Journal-1St-Quarter-April-3-2020.Pdf

1st Quarter, 2020 Volume 116, Number 01

www.wvsma.org 1st Quarter 2020 | Vol. 116 1 True Performers know data is at the heart of prevention.

As part of our True Performance program, we’re helping Dr. Bob Crossey keep his patients healthy. In fact, by using our data, he’s able to identify warning signs for congestive heart failure and get ahead of emergencies. Because of doctors like Bob, this program has avoided signiﬁ cant hospital costs by reducing emergency room visits and hospital stays.* There’s value in that. See how True Performance is helping providers improve care through data and incentives. Download the ebook at HighmarkTruePerformers.com.

True Performance results: 10% fewer emergency room visits 17% fewer hospital admissions

Bob Crossey, DO Premier Medical Associates True Performer

* Based on reduction in hospital costs for patients with True Performance doctors compared to those without from January 1, 2018, to June 30, 2018. Highmark Blue Cross Blue Shield West Virginia is an independent licensee of the Blue Cross and Blue Shield Association.

HC406631

WVSMA President, 2019-2020 Women in Medicine Dr. Elizabeth Blackwell was born school, we have risen to become Feb. 3, 1821 and died on May 31, leaders in medical organizations and 1920. Known as the pioneer to women in our communities. For the first in medicine, she was a British-born time in the history of the American medical practitioner, noted as the first Medical Association, there are three woman to receive a medical degree female presidents in a row; immediate in the United States, as well as the past-president Dr. Barbara McAneny, first woman on the United Kingdom current president Dr. Patrice Harris Scholars have long debated the true Medical Register. National Women and president-elect Dr. Susan Bailey. birth of the practice of medicine. The first evidence of surgery in the skulls of human remains has been found, dating 'For what is done or learned by one back to the stone ages. Fossilized evidence suggests some of these patients survived cranial operations class of women becomes, by virtue as an area within the bone had grown back in cadavers. Whether this is evidence of injuries that these men and of their common womanhood, the women sustained and survived or are a direct result of surgical intervention, we may never know. After all, property of all women.' electronic health records were not in use during the stone ages. Physician Day is celebrated annually Dr. Harris is a remarkable example Most attribute the birth of medicine on Feb. 3 in remembrance of her of female leadership who began her to Hippocrates of Kos, who was born contributions to the medical field. Her journey to becoming a physician in 460 B.C. and died 370 B.C. He was accomplishments are remarkable, in the Mountain State. Dr. Harris, a Greek physician and is considered especially when you consider women originally from West Virginia, was one of the most outstanding figures in did not have the right to vote in U.S. one of the distinguished guests at the the history of medicine, often referred elections until the year she died. 2019 WVSMA Healthcare Summit. to as the “Father of Medicine.” New Dr. Blackwell opened the door for Dr. Harris’s leadership through the physicians take the Hippocratic oath women physicians. Her work allowed American Medical Association is as they graduate and begin their women to earn their place in the remarkable and she continues to medical practices. We continue to see house of medicine. It would be nearly inspire other women in medicine to the importance of the early influences a century laterwhen the tides turned rise into leadership. into modern medicine. However, we when more women than men are With respect to our past, WVSMA did not see the first clinically trained entering medical school. According to will continue to lead the charge in and recognized female physician for the Association of American Medical supporting all physicians in their more than nearly two millennia after Colleges, in 2017, women officially roles, as well as supporting women Hippocrates. became the majority of those entering in becoming leaders within our medical school, at 50.7 %. organization. One of the ways we Not only have women became most have been recruiting our new leaders of the students enrolled in medical has been the policy rotation for

www.wvsma.org 1st Quarter 2020 | Vol. 116 33 President’s Message WVSMA serves an important role in shaping the future of medicine, especially with the support of women physicians. In WVSMA’s 154-year history, there have been four female presidents. I am the fourth. We need more women in leadership roles as we navigate into the future of medicine. The highly successful student policy rotations must continue. They are an excellent conduit for identifying future leaders. WVSMA must continue to welcome students, residents and physicians early in their medical practices. It’s exciting WVSMA is pursuing a women in medicine section, aiming to specifically connect to and support women physicians in West Virginia. To the past leaders of WVSMA, thank you for your time, personal sacrifice and for building the organization we have today. For the future leaders of WVSMA, never, never, never let anyone discourage you in becoming the physician leaders you are meant to be. *This article is dedicated to all women in medicine; past, present and future--specially four women who are the future of medicine; Dr. Lisa Costello, Clara Novotny, MS IV, Rachel Heist, MS IV, and Lyndsey Weatherly, MS IV.

Dr. Blackwell (pictured) opened the door for women

WVSMA Executive Director Danny F. Scalise and physicians. Her work allowed women to earn their Dr. Patrice Harris at the 2019 Healthcare Summit place in the house of medicine. It would be nearly third- and fourth-year medical students. Recently, I had the opportunity to work with three remarkable medical a century later ... when more women than men are students, who are the future of medicine. A few weeks ago, on what seemed an otherwise entering medical monotonous day, I had a visit from three exceptional medical students. What began as an hour-long discussion school. According on policy and the legislative process became a deeper discussion on the future of medicine. Settled into my to the Association new career as a public health officer, I sometimes forget of American to appreciate the importance of WVSMA and how much policy, or legislative change, impacts physicians’ careers. Medical Colleges, After several years as chair of the Legislative Committee, then moving through the ranks of WVSMA leadership, I in 2017, women am so happy with the achievements in our organization. Recruiting young medical students is important for the officiallybecame future of our organization. During this time with the medical students, I felt a the majority of renewed energy for WVSMA and the house of medicine. We must support the energy and bright ideas of those at the those entering beginning their medical careers. I am elated with the course medical school, at 50.7 %. of women in medicine and how much we have collectively achieved in the past 100 years. It is time to plan for the next 100 years.

4 West Virginia Medical Journal ©2020, West Virginia State Medical Association West Virginia Mutual Insurance Company R. Austin Wallace, MD Chairman and CEO West Virginia Mutual Insurance Conmpany A Jury of Our Peers?

