The Decline of the Autopsy in Rhode Island and Nationwide: Past Trends and Future Directions

ALEX BAUMGARTNER, MD; DOUGLAS ANTHONY MD, PhD

36 38 EN ABSTRACT cavities. Medical, or hospital, autopsies are usually per- The autopsy has long been a fundamental aspect of formed at the request of a physician or family member of the medical practice and research. However, in the last 50 deceased in order to answer a specific clinical question or as years, the proportion of deaths for which an autopsy is part of a research effort to investigate new diagnostic or ther- performed has decreased dramatically. Here we examine apeutic interventions. In addition, medical autopsies often some of the reasons for the decline of the autopsy, as well have the added benefit of providing a sense of closure to fam- as several interventions that have been proposed to re- ily members, and also identifying any hereditary factors that 3 vive it. We also present autopsy utilization data from the could have consequences for relatives of the patient. These 1 Lifespan system, which mirrors nationwide trends. autopsies require the informed consent of legal next of kin. On the other hand, forensic autopsies are performed in KEYWORDS: autopsy, pathology, medical education cases of death suspected to be due to injury, poisoning/ intoxication, or unexpected natural death. They are often more focused in nature, and include detailed documentation of injuries, quantification of substances within the body, INTRODUCTION determination of the ultimate cause of death, or other inves- The importance of the autopsy, or post-mortem examina- tigations as required by the criminal justice system. These tion, to the practice of medicine is difficult to overstate. In autopsies are requested by the coroner or medical examiner, the clinical setting, autopsy provides information to provid- and do not require the consent of legal next of kin.1 ers, researchers, and students that cannot be gleaned from living patients. In the forensic setting, it continues to play a THE DECLINE OF THE AUTOPSY critical role in medico-legal cases. However, in the past sev- In the years following World War II, nearly 50% of US hospital eral decades, the autopsy rate in US hospitals has declined deaths underwent an autopsy.2,4 Since then, the autopsy rate precipitously. Many have voiced their opinion about ‘the in the US and other western nations has steadily declined. death of the autopsy’, and the detriment thereof to clini- In 1971, the Joint Commission on Accreditation of Hospi- cians, particularly to the pathologists who perform them. tals eliminated the performance of a minimum number of Still others have offered suggestions for the revival of the autopsies as a requirement for accreditation, which fueled autopsy as well as its transformation to a more modern, less a further decline in the autopsy rate.1 Today, the autopsy invasive, and timelier procedure. Here we provide commen- rate in academic hospitals hovers around 10%, while many tary on the past, present, and future of the autopsy, as well as non-teaching hospitals no longer perform any autopsies.1,5 data from the Lifespan system about recent autopsy trends. Furthermore, the leading indications for autopsy and the We argue that the autopsy remains a critical aspect of mod- ages of those autopsied have changed significantly. The ern medicine, and should remain a part of the training of the proportion of autopsies performed for deaths from disease next generation of physicians. decreased from 16.9% in 1972 to 4.3% in 2007, while the proportion of autopsies performed for deaths from external WHAT IS AN AUTOPSY? causes increased from 43.6% to 55.4% during the same time Autopsy has its roots as far back as 5000 years ago in ancient period.6 Of the ten most common causes of death autopsied Greece, Babylonia, and Egypt. In fact, the word autopsy in 2007, all but one (pregnancy, childbirth, and puerperium) comes from the Greek roots autos (meaning self) and optos were related to external causes.6 Elderly patients are now (meaning sight). Thus an autopsy, literally translated, is an much less likely to undergo autopsy: in 1972, 37% of those opportunity to see for oneself.1 The modern autopsy orig- autopsied were aged 64 or greater, that figure decreased to inated when Renaissance physicians such as Vesalius and 17% in 2007.6 Morgnani began to more reliably correlate autopsy findings Data from the Lifespan system mirror nationwide statis- with clinical disease processes, and it is Virchow who is cred- tics. Approximately 90% of autopsies performed within the ited with integrating the use of the microscope into com- Lifespan system take place at Rhode Island Hospital, with mon autopsy practice.2 Today, the full autopsy includes a the remainder occurring at The Miriam Hospital. Only detailed external examination, as well as full dissection and rarely are autopsies performed at Newport Hospital (usually investigation of the cranial, thoracic, abdominal, and pelvic one or two cases per year). For the years 2012 through 2014,

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Figure 1. Autopsy rates in the Lifespan hospital system. critical to acquitting the physician.9 Autopsy rate, shown as the percentage of total deaths for which an au- There remains the belief that family members are increas- topsy was performed, for the Lifespan system, Rhode Island Hospital, and ingly opposed to autopsy. It is important to note that The Miriam Hospital from the years 2012 through 2014. The data for the patients cannot legally give consent for an autopsy before Lifespan system represent the summation of data from RIH and TMH; their death. It is not uncommon for a patient to express a Newport Hospital is not included in this analysis. Notably, the autopsy desire to undergo autopsy, only to have the next of kin refuse rate at RIH actually increased in 2014 compared with previous years; it is consent once the patient is deceased. The reasons for this are unclear if this represents a new trend or a normal variation. numerous. Common motives for family members’ refusal of autopsy include concerns about mutilation, concerns about delaying the funeral, objections expressed by the patient before death, and religious or cultural beliefs.10 Unfortu- nately, these concerns are often not properly dispelled by clinicians. Shortcomings in the obtaining of consent for autopsy include: consents being performed by inadequately trained staff, use of outdated forms, failure to provide suf- ficient information, and consent being obtained from the incorrect family member.11 One study found that among family members of recently deceased patients, only 42% demonstrated satisfactory knowledge of what the autopsy entails.10 Logistical issues often present another barrier to autopsy. For instance, clinicians or other personnel are sometimes not available at the proper time to sign consent forms, which can delay or prevent the autopsy. approximately 10% of deaths at RIH and 5% of deaths at TMH The financial burden of the autopsy must also be con- underwent autopsy, resulting in an overall autopsy rate around sidered. Although performing an autopsy comes at a mean 8%. Autopsy rates from these years are shown in Figure 1. cost of $1,275, this cost is rarely covered by managed care organizations or third-party insurers.12,13 Thus, the cost is DISCUSSION frequently passed on to the patient’s next of kin, at times Over the years, several reasons have been offered for the making it prohibitive to perform the autopsy. Poor reim- decline in autopsy rate. Often first among them is the belief bursement rates are also to blame for pathologists’ decreased that advances in ante-mortem diagnosis have made autopsy enthusiasm to perform autopsies. Payments for some com- unnecessary. However, several studies have shown this to ponents of the autopsy are made to hospitals through Medi- be an invalid assumption. The most robust of these was a care Part A; however, there is no specific reimbursement 2003 review of 53 autopsy series from 1966 to 2002, which figure for autopsies under the Medicare resourced-based examined both major missed diagnoses (those relating to relative value scale fee schedule.13 Deaths occurring outside the cause of death) and class I errors (defined as major errors the hospital present another level of complexity, in that that, had they been detected during life, would or could have transportation must be arranged and other additional costs affected patient prognosis or outcome). They concluded that are incurred by the next of kin. Although data are sparsely the rate of major missed diagnoses decreased at a rate of available, the autopsy rate for out-of-hospital deaths is far 19.4% per decade, while the rate of class I errors decreased at lower than that for in-hospital deaths. a rate of 33.4% per decade. However, they estimated that a Despite the decreasing rate at which it is utilized, the contemporary institution with an autopsy rate as low as 5% autopsy remains a vital part of medical science. Perhaps could experience rates of major missed diagnoses and class more than any other organ systems, knowledge of diseases I errors as high as 24.4% and 6.7%, respectively.7 Another, of the heart and brain relies heavily on autopsy. There are a 2007 retrospective review of cancer patients dying in the multiple reasons for this: first, diseases of the brain and ICU at a tertiary cancer center where the autopsy rate was heart are responsible for the majority of deaths in devel- 13%, revealed a 26% rate of major missed diagnoses and a oped nations, and second, these organs are among the least 14% rate of class I errors.8 amenable to tissue investigation during life.14 Autopsy is of Another frequently cited cause for the decline of the critical importance to research efforts in which death is an autopsy is the belief that autopsy reports will initiate and outcome measure, particularly when it is necessary to deter- fuel malpractice lawsuits. Again, pathologists have supplied mine whether an intervention may have contributed to, or studies to counter these claims. A 2002 review of court helped prevent, a patient’s death. reviews of malpractice cases showed that defendant phy- Concurrent with the decline of the autopsy rate has been sicians were acquitted in 61% of cases when the autopsy a similar decline in the use of autopsy as an instrument of report favored the plaintiff, and in 100% of cases when the medical education, such that many medical students no lon- autopsy favored the defendant.9 Furthermore, in 17% of ger observe any autopsies during their training.15 However, cases the autopsy findings were deemed to be important or medical students who do have the opportunity to view an

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autopsy consistently describe it as a valuable aspect of their 5. Lundberg GD. Low-tech autopsies in the era of high-tech med- education.15,16,17 Although viewing an autopsy can at times icine: continued value for quality assurance and patient safety. JAMA. 1998; 280(14): 1273-4. be difficult and may produce a wide variety of psychological 6. Hoyert DL. The changing profile of autopsied deaths in the responses in a trainee, it remains the duty of the pathologist United States, 1972-2007. NCHS data brief, no. 6. Hyattsville to minimize these reactions and impart a basic understand- (MD): National Center for Health Statistics, 2011. ing of how and why autopsies are obtained. 7. Shojania KG, Burton EC, McDonald KM, Goldman L. Changes in rates of autopsy-detected diagnostic errors over time: a sys- In an attempt to increase the dwindling autopsy rate, tematic review. JAMA. 2003; 289(21): 2849-56. numerous efforts have been made to improve and modern- 8. Pastores SM, Dulu A, Voigt L, Raoof N, Alicea M, Halpern NA. ize the autopsy. These include performing limited autopsies, Premortem clinical diagnoses and postmortem autopsy findings: discrepancies in critically ill cancer patients. Crit Care. primarily by endoscopy, laparoscopy, needle, or some com- 2007; 11(2): R48. 14 bination of these three. Both computed tomography and 9. Bove KE, Iery C. The role of autopsy in medical malpractice cas- magnetic resonance imaging have been studied as methods es, I: a review of 99 appeals court decisions. Arch Pathol Lab of noninvasive, or virtual, autopsy. However, it has been Med. 2002; 126(9): 1023-31. 10. Oluwasola OA, Fawole OI, Otegbayo AJ, Ogun GO, Adebamowo a struggle to demonstrate that these modalities can be as CA, Bamigboye AE. The autopsy: knowledge, attitude, and per- accurate as the conventional autopsy. A prospective study ceptions of doctors and relatives of the deceased. Arch Pathol of 182 cases comparing CT and MRI to autopsy found the Lab Med. 2009; 133(1): 78-82. discrepancy rate between cause of death identified by radiol- 11. Henry J, Nicholas N. Dead in the water—are we killing the hospital autopsy with poor consent practices? J R Soc Med. 2012; ogy and autopsy to be 32% for CT, 43% for MRI, and 30% 105(7): 288-95. for combined CT-MRI. The most common missed diagnoses 12. Nemetz PN, Tanglos E, Sands LP, Fisher WP Jr, Newman WP were ischemic heart disease, pulmonary embolism, pneu- 3rd, Burton EC. Attitudes toward the autopsy—an 8-state sur- monia, and intra-abdominal lesions.18 It is also important to vey Med Gen Med. 2006; 8(3): 80. 13. Burton EC. Autopsy rate and physician attitudes toward autop- note that imaging is useless for almost all neurodegenerative sy. Retrieved May 17, 2016 from http://emedicine.medscape. disorders. Currently, it appears that imaging is best used as com/article/1705948-overview#a4. a complement to, rather than a replacement for, the conven- 14. Ayoub T, Chow J. The conventional autopsy in modern medi- tional autopsy. cine. J R Soc Med. 2008; 101(4): 177-81. 15. Bamber AR, Quince TA, Barclay SIG, Clark JDA, Siklos PWL, Of course, no endeavor to revive the autopsy will be suc- Wood DF. Medical student attitudes to the autopsy and its util- cessful without considering the multitude of medical, legal, ity in medical education: a brief qualitative study at one UK and societal factors that are responsible for its decline. Some medical school. Anat Sci Educ. 2014; 7(2): 87-96. have called for the Joint Commission to reinstate its min- 16. Anders S, Fischer-Bruegge D, Fabian M, Raupach T, Peters- en-Ewert C, Harendza S. Teaching post-mortem external exam- imum autopsy rate as a requirement for hospital accredi- ination in undergraduate medical education—the formal and tation.5 Others have emphasized the need to standardize the informal curriculum. Forensic Sci Int. 2011; 210(1-3): 87-90. autopsy reporting and optimize workflow in order to deliver 17. Benbow EW. Medical students’ views on necropsies. J Clin Pathol results to clinicians in a timelier manner.1 It will be nec- . 1990; 43(12): 969-76. 18. Roberts ISD, Benamore RE, Benbow EW, Lee SH, Harris JN, essary to improve training, both for medical students and Jackson A, Mallett S, Patankar T, Peebles C, Roobottom C, pathology residents, in order to increase their familiar- Traill ZC. Post-mortem imaging as an alternative to autopsy in ity with, and inclination to utilize, the autopsy. Finally, a the diagnosis of adult deaths: a validation study. Lancet. 2012; 379(9811): 136-42. greater effort will need to be made to educate the public regarding the autopsy and the crucial role it plays in public Authors health, research, and myriad other areas. Alex Baumgartner, MD’16, Alpert Medical School of Brown University; PGY-1, Dept. of Internal Medicine, Beth Israel CONCLUSION Deaconess Medical Center, Boston. The autopsy is a vital aspect of modern healthcare. How- Douglas Anthony, MD, PhD, Pathologist-in-Chief at Rhode ever, rates of autopsy utilization have been in decline for Island and The Miriam Hospitals, Providence, RI; Professor of more than half a century. The Lifespan system is no excep- Pathology at the Alpert Medical School of Brown University. tion to this trend. Although many different reasons have Disclaimer been offered to explain the decline, nearly all agree that it The views expressed in this article are those of the authors and do is a detriment to practice of medicine. A multidisciplinary not necessarily reflect the position or policy of the Lifespan Cor- effort will be necessary to prevent the death of the autopsy. poration, the Alpert Medical School of Brown University, or Beth Israel Deaconess Medical Center.

References Correspondence 1. Levy B. Informatics and autopsy pathology. Surg Pathol Clin. Alex Baumgartner, MD 2015; 8(2): 159-74. Department of Internal Medicine- Deaconess 306 2. McPhee SJ, Bottles K. Autopsy: moribund art or vital science? 330 Brookline Avenue, Boston, MA 02215 Am J Med. 1985; 78(1): 107-13. 617-632-8273 3. Oppewal F, Meyboom-De Jong B. Family members’ experience Fax 617-632-8261 of autopsy. Fam Pract. 2001; 18(3): 304-8. [email protected] 4. Roberts WC. The autopsy: its decline and a suggestion for its revival. NEJM. 1978; 299(7): 332-8.

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Fluid Choice Matters in Critically-ill Patients with Acute Pancreatitis: Lactated Ringer’s vs. Isotonic Saline

MOHAMMED M. ABOELSOUD, MD; OSAMA SIDDIQUE, MD; ALEXANDER MORALES, MD; YOUNG SEOL, ScB; MAZEN O. AL-QADI, MD

39 42 EN ABSTRACT reduction in markers of systemic inflammation after com- OBJECTIVES: To investigate the effect of different crystal- parable volumes of infusion with LR vs. IS, at 24 hours after loid solutions on clinical outcomes in critically-ill presentation6. patients with acute pancreatitis (AP). While the debate over LR vs. IS in improving outcomes remains indecisive, increased attention has been paid in METHODS: We conducted a retrospective study of recent years to the acid-base benefits of LR. Although both patients with AP admitted to the ICU using the Multi- LR (pH 6.5) and IS (pH 5.5) have a lower pH than that of parameter Intelligent Monitoring in Intensive Care III plasma, LR remains more physiologically complementary. (MIMIC-III) database. We investigated the effect of flu- IS infused in large volumes has shown marked non-an- id type; lactated ringer’s (LR) vs. isotonic saline (IS) on ion gap metabolic acidosis and hyperchloremia in trauma hospital mortality rates, and ICU length of stay (LOS). patients7, 8. Saline- induced hyperchloremia was also associ- RESULTS: Hospital mortality of the 198 included patients ated with decreased renal blood flow, and worse clinical out- was 12%. For fluid type, 32.9% were resuscitated with comes9-11. Also, the lactate component of LR is metabolized LR vs. 67.1% with IS. Hospital mortality was lower in by the liver to reduce acidosis induced by acute fluid or renal the LR group (5.8%) vs. 14.9% for IS group, odds ratio losses. LR was found to be superior to IS in animal models of of 3.10 [P=0.041]. This effect was still observed after ad- hemorrhagic shock . Use of IS for large-volume resuscitation justing for confounders. However, ICU LOS was longer in hemorrhagic shock increased the risk for metabolic aci- in LR compared to IS group; 6.2±6.9 vs. 4.2±4.49 days dosis, hyperkalemia, and vasodilation12, 13. We explored LR respectively [P= 0.020]. vs IS in critically-ill patients with acute pancreatitis and its CONCLUSION: The type of fluid used for resuscitation effects on acid-base profile and outcomes. in AP may affect the outcome. LR may have survival benefit over IS in critically-ill patients with AP. METHODS KEYWORDS: acute pancreatitis; Lactated Ringer’s; Isotonic Study design Saline; resuscitation; critically-ill A retrospective study comparing the outcomes of critically-ill patients with acute pancreatitis based on the type of crystalloid fluid used for resuscitation in first 72 hours of their ICU stay.