It is my pleasure and privilege to be a member percentages in the survey are noted, with those of the Medical Professional Liability Association attributable to millennials shown in parentheses: Board of Directors since 2012. This organization, Litigation which underwent rebranding last year from its ~67%: If a case gets to the courtroom, it must have previous name, the Physician Insurers Association merit (80%) of America, to reflect a more diverse membership ~65%: There is a mechanism in the legal system to including international member companies, throw out frivolous lawsuits (74%) has many excellent educational programs for its ~27%: Filing a lawsuit is too hard (40%) member companies and their board members and ~35%: Filing a lawsuit is too easy (15%) employees. A quick review of the statistics reveals that there is definitely more bad news than good in these survey results.

One such offering was a meeting put on by the Disregard for the law/instructions Regional Member Roundtable, a group of similar ~43%: Would let sympathy affect verdict even if regionally focused companies for which I act as forbidden (55%) co-chair, as a part of a larger MPL Association ~34%: Would decide cases based on fairness meeting this past March. Our main speaker was rather than the law (46%) Claire Luna, who is chief executive officer of ~19%: Would consider [awarding] attorney fees JuryImpact, Inc., an Irvine, California, based even if told not to (46%) company that does deposition preparation for ~14%: Would do Internet research even if the defendants in medical liability lawsuits along with judge forbids it (44%) jury consulting for their counsels. She and her firm did a survey of more than 500 Damages/responsibility jury-eligible people recently that revealed what I ~77%: Hospital is responsible if a person is re- found to be some very interesting and occasionally very troubling findings about the attitudes of leased in worse condition than when they arrived potential jurors in general (and millennials in (consistent across generations) particular.) Millennials, often defined as those born from around 1980-1982 until the mid- 1990s, now represent the largest jury-eligible age (Continued on page 9) group in the United States. The positive response

www.wvsma.org 1st Quarter 2020 | Vol. 116 5 6 West Virginia Medical Journal ©2020, West Virginia State Medical Association statistics are often somewhat startling, we need Jury of our peers? to be very careful about what we wish for, as our (from page 7) own physician peers can be much more critical of medical liability defendants’ actions than lay ~43%: Would award money for medical bills even people. if no fault [is found] (62%) Dr. Robert Ghiz, our founding Chairman of ~39%: Would award more than plaintiff demand the Board at the Mutual, called this the “Grand to “make sure plaintiff is taken care of” (52%) Rounds Effect” when he spoke at our CARE risk ~26%: Would award more money if defendant is management seminars, and I picked up the term large hospital chain/medical system (42%) from him. During our training as physicians, ~12%: Would increase award with knowledge that we are conditioned to look at medical care with insurance would pay for it (22%) a very critical eye as part of the very necessary ~44%: Punitive damages claim increases likeli- performance quality improvement process for hood that mistake was made (consistent across residents, interns, and attendings. However, this generations) critical eye does not translate at all well to the le- A quick review of the statistics reveals that there gal arena. One of my CEO colleagues in another is definitely more bad news than good in these state remarked to me once that the physicians survey results. It is apparent that millennials are there had to ditch the state’s physician medical overall significantly more likely to be generous review panel process because the physicians on with jury awards, and I found it somewhat the pre-suit review panels tended to be much shocking that simply having a lawsuit get to the harder on their colleagues being sued than lay courtroom means that it has validity to potential jurors in actual trials. jurors and that merely making a claim for punitive Therefore, despite its flaws, as evidenced by a damages increases their concern about a mistake number of the attitudes of potential jurors dem- being made in all generations surveyed. onstrated in the survey done by Claire Luna and It is a given that our respect for the rule of law her company, a trial by a jury of our (lay) peers has defined Americans for the entirety of the remains the best option for us physicians, in my existence of our great country, and trials before humble opinion, and it continues to stand the juries of our peers are essential to this process. test of time despite societal changes. Please be We physicians not infrequently complain that a assured that your Mutual will continue to moni- jury of lay people does not represent a true jury tor trends such as these that affect you, as we are of our peers. However, even though the above Physicians Insuring Physicians. Save the date! 153rd WVSMA Healthcare Summit Aug. 21-23, 2020

www.wvsma.org 1st Quarter 2020 | Vol. 116 7 Pediatric Resident Legislative Rotation included updating the Naloxone law and the organizational structure of the Office of Drug Control Policy. It was interesting to observe how committees discussed bills, requested expert witnesses, and debated proposed bills based upon their understanding and perception. In medicine, our clinical decisions are supported by the current standard of care and available evidence-based medicine. There are certain instances during committee meetings when this is unavailable and therefore, we must consider the perspective of legislators and their constituents in order to successfully pass a bill into becoming law. We continued our health advocacy journey and met with Cathy Slemp, MD, commissioner of the Bureau for Public Health and State Health Officer. Dr. Slemp was welcoming and familiarized us on the many branches Allyn Small, MD Accompanied by pediatric hospitalist of her organization. She was gracious Jeffrey Lim, DO attendings Neil Copeland, MD, enough to lead us in our discussion and Lisa Costello, MD, we were of social determinants of health and During the month of January, we introduced to Majority Leader Sen. the tremendous impact public health participated in an elective legislative Tom Takubo, DO, and Del. Margaret has on our patients and their families. rotation with the West Virginia State Staggers, MD, fellow physicians We then met with Sherri Young, DO, Medical Association. This rotation passionate about making a change for executive director of the Kanawha- was different from our traditional patients and families in West Virginia. Charleston Health Department, who medicine rotations. Because of the We discussed the lawmaking was extremely kind in inviting us hospitality and leadership of WVSMA, process and researched numerous to her workplace. While discussing we were granted the opportunity of bills related to health care as well as many pediatric topics such as the a lifetime. Throughout our rotation, bills that could potentially impact misconception that immunizations we had a multitude of inspiring and us as physicians in West Virginia. cause autism, Dr. Young shared her eye-opening experiences of how to We formed a legislative group with story of what it was like to be the first best flex our advocacy muscles to be a Elizabeth Strickler and Skylar Kipps state health immunization officer after voice for our patients as well as fellow from the West Virginia University the bill to streamline the process for physicians. School of Dentistry and created a medical exemptions passed several Our series of fortunate events fact sheet our senate bill to protect years ago. Both physicians and their commenced with the annual “Issues patients by prohibiting smoking in passions strengthened and inspired & Eggs” legislative breakfast to kick- vehicles when minors less than 18 us to continue to advocate for our off the 2020 legislative session. At years of age are present. We joined patients. this event, Senate President Mitch Del. Matthew Rohrbach, MD (Chair of In between attending Senate and Carmichael and House Speaker Roger the House Committee on Prevention House Health Committee meetings, Hanshaw addressed their concerns and Treatment of Substance Abuse) we continued our journey towards a and issues that they will be focusing and his committee for their discussion better understanding of health policy on during the legislative session. on multiple originating bills that

8 West Virginia Medical Journal ©2020, West Virginia State Medical Association Pediatric Resident Legislative Rotation and advocacy. We met with Justice associated lung injury) and the Evan Jenkins of the West Virginia WVSMA, Danny Scalise, and his staff regulation of such products. Spending Supreme Court of Appeals, who gave for all of their hospitality and planning time with Justice Jenkins and Sen. us insight on the innerworkings of that went into making this rotation Takubo motivated us to continue the judicial branch and the Rules of such an eye-opening and educational protecting our patients in the same Appellate Procedure, both of which experience. Our biggest takeaway from way these two gentlemen strive daily to were reinforced after observing several this rotation is to benefit our current protect those in West Virginia. oral arguments. Majority Leader Sen. and future patients as well as the As our legislative rotation came to Takubo graciously made time for us future of physicians, it is of the utmost a close, we reflected on the amazing in his busy schedule to discuss several importance to be actively involved in opportunities that were provided for topics that affected us clinically, health policy and advocacy regardless us. Our experiences provided a firm legislatively, and emotionally – of our current level of training or stage foundation which we can now build most notably the dangers of EVALI of life. upon. We would like to thank the (e-cigarette or vaping product use

In between attending Senate and House Health Committee meetings, we continued our journey towards a better understanding of health policy and advocacy. We met with Justice Evan Jenkins of the West Virginia Supreme Court of Appeals, who gave us insight on the innerworkings of the judicial branch and the Rules of Appellate Procedure, both of which were reinforced after observing several oral arguments. Majority Leader Sen. Takubo graciously made time for us in his busy schedule to discuss several topics that affected us clinically, legislatively, and emotionally.

www.wvsma.org 1st Quarter 2020 | Vol. 116 9 Fourth year rotation recollections Clara Novotny autoimmune disease increases. As this proposed bill, House Bill 4773, Meddical Student IV many physicians in West Virginia which would establish a workgroup West Virginia University know, these early stressors are often to investigate and recommend too common in this state. Although screening protocols for ACEs in Rachel Heist the long-term consequences of high this state. It was created by medical Medical Student IV ACE scores have been demonstrated professionals collaborating with West Virginia University in literature for decades, medical lawmakers to design the bill in a way that could be reasonably Lyndsey Weatherly providers lack tools and support to best assess and investigate prevention implemented. While many experts Medical Student IV contributed to the writing process, West Virginia University of these traumas and their adverse effects. we learned that bills must be Beginning this rotation as fourth Early in our health policy rotation, introduced by either a senator or year medical students interested in we met with public officials who delegate. In this case Del. Lisa Zukoff pursuing primary care specialties, address matters of the health of was the lead sponsor, and by her we had an understanding of the West Virginians on a daily basis. Our leadership the bill was formally importance of public health and the supreme court justices shared with introduced to the House of Delegates. reality that health and well-being are us their burden of cases involving Bills must be scrutinized and voted often impacted more by a person's custody decision-making. These cases through committees before they community and surroundings than often involve several of the designated can be presented to the full voting their individual interactions with ACEs, like substance use, divorce, and body of each chamber. HB 4773 was their medical providers. We had the abuse or neglect. We learned from directed to the House Committee incredible opportunity to witness epidemiologists and state leaders on Health and Human Resources. firsthand the process of how bills that at the Department of Health and Committee meetings often include shape both our practice of medicine Human Resources the pervasiveness discussion of the bill’s potential and patient resources are conceived, of ACEs and their associated chronic impact and testimony of members of designed, and implemented. This diseases within our population. Each the community who offer expertise unique experience helped us expert we encountered offered unique on the potential laws. We learned understand the complex system that thoughts on how best to approach there are several different types of crafts laws concerning issues that we the mounting health crises in our these committees in both the House are passionate about as we know they state that stem from these toxic and the Senate that also address will impact our future practices as stressors. This broad range of input health-relevant bills. Bills must physicians. from different perspectives confirmed survive each referenced committee to As students training in West Virginia, that a problem as ubiquitous as ACEs have the chance to be made into law. daily we see the impact that toxic requires a multi-faceted approach. During this rotation, we joined stressors in childhood have on a This legislative session, a group of forces with the West Virginia patient’s health through adulthood West Virginians set out to address Chapter of the American Academy These stressors, commonly called this need--a bill thoughtfully crafted of Pediatrics for Tiny Hearts Day, adverse childhood experiences (ACEs), by delegates and physicians to make an advocacy event for pediatricians, have been examined and shown to a comprehensive plan for handling pediatric residents, and medical correlate with poor health outcomes. ACEs. We medical students used this students from across the state who Examples of these ACEs include rotation as our opportunity to learn came to the Capitol to offer expertise substance use in the home, divorced about the impact ACEs have on our about children's health issues, parents, food insecurity, and abuse state, and by following the progress including ACEs, and arm lawmakers or neglect. When a child experiences of this important bill, we learned how with the education needed to make several of these traumas early in physician involvement can play a informed decisions. On Tiny Hearts life, their risk of chronic illness like beneficial role in population health. Day, after a morning of as many obstructive lung disease, diabetes, We had the opportunity to follow delegate and senator meetings as substance use disorders, and even

10 West Virginia Medical Journal ©2020, West Virginia State Medical Association Fourth year rotation recollections possible, we were ecstatic to witness value of this coalition for their West HB 4773 pass through the House it survives this arduous process. Virginia constituents. By the end of Health committee with multiple Bills such as this often create the our rotation, the bill had progressed delegates speaking passionately potential for change, but we as health to the Senate, where it was assigned about the positive impact that this bill care providers must ensure that to the Senate Committee on Health could have on the health of our state. our patients have the opportunity and Human Resources. Here, it will Delegates recited statistics and details to benefit from these new changes. again be closely examined before it will we had shared only hours before in our Physicians have an important role to have the opportunity to be presented one-on-one meetings as evidence to play in lawmaking. It is crucial, for for vote by the entire Senate. Only support its passage, showing that our the health of patients, to be involved bills that pass both chambers in this educational efforts had truly helped in as much of the process as possible manner can be officially signed by the cause. After passage, the bill then by keeping up-t0-date on health- the governor to become law. [Editor's progressed to the House floor, where related legislation and maintaining note: The bill passed.] all bills must be read on three separate discusssion with local senators We can still engage with the days before a final vote on the third and delegates. We are thankful for legislative process, even though,we day. HB 4773 passed on the House this eye-opening experience and are no longer walking the halls of floor with 95 members supporting will continue to advocate for our the Capitol, and we will continue and only three voting against passage. patients throughout our carfeers and to anxiously follow this important This important moment encouraged encourage others to do the same. piece of legislation in hopes that us that delegates recognize the