INTRODUCTION Study Population Acute Pancreatitis (AP) remains one of the most common We used the Multi-parameter Intelligent Monitoring in gastrointestinal disease processes1. Clinical practice guide- Intensive Care (MIMIC-III) research data-base, developed by lines put forth by the American College of Gastroenterology researchers from the Laboratory for Computational Physiol- (ACG) regarding AP management emphasized large-volume ogy at Massachusetts Institute of Technology (MIT), Cam- fluid resuscitation for improved patient survival2. bridge, MA, USA, and the Department of Medicine at the AP precipitates a systemic inflammatory process, which Beth Israel Deaconess Medical Center (BIDMC) Boston, MA, cascades into reduced end-organ perfusion, further inflam- USA. The data-base has detailed information about intensive mation, and subsequently, massive third-spacing of flu- care unit patient stays, including high-resolution vital sign ids3. Many indices of AP severity have been presented in trends and waveforms, laboratory data, therapeutic inter- order to guide the monitoring of hemodynamic status in ventions, discharge summaries, radiology reports and Inter- those patients undergoing large-volume fluid resuscitation, national Classification of Diseases, 9th Revision (ICD-9) especially within the first 48 hours of presentation4. ACG codes for all patients admitted to BIDMC ICU between 2001 recommends Lactated Ringer’s (LR) as the preferred iso- and 2012. Patients were de-identified in a Health Insurance tonic fluid for resuscitation in acute pancreatitis over iso- Portability and Accountability Act-compliant manner. The tonic saline, (IS) based on expert opinion and supported institutional review boards of BIDMC and MIT approved the by one randomized control study5. Wu et al demonstrated use of the MIMIC-III database14, 15.

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We included adult patients (> 18 years) admitted directly statistical tests and/or confidence intervals (CI), as appropri- to the intensive care unit from the emergency department ate, were performed at α = 0.05. All reported P values were with acute pancreatitis. The diagnosis of acute pancreatitis two sided rounded to three decimal places. Statistical analy- was made based on the ICD-9 code, and confirmed by ele- sis was performed using JMP Pro by SAS Institute. vated serum amylase and/or lipase (> three times the upper limit of normal), and/or finding on CT abdomen consistent with AP. Patients who received colloids were excluded. RESULTS Patients with missing data (demographics, clinical or fluid Out of 1093 patients with ICD-9 of AP, only 198 satisfied intake/output), or with alternative diagnoses other than AP inclusion and exclusion criteria; amongst excluded patients, on admission to the ICU were excluded. 585 were transferred from another facility, 259 were initially admitted to the general medical wards or did not have AP on Study variables presentation, and 51 had missing data (Figure 1). The base- We included demographic information such as age, sex and line characteristics are summarized in Table 1. LR group was race. Predictors of severity included Simplified Acute Phys- older, received more fluid and had more patients with BISAP iology Score II (SAPS-II), and Bedside Index of Severity in <3. Both groups had comparable SAPS-II scores. The over- AP (BISAP) scores on admission, using worst values in the all mortality was 12.6%. Higher SAPS-II and BISAP scores 1st 24 hours. Chart notes were reviewed for etiology of pan- on admission correlated with higher in-hospital mortality creatitis when applicable. Amount and type of resuscitation [P<0.0001]. The key results were summarized in Table 2. fluid were extracted from the database. The amount of fluid There was higher mortality in the IS group (16.1%) com- was expressed as total amount in first 24, 48 and 72 hours of pared to the LR group (5.8%) in both univariate and mul- ICU stay. Based on type of fluid, patients were categorized tivariate logistic regression model; [P=0.029 and 0.045] into two groups; LR vs. IS. If a given patient received both LR and IS, they were assigned to the group of predominant Table 1. Baseline Characteristics fluid amount administered in 72 hours. Serial biochemical profile and vital signs were extracted for the first 72 hours. Lactated Ringer’s Isotonic Saline (n=68) (n=130) We specifically used serum bicarbonate and chloride as surrogates for non-gap metabolic acidosis. We reviewed serum Age, median (IQR), years 63 (52–74)* 56 (44–72)* levels of bicarbonate and chloride on admission and at 24 Men, % 51 50 hours. The difference between the two points was calculated Ethnicity, % for both, and presented as percentage of change from the ini- Caucasian 78 76 tial level (ΔHCO3% and ΔCl%). African American 10 13 Study outcomes Other 12 11 The primary study outcome was in-hospital mortality. The Etiology, % secondary outcomes were ICU length of stay, the trend of serum bicarbonate and chloride after 24hrs of resuscitation. Stones 36 21 Alcohol 14 21 Statistical analysis Unknown 50 58 Age, SAPS score, vital signs, biochemical profile, amount of fluid and LOS were defined as continuous variables; race, Amount of fluid, median (IQR), liters gender, etiology of pancreatitis, BISAP score (as ≥3 or <3), 24 hours 7.2 (4.3–11.0)* 5.6 (3.5–7.9)* type of fluid and hospital death were defined as categorical 48 hours 9.0 (5.3–15.8)* 7.5 (4.5–11.3)* variables. Continuous variables are reported as mean with 72 hours 10.3 (6.4–17.3)* 8.6 (4.7–14.0)* standard deviation or median with interquartile range when appropriate; categorical variables are reported as percent- BISAP ≥3, % 22* 35* ages. Comparisons between groups for categorical variables SAPS-II, median (IQR) 33 (24–41) 35 (25–47) were evaluated using Pearson’s chi-square test for contin- * P value < 0.05. Abbreviations: IQR, interquartile range; BISAP, Bedside Index of gency and for continuous variables a two-sided t test was Severity in Acute Pancreatitis; SAPS-II, Simplified Acute Physiology Score-II. used. To adjust for confounders, a multivariate analysis for in-hospital death was done using a logistic regression model. Table 2. Results summary Variables were introduced into the model based on clinical Lactated Ringer’s Isotonic Saline and/or statistical significance (p value <0.1 on univariate P Value (n=68) (n=130) analysis). In the event of co-linearity between variables, only In-hospital one variable was included. The final model included the fol- 5.8 16.1 0.029 mortality, % lowing variables: type of fluid, age, total amount of fluid in ICU LOS, mean first 24 hours and BISAP score. As a supplemental analysis, 6.2 (6.9) 4.2 (4.49) 0.020 we investigated the effect of LR. Vs. IS on changes in serum (SD), days chloride and bicarbonate as surrogates for acidosis. All Abbreviations: LOS, length of stay; SD, standard deviation

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Figure 1. Cohort derivation and study scheme. Figure 2. Mean change in serum bicharbonate after 24 hours of resuscitation.

Figure 3. Mean change in serum chloride after 24 hours of resuscitation.

respectively with odds ratio of 3.10, 95% (CI 1.11-10.92). The multivariate model included age, amount of fluid in 72 hours and BISAP score to adjust for differences between the two groups. Interestingly, ICU LOS was longer in the LR com- physiologically compatible with human serum than normal pared to IS group; 6.2±6.9 vs. 4.2±4.49 days respectively, [P= saline, and is associated with better outcomes in different 0.020]. Mean serum bicarbonate on admission was com- settings, including AP. parable between the two groups 22.16 vs. 20.84 mEq/L for The findings from our study, and previous studies are all LR and IS respectively, [P= 0.18]. More patients (44%) in consistent with the identified advantages of LR over IS in IS group had a drop in serum bicarbonate after 24 hours of terms of reduction in SIRS, lower CRP level at 24 hours, resuscitation compared to the LR group (36%); however, this improved pH-homeostasis, and electrolyte balance13, 16-18. We didn’t reach statistical significance P[ = 0.323]. Among those hypothesized that all of these advantages may culminate whom HCO3 dropped, ΔHCO3% was more prominent in IS into a survival benefit. Moreover, a well-known phenome- group -18% vs. -13% for LR, [P=0.033] (Figure 2). For chlo- non related to large volume saline infusion is the develop- ride, although mean serum level on admission was higher ment of hyperchloremic metabolic acidosis19, which further in LR group 103.80 vs.100.17 mEq/L in IS group, [P=0.012], builds a case for the superiority of LR over IS in AP, and thus both groups had comparable percentage of patients who had to the observed lower mortality with LR. This also supports increase in Cl levels after 24 hours 78% vs. 77% for LR and our finding of a more prominent ΔHCO% 3 drop (p=0.033) IS respectively [P=0.867]. Among those whom Cl increased, and %Δ Cl increase (p=0.002) in the IS group than LR after IS group showed higher ΔCl% of 10% vs. 7% for LR group 24 hours of resuscitation. The above findings coincide with [P= 0.002] (Figure 3). the fact that metabolic acidosis itself, is a part of the pathophysiology of AP20. Despite the advantages observed with the use of LR, it was interestingly associated with a longer DISCUSSION duration of hospital stay. Differences in the age between In our study, we found that fluid choice in resuscitation of the two groups could be contributing to the longer hospi- critically ill patients with AP may impact outcomes. Spe- tal stay observed in the LR group. Noteworthy however, is cifically, LR was associated with decreased mortality when the fact that the LR group showed lower mortality in our used for resuscitation compared to IS. This association per- study despite an overall more advanced age, making the sisted after adjusting for differences between the two groups dominance of LR over IS in AP even more consequential. such as age, amount of fluid and severity on presentation. The observational nature of our study is susceptible to bias Moreover, we found that LR is associated with a less dra- and confounding. We adopted a very rigorous inclusion and matic drop in serum bicarbonate and less increase in serum exclusion criteria which makes the study susceptible to chloride; thus, reduced incidence of acidosis. Our study adds selection bias and impacting sample size as we excluded to the growing body of evidence suggesting that LR is more patients who were transferred from other facilities or who

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were initially admitted to the floor, which was necessary 7. Barker ME. 0.9% saline induced hyperchloremic acidosis. since the first 24 hours in AP is the most crucial in treat- J Trauma Nurs 2015;22:111-6. 8. Ho AM, Karmakar MK, Contardi LH, et al. Excessive use of nor- ment. Other confounding variables included the amounts mal saline in managing traumatized patients in shock: a pre- of fluid administered during first 24, 48 and 72 hours was ventable contributor to acidosis. J Trauma 2001;51:173-7. higher in LR group. However, both groups received amounts 9. Kellum JA. Saline-induced hyperchloremic metabolic acidosis. of fluid (7.2L for LR vs. 5.6L for NS) that were almost within Crit Care Med 2002;30:259-61. 10. Young JB, Utter GH, Schermer CR, et al. Saline versus Plas- the recommended range by the ACG guidelines (6-12L) in ma-Lyte A in initial resuscitation of trauma patients: a random- the first 24 hours, which is considered the most crucial ized trial. Ann Surg 2014;259:255-62. period for adequate treatment5. IS has been shown to cause 11. Neyra JA, Canepa-Escaro F, Li X, et al. Association of Hyper- vasodilation, thus requiring increased volumes for resuscita- chloremia With Hospital Mortality in Critically Ill Septic Pa- tients. Crit Care Med 2015;43:1938-44. tion12. Decreased amount of IS was used in our study, lead- 12. Martini WZ, Cortez DS, Dubick MA. Comparisons of normal ing to a question of under-resuscitation, yet a larger amount saline and lactated Ringer’s resuscitation on hemodynamics, would have led to higher acidemia and mortality. Although metabolic responses, and coagulation in pigs after severe hemorrhagic shock. Scand J Trauma Resusc Emerg Med 2013;21:86. our patients showed varied proportions of ≥3 BISAP score in 13. Todd SR, Malinoski D, Muller PJ, et al. Lactated Ringer’s is both groups (22% in LR group and 35% in IS group) they dis- superior to normal saline in the resuscitation of uncontrolled played comparable median SAPS II scores (33 for LR vs. 35 hemorrhagic shock. J Trauma 2007;62:636-9. for IS). Nonetheless, we included BISAP in the multivariate 14. Saeed M, Villarroel M, Reisner AT, et al. Multiparameter Intelli- model to adjust for any possible confounding. Also a major gent Monitoring in Intensive Care II (MIMIC-II): A public-access intensive care unit database. Crit Care Med 2011;39:952-60. limitation of our study was that most of our patients received 15. MIMIC-III Critical Care Database. both IS and LR which is hard to control for in retrospec- 16. Wu BU, Hwang JQ, Gardner TH, et al. Lactated Ringer’s solu- tive studies. We assigned patients to the group based on the tion reduces systemic inflammation compared with saline in predominant amount which still can introduce some bias. patients with acute pancreatitis. Clin Gastroenterol Hepatol 2011;9:710-717 e1. Another limitation of our study was that it included only AP 17. Hadimioglu N, Saadawy I, Saglam T, et al. The effect of different in critically-ill patients from a single center, which should crystalloid solutions on acid-base balance and early kidney func- caution us from generalizing the results to a larger population after kidney transplantation. Anesth Analg 2008;107:264-9. tion. Although we attempted to adjust for confounders and 18. Khajavi MR, Etezadi F, Moharari RS, et al. Effects of normal saline vs. lactated ringer’s during renal transplantation. Ren Fail differences between the two groups by multivariate logistic 2008;30:535-9. regression model (specifically age, BISAP score and amount 19. Sharma V, Shanti Devi T, Sharma R, et al. Arterial pH, bicarbon- of fluid), residual confounding by unmeasured covariates ate levels and base deficit at presentation as markers of predicting mortality in acute pancreatitis: a single-centre prospective may not have been completely eliminated. Moreover, our study. Gastroenterol Rep (Oxf) 2014;2:226-31. study included patients (2001–2012) that were treated before 20. Pant N, Kadaria D, Murillo LC, et al. Abdominal pathology in pa- the updated guidelines for management of AP were pre- tients with diabetes ketoacidosis. Am J Med Sci 2012;344:341-4. sented in 2013, which could raise the question that there Authors was no consensus on treatment protocols during that time. In conclusion, we showed that LR may have a survival Mohammed M. Aboelsoud, MD, Department of Medicine, Memorial Hospital of Rhode Island/Alpert Medical School of benefit over IS in critically-ill patients with AP. We encour- Brown University. age similar studies to be conducted, in the hopes that the Osama Siddique, MD, Department of Medicine, Memorial seemingly endless debate regarding the optimal choice of Hospital of Rhode Island/Alpert Medical School of Brown isotonic fluid resuscitation can reach a conclusion. University. Alexander Morales, MD, Department of Medicine, Memorial References Hospital of Rhode Island/Alpert Medical School of Brown 1. Peery AF, Dellon ES, Lund J, et al. Burden of gastrointestinal University. disease in the United States: 2012 update. Gastroenterology Young Seol, ScB, Alpert Medical School of Brown University. 2012;143:1179-87.e1-3. Mazen O. Al-Qadi, MD, Department of Medicine, Memorial 2. Tenner S, Baillie J, DeWitt J, et al. American College of Gastro- enterology guideline: management of acute pancreatitis. Am J Hospital of Rhode Island/Alpert Medical School of Brown Gastroenterol 2013;108:1400-15; 1416. University, Division of Pulmonary, Critical Care and Sleep 3. Tenner S, Sica G, Hughes M, et al. Relationship of necrosis to Medicine. organ failure in severe acute pancreatitis. Gastroenterology 1997;113:899-903. Disclosures 4. Qiu L, Sun RQ, Jia RR, et al. Comparison of Existing Clinical All the authors have nothing to disclose. No funding was used for Scoring Systems in Predicting Severity and Prognoses of Hyper- this study. lipidemic Acute Pancreatitis in Chinese Patients: A Retrospec- tive Study. Medicine (Baltimore) 2015;94:e957. Correspondence 5. Tenner S, Baillie J, DeWitt J, et al. American College of Gastro- Osama Siddique, MD enterology guideline: management of acute pancreatitis. Am J Department of Medicine, Memorial Hospital of Rhode Island Gastroenterol 2013;108:1400-15; 1416. 111 Brewster St, Pawtucket, RI, 02860 6. Wu BU, Hwang JQ, Gardner TH, et al. Lactated Ringer’s solution reduces systemic inflammation compared with saline in 401-441-9781 Fax 401-729-2022 patients with acute pancreatitis. Clin Gastroenterol Hepatol [email protected] 2011;9:710-717.e1.