Physicians have an important Enrolled Committee role to play in lawmaking. Substitute for HB 4773 completed It is crucial, for the health legislative action of patients, to be involved on March 4, 2020. in as much of the process It was approved by as possible by keeping up- West Virginia Gov. Jim Justice on March to-date on health-related 25, 2020. legislation and maintaining It is effective discusssion with local June 2, 2020. senators and delegates.

www.wvsma.org 1st Quarter 2020 | Vol. 116 11 2019 Appalachian Addicition and Prescription Drug Abuse Conference

Prescriber Education Continued The 2019 powerful insight about the stigma of addiction and his Apppalachian personal journey. Addiction & Prescription Drug Abuse Conference exceeded our expectations for continued growth, P. Bradley Hall, MD integration and Executive Director collaboration of Lytle WV Medical Professionals Health multiple health Program, Inc. care professional AAPDAC Conference Chair disciplines.

MD, DABAM, DFASAM, and Catherine Slemp, MD, The 2019 Apppalachian MPH, commissioner of the Addiction & Prescription Bureau for Public Health Drug Abuse Conference Rodenbaugh and State Health Officer exceeded our expectations within the West Virginia for continued growth, Andrew Kolodny, MD, Departmentof Health and integration and codirector, Opioid Policy Human Resources collaboration of multiple Research Institute for health care professional Behavioral Health Schneider Berry disciplines. Institutes for Health Policy, Heller School for Social It was held Oct. 17-19 at James H. Berry, DO, Policy and Management, the Morgantown Marriott medical director, Chestnut Brandeis University, fol- at Waterfront Place with Ridge Center & Inpatient lowed with a presentation more than 500 participants Diagnosis Program, and on the opioid crisis, under- from 12 disciplines and 35 Stephanie Lytle, West standing and responding to exhibitors in attendance. Virginia University phar- an epidemic. This year's conference macy student, co-moderated opening and overview the first day of the confer- were lead by AAPDAC Slemp ence. Ken Rodenbaugh, RN, organizer, P. Bradley Hall, CARN, CEN, provided a

perspective. The Honorable Justice Walker commented on her experience and con- veyed her personal support to everyone involved in the conference.

Kelly Goff Abbott The luncheon program fea- tured Anna Kelly, LAc., MD, Michael Goff, executive officer, Hazelden Betty Ford FAAMA, addiction medi- director, West Virginia Foundation, discussed the cine, Gundersen Healthcare, Board of Pharmacy, integration of opioid addic- who spoke on spirituality as providing a legislative tion treatment with MAT medicine and in recovery. update and discussing and 12-step programs. Renna McGinnis, RN, proj- laws, rules and regulations, ect consultant, Intervention including the Controlled Project for Nurses, provided Substance Monitoring Walker a nurse’s fit to perform Program. training breakout sessions.

Seppala Kirk Moberg, MD, PhD, FASAM, UnityPoint Health Illinois Institute Stanger Duran for Addiction Recovery, Louise Stanger, EdD, clinical professor of Internal LCSW, CIP, CDWF, author, The evening concluded Medicine and Psychiatry, educator, speaker and with Alisa Duran, MD, University of Illinois College interventionist, spoke on the FACP, associate professor of Medicine, provided an relevant topic of addiction, of medicine, University of indepth presentation on mental health and suicide Minnesota, who spoke of pain and addiction best Jawaid among professionals, noting leaning into vulnerability practices. Jeannie Sperry, 400 physicians commit and the power of the person- Umar Jawaid, resident, PhD, LP, cochair, Division suicide each year. al story for reducing stigma West Virginia School of of Addictions, Transplant, The first day’s around addiction. Osteopathic Medicine, and Pain, Mayo Clinic, presentations ended Supreme Court Justice and Susan Abbott, MSN, Department of Psychiatry with Arthur Rubin, DO, Beth Walker welcomed par- APRN, FNP-BC, co-mod- and Psychology; assistant FACOP, MHA, president, ticipants and provided an erated the second day of professor, Mayo School of West Virginia Osteopathic update on West Virginia’s the conference. Marvin D. Medicine, discussed cogni- Medicine Association, and drug epidemic and her Seppala, MD, chief medical tive behavioral therapy in

www.wvsma.org 1st Quarter 2020 | Vol. 116 13 2019 Appalachian Addicition and Prescription Drug Abuse Conference

Potenza

Burton Hospital, and Jeremiah Hopkins, MD, assistant Sperry professor/adult psychiatrist- student health, J.W. Ruby Clark Gaither, MD, medical Memorial Hospital, started director, North Carolina the morning discussing Physicians Health Program, Moberg anxiety and ADHD. stressed the importance Stuyt the treatment of pain. of “self-care” in his Laura Lander, MSW, presentation from burnout psychiatrist, Pueblo LCSW, associate professor, to wellness: a road map to Community Health Center, Department of Behavioral engagement. Kelly Lemon, provided a detailed overview Medicine and Psychiatry, MSN, CNM, WHNP-BC, on marijuana/CBD, fact or WVU, and Keith Zullig, WVU Medicine, provided fiction. PhD, MSPH, FASHA, insights on management of FAAHB, chair and profes- addiction during pregnancy sor, Department of Social and neonatal abstinence and Behavioral Sciences, syndrome. WVU; associate direc- Our evening was topped Quigley tor, WVU Injury Control off with Judith Grisel, PhD, Marc Potenza, PhD, MD, Research Center, provided Behavioral Neuroscience/ professor of psychiatry, the luncheon program Psychology, Bucknell in the Child Study Center focusing on mindfulness in University and author, of Neuroscience; direc- the treatment of opioid use Never Enough; who gave a tor, Center of Excellence disorder. compelling personal story of in Gambling Research; her journey and drive to end director, Yale Program for addiction in Never Enough Research on Impulsivity – how affective homeostasis and Impulse Control creates addiction: marijua- Mock Disorders; director, Women na and opiates. and Addictive Disorders, Saturday morning Our moderator for the Women’s Health Research ended with an update on third day was Thomas at Yale, discussed connectiv- understanding lethality, Burton, resident, Joan ity addiction, problematic West Virginia overdose C. Edwards School of internet, gaming and social statistics, provided by Allen Medicine. Brian Quigley, media. Elizabeth “Libby” Mock, MD, MS, FCAP, MD, assistant profes- Stuyt, MD, medical director, FNAME, chief medical sor/medical director of Zullig Circle Program, Crossroads examiner, State of West Psychiatry Services WELL Turning Point, Colorado; Virginia, Office of the Chief WVU, J.W. Ruby Memorial