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A Five-Year Evolution of a Student-led Elective on Health Disparities at The Alpert Medical School

LUCINDA B. LEUNG, MD, MPH; JAMES E. SIMMONS, MD; JULIUS HO, BS; EMMA ANSELIN, BA; RIAN YALAMANCHILI, BA; JOSEPH S. RABATIN, MD

43 47 EN ABSTRACT themselves on this important subject. BACKGROUND AND OBJECTIVE: Medical students are Student-run clinic participants are quick to recognize often unprepared for social challenges in caring for safety that patients they care for have complex needs and are net patients. We aim to evaluate and chronicle the evo- calling for more health disparities training. University of lution of a pre-clinical elective alongside medical dispar- California San Diego medical student survey respondents ities curriculum. perceived that student-run free clinics were a valuable educational experience and improved attitudes toward working DESIGN AND METHODS: Medical students designed with underserved patients.6 Jefferson Medical College stu- the course to supplement clinical training on care of vul- dent-run clinic participants reported on a survey that they nerable patients. From 2011–2015, there have been 80 were not prepared to confront social problems and barriers first-year medical student participants, five cohorts of to care encountered at free clinics but that they welcomed second-year course leaders, and two supporting faculty orientation to these issues prior to working in these clinics.7 advisors for this 10–12 session evening elective. Despite both institutional and student-led demands to RESULTS: Students (n=67) rated the course extremely incorporate health disparities into medical education, there highly (ranging from 4.4-4.6 on a five-point Likert scale). are few case reports of health disparities training in didactic Medical students reported having significantly more settings. Literature describes examples of peer mentoring knowledge of underserved populations after taking the and clinical teaching in student-run clinics9,10 and also exam- course (difference=0.72, SE=0.16, P <0.001). Career in- ples of student-initiated didactic curricula separate from terests and attitudes toward health disparities remained clinical experience.8 One case report from the University strong after taking the course. of California San Francisco highlighted students who devel- CONCLUSIONS: This student-created elective equipped oped a preclinical service-learning curriculum about hepa- participants with improved knowledge in caring for un- titis B viral infection.11 To our knowledge, this report is the derserved patients and contributed to the incorporation first to chronicle student-led efforts to care for underserved of health disparities in medical curriculum. patients alongside the evolution of medical curriculum to include health disparities education. KEYWORDS: medical education, health disparities, At The Warren Alpert Medical School of Brown Uni- underserved patients versity, student-run clinic participants observed a gap in their ability to successfully care for the needs of uninsured Rhode Island patients. In order to enhance and deepen their patient care at these clinics, medical students developed a INTRODUCTION preclinical elective called “Healthcare for the Underserved.” Medical students increasingly have the opportunity to care Based on a peer-learning model, the elective examines the for underserved patients. Student-run health clinics are unique health and healthcare challenges faced by under- present in most medical schools, accounting for more than served patients in Rhode Island. This paper aims to share the 36,000 annual patient–physician visits nationally.1 In these opportunities, mechanics, and challenges characterizing the clinics, medical students learn how to treat acute illness and experiences of student leaders in pre-clinical course devel- manage chronic conditions in predominantly low-income, opment. We argue for the feasibility and sustainability of minority patients. These clinical experiences are often a stu- this student-led elective’s structure as a supplement to student’s first exposure to social and economic determinants dent-run clinic efforts, formal medical school curriculum, of health inequality, extensively documented in Institute of and as a model for shaping pre-clinical medical education. Medicine’s Unequal Treatment report on racial-ethnic disparities in United States healthcare.2 While many author- ities urge academic institutions to take responsibility for INTERVENTION educating medical students on these health disparities,3-5 In 2010, several medical students founded Alpert Medi- medical students have risen to the challenge of educating cal School’s inaugural student-run health clinics, Brown

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Figure 1. Timeline of events pertinent to development of the Healthcare for the Underserved elective. disparities, while preserving student-determined course content. In response, student leaders • “Unequal Treatment” published by Institute of Medicine reorganized the course into five 2002 modules on designated topics: (1) refugee/immigrant health • Patient Protection and Affordable Care Act enacted and medical-legal issues, (2) 2010 • Society of General Internal Medicine developed health disparities curriculum child obesity and the built environment, (3) hypertension rates and race/ethnicity, (4) teen preg- • Brown Student Community Clinic founded at Rhode Island Free Clinic 2011 • Healthcare for the Underserved elective began enrollment nancy and sex education, and (5) mental health and homelessness. Students were also divided • Clinica Esperanza Student Clinic founded into five groups based on these • “Shades of Providence” health disparities curriculum created for incoming Alpert medical students 2012 modules, and each group was asked to collaborate on a pre- • Healthcare for the Underserved elective underwent curricular modifications sentation or workshop. This 2013 • Brown University School of Public Health opens framework allowed the flexibility of peer-learning within a set • Alpert Medical School Free Clinic Alliance formed of core topics in healthcare for • First Annual Alpert Medical School Symposium on Health Disparities held the underserved. 2014 • Alpert Medical School began interviewing applicants for Primary Care–Population Health program Student evaluations also pointed to the importance of linking class topics to clinical practice. Because students were Student Community Clinic within the Rhode Island Free no longer required to volunteer at local free clinics (although Clinic, and later, a second one within the existing Clinica many did), student leaders incorporated clinical cases into Esperanza (Figure 1). Quickly thereafter, student clinic lead- didactic sessions. They invited physicians to present exam- ers recognized the need for more formal education in the care ples of patients they cared for in underserved communi- of underserved patients. In addition to an experiential com- ties. These examples included asthmatic children living in ponent in free clinics, the classroom allowed a forum for dis- mold-infested housing and overweight children with poor cussion on topics relevant to underserved populations with access to balanced and healthy nutrition. a focus on health disparities. Two medical students designed In addition, didactic sessions were typically followed the pre-clinical elective, Healthcare for the Underserved, by workshops that aimed to teach students patient-cen- as a venue to engage others in peer-learning about health tered skills essential to the care of underserved patients. disparities. In 2011, the Medical Curriculum Committee These skills included optimizing interpretation in patient approved the elective and opened the course to enrollees. encounters, techniques in culturally-sensitive motiva- A senior medical student and a faculty advisor helped tional interviewing, and composition of legal advocacy with the elective during its first two years and recruited the letters. Following the 2013 course, this new structure has initial cohort of 19 junior medical students from a student persisted and even incorporated new topics based on stu- activity fair. Students determined class content, invited dent feedback each year (Table 1). All the while, the same class speakers (i.e., physicians, community leaders), facili- faculty advisor, since the elective’s inception, continues to tated class discussion for realistic solutions to problems dis- support all curricular activities and attend class sessions. cussed. This effort culminated in 10–12 evening seminars Following the Healthcare for the Underserved elective, on student-selected topics such as homelessness/teenage new electives and required courses increased opportunities runaways, immigrants and non-English speakers, and safe- for health disparities training for Brown medical students. ty-net workplace culture. At the end of the elective’s second Emerging preclinical electives furthered several issues year, three class participants volunteered to be course lead- touched on by Healthcare for the Underserved (e.g., “Poverty, ers for the following year and continued to engage previous Health and Law,” “Gender and Sexuality in Healthcare,” students in preparing for the next series of seminars. “Refugee Health and Advocacy”).6 In 2013, based on course feedback showing evolving student interests, course leaders restructured the elective. Evaluations from the previous year called for more formal RESULTS structure and content in each student-led session. Students Following each class and at the end of every Healthcare for wanted a more cohesive framework for exploring health the Underserved course, students provided quantitative

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Table 1. Elective curricular content as chosen and organized by students feedback, including the benefit of discussing topics relevant Class seminar topics by academic year to the local community, learning from different perspectives among peers, and engaging with local experts. Students felt 2011–2012 Healthcare for homeless class sessions “inspired fruitful discussion between the Geriatric issues medical community at Brown and local advocacy groups.” Med student cynicism, professionalism, and the underserved Students particularly valued the course as a space to dis- Addiction and substance abuse cuss and implement solutions to health inequities. They 2012–2013 asked for more emphasis on “on student projects and find- Underserved communities in Rhode Island ing problems that can be fixed by student involvement.” Adolescent mental health They found discussion “thought-provoking” and “definitely Domestic violence something that I want to look more into and think more Emergency room diversion At-risk youth about.” Ultimately, they connected policy discussions back Race and biomedicine in historical perspective to the patients they served: “I think this is a great way for Patient-physician communication us to start thinking about health policy and how we as cli- 2013–2014 nicians can establish or develop programs that will help the Refugee and immigrant health livelihoods of our patients.” Immigration and medical-legal partnerships Student feedback was instrumental in shaping curriculum Disparities in childhood obesity changes from year to year. A specific recommendation in Nutrition counseling and WIC/SNAP* 2012 asked to integrate the sessions into a more cohesive Disparities in hypertension Race and biomedicine framework and for “a bit more continuity between ses- Teen pregnancy in Rhode Island sions.” Students reflected on the importance of structure Interventions in teen pregnancy and asked for leaders to “be more systematic and focused,” Veteran homelessness citing, “Because we are handling so much information every Mental health day, it is difficult to follow when things get too informal at 2014–2015 6 pm (for the elective).” These comments led to the develop- Refugees and medical-legal partnerships ment of the five modules in 2013. Working with interpreters Following the implementation of modules, a one-time Prisoner health Lesbian, gay, bisexual, transgender, and queer health pre- and post-course survey with 4-point Likert scales was Veterans health and the VA added to track changes in student knowledge (i.e., defini- Teen pregnancy and sex education tion of “underserved”) and attitudes (i.e., interest in a med- Homelessness ical career providing care for underserved and interest in Race and biomedicine non-clinical health disparities work). Univariate analysis 2015–2016 with paired t-tests was performed on STATA 13.0. From Introduction to social determinants of health 2013-2014, the overall survey response rate was 90% (n=18). Power, privilege and oppression Following course completion, students reported having Racial and ethnic disparities in health and healthcare Race and medicine more knowledge about underserved populations and their Gender, sexuality and intersectionality career interests and attitudes toward health disparities Unconscious bias in medicine remained above average (2.5 out of 5 on Likert scale). There Neighborhood and the built environment was a large increase in self-reported understanding of what Health, social policy & the role of the physician advocate “underserved” means (difference = 0.72, SE = 0.16, p<.001) *WIC/SNAP= Supplemental Nutrition Assistance Program for Women, Infants, (Table 2). However, all other statements concerning career and Children choices and interests (i.e., devotion to caring for underserved, work in primary care, interest in health disparities feedback on their experiences via 5-point Likert scales. From research) were not statistically significant. There was still 2011–2014, a total of 67 students enrolled in our class and an overall increase in knowledge and interest in caring for 48 completed evaluations on the final session, for an over- the underserved (difference = 0.15, SE = 0.06, p=.02), which all survey response rate of 72%. Unweighted average ratings likely resulted from the substantial self-reported improve- across the years were high on all four of our measures: qual- ment in knowledge of the underserved. Results should be ity of information provided (4.5), clarity and organization of interpreted knowing that there was no comparison group. presentations (4.4), topics’ level of interest (4.4), and whether Evaluation from 2014 of the elective continues to inform students would recommend the class (4.6). course leaders. Students called for patients to speak about Class surveys also included qualitative feedback. In their own experiences of health disparities (e.g., “Definitely a free response section, participants reflected on what bring a patient next time! Would really love to hear a patient they learned and offered suggestions on course improve- perspective.”). At the same time, students called for more ment. Several themes emerged from students’ qualitative time for group discussion. They further reinforced the value

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Table 2. Pre- and post-course student survey on knowledge and attitudes surrounding health disparities in 2013-2014.

Pre Post Diff (SE) P-value

I have a good understanding of what “underserved” means 3.06 3.78 0.72 (0.16) <0.001

I envision myself devoting my future career to caring for underserved communities 3.33 3.61 0.28 (0.16) 0.10

Addressing health disparities will be a part of my future medical career 3.72 3.89 0.17 (0.12) 0.19

I am interested in working in a primary care field 2.89 2.89 0 (0.14) 1.00

There are special/additional skills unique to effectively caring for underserved populations 3.61 3.83 0.22 (0.13) 0.10 (as opposed to patients at large)

I am interested in health policy 3.28 3.28 0 (0.11) 1.00

I am interested in physician advocacy 3.44 3.17 -0.27 (0.14) 0.06

I am interested in quantitative health disparities research (epidemiology, etc) 3.06 3.11 0.05 (0.21) 0.79

I am interested in qualitative health disparities research (humanities, social sciences, etc) 2.94 3.17 0.23 (0.26) 0.41

Overall 3.26 3.41 0.15 (0.06) <0.02 of a student-driven course design, consistently giving positive issues pertaining to health disparities, and (4) an Objective feedback on student-led presentations (e.g., “My classmates Structured Clinical Examination that requires students to really did a great job; I was very impressed.”). navigate cases addressing health disparities (e.g., counseling non-English speaking patient against leaving against medical advice).13 There is also recognition of the shortage of phy- DISCUSSION sicians to care for underserved populations in Rhode Island, As the only medical students in the state of Rhode Island, with an explicit goal to train Brown medical students to Brown students successfully advocated for the creation of stu- provide outstanding primary care for them.14 dent-run clinics and more didactics to provide better care for Healthcare for the Underserved is a successful, sustain- its most vulnerable patients. The innovation in Healthcare able elective at the Alpert Medical School and a contribu- for the Underserved is not in curricular content, but rather tion to health disparities education. The increasing overlap in its dissemination method, in which students became between its content and that of required medical curriculum the catalyst for encouraging medical curriculum change. is evidence of the impact student efforts can have on the As student leaders and faculty of Healthcare for the Under- medical curriculum. Healthcare for the Underserved will served, the authors learned several lessons. First, the elec- continue to evolve to meet the needs of current students and tive is an example of how student demand was harnessed make medical education relevant to the most vulnerable into medical education reform. Second, it demonstrated that patients served by tomorrow’s physicians. a student-designed elective with both clinical and didactic components can increase self-reported knowledge about health disparities and caring for the underserved. Despite its References original intentions, it is unclear if the elective inspired any 1. Simpson SA, Long JA. Medical student-run health clinics: important contributors to patient care and medical education. attitude or career changes, though the lack of demonstrated Journal of general internal medicine. 2007;22(3):352-356. change may be due to significant interest of students who 2. Nelson A. Unequal treatment: confronting racial and ethnic dis- self-selected into this class. Despite limitations to extrap- parities in health care. Journal of the National Medical Associ- olating from case reports, Healthcare for the Underserved ation. 2002;94(8):666-668. 3. Betancourt JR. Eliminating racial and ethnic disparities in appears to be a sustainable student-run effort that generates health care: what is the role of academic medicine? Academic strong support from class participants. medicine : journal of the Association of American Medical Col- Since the elective’s inception, the Alpert Medical School leges. 2006;81(9):788-792. has undergone vast curricular change. An issue of the Rhode 4. Lunn MR, Sanchez JP. Prioritizing health disparities in medical education to improve care. Academic medicine : journal of the Island Medical Journal dedicated a 25-page special section Association of American Medical Colleges. 2011;86(11):1343. to health disparities education at Brown, highlighting cur- 5. Awosogba T, Betancourt JR, Conyers FG, et al. Prioritizing ricular innovations and future directions around health health disparities in medical education to improve care. Annals disparities.12 In addition to elective courses, the following of the New York Academy of Sciences. 2013;1287:17-30. 6. Smith SD, Johnson ML, Rodriguez N, Moutier C, Beck E. Medi- now exist: (1) a required multimodality health disparities cal student perceptions of the educational value of a student-run curriculum, (2) an annual health disparities symposium, (3) free clinic. Family medicine. 2012;44(9):646-649. required inter-professional workshops focusing on clinical 7. Simmons BB, DeJoseph D, Diamond J, Weinstein L. Students

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who participate in a student-run free health clinic need educa- Authors tion about access to care issues. Journal of health care for the Lucinda B. Leung, MD, MPH, is a general internist, Robert Wood poor and underserved. 2009;20(4):964-968. Johnson Foundation Clinical Scholar / Veteran’s Affairs 8. Chew D, Jaworsky D, Thorne J, et al. Development, implemen- Scholar at University of California Los Angeles, alumnus of tation, and evaluation of a student-initiated undergraduate med- Alpert Medical School of Brown University and co-founder of ical education elective in HIV care. Med Teach. 2012;34(5):398- 403. Brown Student Community Clinic and the Healthcare for the Underserved elective. 9. Choudhury N, Khanwalkar A, Kraninger J, Vohra A, Jones K, Reddy S. Peer mentorship in student-run free clinics: the impact James E. Simmons, MD, pulmonary and critical care fellow at on preclinical education. Family medicine. 2014;46(3):204-208. Brown University, alumnus of the Alpert Medical School 10. Hamso M, Ramsdell A, Balmer D, Boquin C. Medical students as of Brown University and co-founder of Brown Student teachers at CoSMO, Columbia University’s student-run clinic: Community Clinic and the Healthcare for the Underserved a pilot study and literature review. Med Teach. 2012;34(3):e189- elective. 197. Julius Ho, BS, medical student at the Alpert Medical School of 11. Sheu LC, Toy BC, Kwahk E, Yu A, Adler J, Lai CJ. A model for Brown University and student leader for the Healthcare for the interprofessional health disparities education: student-led cur- Underserved elective from 2013 to 2014. riculum on chronic hepatitis B infection. Journal of general internal medicine. 2010;25 Suppl 2:S140-145. Emma Anselin, BA, medical student at the Alpert Medical School 12. Tunkel AR. Health disparities education - the time is now. of Brown University and student leader for the Healthcare for Rhode Island medical journal. 2014;97(9):21. the Underserved elective from 2013 to 2014. 13. Erlich M, Blake R, Dumenco L, White J, Dollase RH, George Rian Yalamanchili, BA, medical student at the Alpert Medical P. Health disparity curriculum at the Warren Alpert Medical School of Brown University and student leader for the School of Brown University. Rhode Island medical journal. Healthcare for the Underserved elective from 2013 to 2014. 2014;97(9):22-25. Joseph S. Rabatin, MD, is an Associate Professor of Medicine 14. Anthony D, El Rayess F, Esquibel AY, George P, Taylor J. Build- (Clinical) at the Alpert Medical School of Brown University ing a workforce of physicians to care for underserved patients. and faculty sponsor for the Healthcare for the Underserved Rhode Island medical journal. 2014;97(9):31-35. elective. Acknowledgments Disclosures We acknowledge Associate Dean for Medical Education, The Warren Support for this article was provided by the Robert Wood Johnson Alpert Medical School of Brown University, Allan R. Tunkel, MD, Foundation Clinical Scholars® program and the U.S. Department PhD, for his editorial assistance and support of this manuscript. of Veterans Affairs.

Correspondence Lucinda B. Leung, MD Robert Wood Johnson Foundation Clinical Scholar at UCLA and the U.S. Department of Veteran’s Affairs, 10940 Wilshire Boulevard, Suite 710 Los Angeles, CA 90024 310-794-8309 Fax 310-794-3288 [email protected]

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Medical School Ranking and Student Research Opportunities

ANNIKA G. HAVNAER; PAUL B. GREENBERG, MD

48 53 EN ABSTRACT require a research experience as part of the core curricu- OBJECTIVE: This study aimed to characterize the cur- lum; others offer optional scholarly tracks, annual student rent state of student research opportunities in a sample of research days where students can showcase their research US medical schools ranked in three different tiers. projects, summer research experiences, or an entire year dedicated solely to research. Several recent studies have evalu- METHODS: The authors examined the websites for five ated student research opportunities at US medical schools. US medical schools in each of the first, second, and third A 2015 systematic review by Chang et al characterized the tiers per National Institutes of Health funding and U.S. outcomes associated with medical student research pro- News & World Report rankings. Available research op- grams and found that the majority of students perceive their portunities were identified and categorized. research experiences to be positive and author at least one RESULTS: There were 26 schools in the first (n=6), second article.2 In their 2010 literature review, Bierer et al focused (n=10), and third (n=10) tiers. From the first, second, and on a specific type of research program – scholarly concentra- third tiers, 4/6 (67%), 1/10 (10%) and none, respective- tions – and found that the diversity of articles and variable ly, required a research experience (p=0.003); 6/6 (100%), results prevent definitive conclusions about the value of 4/10 (40%) and 1/10 (10%), respectively, offered inter- these programs.3 Numerous studies have also evaluated stu- nally funded one-year research (p=0.002); and 5/6 (83%), dent research programs at single institutions.4-9 However, no 4/10 (40%) and 2/10 (20%), respectively, offered student studies to-date have comprehensively examined the avail- research days (p=0.045). able student research opportunities across a wide selection of CONCLUSIONS: Higher ranked schools provided more medical schools or sought to compare research opportunities opportunities for student research by providing internal- among medical schools in different tiers. ly funded one-year research, requiring research, and offer- Given the recent trend toward increased student partic- ing student research days. ipation in research, it is important to identify the types of research programs presently available to medical students. KEYWORDS: medical student research; research program; This study aimed to characterize the current state of medi- research experience; medical school research opportunity cal student research opportunities in a sample of US medical schools ranked in three different tiers.

INTRODUCTION Over the past five years medical student involvement in METHODS scholarly research at United States (US) medical schools To determine the nature of research opportunities available has grown.1 The Association of American Medical Colleges to medical students, the authors examined the websites (AAMC) 2014 Medical School Graduation Questionnaire cited a Table 1. Student Participation in Research During Medical School 7.9% increase in the proportion of % Increase students who conducted a research 2010 2011 2012 2013 2014 (2010–2014) project with a faculty mentor Independent study project for credit 41.4 42.2 42.4 42.4 43.8 5.8 between 2010 and 2014 (Table 1). The proportion of students with Research project with faculty mentor 64.2 66.3 68.1 68.2 69.3 7.9 Authorship (sole or joint) of a research sole or joint authorship of a research 39.1 40.6 41.8 41.7 42.0 7.4 paper submitted for publication paper submitted for publication Authorship (sole or joint) of a peer- increased by 7.4% over the same 43.6 N/A time period (Table 1). reviewed oral or poster presentation Medical schools can promote Thesis project 10.0 10.1 10.1 10.5 10.5 5.0

medical student research through a Source: https://www.aamc.org/download/397432/data/2014gqallschoolssummaryreport.pdf number of programs. Some schools (Accessed September 15, 2015)

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for five US medical schools ranked in each of the first, sec- second (Table 3), and third (Table 4) tiers, four (67%), one ond (38-42) and third (76-80) tiers per National Institutes (10%) and none, respectively, required a research experience of Health (NIH) funding and U.S. News & World Report (p=0.003); six (100%), four (40%) and one (10%), respectively, (USNWR) research rankings. offered internally funded one-year research (p=0.002); and As USNWR only ranked schools to 84 in 2015, the authors five (83%), four (40%) and two (20%), respectively, offered a capped both ranking lists at 80. When medical schools were student research day (p=0.045). tied in rank, schools closest in rank to the predetermined Research opportunities that fell outside these categories ranges were included. For each predetermined range, only included for-credit research offered by three schools in the the first five schools from each ranking list were included. first tier and one school in the second tier (Tables 2, 3). In Available research opportunities were grouped into the fol- addition, one school in the first tier offered weekly group lowing categories: internal funded year-off research opportu- scholarship sessions (Table 2) and one school in the first nities (e.g., year-long research awards from medical school tier and another in the third tier each offered an M.D. with funds); internal funded summer research opportunities; an Research Honors (Tables 2, 4). annual student research day; external funded research opportunities for one year or longer; and external funded summer research opportunities. Research opportunities that fell out- DISCUSSION side these categories were noted but not ranked. Only funds We sought to characterize current research opportunities at provided to medical students directly, whether for stipends US medical schools by examining the websites of schools in or research costs, were included. Combined MD-PhD pro- the first, second, and third tiers from two separate ranking grams were not included as participation involves students systems. We found that higher ranked medical schools were pre-selected for a research career. more likely to require a research experience, provide internally Descriptive statistics, such as frequencies and percentages, funded one-year research, and offer a student research day. were used to describe the availability of research opportuni- The role of required versus elective research experience ties within each tier. Chi-square analysis was performed to on student satisfaction and scholarly productivity remains compare the availability of each type of research opportu- uncertain. In their systematic review, Chang et al found that nity among the three tiers; the significance level was 5%. students in elective research programs were both more satisfied with their research experiences and had similar rates of publications and presentations as students in mandatory RESULTS research programs.2 The authors attributed differences in There were 26 medical schools in the first (n=6), second satisfaction to the inherent self-selection bias of voluntary (n=10), and third (n=10) tiers. The research opportunities research programs or to the additional funding or distinc- at the schools from each tier are outlined in Tables 2-4 and tions offered by some elective programs.2 However, the stud- the chi-square analysis in Table 5. From the first (Table 2), ies included in Chang’s report were limited in number and

Table 2. Top-Ranked Medical Schools by NIH Funding 2014 & U.S. News & World Report – Best Medical Schools 2015 (Research) US News Internal External Additional Research Optional Internal External Medical NIH & World Required Funded Research Funded Opportunities & Services Scholarly Funded Funded School Ranking Report Research Summer Day Summer Supporting Student Track Year-Off Year-Off Ranking Opportunities Opportunities Research Up to 4 months of for- University credit research permitted of California 1 4 X X X X X X Optional weekly group San Francisco scholarship discussion sessions Johns Hopkins 2 3 X X X X X X University University of 3 4 X X X X X Pennsylvania Washington For-credit research 4 - X X X X X University permitted Stanford For-credit research 5 2 X X X X X X X University permitted Harvard - 1 X X X X X X MD with Honors offered University Sources: http://www.brimr.org/NIH_Awards/2014/NIH_Awards_2014.htm (Accessed November 24, 2014) http://grad-schools.usnews.rankingsandreviews.com/best-graduate-schools/top-medical-schools/research-rankings (Accessed November 24, 2014)

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Table 3. Mid-Rankeda Medical Schools by NIH Funding 2014 & U.S. News & World Report – Best Medical Schools 2015 (Research)

US News Internal External Additional Research Optional Internal External NIH & World Required Funded Research Funded Opportunities & Medical School Scholarly Funded Funded Ranking Report Research Summer Day Summer Services Supporting Track Year-Off Year-Off Ranking Opportunities Opportunities Student Research Purdue University 38 - X X X at Indianapolis University For-credit research 39 - X X X X X X of Virginia permitted University 40 - X X X X X of Utah University 41 - X X X X X X of Iowa University 42 - of Miami Dartmouth - 34 College Ohio State - 34 X X X X University University - 34 X X X of Maryland University - 34 X X X of Minnesota University - 34 X X X X of Rochester a 38th through 42nd ranked U.S. medical schools. Note that because many USNWR rankings are tied, only the first five from each predetermined range are included.

Table 4. Low -Rankeda Medical Schools by NIH Funding 2014 & U.S. News & World Report – Best Medical Schools 2015 (Research)

US News Internal External Additional Research Optional Internal External NIH & World Required Funded Research Funded Opportunities & Medical School Scholarly Funded Funded Ranking Report Research Summer Day Summer Services Supporting Track Year-Off Year-Off Ranking Opportunities Opportunities Student Research Tulane 76 - X X X X X University SUNY Stony 77 - X X X X Brook Brown 78 - X X X X University Tufts MD with Research 79 - X X` X University Honors offered University 80 - X X X X X of Tennessee Georgia Regents - 75 X University St. Louis - 75 University University - 75 X X of Missouri University of - 78 Hawaii – Manoa University - 78 X X of Louisville a 76th through 80th ranked U.S. medical schools. Note that because many USNWR rankings are tied, only the first five from each predetermined range are included.

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Table 5. Available research opportunities among three medical school tiers First Tier Medical Schools Second Tier Medical Schools Third Tier Medical Schools (N = 6) (N = 10) (N = 10) P valuea n (%) n (%) n (%) Required Research 4 (67) 1(10) 0 (0) 0.003 Optional Scholarly Track 2 (33) 3 (30) 6 (60) 0.35 Internal Funded Year-Off 6 (100) 4 (40) 1 (10) 0.002 Internal Funded Summer 6 (100) 8 (80) 8 (80) 0.49 Opportunities Research Day 5 (83) 4 (40) 2 (20) 0.045 External Funded Year-Off 6 (100) 8 (80) 5 (50) 0.08 External Funded Summer 6 (100) 6 (60) 4 (40) 0.06 Opportunities a Calculated using χ2 tests. used disparate metrics to evaluate student satisfaction and research time. Among top-ranked schools that required a publication and presentation rates. In addition, the authors research experience, there was a high degree of flexibility in did not include the role of required research in students’ terms of allowable research time, ranging from a minimum choice of a medical school; students who are highly inter- of three months to a maximum of several years. Top-ranked ested in research may be drawn to schools with more estab- schools were also more likely to provide internal funding lished research programs and devote more extracurricular for year-off research, though the number of schools offering time to scholarly pursuits. internal funding for summer research did not differ across An important characteristic to consider across all research tiers. Dyrbye et al examined allotted research time in a man- opportunities is level of funding available to both students datory research program and found that more students in a and faculty mentors. We found that top-ranked medical required 21-week research experience were first authors than schools were more likely to require a research experience those in a 17/18-week experience.5 However, other measures and offer internally funded year-off research. This suggests of research productivity did not change with decreased allot- that higher funding levels are available at these institutions, ted research time. The authors concluded that a required given the greater resource requirements inherent in both lon- medical research experience facilitated greater research ger and required programs. Although it is difficult to deter- productivity, with shorter experiences yielding similar out- mine exact available funding levels based on school websites comes as longer experiences.5 Jacobs et al also examined alone, many of the top-ranked schools that required research allotted research time and found that allowing medical also listed associated internal funding for these programs. A students up to six years to complete course requirements study by Jacobs et al at a single medical school reported that facilitated student research and high student publication student research productivity and satisfaction with research rates.6 Allowing students more time to engage in an in-depth was facilitated by financial incentives, with 79% of students research project may be necessary for project completion, satisfied with their research experience and 75% coauthor- especially given the many unforeseen setbacks inherent in ing at least one published article.6 In addition, 28% of faculty conducting research and the limited available time for activ- cited lack of funding as a reason why they chose not to work ities outside the core medical school curriculum. However, with students on a research project.6 Similarly, Hunskaar it is also important to make sure that students have detailed et al examined students in a two-year elective research timelines and goals to make sure they maximize the use of program implemented across four schools and reported an the allotted research time.15 association between level of funding availability and student Providing students with excellent support and opportu- satisfaction rates, with higher rates of dissatisfaction found nities for presenting their research projects likely plays an among students in lower-funded programs.10 Funding of stu- important role in encouraging student research.9,16 We found dents’ research was also crucial to faculty mentors’ interest that top-ranked schools were more likely to offer a student in recruiting students to the research program.10 Although research day during which students could present their the studies from Jacobs and Hunskaar lacked control groups research and view the research projects of their peers. Zier and relied on questionnaires for data, their findings suggest et al found that infrastructure created to support student that adequate funding for student research projects – e.g., research activity, including a student research day, increased educational,11,12 faculty,13 or departmental14 grants – is an student interest and participation in research.9 In addition, essential characteristic for promoting greater medical stu- the percentage of graduating students publishing peer-re- dent satisfaction and involvement in research. viewed manuscripts increased from 11% to 25% between An additional program characteristic that may promote two and eight years following implementation of these medical student research is program length and allotted structured research opportunities.9 This trend is likely due to

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maturation and improvement of research programs; as more References students participate over time, specific program character- 1. Medical School Graduation Questionnaire. Available at: https:// istics can be tailored to better meet student needs and fos- www.aamc.org/download/397432/data/2014gqallschoolsssum- maryreport.pdf [Accessed September 15, 2015]. ter increased productivity. Langhammer et al also examined 2. Chang Y, Ramnanan CJ. A review of literature on medical stu- research program maturation and student participation rates dents and scholarly research: experiences, attitudes, and out- at a single medical school7: the evolution of a Distinction in comes. Acad Med. 2015;90(8):1162–1173. Research (DIR) track coincided with a greater proportion of 3. Bierer SB, Chen HC. How to measure success: the impact of scholarly concentrations on students – a literature review. Acad students taking six months to a year off for research, which Med. 2010;85(3):438–452. the authors attributed to the increased visibility of funding 4. Dorrance KA, Denton GD, Proemba J, et al. An internal med- opportunities for year-out programs and maturation of the icine interest group research program can improve scholarly DIR program to provide an intensive research training expe- productivity of medical students and foster mentoring relationships with internists. Teach Learn Med. 2008;20(2):163–167. 7 rience. Given the retrospective study design, it is difficult to 5. Dyrbye LN, Davidson LW, Cook DA. Publications and presenta- conclude that greater student participation rates stem from tions resulting from required research by students at Mayo med- program maturation. However, for medical schools imple- ical School, 1976-2003. Acad Med. 2008;83(6):604–610. menting student research programs, more mature programs 6. Jacobs CD, Cross PC. The value of medical student research: The experience at Stanford University School of Medicine. Med may serve as better models. Educ. 1995;29(5):342–346. Our finding that higher ranked medical schools offered 7. Langhammer CG, Garg K, Neubauer JA, Rosenthal S, Kinzy TG. more student research opportunities is consistent given Medical student research exposure via a series of modular re- our use of NIH and USNWR research rankings, which rank search programs. J Investig Med. 2009;57(1):11–17. 17 8. Schor NF, Troen P, Kanter SL, Levine AS. The Scholarly Proj- schools according to total NIH awards and a weighted aver- ect Initiative: introducing scholarship in medicine through age that includes research indicators,18 respectively. Research a longitudinal, mentored curricular program. Acad Med. programs and opportunities offered by schools in the first tier 2005;80(9):824–831. may serve as a template for schools in the second and third 9. Zier K, Friedman E, Smith L. Supportive programs increase medical students’ research interest and productivity. J Investig Med. tiers. However, while schools in the first tier may offer more 2006;54(4):201–207. student research opportunities, additional evidence is needed 10. Hunskaar S, Breivik J, Siebke M, Tømmerås K, Figenschau K, to determine the efficacy of particular program features Hansen JB. Evaluation of the medical student research pro- in promoting student research productivity. gramme in Norwegian medical schools. A survey of students and supervisors. BMC Med Educ. 2009;9:43. This study has several limitations. We used school web- 11. Green EP, Borkan JM, Pross SH. Encouraging scholarship: med- sites as the sole determinant of research opportunities ical school programs to promote student inquiry beyond the available to medical students. Some schools may require a traditional medical curriculum. Acad Med. 2010;85(3):409-418. school login to view certain research opportunities, or may 12. Ruth L. Kirschstein NRSA Short-Term Institutional Research Training Grant. Available at: https://researchtraining.nih.gov/ inform students of research opportunities through other programs/training-grants/T35 [Accessed July 28, 2016]. means such as e-mail or information sessions. In addition, 13. NIH Academic Research Enhancement Award Program. Avail- despite its popular appeal, the USNWR methodology has able at: https://grants.nih.gov/grants/funding/area/area.htm been criticized on a number of grounds19; hence, we used [Accessed July 28, 2016]. 14. Research to Prevent Blindness. Institutional Grants. Available a ranking system based on listings from both USNWR and at: https://www.rpbusa.org/rpb/grants-and-research/grants/in- the NIH. Due to high variability in school website design, stitutional-grants/ [Accessed July 28, 2016]. it is also possible that we may have missed certain research 15. Young BK, Cai F, Tandon VJ, George P, Greenberg PB. Promoting opportunities on school websites that had poor organization medical student research productivity: the student perspective. R I Med J. 2014;97(6):50–52. and navigational features. To help promote student schol- 16. Zier K, Stagnaro-Green A. A multifaceted program to encourage arly activity, we recommend schools keep their web pages medical students’ research. Acad Med. 2001;76(7):743–747. on student research opportunities up-to-date with thorough 17. Ranking Tables of NIH Funding to US Medical Schools in 2014. descriptions of opportunities, including length, funding Available at: http://www.brimr.org/NIH_Awards/2014/NIH_ Awards_2014.htm [Accessed November 24, 2014]. source, requirements, deadlines, and a clearly delineated 18. Methodology: Best Medical Schools Rankings. Available at: research contact person. http://www.usnews.com/education/best-graduate-schools/articles/medical-schools-methodology [Accessed October 5, 2015]. 19. McGaghie, WC, Thompson, JA. America’s Best Medical Schools: A Critique of the U.S. News & World Report Rankings. Acad Med. 2001;76(10):985–992.

Presentation Presented at the 2016 Canadian Conference on Medical Education, April 18, 2016, Montreal, Quebec, Canada.

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Acknowledgments Correspondence The authors thank Curtis E Margo, MD, MPH from the Morsani Paul B. Greenberg, MD College of Medicine, University of South Florida for critically re- Professor of Surgery (Ophthalmology) viewing the manuscript and Allison Chen, MPH, from the Warren Division of Ophthalmology, Brown University Alpert Medical School of Brown University for assistance with the Coro Center West data analysis. One Hoppin Street, Suite 200 Disclaimer Providence, RI 02903 401-444-4669 The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Fax 401-444-7076 Veterans Affairs or the United States government. [email protected]

Authors Annika G Havnaer is a medical student at the Warren Alpert Medical School of Brown University, Providence, RI. Dr. Paul B Greenberg is a Professor of Surgery (Ophthalmology), Division of Ophthalmology, Warren Alpert Medical School of Brown University and Chief of Ophthalmology, Providence VA Medical Center, Providence, RI.