Medical Examiner. Dr. record setting highs. Nurses and the WVOMA. by the WVDHHR Bureau Mock provided statistical The conference was Charleston Area for Behavioral Health information indicating that supported by WVSMA, Medical Center and the and Health Facilities while West Virginia has WVMPHP, WVDHHR, West Virginia Medical and administered by the seen a reduction in opioid WVSAM, WVBOM, WV Foundation worked jointly WVMPHP helped make overdoses, heroin-related Board of Osteopathic in providing continuing this conference possible. overdoses continue to be a Medicine, WVOMA, medical education Mark your calendars major concern with rates WV Pharmacy Recovery accreditation for the for next year’s surpassing previous years, Network, WV Restore, WV conference. A physician conference, Oct. 1-3, and the co-use of heroin Board of Examiners for education grant provided 2020. and fentanyl have reached Registered Professional

More than 500 people attended the 2019 conference in Morgantown.

This year's conference is Oct. 1-3 at the Marriott at Waterfront Place in Morgantown.

www.wvsma.org 1st Quarter 2020 | Vol. 116 15 THANK YOU 2019 WVMPHP 'Spirit of Wellness in Medicine' Contributors On behalf of the West Virginia Medical Professionals have been more than 500 indirectly provided guidance Health Program, our participants, all of organized medicine informally, not as participants. and the public we serve, the WVMPHP wishes to express Eighty-plus-percent of those individuals have achieved our sincere appreciation to our 2019 WVMPHP “Spirit of successful completion or are pending completion of the Wellness in Medicine” contributors. program. In addition, the WVMPHP has provided more The West Virginia Medical Professionals Health Program than 160 educational presentations, with more than 17,000 was established in 2007 by organized medicine as an attendees, and continues to provide additional education at independent, non-profit 501(c)3 corporation. the annual Appalachian Addiction and Prescription Drug The WVMPHP promotes the health of West Virginians Abuse Conference – most recently hosting more than 500 through improving the well-being of West Virginia professionals. physicians, podiatrists, physician assistants, medical The accomplishments achieved for the participant, students/residents, and other health care professionals. the patient, the healthcare system, and the state of The WVMPHP remains the designated physician health West Virginia are only because of the ongoing support program by both the allopathic and osteopathic licensure and recognition of organized medicine and specifically boards. including our 2019 “Spirit” contributors. The WVMPHP has provided assistance and guidance The WVMPHP Board of Directors wishes to recognize our to more than nearly 300 ill health care professionals 2019 “Spirit of Wellness in Medicine” Funding Campaign experiencing addiction and/or mental illness. There Contributors. Leader of Healing Friend ($1 - $499) Advocate ($1,000 - $2,499) John Aldis, M.D. R. Curtis Arnold, DPM ($25,000 - $34,999) Aous Al-Khaldi, M.D. Huntington Internal Medicine Charleston Area Medical Center Russell Biundo, M.D. Group & Charleston Area Medical Center Craig Boisvert, D.O. Laura & Owen Lander, M.D. Medical Staff Lance Dubberke, M.D. Joseph Selby, M.D. Christopher Edwards, D.O. Stonewall Jackson Memorial Legacy of Wellness James Felsen, M.D. Hospital ($35,000 +) Robert Knittle WVU Health Systems: William A. Merva, M.D. Ally of Hope Barnesville Hospital T. Pinckney McIlwain, M.D. Berkeley Medical Center Pam Scott, PA ($2,500 - $4,999) Braxton Hospital Shafic Sraj, M.D. Steven Novotny, M.D. Camden Clark Medical Center Elizabeth & Peter Strobl, M.D. Pillar of Hope Garrett Regional Medical Center Philip H. Strobl, M.D. Jackson General Patricia & Albert Villarosa, M.D. ($5,000 - $9,999) Jefferson Medical Center Princeton Community Hospital Potomac Valley Hospital Caregiver ($500 - $999) Roane General Hospital Reynolds Memorial Hospital Phyllis & Sam Cann Thomas Health System Inc. St. Joseph's Hospital- Buckhannon Cheryl & Creel Cornwell, M.D. Summersville Regional Medical Lisa & Bradley Henry, M.D. Partner in Health Center Carl Overmiller, M.D. United Hospital Center Lorenzo Pence, D.O. ($10,000 - $24,999) West Virginia University Hospitals Cabell-Huntington Hospital Irene Wasylyk, M.D. Wetzel County Hospital Monongalia General Hospital Sherri Young, D.O. Wheeling Hospital

16 West Virginia Medical Journal ©2020, West Virginia State Medical Association 2019 WVMPHP 'Spirit of Wellness in Medicine' Contributors To date, your 2019 contributions have supported the WVMPHP that will assist us as we proceed forward in The WVMPHP promotes the health of further establishment of a viable and successful Physicians Health Program. West Virginians through improving On behalf of myself, the WVMPHP Board of Directors, our participants (current and future) and the public we serve, the well-being of West Virginia THANK YOU for your contributions and continued support of the West Virginia Medical Professionals Health Program. physicians, podiatrists, physician assistants, medical students/ P. Bradley Hall, M.D. Executive Medical Director, WVMPHP residents, and other health care Immediate Past-President, FSPHP professionals. The accomplishments achieved for the participant, the patient, the healthcare system, and the state of West Virginia are only because of the ongoing support and recognition of organized medicine ... including our 2019 “Spirit” contributors.