Financial Support None

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Systemic Amyloidosis Masquerading as Intractable Cardiomyopathy

LINDSEY CILIA, MD; LESLIE PARIKH, MD; MADHU M. OUSEPH, MD, PhD; EDWARD STOPA, MD; MICHAEL K. ATALAY, MD, PhD

54 56 EN

of cardiac amyloid (Figures 1&2). Hospitalization was com- KEYWORDS: cardiac amyloidosis, MRI, multiple myeloma plicated by multiple episodes of monomorphic ventricular tachycardia. He was started on lisinopril and metoprolol and discharged with the diagnosis of heart failure secondary to myocarditis of unknown etiology. INTRODUCTION At his current presentation, his temperature was 101.2F, Cardiac amyloidosis is an infiltrative cardiomyopathy in with a blood pressure of 122/74 mmHg, a regular heart rate which amyloid protein is deposited throughout the myocar- of 100 bpm, and a respiratory rate of 20 breaths per min- dium. It is increasingly recognized as a cause of heart failure ute with an oxygen saturation of 97% on room air. His with preserved ejection fraction in the elderly. Presenting exam was notable for diffuse abdominal tenderness. EKG symptoms include exercise intolerance, fatigue, angina, showed normal sinus rhythm, normal voltage, and QTc pro- breathlessness and syncope or pre-syncope.1 Atrial fibrilla- longation of 514. Computed tomography of the abdomen tion is the most common early arrhythmia, with ventricular showed new hypodense lesions within the right hepatic lobe fibrillation occurring later in the course of the disease.1 This case presents a 79-year-old man with multiple Figure 1. Cardiac MRI of the patient. Horizontal long axis (a) and mid-ven- myeloma and non-ischemic cardiomyopathy whose diag- tricle short axis (b) end-diastolic views were taken from “bright-blood” nostic tests failed to illustrate the typical findings seen in cine loops. The left atrium (LA) is mildly dilated. There is no left ventric- cardiac amyloidosis, although extensive cardiac amyloid ular (LV) thickening. Images (c) and (d) are corresponding post-contrast deposition was seen at autopsy. This case highlights the views. Normal myocardium appears black and abnormal myocardium, need to pursue myocardial biopsy as the gold standard test if bright (enhancement). The proximal interventricular septum has a small clinical suspicion is high. linear focus of enhancement (arrow). Questionable enhancement is seen in the LA posterior and subendocardial LV free walls (arrowheads). These imaging findings are not typical of cardiac amyloidosis. RV: right ventricle. CASE PRESENTATION A 79-year-old man presented to the hospital after one day of fever, nausea and vomiting. History included non-ischemic cardiomyopathy with an ejection fraction (EF) of 35%, smoldering multiple myeloma diagnosed by bone marrow biopsy in 2014 with evidence of focal amyloid deposition, and cholangiocarcinoma status-post roux-en-y and hepa- to-jejunostomy with stenting in 2013. He had diabetes, hyperlipidemia, and anxiety. After the diagnosis of smoldering myeloma, he was lost to follow-up, so no treatment was initiated. Medications included aspirin, atorvastatin, met- formin, metoprolol, lisinopril, mirtazapine and venlafaxine. He had a 20 pack-year smoking history and drank alcohol occasionally. His family history was significant for multiple myeloma in his sister. Nine months earlier he was hospitalized for new onset heart failure. EKG was normal and echocardiogram demonstrated an EF of 35%. Cardiac catheterization showed min- imal coronary artery disease. Clinical concern for cardiac amyloidosis, given his history of smoldering myeloma and bone marrow amyloid, prompted cardiac MRI. MRI demonstrated features concerning for myocarditis without evidence

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Figure 2. Cardiac MR images of another patient with biopsy proven extensive deposition in the cardiovascular, gastrointestinal, cardiac amyloidosis. Image on left is a mid-ventricle short axis end-dia- respiratory, and genitourinary systems, and involvement of stolic view from a bright-blood cine loop. Note the left ventricular (LV) skin and bone marrow. thickening, worst inferiorly (arrowheads). A small pericardial effusion is also present (arrows). Image on right is a corresponding post-contrast view. There is no normal (black) myocardium; instead the myocardium DISCUSSION is heterogeneously gray. These findings are virtually pathognomonic for Three types of amyloid are responsible for the majority of cardiac amyloidosis. cardiac involvement. They include (1) light chain (AL) amyloidosis (2) senile systemic amyloidosis (SSA) and (3) the hereditary forms. While AL amyloidosis occurs in isolation, 10% of patients with multiple myeloma develop systemic AL amyloid.2 Clinical evidence of cardiac involvement occurs in up to 50% of patients with AL amyloidosis.2 The classic electrocardiogram finding is low voltage.3 Low QRS voltages (all limb leads <5 mm in height) with poor R-wave progression in the chest leads occur in up to 50% of patients with cardiac AL amyloidosis. Characteristic echocardiographic features include a thickened interventricular wall, diastolic dysfunction and preserved EF.2 EKG and echocardiogram have poor sensitivity to detect cardiac amyloidosis, so car- Figure 3. Congo red stain of interventricular myocardium shows scattered diac MRI is emerging as the preferred diagnostic modality.4 plasma cells with extensive salmon pink colored amorphous deposits in Cardiac MRI has excellent spatial resolution for tissue char- the interstitium and small arteries (left), also present in both atria and acterization with an 80% sensitivity for detecting infiltrative ventricles. These deposits demonstrate apple green birefringence under cardiomyopathy.4,1 MRI in cardiac AL amyloidosis usually polarized light, consistent with amyloid deposition (right). demonstrates global and subendocardial late gadolinium enhancement of the myocardium due to increased interstitial cardiac volume as amyloid replaces normal myocardium.3 Despite extensive amyloid deposition throughout the myocardium and cardiac conduction system, our patient did not demonstrate characteristic electrocardiographic, echocardiographic, or cardiac MRI findings Figures( 1&2), highlighting the importance of endomyocardial biopsy. Biopsy remains the gold standard for diagnosis, and shows amyloid deposits (Figure 3).3 AL amyloidosis management involves both slowing protein production and deposition, and preventing complications including cardiac arrhythmias and decompensated with intrahepatic biliary ductal dilatation, concerning for heart failure. AL amyloidosis results from extracellular micro-abscesses. He had a white blood cell count 12.1 x 10^9 deposition of monoclonal immunoglobulin light chains cells/L, elevated alkaline phosphatase (223 IU/L, upper limit secreted by a plasma cell clone. Most patients have an iso- of normal is 104 IU/L), and elevated troponin (0.21 ng/mL, lated monoclonal gammopathy or smoldering myeloma.5 upper limit of normal is 0.06 ng/mL). He was admitted for Treatment goal is to suppress the plasma cell dyscrasia, thus ascending cholangitis complicated by liver micro-abscesses reducing the production of immunoglobulin light chains and started on piperacillin-tazobactam and vancomycin. and minimizing end-organ damage.6 Combination therapy Blood cultures returned positive for Enterococcus faecalis, with bortezomib, melphalan and dexamethasone provokes prompting a switch to linezolid and gentamicin. His course a rapid response in most patients with AL amyloidosis and was complicated by multiple episodes of polymorphic ven- is preferred for cardiac amyloidosis patients needing prompt tricular tachycardia (PMVT), in the absence of profound reduction of pathogenic light chain.7 Further regimen selec- electrolyte abnormalities, ischemia or acidosis, requiring tion is dependent upon extent of organ involvement and direct current cardioversion and amiodarone. The refractory potential toxicities.6 PMVT episodes raised concern for recurrent myocarditis or Cardiac involvement, manifested as diastolic heart failure, progressive cardiomyopathy. His family decided to focus on left ventricular hypertrophy and ventricular arrhythmias, is comfort measures and hours later, the patient expired from the main determinant of prognosis in AL amyloidosis. Elec- a ventricular arrhythmia. Autopsy revealed plasma cell trophysiology studies suggest the His-Purknjee system is myeloma and systemic AL (light chain) amyloidosis with the most affected part of the conduction system in patients,

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causing QTc prolongations and ventricular arrhythmias.3 Authors Cardioverter-defibrillator (ICD) implantation in cardiac AL Lindsey Cilia, MD, PGY-3, Department of Internal Medicine, amyloidosis can prolong survival with a good quality of life, Alpert Medical School of Brown University, Rhode Island and may be appropriate in some settings.8 Although data on Hospital, Providence, RI. the efficacy of antiarrhythmic medications in AL amyloidosis Leslie Parikh, MD, Fellow, Division of Cardiology, Alpert 6 Medical School of Brown University, Rhode Island Hospital, is lacking, amiodarone is widely used and has shown benefit. Providence, RI. In patients with AL amyloidosis with limited extra-cardiac Madhu M. Ouseph, MD, PhD, Resident, Department of Pathology, involvement and systemic disease control, cardiac transplan- Alpert Medical School of Brown University, Rhode Island tation is an evolving therapeutic option that may decrease Hospital, Providence, RI. mortality and reduce complications including heart failure Edward Stopa, MD, Professor, Department of Pathology, and arrhythmia.9 The prognosis of systemic AL amyloidosis Alpert Medical School of Brown University; Director of with dominant cardiac involvement is generally very poor. the Neuropathology Division at Rhode Island Hospital, Providence, RI. However, timely and tailored chemotherapy along with Michael K. Atalay, MD, PhD, Associate Professor of Diagnostic ICD implantation, antiarrhythmic therapy or cardiac trans- Imaging and Associate Professor of Medicine, Department 8 plantation can improve survival and decrease morbidity. of Diagnostic Imaging, Alpert Medical School of Brown University, Providence, RI. Acknowledgments Disclosures We thank Dr. Caitlin Dugdale for editorial assistance and None of the authors report a conflict of interest contribution to literature review. Correspondence References Lindsey Cilia, MD 1. Sharma, N. & Howlett, J. Current state of cardiac amyloidosis. Department of Internal Medicine Current Opinion in Cardiology 28, 242-248 (2013). Rhode Island Hospital – JB 0100 2. Sedaghat, D., Zakir, R. M., Choe, J., Klapholz, M. & Saric, M. Cardiac amyloidosis in a patient with multiple myeloma: a case 593 Eddy Street report and review of literature. Journal of clinical ultrasound : Providence, RI 02903 JCU 37, 179-184, doi:10.1002/jcu.20552 (2009). 516-524-2114 3. Basha, H. I., Raj, E. & Bachuwa, G. Cardiac amyloidosis mas- Fax 401-444-3056 querading as biventricular hypertrophy in a patient with mul- [email protected] tiple myeloma. BMJ case reports 2013, doi:10.1136/bcr-2012- 008113 (2013). [email protected] 4. Mohty, D. et al. Cardiac amyloidosis: updates in diagnosis and management. Arch Cardiovasc Dis 106, 528-540, doi:10.1016/j. acvd.2013.06.051 (2013). 5. Desport, E. et al. Al amyloidosis. Orphanet J Rare Dis 7, 54, doi:10.1186/1750-1172-7-54 (2012). 6. Wechalekar, A. D. et al. Guidelines on the management of AL amyloidosis. British journal of haematology 168, 186-206 (2015). 7. Hayashi, T. et al. Addition of bortezomib to melphalan plus dexamethasone provides rapid response in AL amyloidosis. Blood 124 (2014). 8. Patel, K. S., Hawkins, P. N., Whelan, C. J. & Gillmore, J. D. Life-saving implantable cardioverter defibrillator therapy in cardiac AL amyloidosis. BMJ case reports 2014, doi:10.1136/bcr- 2014-206600 (2014). 9. Roeker, L. E. et al. Cardiac transplantation in immunoglobulin light chain amyloidosis: A large single center experience. Jour- nal of the American College of Cardiology 63, A887 (2014).

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Community Health Teams: A Healthcare Provider’s System Transformation Opportunity 57 JAMES C. RAJOTTE, MS; DEBORAH GARNEAU, MA; NANCY SUTTON, MS, RD, LDN; AILIS CLYNE, MD, MPH 60 EN ABSTRACT Rhode Island’s CHTs are comprised of two major staff “The goal of community health teams is to develop components: Community-Based, Licensed Health Profes- and implement care models that integrate clinical and sionals (CBLHPs) and Community Health Workers (CHWs). community health promotion and preventive services CBLHPs are typically licensed nurse care managers or for patients.” behavioral health providers. Other CBLHPs include licensed —Association of State and Territorial Health Officials health professionals who serve as clinical educators (e.g., 1 (ASTHO) nutritionists, pharmacists). All Rhode Island CHTs employ Eleven community health teams (CHTs) operate in vari- CHWs who are non-licensed staff trained as patient navi- ous geographies within Rhode Island. Physicians and pay- gators, care coordinators, or resource specialists. Specialty ers refer their highest-risk patients to CHTs that serve as CHWs are certified CHWs who also have successfully com- community extenders. Community health workers and pleted separate workforce development training (e.g., Dia- others work to link referred individuals to primary care betes Prevention Program, medical home model). Certified and work to address the other determinants affecting Peer Recovery Specialists who focus on behavioral health their health, such as safe housing. Since much of health (including substance abuse recovery) given one’s own lived is driven by factors outside of the healthcare setting, experience may comprise a third component of a CHT, based CHTs compliment the work of physicians within the of- on population and setting needs. fice environment. Transforming practices and addressing Several models for CHTs exist in Rhode Island, each oper- both the physical and behavioral needs of patients simul- ating in different locations and with slightly different foci. taneously is key to CHT success. This article attempts In general, Rhode Island CHTs fall into one of four models— to quantify the expanding need for CHTs within Rhode an extension of a patient-centered medical home (PCMH) Island and describes ways in which CHTs as a practice within a specified geography; an extension of general primary transformation resource may be leveraged by providers. care practice; a statewide extension of a payer; or an extension of an accountable care organization. According to the Rhode Island State Innovation Model (SIM) Operation Plan, PCMH and primary care-based CHTs are estimated to have BACKGROUND a catchment population of 75,000 and at least 14,000 Medic- ASTHO’s aim for developing CHTs resonates in Rhode aid beneficiaries are within catchment areas of payer-based Island. Rhode Island’s CHTs serve as extensions of pri- CHTs. Only one CHT organization provides services to chil- mary care, reaching into the community setting to help dren who have special healthcare needs in Rhode Island. patients (re)establish relationships with primary care while All CHTs within Rhode Island seek high-risk individuals also addressing the social, behavioral, and environmental for CHT referrals, services, and targeted interventions. To needs that affect health. Primary care may include those improve population health, address social and environmen- specialists who in some instances assume the role of pri- tal determinants of health, and make progress in eliminat- mary care provider and care coordinator for their patients ing health disparities, CHTs are an essential health system (e.g., geriatrician, oncologist, and obstetrician/gynecologist). transformation resource. As such, CHT services should be In Rhode Island, there are currently 11 teams operating in made available to all Rhode Islanders who need continued various geographies. Rhode Island CHTs serve three critical multi-disciplinary, community-based services to address functions: the factors that impact one’s health. This article attempts • Improving population health by addressing social, to quantify the current need for CHTs within Rhode Island behavioral, and environmental needs; and describes ways in which CHTs as a practice transforma- • Supporting providers in transitioning to value-based tion resource may be leveraged by providers. As part of the 2 systems of care; and SIM Test Grant, “highest-risk” patients who are eligible for CHT services are not just those living in poverty but rather • Transforming primary care in a way that increases quality of care, improves coordination of care, and those who: reduces/controls related costs. • Have three or more known chronic conditions;

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• Have two or more special healthcare needs RESULTS (i.e., disabilities); The Rhode Island prevalence for each indicator is listed in • Have a significant behavioral health co-morbidity Table 1. The estimated adult population size for each indi- (including substance abuse); cator was estimated using the respective year’s U.S. Census • Are not regularly accessing primary care; estimate for Rhode Island adults (ages 18 and older), while the estimate for children and adults used the overall esti- • Are unable to access essential healthcare due to cost; and mate for all Rhode Islanders. The largest percentage of the • Have three or more in-patient or emergency department population meeting any of the CHT eligibility criteria was visits within six months. for those adults with an identified behavioral health or substance abuse condition (35.6%). The smallest percentage of the population meeting any of the CHT eligibility criteria METHODS was for those children and adults who have had three or Data to quantify the patient population considered to be more emergency department visits in a calendar year (1.9%). “highest-risk,” and therefore a priority for CHTs, were compiled using the Behavioral Risk Factor Surveillance System (BRFSS) and HealthFacts RI. The BRFSS is a national tele- DISCUSSION phone survey that monitors behavioral health risks, access The estimated prevalence, by indicator, for those of “high- to health care, and health conditions of randomly selected est-risk” (i.e., eligible for CHT services), demonstrate that adults ages 18 and older. From January through December, Rhode Island’s population would benefit from increased the Rhode Island BRFSS conducted random-digit dialed tele- access to CHTs. While CHTS are currently attributed to at phone interviews with 6,531 (2013) and 6,450 (2014) Rhode least an estimated 89,000 patients, it is unlikely that any Island, non-institutionalized adults. one of the criteria are covered fully by these estimates. This HealthFacts RI, which first began collecting all-payer is increasingly likely given that limited geographic-specific claims in 2014, aims to ensure transparency of information coverage extends only to Washington County, Blackstone about the quality, cost, efficiency, and access of Rhode Island’s Valley, and West Warwick. Access to quality care through healthcare delivery system. Use of this data system provides CHTs that demonstrate the ability to adequately serve cli- insight into healthcare system use, the effectiveness of pol- ents to address social and environmental determinants of icy interventions, and the health of the population. Health- health is critical. Further return-on-investment studies are Facts RI collects, organizes, and analyzes healthcare data planned to confirm the effectiveness of CHTs and models in from nearly all major insurers who cover at least 3,000 Rhode Rhode Island. Islanders. The system is based on claims paid and allows There are a few study limitations. The indicators are not users to track the healthcare system’s utilization through exact matches or exhaustive lists that fully represent the measures of hospital readmissions, total cost of care, and proposed criteria. Because questions such as hypertension participation in preventive/disease management services. are asked on odd-years only, use of a single survey was While data reflecting the exact “highest-risk” criteria is unavailable; therefore a percentage of respondents meeting not readily available, proxy indicators were created using a at least one highest-risk criteria was not generated. Behav- combination of variables from existing survey questions and ioral health morbidity was not analyzed across other condi- claims codes. Estimates that best represent the delineated tions to indicate co-morbidity. For the HealthFacts RI data, “highest-risk” criteria were calculated. Table 1 depicts the all counts and percentages could only be estimated since questions that were combined into indicators for each of the Medicare data were from 2013, while Medicaid and com- criteria and resulting estimates. Respondents were included mercial data were from 2014. Only insurers with more than in the indicator count if they answered “yes” to any BRFSS 3,000 patients were included in HealthFacts RI. measure. Respondents who answered “no,” “not sure,” or “refused” were excluded from the indicator. Respondents missing one or more data elements for the disability indi- MOVING FORWARD cator were excluded (5.3%). Respondents who reported that The Rhode Island SIM Test Grant is committed to investing “they did not need a prescription” were excluded from the in ways to support providers in health system transforma- cost indicator. Confidence intervals (CI) were generated to tion and empower patients to embrace and navigate a chang- reflect the stability of prevalence estimates. To account for ing delivery system focused on patient outcomes. As such, the complex sampling design, BRFSS data were analyzed SIM encourages providers to engage in practice transforma- using SAS® 9.3. Claims from HealthFacts RI were included tion efforts including, but not limited to: creating or partic- in the indicator count if they had three or more emergency ipating in existing agreements that provide access to CHTs department visits within 2013 or 2014. Note, these indica- for their patients; employing certified CHWs to assist prac- tors do not represent unique respondents across indicators, tices in assuring health equity for patients; and integrating only unique counts within the specified indicator. physical and behavioral healthcare through Screening, Brief