SAVE the DATE OCTOBER 1 – 3, 2020

Appalachian Addiction & Prescription Drug Abuse Conference Pain & Addiction Best Practices & Proper Prescribing

Morgantown Marriott @ Waterfront, Morgantown, WV

www.aapdac.org | www.wvmphp.org | 304.933.1030

www.wvsma.org 1st Quarter 2020 | Vol. 116 17 LCME accredits Marshall School of Medicine for full eight years

Marshall University Joan C. Edwards School of Medicine has received a full, eight-year accreditation from the Liaison Committee on Medical Education, the maxi- mum period of accreditation a school can receive. “This is a tremendous achieve- ment for a school of medicine,” said Joseph I. Shapiro, MD, dean of the school of medicine. “The LCME continues to raise the bar for medical education, and I am so pleased with how our school has generated its final report in October 2019. worked to meet and exceed those During that same time, Marshall School of Medicine was preparing for benchmarks.” a major revision to its medical education curriculum. In June 2019, the The accreditation process in- school submitted its revised curriculum plans, which merge pre-clinical and volved a two-year period during clinical education into an active-learning format, to the LCME. Although which teams of faculty, staff and the LCME does not decide whether a school can move forward with curric- students produced an extensive ulum changes, the LCME accreditation notice validated that the school has self-study that was submitted to the necessary resources to proceed with implementing the new curriculum the LCME in December 2018. The during the 2020-2021 academic year. self-study was then comprehen- The next full survey visit for Marshall’s School of Medicine will be dur- sively reviewed by an LCME sur- ing the 2026-2027 academic year. During the interim period, the school vey team prior to a three-day site will continue to make adjustments and monitor key areas, including career visit during spring 2019. LCME advising, through a continuous quality improvement process. Marshall School of Medicine establishes dedicated Department of Oncology

Effective Jan. 1, 2020, housed within a handful of collaboration in research as throughout the state and a new Department departments. well as patient care among region. The move creates of Oncology brings Creating a dedicated its oncology faculty, provide more opportunities together more than department at the school more opportunities for for expansion in the a dozen oncology alongside Edwards faculty advancement and areas of graduate faculty at the Comprehensive Cancer recruitment and continue to medical education and MUJESM currently Center facilitates increased grow advanced cancer care future fellowships.

18 West Virginia Medical Journal ©2020, West Virginia State Medical Association www.wvsma.org 1st Quarter 2020 | Vol. 116 19 WVU healthcare simulation center earns full accreditation Joins less than 3 percent of centers worldwide capabilities of manikins. “In the past 10 years, STEPS, which will soon STEPS has provided the celebrate its 10-year next level of healthcare anniversary, aims to education to the schools improve patient safety by of Health Sciences creating an environment in and beyond with over which students can learn, 130,000 learner visits,” practice and measure said Daniel Summers, clinical skills. director of STEPS. The center helps clinical “From beginner levels learners improve their to the most complex analytical, diagnostic, scenarios, using cutting communication and crisis- edge technology, we intervention skills by have been integral in utilizing a variety of patient educating the next simulators that can blink, Students at West Virginia University’s Health generation of healthcare breathe, have a heartbeat Sciences campus now have the opportunity to learn providers.” and react to medications. hands-on patient care at one of the world’s only fully To learn more about Additionally, standardized accredited healthcare simulation centers. STEPS, visit steps.wvu. patients (real human actors) David and JoAnn Shaw Simulation Training and edu. portray complex realistic Education for Patient Safety (STEPS) recently scenarios beyond the attained full accreditation by the Society for Simulation in Healthcare’s accreditation council. STEPS is now the first and only center in West One of our goals of adding Virginia to be accredited in every area by the Society for Simulation in Healthcare. More than 700 Systems Integration and centers worldwide are registered with the Society for Simulation in Healthcare, but less than 3 percent are accredited in all five areas. Research is to show that WVU’s center has been accredited in Core, Teaching and Assessment since 2014, and has now added Systems Integration and Research to its we are making healthcare achievements. “One of our goals of adding Systems Integration and Research is to show that we are making healthcare delivery safer for all of our delivery safer for all of our patients at WVU Medicine,” said Dorian Williams, Medical Director of patients at WVU Medicine. STEPS.

20 West Virginia Medical Journal ©2020, West Virginia State Medical Association Health Law Society Needle Exchange Programs This is a collaboration between the West Virginia Lakyn Cecil J.D. Candidate 2020 Unvversity College of Law WVU College of Law and West Virginia State Juan Pittaluga, M.D. Medical Association. J.D. Candidate 2020 WVU College of Law Citizens, first responders, and municipal sanitation Federal and state laws criminalize possession of drug workers complained they frequently came across used paraphernalia, including possession of syringes and needles in public spaces. The accidental stabbing of a hypodermic needles without a prescription. Federal law five-year-old girl by a used needle in a public restroom prohibits the use of federal dollars to pay for needles to be early in 2018 triggered an audit that revealed deficiencies used in exchange programs; exchanges typically operate in the program. The program would have to start serving with state, local, or donated funds. States with these only county residents with proper identification. Self- programs justify the implementation by acknowledging the retracting needles would be dispensed strictly on a one- current opioid epidemic and the resurgence of HIV/AIDS, to-one exchange ratio. Accurate records of referrals to Hepatitis B, and Hepatitis C. In choosing to enact these treatment and substance rehabilitation needed to be statutes and ordinances, states believe they are choosing precisely maintained. Although initially well received and the lesser of two evils. West Virginia does not have a state successful, the program's success was in question. The statute authorizing exchange programs, despite being the program closed in March 2018 after losing its operating epicenter of the nation's drug epidemic. A bill introduced certificate. in 2017 that would have permitted the development and How this closure is going to affect the citizens of operation of needle exchange programs in local health Charleston and Kanawha County remains to be departments through the amendment of W.Va. Code §16-1- determined. The decreased availability of unused sterile 6 never reached the State Senate. needles will likely diminish the inflow of non-resident Syringe and needle exchange programs provide free addicts and increase the utilization and sharing of needles. unused sterile needles to those with intravenous drug With fewer needles in the hands of individuals with addiction in exchange for used needles they bring to the addictions, fewer will be found in public spaces. This, centers. Once the individual is registered, staff members unfortunately, may lead to an increase in transmission can perform public health interventions that would have rates of blood-borne illnesses, and the opportunity for otherwise been almost impossible to provide. These offering disease prevention, treatment, and rehabilitation include counseling, medical attention for minor drug use options to substance abuse users will be lost. complications or referrals to hospitals when appropriate, About 333 needle exchange programs exist in the United as well as HIV and Hepatitis B and C screening. By States of America with varying degrees of success. Their capturing used needles and keeping them off the streets, success is measured using various parameters: the number the risk of accidental stabbings with infected needles by the of visitors to the program, the rate of referrals to addiction population at large is significantly reduced. Proponents of treatment centers, the decrease in needles found in public these programs point to the opioid crisis and to the increase places, and the decrease in the incidence of HIV/AIDS, in heroin use as proof of their need. Opponents fear they Hepatitis B and Hepatitis C in the community, among enable individuals to continue using drugs, attract unsavory others. West Virginia continues to combat a crisis. While characters, increase drug dealing in the neighborhoods near the ethics surrounding the concept of a needle exchange the centers, and depress real estate values. program remain questionable, there is no question that After enacting ordinances empowering the chief of police implementing a needle exchange program would be a to approve programs, the Kanawha-Charleston Health proactive step in providing West Virginians with resources Department established a needle exchange program in and interim measures amid the opioid crisis. Charleston towards the end of 2015. The program grew rapidly and ultimately became a victim of its own success.

www.wvsma.org 1st Quarter 2020 | Vol. 116 21 WVSOM, MU announce collaborative agreement

The West Virginia School of Osteopathic Medicine and Marshall University, through its Joan C. Edwards School of Medicine, announced a memorandum of understanding allowing for collaborative medical education efforts between osteopathic and allopathic programs at each WVSOM President James W. Nemitz, PhD, left, and Marshall institution. University President Jerome A. Gilbert, PhD, sign the agreement at WVSOM President James W. Marshall’s South Charleston campus. Nemitz, PhD, and Marshall Gilbert also spoke in support of the hospitals, and explore opportunities University President Jerome collaboration. to enhance residency placement for A. Gilbert, PhD., signed the “For years, we have partnered graduates. WVSOM and Marshall will agreement at Marshall’s South with the West Virginia School of advocate jointly on issues of mutual Charleston campus. Both higher Osteopathic Medicine on providing interest before the West Virginia education institutions share quality clinical education for their Legislature, the West Virginia Higher the goal of advancing first-class students in our region,” Gilbert Education Policy Commission and medical education in West said. “This agreement formalizes other governmental bodies. Virginia and improving access our relationship and paves the way Chairman Michael J. Farrell, from to quality physician care in for a more integrated, collaborative the West Virginia HEPC, attended the communities throughout the framework that will continue to ensure signing. He said the collaboration is an Mountain State. a top-notch clinical experience for all important step for the state. “I believe the signing of this medical students and better access to “I commend these two presidents memorandum of understanding physicians for citizens in the southern and look forward to the results of this will result in a stronger part of our state.” agreement, which will be fantastic for collaboration between Marshall The agreement states the schools students and patients of West Virginia. University and WVSOM that will work to develop and expand The HEPC strongly endorses what you will increase opportunities for clinical rotations for medical students all are doing.” the benefit of our students and at institutions associated with the the citizens of West Virginia,” Mountain Health Network, a regional Nemitz said. health system comprising three

Tyler Buchanan, MD review current literature on both topics with the aim to West Virginia University School of Medicine clarify when pediatric patients should be referred for Morgantown, WV appropriate surgical intervention.

Phillip R Purnell, MD, PhD Introduction The American Academy of Pediatrics recommends Department of Otolaryngology -Head and Neck Surgery exclusive breastfeeding for the first six months of life, as WVU School of Medicine breastfeeding has been shown to benefit the newborn’s immune system, which protects against a variety of diseases Michele M. Carr, DDS, MD, PhD, FRCSC and conditions1. Abnormal newborn oral anatomy has Department of Otolaryngology -Head and Neck Surgery been suspected to be involved in breastfeeding difficulties. WVU School of Medicine Ankyloglossia, or, and a short superior labial frenulum, also known as upper lip tie, have received attention Corresponding Author: as contributors to breastfeeding failure. Over the past Department of Otolaryngology -Head and Neck Surgery decade, surgical intervention rates for both have increased, WVU School of Medicine despite lack of good quality data and well-defined clinical 1 Medical Center Drive guidelines. The goal of this review is to provide clinicians Morgantown, WV 26506, USA with an up-to-date guide for evaluating oral frenula in Phone: 304-293-3223 newborns and to provide information regarding when these Email: [email protected] patients should be referred for surgical intervention. Tongue tie Statement of Authors: Ankyloglossia, colloquially known as tongue-tie, is a This article is based on work by the authors and is not a common congenital abnormality, which leads to restricted representation of West Virginia University. The authors mobility of the tongue (Figure 1). The Academy of deny any conflict of interests or funding sources associated Breastfeeding Medicine describes ankyloglossia as “a with this work. sublingual frenulum which changes the appearance and/ or function of the infant’s tongue because of its decreased Author Disclosure Statements" length, lack of elasticity or attachment too distal beneath The authors deny any conflict of interests or funding the tongue or too close to or into the gingival ridge”2. sources associated with this research study. No competing Ankyloglossia can be classified as either anterior or financial interests exist. posterior. Anterior ankyloglossia, or classic ankyloglossia, is described as the lingual frenulum attaching at or near Abstract the tongue tip, which may limit normal tongue movement. Ankyloglossia is a common congenital anomaly, Posterior ankyloglossia, a more recently described entity, characterized by limited tongue mobility because of is the attachment of the lingual frenulum at the middle or anatomical restriction by the lingual frenulum. The posterior portion of the undersurface of the tongue thought reduced tongue mobility has been associated with to result in impaired tongue mobility demonstrated by breastfeeding difficulty. Consensus on the functional cupping of the tongue. However, controversy surrounds effect of ankyloglossia is lacking and a small minority the significance of posterior ankyloglossia, with some of pediatricians and otolaryngologists believe it affects authors suggesting that posterior ankyloglossia is a normal feeding. A larger proportion of lactation specialists believe variant of attachment.3 Most literature about prevalence, ankyloglossia contributes to feeding issues. Diagnostic incidence, and the treatment of ankyloglossia does not assessment tools can guide the appropriateness of surgical include patients with posterior ankyloglossia. correction in cases of ankyloglossia. Estimates of the incidence and prevalence of ankyloglossia Recent attention has been directed to the role of the maxillary frenulum in breastfeeding difficulty. We will