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Intervention, and Referral to Treatment (SBIRT) for patients. and evaluation that explores the return-on-investment of SIM is poised to prioritize a segment of Rhode Island for these strategies to inform sustainability planning. Providers such services by investing funding to implement SBIRT can engage in new opportunities by attending a SIM Steering in 10-12 sites and create at least two new CHTs to meet Committee Meeting and checking the State of Rhode Island unmet social, behavioral, and environmental needs of Rhode for Requests for Proposals. Islanders. SIM’s investment also includes data collection

Table 1. Indicators Estimating Rhode Island Needs for CHTs Using Highest-Risk Eligibility Criteria Criteria Indicator Measure(s) Data Source Estimated Prevalence Patients who have Adults with three or more • Has a doctor, nurse, or other health BRFSS (2013) 11.0% three or more of the following conditions: professional EVER told you that you had any 95% CI: 10.1-11.9 known chronic hypertension, diabetes, coronary of the following? For each, tell me “Yes,” (Est. 91,444 adults) conditions heart disease, cardiopulmonary “No,” or “Not sure” disease, arthritis, and asthma Patients who have Adults with two or more • Are you blind or do you have serious BRFSS (2014) 9.2% two or more special disabilities as defined by difficulty seeing, even when wearing glasses? 95% CI: 8.2-10.2 healthcare needs five functional components/ • Because of a physical, mental, or emotional (Est. 76,480 adults) (i.e., disabilities) limitations condition, do you have serious difficulty concentrating, remembering, or making decisions? • Do you have serious difficulty walking or climbing stairs? • Do you have difficulty dressing or bathing? • Because of a physical, mental, or emotional condition, do you have difficulty doing errands along such as visiting a doctor’s office or shopping? Patients who Adults with one or more • Do you now smoke cigarettes every day, BRFSS (2014) 35.6% have a significant identified behavioral health or some days, or not at all? 95% CI: 33.8-37.4 behavioral health substance abuse condition only • During the past 30 days, how many days per (Est. 295,945) co-morbidity (i.e., not a co-morbidity): week or per month did you have at least one (including Smoking, chronic/binge drinking, drink of any alcoholic beverage such as beer, substance abuse) or diagnosed depression. wine, a malt beverage or liquor? • (Ever told) you have a depressive disorder, including depression, major depression, dysthymia, or minor depression? Patients who Adults who have not visited a • About how long has it been since you last BRFSS (2014) 19.8% are not regularly doctor for a routine check-up visited a doctor for a routine checkup? A 95% CI: 18.2 – 21.3 accessing primary within 12 months routine checkup is a general physical exam, (Est. 164,599 adults) care not an exam for a specific injury, illness, or condition Patients who are Adults unable to access care, • Was there a time in the past 12 months BRFSS (2014) 17.1% unable to access meaning see a provider or fill a when you needed to see a doctor but could 95% CI: 15.6-18.6 essential healthcare prescription, due to high costs not because of cost? (Est. 142,153 adults) due to cost • Was there a time in the past 12 months when you did not take your medication as prescribed because of cost? Do not include over-the-counter (OTC) medication. Patients who Children and adults who have • Number of Medicare-insured individuals with HealthFacts Est. 1.9% have three or had three or more emergency three or more claims for Emergency Room RI (2013; Est. 16,097 adults and more in-patient department visits in a calendar visits per calendar year 2014) children or emergency year • Number of Medicaid-insured individuals with department visits three or more claims for Emergency Room within six months visits per calendar year • Number of commercially-insured individuals with three or more claims for Emergency Room visits per calendar year

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References Authors 1. Association of State and Territorial Health Officials. (Not Avail- James C. Rajotte, MS, is a Chief Health Program Evaluator at the able). Community Health Teams Issue Report. Washington, DC: Re- Rhode Island Department of Health (RIDOH), serving as a SIM trieved online at http://www.astho.org/Programs/Access/Prima- Liaison. ry-Care/_Materials/Community-Health-Teams-Issue-Report/. Deborah Garneau is the Health Equity Institute’s Co-Director. 2. State of Rhode Island. (2016). Rhode Island State Innovation Model Test Grant—Operational Plan. Providence, RI: Retrieved Nancy Sutton, Chief, Center for Chronic Care and Disease online at http://www.eohhs.ri.gov/Portals/0/Uploads/Docu- Management. ments/State%20Innovation%20Model/RISIMOperationalPlan- Ailis Clyne, MD, MPH, Medical Director for the Division of Version1April282016.pdf. Community Health and Equity.

Acknowledgments Correspondence Special thanks to Hannah Hakim, and Sarah Nyguen, for program- James C. Rajotte matic insights and Dora Dumont, Yongwen Jiang, and Melissa Rhode Island Department of Health Lauer for data expertise. This article was supported by Centers Three Capitol Hill–Room 407 for Medicare and Medicaid Services (CMS) funding; however, Providence RI 02908 the findings/conclusions are those of the authors and do not necessarily represent the views of CMS. [email protected]

WWW.RIMED.ORG | RIMJ ARCHIVES | OCTOBER WEBPAGE OCTOBER 2016 RHODE ISLAND MEDICAL JOURNAL 60 VITAL STATISTICS PUBLIC HEALTH NICOLE E. ALEXANDER-SCOTT, MD, MPH DIRECTOR, RHODE ISLAND DEPARTMENT OF HEALTH COMPILED BY ROSEANN GIORGIANNI, DEPUTY STATE REGISTRAR

Rhode Island Monthly Vital Statistics Report Provisional Occurrence Data from the Division of Vital Records

REPORTING PERIOD APRIL 2016 12 MONTHS ENDING WITH APRIL 2016 VITAL EVENTS Number Number Rates Live Births 900 11,588 11.0* Deaths 846 10,153 9.6* Infant Deaths 4 65 5.6# Neonatal Deaths 4 52 4.5# Marriages 451 6,824 6.5* Divorces 206 3,083 2.9* Induced Terminations 181 2,440 210.6# Spontaneous Fetal Deaths 48 587 50.7# Under 20 weeks gestation 37 523 51.5# 20+ weeks gestation 11 64 5.5#

* Rates per 1,000 estimated population # Rates per 1,000 live births

REPORTING PERIOD OCTOBER 2015 12 MONTHS ENDING WITH OCTOBER 2015 Underlying Cause of Death Category Number (a) Number (a) Rates (b) YPLL (c) Diseases of the Heart 204 2,421 230.1 3,758.5 Malignant Neoplasms 221 2,319 219.5 5,137.5 Cerebrovascular Disease 40 444 42.0 480.0 Injuries (Accident/Suicide/Homicide) 83 857 81.1 12,858.0 COPD 39 539 51.0 537.5.

(a) Cause of death statistics were derived from the underlying cause of death reported by physicians on death certificates. (b) Rates per 100,000 estimated population of 1,056,298 (www.census.gov) (c) Years of Potential Life Lost (YPLL).

NOTE: Totals represent vital events, which occurred in Rhode Island for the reporting periods listed above. Monthly provisional totals should be analyzed with caution because the numbers may be small and subject to seasonal variation.

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The Rhode Island Medical Society now endorses Coverys. Coverys, the leading medical liability insurer in Rhode Island, has joined forces with RIMS to target new levels of patient safety and physician security while maintaining competitive rates. Call to learn how our alliance means a bright new day for your practice. 401-331-3207 Safe and affordable housing is a major social determinant of a person’s health. On November 8, the Rhode Island Medical Society urges you to vote Yes on Question 7.

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Working for You: RIMS advocacy activities

September 6, Tuesday RIMS Physician Health Committee: Herbert Rakatansky, MD, Chair September 8, Thursday Meeting with Neighborhood Health Plan regarding legislation AMA conference call regarding opioid toolbox SIM Meeting, Peter Hollmann, MD, and staff September 12, Monday Conference call with RI Urological Association regarding Modifier 25 Board of Directors Meeting September 13, Tuesday Primary Election Day September 14, Wednesday Board of Licensure and Discipline meeting Governor’s Opioid Taskforce September 15, Thursday SIM Measurement sub-committee “Yes on 7” Coalition Kick Off Senate Health and Human Services Committee Hearing on Mental Health September 16, Friday Diabetes Prevention Program Employment 101: A Guide to Important RIMS inaugurated a new slate of officers Stakeholder Group Considerations for Your Future at the annual Convivium on September September 17, Saturday September 23 Friday 23 at the Squantum Association. New England Delegation to the RIMS Annual Convivium, Squantum [L–R] Treasurer Jose R. Polanco, MD; AMA meeting and Council of State Association, East Providence Secretary Christine Brousseau, MD; Medical Societies of New England September 27, Tuesday President-Elect Bradley J. Collins, MD; meeting, Massachusetts Medical President Sarah J. Fessler, MD; Society Headquarters, Waltham; Peter Meeting with Rhode Island Public Health Hollmann, MD; Yul Ejnes, MD; and Institute regarding legislation Vice President Peter A. Hollmann, MD; staff EOHHS Advisory Council; Secretary and seated in front, Immediate Past- Roberts, at RIMS Offices President Russell A. Settipane, MD September 19, Monday US Attorney Peter Neronha event at September 29, Thursday Brown University, National Opioid Tobacco Free RI Executive Committee Awareness Week Meeting September 20, Tuesday September 30, Friday Office of the Health Insurance Senior Physicians: Addressing Age, Commissioner’s Health Insurance Ability, and Acumen; a regional Advisory Committee meeting conference initiated by RIMS Physician Health Program and made possible by September 22, Thursday a grant from the Coverys Community Meeting with Blue Cross Blue Shield of Healthcare Foundation. RI regarding legislation AMA conference call regarding opioid toolbox

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DEMYSTIFYING THE LEGISLATURE Join us in this opportunity to meet and mingle with your local legislators at regional receptions.

KENT AND WASHINGTON COUNTY RESIDENTS Wednesday, October 5, 5:30–8:30pm Meritage Restaurant, 5454 Post Road, East Greenwich

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FOR RIMS MEMBERS AND THEIR GUESTS Light fare provided $30 per person per event Limited space availability, RSVP by September 15 Reserve via the Member Portal on www.rimed.org or contact Megan Turcotte at 401-331-3207 rims corporate affiliates

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Doctor’s Choice provides no cost Medicare consultations. Doctor’s Choice was founded by Dr. John Luo, a graduate of the Alpert Medical School at Brown University to provide patient education and guidance when it comes to choosing a Medicare Supplemental, Advantage, or Part D prescription plan. Doctor’s Choice works with individuals in RI, MA, as well as CT and helps compare across a wide variety of Medicare plans including [email protected] Blue Cross, United Health, Humana, and Harvard Pilgrim.

Neighborhood Health Plan of Rhode Island is a non-profit HMO founded in 1993 in partnership with Rhode Island’s Community Health Centers. Serving over 185,000 members, Neighborhood has doubled in membership, revenue and staff since November 2013. In January 2014, Neighborhood extended its service, benefits and value through the HealthSource RI health insurance exchange, serving 49% the RI exchange market. Neighborhood has been rated by National Committee for Quality Assurance (NCQA) as one of the Top 10 Med- www.nhpri.org icaid health plans in America, every year since ratings began twelve years ago.

RIPCPC is an independent practice association (IPA) of primary care physicians located throughout the state of Rhode Island. The IPA, originally formed in 1994, represent 150 physicians from Family Practice, Internal Medicine and Pediatrics. RIPCPC also has an affiliation with over 200 specialty-care member physicians. Our PCP’s act as primary care providers for over 340,000 patients throughout the state of Rhode Island. The IPA was formed to provide a venue for the smaller independent practices to work www.ripcpc.com together with the ultimate goal of improving quality of care for our patients.

The Rhode Island Medical Society continues to drive forward into the future with the implementation of various new programs. As such, RIMS is expanded its Affinity Program to allow for more of our colleagues in healthcare and related business to work with our membership. RIMS thanks these participants for their support of our membership.

Contact Megan Turcotte for more information: 401-331-3207 or [email protected] RHODE ISLAND MEDICAL SOCIETY

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Why You Should Join the Rhode Island Medical Society

The Rhode Island Medical Society delivers valuable member benefits that help physicians, residents, medical students, physican-assistants, and retired practitioners every single day. As a member, you can take an active role in shaping a better health care future. RIMS offers discounts for group membership, spouses, military, and those beginning their practices. Medical students can join for free.

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Career management resources Insurance, medical banking, document shredding, collections, real estate services, and financial planning Powerful advocacy at every level Advantages include representation, advocacy, leadership opportunities, and referrals Complimentary subscriptions Publications include Rhode Island Medical Journal, Rhode Island Medical News, annual Directory of Members; RIMS members have library privileges at Brown University Member Portal on www.rimed.org Password access to pay dues, access contact information for colleagues and RIMS leadership, RSVP to RIMS events, and share your thoughts with colleagues and RIMS

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Dept. of Health, AG Give Conditional Approval to LMW Healthcare (Westerly Hospital) and Yale-New Haven Affiliation

PROVIDENCE – The Rhode Island Department of Health • Ensure access to services for all patients without discrim- (RIDOH) approved, with conditions, the proposed affiliation ination, including payment source or ability to pay; between Westerly Hospital (LMW Healthcare) and Yale-New • Participate in interventions to improve the safety of Haven Health Services Corporation. opioid prescribing and expand medication-assisted treat- “We looked very closely at the application and issued a ment and services to address the overdose epidemic; decision with a series of patient- and community-focused • Submit a plan to RIDOH for the development of conditions,” said Director of Health NICOLE ALEXANDER- relationships with local tribal nations; and SCOTT, MD, MPH. RIDOH accepted an affiliation application from the orga- • Make the CurrentCare data available at all clinical sites. nizations on June 11, 2016. A public meeting about the affil- In addition to this Hospital Conversion Act approval signed iation was held in Westerly on August 2, 2016. by Dr. Alexander-Scott, she also accepted the unanimous Some of the conditions of the decision include that the recommendation of the Health Services Council to approve new hospital must: the Change in Effective Control application submitted by • Submit a plan for the delivery of primary care within the two organizations. an integrated healthcare delivery system for physical The Health Services Council is a group that advises (including oral health) and behavioral health (including RIDOH on healthcare facility licensing reviews. For the mental health and substance use) in the new hospital’s affiliation to move forward, both the Hospital Conversion service area; Act and Change in Effective Control applications needed approval (along with approval from the Rhode Island Attor- • Submit a plan to address the social and environmental ney General). factors within the new hospital’s service area that affect On September 6, Attorney General Peter F. Kilmartin also people’s health (for example, through coordination with announced that the Office of Attorney General (RIAG) has RIDOH’s Health Equity Zone initiative); approved, with conditions, the proposed affiliation. Under the Hospital Conversions Act, the Attorney General has 90 days to review and issue a decision on an expedited application. v

Dana-Farber Cancer Institute, Lifespan sign MOU

PROVIDENCE – Dana-Farber Cancer Institute and Lifespan leadership have signed a memorandum of understanding to form a partnership that will advance cancer treatment and expand research. The details will be finalized early next year. The partnership will focus on five areas: genomics and precision medicine; clinical trials; value-based care and cancer care delivery innovation; shared care models; and cancer workforce development. As the planning moves forward, the two organizations are already collaborating on a multi-site grant application to the National Human Genome Research

Institute (NHGRI) to study the clinical utility of genomics Standing up for equality information. “This is an exciting opportunity to create a meaningful in the communities we serve and impactful partnership,” said DAVID E. WAZER, MD, Aetna is proud to support the members director of the Lifespan Comprehensive Cancer Center. of the Rhode Island Medical Society. “More can be accomplished when strong organizations work together on joint research projects, the development of inno- Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna). vative new treatments, and ensuring access to the best care ©2016 Aetna Inc. for our entire community.” v 2016028

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Brown launches the country’s first four-year, integrated MD/MPA program

PROVIDENCE – A new dual-degree program at Brown Uni- collaboration across the campus. Everyone can see the need versity aims to train students in both medicine and health for policy-savvy health care leadership. There’s nothing else care policy and create the next generation of leaders in those like this program. This is a terrific collaboration that will ben- intersecting fields. Students who complete the four-year efit and educate the students in both medicine and policy.” program will earn both a doctorate of medicine (MD) and a In the first year, stu- master of public affairs (MPA). dents take courses in Students who complete the four- “This degree program was developed knowing what health systems science knowledge and skills students will need if they want to and public organizations year program will earn both a effect change in health care moving forward,” said DR. PAUL management. They also doctorate of medicine (MD) and GEORGE, assistant dean of medical education at Brown’s begin a four-year Policy Warren Alpert Medical School. “It is important for us that in Action consultancy, a master of public affairs (MPA). students have an idea of what shapes health policy and gain spending a half-day per practical experience in this arena, so that they will be facile week in a leading health care system, foundation or non-gov- in promoting health policy changes during their careers.” ernmental organization, shaping and implementing a project This is the first integrated program of its kind in the U.S., with a real-world client. in which students are able to complete their degrees in four In subsequent years, students engage in a longitudinal years and take courses taught by both medical school and clerkship with a mentor physician. They work with an public policy faculty. Other institutions offer five- or six- assigned panel of about 30 patients, whom they follow to year joint programs and sometimes require students to apply health care settings ranging from the operating room to pri- to a master of public affairs program only after their course mary care doctors’ and specialists’ offices. of medical study is underway. At Brown, the degrees are By the third year, MD/MPA students gain global policy integrated from the start. experience by spending 10 days in an international setting Students must be admitted to the Warren Alpert Medical where they meet with elected officials, entrepreneurs and School before opting for the dual-degree track, in which they lawmakers to examine how policy is constructed. Past sites study with faculty from Brown’s Watson Institute for Inter- for these immersion programs have included Sweden, Brazil, national and Public Affairs. The integrated MD/MPA pro- India and Cambodia. gram has a June start date, and the first cohort of dual-degree This international emphasis is unique to the Watson students will be enrolled in the summer of 2017. Institute’s MPA program, the only program in the country James Morone, director of the A. Alfred Taubman Center to integrate an international policy experience into the core for American Politics and Policy, said, “This is an exciting curriculum. v program that reflects one of Brown’s great strengths – active

EpiVax awarded $600,000 NIH grant to improve a vaccine for the H7N9 avian influenza virus

KINGSTON – University of Rhode Island at the National Institutes of Health. The H7N9 influenza has been called Research Professor ANNIE DE GROOT, De Groot and URI associate professor a “stealth virus’’ because of its ability MD, and her team at EpiVax have Lenny Moise, the director of vaccine to evade the human immune response, been awarded a $600,000 grant from research at EpiVax, will oversee the both in natural infections and in vac- the National Institutes of Health to research in collaboration with Ted cine formulations. H7N9 vaccines improve a vaccine for the H7N9 avian Ross, director of the Center for Vaccines developed using conventional methods influenza virus. and Immunology at the University have significantly underperformed in De Groot is the co-founder, chief of Georgia. clinical trials. De Groot says that the executive officer and chief scientific The novelty of the program stems EpiVax program aims to re-engineer officer of EpiVax, a Providence-based from the concept that vaccines can be H7N9 viral proteins to be more easily biotechnology company. She is also the “immune engineered’’ to be more effec- detected by the immune system, result- director of the URI Institute for Immu- tive, De Groot says. Re-engineering ing in a more potent vaccine product. nology and Informatics, where she and the viral proteins to produce more of The first version of the vaccine from her colleagues apply bioinformatics an immune response without modify- EpiVax will soon enter a trial in Aus- tools to develop vaccines for emerging ing their ability to generate protective tralia in collaboration with Vaxine in infectious diseases. antibodies to the original “wild-type” Australia and Protein Sciences Corp. The grant was from the Small Busi- version is the major focus of the work in Connecticut. v ness Innovation Research program under the new program, she says.

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Drs. Viren D’Sa, Barry Lester awarded $11.1M NIH grant to study environmental influences on child health

The National Institutes of Health University, which has followed chil- for the Study of Children at Risk and (NIH) recently announced $157 mil- dren from as young as three months of professor of psychiatry and pediat- lion in awards in fiscal year 2016 to age since 2010 under a previous NIH rics at the Alpert Medical School, and launch a seven-year initiative called grant, and a second based in Colorado, CARMEN MARSIT, PhD, formerly of Environmental Influences on Child which has enrolled pregnant mothers. Women & Infants/Brown and now Health Outcomes (ECHO) – a program Combined, these studies sought to a professor at Emory University in that will investigate how exposure to a examine pre and postnatal influences Atlanta. The project is entitled “Envi- range of environmental factors in early that shape pediatric development. ronmental Influences of Neurodevel- development influences the health of “We are looking to better under- opmental Outcome in Infants Born children and adolescents. stand how the various environmen- Very Preterm.” Two Care New England hospitals tal, genetic and nutritional influences This grant will enable Dr. Lester and – Memorial Hospital and Women & interact to shape early brain develop- his colleagues to enhance the work they Infants Hospital of Rhode Island – were ment from the prenatal stage through are doing through an existing study – among the 35 pediatric cohorts who childhood and to puberty,” Dr. Deoni the Neonatal Neurobehavior and Out- will together enroll more than 50,000 said. “We will investigate how fac- comes in Very Preterm Infants (NOVI) children to study the early environ- tors such as the in utero environment, Study. Sponsored by the National mental origins of health outcomes. The starting as early as 22 weeks gestation, Institute of Child Health and Human initial award to Memorial is a two-year breastfeeding and early nutrition, lead Development, the primary goal of the grant of $6.2 million, and $4.9 million exposure, parent interaction, sleep and NOVI study is to learn about how early over two years to Women & Infants. daytime activity, pollution, and spe- detection of neurobehavior can iden- Pending successful completion of cific genes influence brain structure tify which individual infants are most this “feasibility phase,” an additional and function.” likely to suffer later developmental five years of funding is expected to The research will track the chil- impairment and advance interventions be available. dren’s performance in many functional to combat those developmental deficits. domains including academic progress “ECHO will enable us to study the Memorial as well, according to Dr. D’Sa. development of these infants in the The principal investigator at Memo- “By understanding how and when broader environmental cohort in which rial is VIREN D’SA, MD, the hospi- this diverse array of influences impact they develop, including a range of tal’s pediatrician-in-chief, director of brain growth and ultimately affect exposures from air pollution and chem- the New England Pediatric Institute childhood outcomes such as their per- icals in our neighborhoods to societal of Neurodevelopment (NEPIN) and formance in school or their chance of factors such as stress and parenting,” associate professor of pediatrics at developing a medical, developmental or Dr. Lester said. “At the same time, The Warren Alpert Medical School of behavioral disorder, we hope to identify NOVI will contribute a unique popu- Brown University, who is working with predictors of such outcomes and learn lation of very low birthweight infants SEAN DEONI, PhD, a neuroimaging how interventions can be optimized for to the pooled ECHO sample and study physicist at the University of Colorado a particular child to maximize their how the effects of the kind and timing of and adjunct professor at the School of individual potential,” he said. early exposures can be detected amongst Engineering at Brown University. these diverse populations. This is a They will draw on information Women & Infants win-win study, with children and their gleaned from about 1,100 children Principal investigators at Women & families as the ultimate winners.” v enrolled in two ongoing studies – one Infants are BARRY M. LESTER, PhD, based at Memorial Hospital and Brown director of the hospital’s Brown Center

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Hasbro receives $1.8M from NIH to study environmental influences on child health

PROVIDENCE – Hasbro Children’s Hos- by THOMAS CHUN, MD, a pediatric Researchers will look at a broad pital, the pediatric division of Rhode emergency medicine physician at Has- range of potentially harmful exposures, Island Hospital, has been awarded a bro Children’s Hospital, and ABBOT from air pollution and chemicals in $1.8 million grant from the National LAPTOOK, MD, medical director of neighborhoods, to societal factors such Institutes of Health (NIH) as part of the Neonatal Intensive Care Unit at as stress, to individual behaviors like a national research project to study Women & Infants Hospital. sleep and diet. Some exposures may the effects of environmental expo- ECHO studies will focus on four key act through any number of biological sures on the health and development pediatric outcomes: upper and lower processes, for example, changes in the of children. The grant is tied to a NIH airway; obesity; pre-, peri- and postna- expression of genes or development of $157-million, seven-year initiative tal outcomes; and neurodevelopment. the immune system. called Environmental influences on “We know that pediatric health A critical component of ECHO will Child Health Outcomes (ECHO). issues can impact a child for the rest be to use the NIH-funded Institutional The ECHO program will investigate of his or her life,” said Dennery. “But, Development Awards (IDeA) program how exposure to a range of environ- we also know that early intervention to build state-of-the art pediatric clin- mental factors in early development can drastically improve the course of a ical research networks in rural and – from conception through early child- child’s long-term health and even avoid medically underserved areas, so that hood – influences the health of chil- negative outcomes altogether. So, bet- children from these communities can dren and adolescents. ter understanding of how maternal and participate in clinical trials. Hasbro The Hasbro Children’s Hospital environmental influences impact dis- Children’s Hospital is one of 17 of these research will be led by PHYLLIS DEN- eases such as autism, obesity and asthma sites, with a goal of enrolling more than NERY, MD, pediatrician-in-chief at amongst others, will be very import- 50,000 children nationally. v Hasbro Children’s Hospital. Den- ant to the health of Rhode Island chil- nery will be joined on the initiative dren and children across the country.”

Research Team Studies Use of Smartphone App to Teach Sexual Health to Adolescent Girls New research published in The Journal of Pediatric and Adolescent Gynecology

PROVIDENCE – A research team 17 girls with iPhones used the led by LYNAE M. BRAYBOY, MD, Girl Talk application for two reproductive endocrinologist in weeks and answered the revised the Division of Reproductive sexual health questionnaire and Endocrinology and Infertility at interview questions before and Women & Infants Hospital of after the application use. The Rhode Island and at The Warren participants’ responses to the Alpert Medical School of Brown sexual health questionnaire, University, found that a smart- interviews and time viewing the phone application vs. traditional application were used to deter- methods can potentially con- mine feasibility and desirability nect teenage girls to more infor- Lynae M. Brayboy, MD Carol Wheeler, MD of Girl Talk. mation about sexual health. The Dr. Brayboy explained that research, entitled “Girl Talk: A Smartphone Application to Girl Talk was used on average for 48 minutes during partic- Teach Sexual Health Education to Adolescent Girls,” was ipants’ free time on weekends, generally in 10 to 15 minute recently published in The Journal of Pediatric and Adoles- intervals. The reported usefulness of Girl Talk as a sexual cent Gynecology. The article was co-authored by CAROL health application increased significantly from baseline WHEELER, MD, also of Women & Infants/Brown University. (35.3%) to follow-up (94.1%).“More than three-quarters of “We found that a smartphone application is a feasible the participants were exposed to sexual health education sexual health educational tool that is appealing to teenage before using Girl Talk, but 94.1% of participants stated that girls,” said Dr. Brayboy. “In fact, our participants recom- the application provided new and/or more detailed informa- mended the application as a valuable resource to learn about tion than health classes.” comprehensive sexual health.” Dr. Brayboy and her team will be seeking opportunities to For their research, Dr. Brayboy and her team recruited perform additional trials to determine if Girl Talk improves 39 girls ages 12 to 17 from Rhode Island to participate in a sexual health knowledge, increases contraception usage and two-phase prospective study. In phase one, 22 girls assessed decreases sexually transmitted infections and unplanned a sexual health questionnaire in focus groups. In phase two, pregnancy. v

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Research Evaluates Risk Factors for Postpartum Depression in Mothers of Preterm Infants Research team from Women & Infants Hospital publishes in The Journal of Pediatrics

PROVIDENCE – Postpartum depression Department of Pediatrics at the Alpert Hawes said, “Mothers of early, mod- is the most common complication Medical School. erate and late preterm infants reported of pregnancy and childbirth, affect- “We found mothers with a previous similar rates of possible depression – ing up to 15 percent of all women mental health disorder and experienc- 20%, 22% and 18% respectively – one within the first three months fol- ing negative perceptions of herself and month after NICU discharge. A history lowing delivery. Research has shown her infant at NICU discharge were of mental health disorder, decreased that mothers of infants born prema- at increased risk for depression one perception of maternal well-being, turely have almost double the rates month post discharge, regardless of decreased maternal comfort regarding of postpartum depression, particu- the infant’s gestational age at birth,” her infant, and decreased perception of larly during their time in the neonatal explained Hawes. family cohesion were also associated intensive care unit (NICU). The study included 724 mothers of with possible depression at one month Research led by BETTY R. VOHR, MD, preterm infants who were cared for post discharge.” director of Women & Infants’ Neonatal more than five days in the NICU and Hawes and her colleagues con- Follow-Up Program and professor of participated in a Transition Home Pro- cluded that comprehensive mental pediatrics at The Warren Alpert Med- gram. Families in the program received health assessment prior to discharge ical School of Brown University, found enhanced support and education about is essential to identify women at risk that there are certain social and emo- their infants from former NICU parents and provide appropriate referrals. She tional factors that further increase the trained as family resource specialists. said, “Comprehensive transition home risk of postpartum depression in moth- Participants completed an evaluation assessment and interventions to reduce ers of preterm infants. The research, prior to discharge to determine their anxiety and bolster maternal mental entitled “Social Emotional Factors perceptions of NICU staff support, health, confidence and readiness, along Increase Risk of Postpartum Depres- infant well-being, maternal well-be- with post discharge assessment, are sion in Mothers of Preterm Infants,” ing (emotional readiness/competency), needed to identify, treat and support has been published in The Journal of and maternal comfort (worry about mothers of preterm infants.” Pediatrics. Lead author is KATHELEEN her infant). Mental health history and The research team also included HAWES, PhD, RN, of the Center for social risk factors were also obtained Women & Infants/Brown University col- Children and Families at Women & by the researchers. At one month post leagues ELISABETH MCGOWAN, MD; Infants Hospital of Rhode Island and discharge, the Edinburgh Postnatal MELISSA O’DONNELL, MSW; and assistant professor (adjunct) in the Depression Scale was administered. RICHARD TUCKER, BA. v

Women & Infants Participating in National Pelvic Floor Disorders Network

PROVIDENCE – Women & Infants Hospital has generations to come. From a patient perspec- been selected by the National Institutes of tive, being part of this network also brings new Health’s (NIH) to participate in the Pelvic Floor and cutting edge treatment options to women Disorders Network (PFDN) for a second con- in our region.” secutive five-year cycle. Women & Infants is The five-year grant from the NIH’s Eunice one of just seven medical centers from across Kennedy Shriver National Institute of Child the US, and the only one in the Northeast, to Health and Human Development will enable work collaboratively to develop and perform members of the Network to design and conduct research studies related to women with pelvic large-scale, high quality studies to significantly floor disorders. advance the care of women with pelvic floor dis- Principal investigator at Women & Infants orders. Studies include treatments and preven- is VIVIAN SUNG, MD, MPH, FACOG of Women & Infants’ tion of urinary incontinence, fecal incontinence, pelvic organ Division of Urogynecology and Reconstructive Pelvic Sur- prolapse, and other sensory and emptying abnormalities gery and associate professor at The Warren Alpert Medical of the lower urinary and gastrointestinal tracts. School of Brown University. Studies currently enrolling include a randomized trial “Pelvic floor disorders are an issue of growing importance, studying the most effective procedures for prolapse of the from both an individual and public health point of view,” vagina, a randomized trial studying different treatment said Dr. Sung. “Participating in such high-level, national options for controlling bowel leakage, and a randomized research will offer us the opportunity to test and refine trial evaluating the best treatments for mixed urinary the most appropriate treatment protocols for women for incontinence. v

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Enrollment 100% in Prescription Drug Monitoring Program Dr. Linda J. Resnik at Providence

PROVIDENCE – One hundred percent of healthcare providers who are authorized VA awarded $2.5M for Multi- to prescribe opioids and other potent medications are now enrolled in the Center Amputation Care Study state’s Prescription Drug Monitoring Program (PDMP), the Rhode Island PROVIDENCE – DR. LINDA J. RESNIK, a Department of Health (RIDOH) announced last week. researcher at the Providence VA Medical In addition to prescribers, the PDMP is used by pharmacists when filling Center, was awarded a prescriptions. Legislation from 2014 requires all prescribers of controlled sub- three-year contract by the stances to register for the PDMP; however, before RIDOH initiated a PDMP Department of Defense Education, Notification, and Enforcement Plan in January 2016, only approx- on Sept. 23rd to study imately 40% of prescribers had done so. Through increased training and staff the care of veterans and visits to practices, RIDOH helped boost enrollment to 100%. service members with “The Prescription Drug Monitoring Program is an indispensable tool in the upper-limb amputations. fight against the epidemic of overdose in Rhode Island,” said Director of Health “This study will be the and Overdose Task Force Co-Chair NICOLE ALEXANDER-SCOTT, MD, MPH. largest, most comprehen- In addition to ensuring all eligible users are enrolled in the PDMP, RIDOH sive, study of Veterans is working to enhance the tool to make it easier for users to integrate it into and service members with upper-limb their current practice and support better patient care. amputation,” said Dr. Resnik, the princi- Rhode Island’s PDMP is now connected to similar databases in Massachu- pal investigator for the study, who is also setts, Connecticut, and seven other states, and prescribers will soon auto- a professor of research at the Department matically be notified about potentially risky prescribing behaviors by any of Health Services, Policy and Practice at prescriber treating their patients. RIDOH is also working with practices to Brown University. “Findings will be used help connect the PDMP to patients’ electronic health records. v to improve quality of care, and inform evidence based policies for device pre- Southcoast Health’s Center for Weight Loss at Charlton scription and provision of rehabilitation earns national accreditation services.” The nearly $2.5 million contract, FALL RIVER, MASSACHUSSETS — Southcoast Health announced last week that the awarded by DOD’s Orthotics and Pros- Center for Weight Loss at Charlton Memorial Hospital in Fall River has been thetics Outcomes Research Program to accredited as a Comprehensive Bariatric Center under the Metabolic and Bar- the Ocean State Research Institute Inc., iatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), the non-profit arm of the Providence a joint program of the American College of Surgeons (ACS) and the American VAMC, will provide data to assess the Society for Metabolic and Bariatric Surgery (ASMBS). quality of amputation care in VA and Southcoast Health’s Center for Weight Loss at Tobey Hospital in Wareham the DOD, and the impact of their new is also accredited by the MBSAQIP. evidence based clinical practice guide- The MBSAQIP standards ensure that bariatric surgical patients receive a lines for the rehabilitation of people with multidisciplinary program, not just a surgical procedure, which improves upper limb amputation over a one-year patient outcomes and long-term success. The accredited center offers preop- follow-up period. erative and postoperative care designed specifically for their severely obese A cross-agency collaboration, the study patients. will include participation by the Univer- “We are pleased to add Charlton Memorial Hospital to our already well- sity of Massachusetts Medical School; established bariatric program at Tobey Hospital. Patients in the Fall River and University of South Florida; Henry M. Rhode Island region now have easy access to a comprehensive weight loss Jackson Foundation for the Advancement surgery program that has been recognized nationally for excellence. Local sur- of Military Medicine Inc. at the Center gical care provides patients with convenient access and improves outcomes for the Intrepid at Brooke Army Medical with better long-term follow up support,” said RAYFORD KRUGER, MD, Center; Tampa VA Research and Educa- FACS, Chief of the Southcoast Center for Weight Loss. tion Foundation at the James A. Haley To earn the MBSAQIP designation, the Center for Weight Loss at Charlton VA Medical Center; North Florida Foun- Memorial met essential criteria for staffing, training and facility infrastruc- dation for Research and Education at the ture and protocols for care, ensuring its ability to support patients with severe Malcom Randall VA Medical Center; obesity. The center also participates in a national data registry that yields McGuire Research Institute at Hunter semiannual reports on the quality of its processes and outcomes, identify- Holmes McGuire VA Medical Center; ing opportunities for continuous quality improvement. The standards are and the Seattle Institute for Biomedical specified in the MBSAQIP Resources for Optimal Care of the Metabolic and and Clinical Research at VA Puget Sound Bariatric Surgery Patient 2014, published by the ACS and ASMBS. v Health Care System. v

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A Long Journey from Thailand to Memorial Lab for a Good Night’s Sleep

PAWTUCKET – Eden Weinmann hadn’t had a good night’s sleep in 30 years. Scolio- sis arcs his spine into a 103-degree curve, making it difficult to breathe when he would lie down. When he did drift off, the curvature triggered gastroesophageal re- flux disorder (GERD), high blood pressure and a pressing need to urinate several times a night. Over the years, Weinmann, a Wash- ington, DC, native who lives in Thai- land and has worked as a lawyer, writer, economist, urban planner and management consultant – sought medical help for much-needed sleep. He says he found that “every doctor tends to know what’s in their specialty, whether it’s urology or pulmonology.” “I went to five major medical centers – four in America, one in Asia – and nine doctors in the last year and a half and none could pull it all together. Many wanted to operate on my back,” Weinmann said. Called “teenage onset idiopathic scoliosis,” the disease left him unable to sleep F. Dennis McCool, MD, at left, interim chief of pulmonary, sleep and critical care medicine at more than an hour straight, which made Memorial and medical director of the sleep labs at both Memorial and Kent hospitals stands with him think he might have chronic fatigue grateful patient, Eden Weinmann. syndrome. Then he noticed that his blood pressure would be elevated when he weren’t fully inflating and there was little Columbia and Massachusetts Institute of woke up. He researched the connection difference in his sleep. Needing to get an Technology graduate. and found sleep apnea. expert’s help, he made an appointment in Dr. McCool, who is also a Professor of “It was like being waterboarded inces- January and took the long transcontinental Medicine at the Warren Alpert Medical santly all night long, but I saw that and it trip to see Dr. McCool. School of Brown University, says he be- was like ‘boom!’ Then I found a chapter The doctor scheduled a sleep study. lieves in blending clinical acumen with about diseases of the chest wall in Mur- Based on the numbers from Weinmann’s knowledge of respiratory physiology. ray and Nadel’s Textbook of Respiratory machine, Dr. McCool says he was able to This allows one to make better connec- Medicine,” Weinmann says of the piece start the machine on a high pressure and tions between a specific disease or condi- written by F. DENNIS MCCOOL, MD, inch backwards until he reached the right tion with other possible symptoms. interim chief of pulmonary, sleep and setting. “People don’t have the time to think critical care medicine at Memorial and After trying five categories of urine about the physiological side of things, but medical director of the sleep labs at both remedies, cognitive behavior therapy, they need to because there are so many Memorial and Kent hospitals. GERD medications, and limiting caffeine answers in the overlap,” he says. “In the chapter, Dr. McCool connects during the day, Weinmann says his night Weinmann, who remains temporarily chest wall disease with sleep apnea,” in the Memorial Hospital Sleep Lab was in Rhode Island to continue seeing Dr. Weinmann said. “great.” Once he was able to get more McCool, says he is so pleased with the Dr. McCool wrote that he had seen sleep, he found his daytime work sched- comprehensive approach taken in caring significant improvement when patients ule improved as he was able to concen- for him at Memorial that he would like with chest wall diseases use a bipap ma- trate more on work and did not need naps. to “find a way to extend ‘Pawtucket care’ chine that uses pressure to get the air “It was a huge weight being lifted off over the rest of my medical treatment, in- into the lungs. Weinmann bought his my shoulders, like a major black cloud cluding outside Pawtucket, both now and own machine, but didn’t know what pres- of the quality of my life going away and into the future, in this country and also sure setting to use. As a result, his lungs the sunshine coming back out!” says the in Asia.” v

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Recognition Patrick Sweeney, MD, receives ACCME’s 2016 Rutledge W. Howard, MD, Award Dr. Alan Morrison’s Research Project at VA CHICAGO – The Accreditation Council for Continuing Medical Education (ACCME®) Funded to Study Heart Valve Disease announced that PATRICK SWEENEY, PROVIDENCE – DR. ALAN MORRISON, a MD, MPH, PHD, is the recipient of the cardiologist at the Providence VA Medi- 2016 Rutledge W. Howard, MD, Award for cal Center, was awarded a 12-month pilot Individual Service to the Intrastate Accred- project August 29 through Ocean State itation System. Research Institute to study the thicken- Given in two categories, this award ing and hardening of aortic heart valves. recognizes state medical societies, their staff, and volunteers for Dr. Morrison, who is also an assistant their contributions and commitment to advancing community- professor of medicine at the Warren Alp- based continuing medical education (CME) programs and the intra- ert Medical School of Brown Universi- state accreditation system. ty, said his team’s long-term goal is to The recipients will be given their awards during a ceremony at develop new treatments to improve the the ACCME State/Territory Medical Society Conference, to be held survival rate and quality of life for veterans with calcific December 7–8, 2016, in Chicago. aortic valve disease. Dr. Sweeney was nominated for the award by the Rhode Island Coronary heart disease is the leading cause of death for Medical Society (RIMS). For the past 23 years, Dr. Sweeney has U.S. veterans. led the RIMS Committee on CME as Chair. Under his leadership, Morrison said previous research identified some key RIMS has continued to be designated as an ACCME Recognized inflammatory signals associated with the calcification of Accreditor of intrastate CME. plaque in the hearts of veterans. “It turns out that, as we Dr. Sweeney has served in many roles at Women and Infants Hospi- inhibited the calcification of plaques, we also slowed aor- tal, including as Director of Medical Education, Director of CME, Chair tic valve thickening and hardening,” said Dr. Morrison. of the CME Committee, and Chair of the Graduate Medical Education “We hope to apply what we’ve learned to develop effective Committee. He also spent 17 years as Associate Dean of Medicine for treatments for aortic stenosis.” v CME at Brown Medical School. Dr. Sweeney has been involved with CME on a national level since 1992 as an ACCME surveyor, surveying more than 75 nationally accredited CME programs. He has served as a member of the ACCME Committee for Review and Recognition, and as a member, Vice Chair, and Chair of the ACCME Accreditation Review Committee. “As I look back over the list of previous recipients of this award, I am impressed by how many of them have become valued personal friends and colleagues. I am indeed honored to have my name added to such a prestigious list of CME professionals, and I am grateful to the Rhode Island Medical Society for having submitted my name in nomination. During my 25 years in CME I consider myself extremely fortunate to have worked with some of the most talented and committed individuals in our field, and I gratefully share this recognition with them,” he said. “It is very difficult to do justice to the breadth, depth, and distinction of Dr. Patrick Sweeney’s long service to CME in Rhode Island and nationally. He has been recognized and honored by his peers on numerous occasions, and has earned the respect of our legislators and regulators for his steadfast single-handed defense of the integrity of CME from the

MATTHEW HEALEY MATTHEW many unripe ideas that too often spring up in the halls of state govern- More than 500 swimmers participated in the seventh annual Swim ment. Due to Patrick’s commitment to the community and education, he Across America at Roger Wheeler State Beach in Narragansett re- was honored by his colleagues with the Medical Society’s special award cently, raising more than $158,000 for cancer research at Women & for medical professionalism. On behalf of all his colleagues and friends Infants Hospital. At the event were, from left, Mark R. Marcantano, in Rhode Island, we thank the ACCME for formally recognizing this president and chief operating officer at W&I; Dr. Maureen Phipps, fine gentleman and physician,” said RUSSELL A. SETTIPANE, MD, chief of obstetrics and gynecology at W&I, and Dr. Paul DiSilves- President, Rhode Island Medical Society. v tro, W&I’s interim director of the Program in Women’s Oncology.

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Appointments Edward Hurley, MD, named President-elect of Pediatric Research Society, Junior Section EDWARD HURLEY, MD, a second-year neonatal-perinatal med- Dr. Stephanie Curry joins icine fellow at Women & Infants Hospital, has been chosen as president-elect of the Junior Section of the Society for Pediatric CharterCARE Medical Associates Research (SPR). His term begins immediately and will run through PROVIDENCE – DR. STEPHANIE A. CURRY, a June 2017, at which point he will begin his one- physician specializing in endocrinology, di- year term as president of the society. abetes and metabolism with an added inter- A graduate of the University of Massachusetts, est in obesity medicine, has joined Charter Amherst, and of Harvard University, Dr. Hurley CARE Medical Associates (CCMA). earned his medical degree at New York Medical Dr. Curry is a graduate of the Medical College. He completed an internship and resi- University of the Americas, completed her dency in pediatrics at Brown University/Hasbro Internal Medicine residency at Roger Wil- Children’s Hospital. He has published research in liams Medical Center and recently completed a Fellowship Pediatrics, The American Journal of Medical Ge- in Endocrinology, Diabetes and Metabolism at Lahey Hos- netics, The Rhode Island Medical Journal, and pital and Medical Center in Burlington, Mass. Dr. Curry has The Archives of Disease in Childhood, Fetal and Neonatal Edition. co-authored 14 academic publications and presentations. She The mission of the American Pediatric Society’s Society for has also participated in numerous research projects at Lahey Pediatric Research is to foster the research and career development Hospital and Medical Center, Miriam Hospital and Roger of investigators engaged in creating new knowledge that advances Williams Medical Center. the health and well-being of children and youth. Since 2012, the At CCMA, Dr. Curry’s practice will concentrate on general Society for Pediatric Research Junior Section has helped to intro- endocrinology with a special focus on treating diabetes and duce and integrate trainees into the Society by promoting scholarly on medical weight loss, in collaboration with the Roger work and serving as a resource for those making the transition to Williams Weight Loss Surgery Program. v junior faculty. v

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Daughters of Asclepius: Early women physicians in Rhode Island

MARY KORR RIMJ MANAGING EDITOR

In a 1971 issue of the Rhode Island Med- position, which she held for a year. Here ical Journal, Dr. Seebert J. Goldowsky she began a lifelong association with described MARTHA H. MOWRY, MD, abolitionist and leader of the women’s (1818–1899), as the first woman medi- suffrage movement, Lucretia Mott. cal practitioner in the state, although he However, a year later Dr. Mowry could find no record of her as a Fellow returned to Providence at the wish of of the Rhode Island Medical Society. her father, a longtime widower. She then According to his account, she began began a regular practice on South Main to study medicine in 1844 with Drs. Street. “Her father presented her with Briggs, Fabyan, Fowler and Mauran. a horse and chaise, and since then, for They advised her to continue her stud- nearly 40 years, she has constantly kept ies in Boston, particularly in laboratory one or two horse in use in her rounds dissections. In 1850, Mowry was asked of practice. In 1880 she partially retired to take charge of a medical college in from practice, but the demands upon her Boston (probably the New England seemed so pressing that she consented in Female Medical College) where she 1882 to resume work under limitations absolving her from going out nights, except in extreme cases,” Helen C. Putnam, MD “Of all the crimes against life the wrote Richard M. Bayles, in the History of Providence County, for Women and Children in Boston. worst is our infant mortality rate.” Rhode Island in1891. When she began her practice in Prov- — Helen C. Putnam, MD DR. ANITA ELIZABETH TYNG idence she won the esteem of “many was the first woman to be admit- prominent people by her good sense ted as a Fellow of the medical and ability.” worked closely with “Drs. Cornell, society, on Dec. 18, 1872. She was an Hersey noted her most famous Page, Gregory and to others,” accord- 1864 graduate of the Woman’s (previ- case was “one of removal of the ova- ing to American Women: Fifteen Hun- ously Female) Medical College of Penn- ries by abdominal section to check dred Biographies, published in 1893. sylvania in Philadelphia. At the society’s the growth of a uterine fibroid.” The At the same time, The Providence annual meeting in 1882, Dr. Charles operation was performed in 1880 in Physiological Society, founded in 1850, W. Parsons described Tyng as the med- Providence, with only women in the sponsored monthly lectures and meet- ical society’s first Soror-Socius“ ” at operating theater, “all of whom had ings, attended mostly by women, for 12 the annual meeting. “If we are to have carefully bathed with carbolized water years. According to Rhode Island His- women doctors at all, do let us have and wore fresh, clean, calico dresses.” torical Society records, “Many lectures well-educated ones, and if this Society In 1883, Tyng accepted a position as were given by the Society’s members, does anything to keep up the standard, surgeon at the Woman’s Hospital in including Dr. Martha H. Mowry, one let them and their patients have the good Philadelphia. “By consecrated indus- of the first female physicians practic- of it.” He noted “the contrast between try and a constant striving after that ing in Rhode Island and president of the action of this Society and our broth- happy buoyancy of mind which Dr. the Society for several years. Topics of ers in Massachusetts, who have not yet Osler tells us underlies all successful lectures ranged from anatomy lessons opened their doors to women.” effort, our first woman fellow raised to discussions of women’s rights.” According to an appreciation of her herself to eminence in her profession,” In 1853, the Female Medical College life written by Dr. George H. Hersey Hersey wrote. of Pennsylvania, conferred on Mowry in 1913, Tyng began her medical work In an 1883 issue of Transactions, an MD and offered her a teaching early in life at the New England Hospital Dr. Dan King is quoted: “If women

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choose to dip their delicate fingers society in 1892, could be called the cup a part of the schoolhouse since it is in dead men’s gore and become skill- queen of hygiene. Also a graduate of the chained to the wall. The sooner moth- ful anatomists and otherwise qualify Woman’s Medical College of Pennsylva- ers insist on its banishment, the safer themselves for the practice of medi- nia, she was born in Minnesota and once their children will be from other chil- cine, we do not refuse to admit them.” described her family as “frontiersmen, dren’s sore lips, sore mouths, poison Providence native MARY P. ROOT, surrounded by Indians.” She kept the of decaying teeth and sore throats.” MD, an 1883 graduate of the Wom- pioneer spirit throughout her 93 years. Putnam also co-founded the Ameri- an’s Medical College of Pennsylvania, The National Institutes of Health can Child Health Association with Dr. joined the medical society in 1884, features Putnam in its traveling and Abraham Jacobi of New York City, con- but a year later sailed to India with the online exhibit of women physicians, sidered the father of American pedi- American Board of Foreign Missions. “Changing the Faces of Medicine,” as atrics. The following anecdote from She was appointed administrator of the a pioneer in introducing pre-natal and Vassar College’s Women in Science Women’s Hospital in Madura. neo-natal care for low-income families. archives (she was an 1878 alumna) In a letter to her Alumnae Associa- “Of all the crimes against life the worst shows her moxie: “At a meeting of tion, she wrote: “Uterine diseases are is our infant mortality rate,” she often the American Medical Association, a very common here, due partly to the proclaimed. learned doctor who was to speak on barbarous methods of the native mid- Putnam practiced infant and child social diseases declined to do so because wives, and partly no doubt to the early health and gynecology in Providence ‘there were ladies present.’ Putnam marriages and confinements…Miscar- for 43 years. As president of the Amer- rose to her feet, declared that she was riages are quite frequent. ican Academy of Medicine, she helped not so squeamish, and proceeded to “The people are fearfully anemic and organize a conference on infant mortal- deliver an address on the subject. She go into collapse easily. I am told that it ity in 1909, which led to the founding of was met with tumultuous applause.” is very common for the body to become the American Association for the Study In 1939 Putnam donated most of her suddenly cold – the patient shudders, and Prevention of Infant Mortality. sizable inheritance from a family mem- faints and dies.” She worked relentlessly to clean up ber to Butler Hospital and the Rhode Root remained in Madura until 1891. elementary school classrooms, fighting Island School of Design. She died in Later in her career she worked as res- for medical inspections and legislative Providence on February 3, 1951. v ident physician at Smith College in initiatives. In 1913, she published the Massachusetts, from 1906–1909. book, School Janitors, Mothers and In Providence, HELEN C. PUTNAM, Health. “Our topic is clean school- MD, who joined the state medical houses, and it is fair to call the common

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