www.wvsma.org 1st Quarter 2020 | Vol. 116 23 |

Estimates of the incidence and prevalence of ankyloglossia utilizing anatomic and functional measures have been are well characterized in the literature; however, the described. One method is the Hazelbaker Assessment diagnostic criteria used in these studies vary widely. Tool for Lingual Frenulum Function (HATLFF).10 This Incidence estimates of ankyloglossia range between 0.02% assessment has been shown to have a high degree of inter- and 10.7%4-6. It is more prevalent in males than females, rater reliability with regard to recommendation for surgical with estimated male:female ratios ranging from 1.5:1 to intervention.11 This assessment has been further simplified 2.6:17. Given the prevalence of ankyloglossia, a precise and into the Bristol Tongue Assessment Tool (BTAT). This reliable method of diagnosis would be expected to be in assessment has been shown to positively correlate with place and commonly used by practitioners. Unfortunately, HATLFF scores.12 such criteria are not widely accepted and establishing the Symptoms diagnosis and functional impact of the ankyloglossia can be Ankyloglossia is reported to cause a wide variety of dif- difficult. ficulties associated with feeding, in particular latching and Diagnosis breastfeeding. Although most infants born with ankyloglos- New diagnoses of ankyloglossia are on the rise; Walsh, sia will feed normally, problems with breastfeeding are 13 et al. reported an 834% increase in the diagnosis between more likely to arise in infants with ankyloglossia. More 1997 and 2012, with the greatest increase in the latter specifically, ankyloglossia has been shown to be associated six years.7 Although the incidence of new diagnoses has with ineffective latching, with a decreased ability to create a increased, there is a lack of consensus about criteria for seal, leading to poor infant weight gain and maternal nipple 14 diagnosis. Methods of assessing ankyloglossia based on pain. Infants with symptomatic ankyloglossia are unable anatomic characteristics have been described (Table 1). The to extend the tongue beyond the mandibular alveolar ridge Coryllos classification grades ankyloglossia based on the which prohibits proper latch. Non-surgical treatments in- point of attachment of the frenulum to the tongue.9 Taken clude positioning and nipple shields. Surgical correction of one step further, two methods of diagnosing ankyloglossia ankyloglossia has been shown to result in significant im-

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24 West Virginia Medical Journal ©2020, West Virginia State Medical Association provement in breastfeeding outcome measures.15 Unlike frenotomy, frenuloplasty requires general Older children may experience speech articulation difficul- anesthesia. These are more advanced techniques requiring ties, particularly lingual sounds /l/ and interdental sounds tissue movement and local transfer. Advantages to these /th/, because of ankyloglossia,16 but it is important for techniques include decreased recurrence of ankyloglossia practitioners to know that ankyloglossia does not delay the and less contracture of scar tissue. An otolaryngologist will onset of speech.17 Repair for articulation issues should not be familiar with the multiple surgical options and will aid in be undertaken prophylactically as they are not universal in selection of the appropriate approach. Despite the chosen this population. method, patients generally have increased tongue mobility Surgical Interventions shortly after the procedure. An algorithm for management of infants with Complications and Post-Operative Care breastfeeding problems and possible ankyloglossia appears While generally considered a minor procedure with in Figure 2. Consultation with a lactation specialist should minimal post-operative care, frenotomy is not without be undertaken when infants experience difficulty with complications. Although no studies have been performed breastfeeding, as improved technique may obviate the to assess the comparative safety of performing the need for surgical intervention for ankyloglossia.18 Although operation in the operating room versus the clinic, a surgical intervention in cases of breastfeeding difficulties lower rate of revision surgery has been demonstrated has been shown to be of benefit in some studies1,15 larger in patients undergoing the procedure in the operating systematic reviews have found a paucity of evidence. room.23 Most common risks include bleeding and Overall, the quality of evidence is low to insufficient.19 As damage to submandibular (Wharton’s) ducts.22 Rarely, well, a systematic review of the literature reported the data airway complications can be seen after frenotomy. Two to be insufficient to support the use of surgical intervention case reports of infants with Pierre-Robin sequence who in cases of speech articulation difficulties.20 underwent frenotomy resulted in airway obstruction Two general methods of surgical intervention have been secondary to posterior tongue movement. The authors described in cases of ankyloglossia, frenotomy (lengthening of these case reports argued that surgical treatment the frenulum by incising it) and frenuloplasty (surgical of ankyloglossia should be contraindicated in patients alteration of the frenulum). Frenotomy is often done with anomalies that may increase their risk of airway without anesthesia in the newborn nursery.21 The infant obstruction.24 The risks of the procedure are not restricted is placed in the supine position, and a clamp is placed at to patients with anatomic/physiologic anomalies, as was the site of incision to create a hemostatic plane. A cut is demonstrated by a case report of a four-year old male who made through the frenulum with fine scissors, with care presented with hemorrhagic shock following frenotomy.25 to avoid the submandibular ducts. The patient is then These reports represent rare post-operative complications, given back to the mother for breast or bottle-feeding, as most patients do well and return to normal activity which is thought to accelerate hemostasis. Although this immediately. Follow-up may be scheduled to monitor the is a common procedure, the authors recommend having resolution of feeding or speech symptoms.22 the procedure done in the operating room or with general Upper Lip Tie anesthesia to allow more complete release and control of Definition bleeding.22 Research suggests that need for re-operation for The maxillary frenulum, also known as the superior labial ankyloglossia is higher with those procedures done without frenulum, has been described as a fold of connective tissue anesthesia.23 with overlying mucosa that attaches the upper lip to the In the operating room, the infant is placed supine with anterior surface of the maxillary gingiva26 (Figure 3). While intermittent mask ventilation, laryngeal mask airway or the significance and function of the maxillary frenulum endotracheal tube.22 A midline tongue retraction suture is the topic of much debate, studies have shown that all is placed to optimize visualization of the ventral tongue. newborns have a maxillary frenulum and the appearance The frenulum is incised half way between the ventral is reported to change, becoming less prominent, with age tongue and floor of mouth with fine scissors or cautery. The as the teeth develop and the alveolar ridge elongates.27, remaining frenulum is blunt dissected back to the tongue .28. Given that the appearance of a maxillary frenulum will musculature. The resulting mucosal opening is closed with change with age, differentiating normal from abnormal has a continuous resorbable suture. This method offers less been controversial. Most of this controversy has centered risk of damage to the venous supply alongside the frenulum on the use of surgical procedures to correct perceived and the submandibular ducts and allows more complete abnormalities of this structure. Many have justified these frenulum release. procedures as a way to improve breastfeeding, though

www.wvsma.org 1st Quarter 2020 | Vol. 116 25 evidence to support this justification is lacking.29 to explain the hemorrhage.25 Symptoms Conclusions While what constitutes a “normal” or “abnormal” maxillary Oral anomalies in infants can be associated with breast- frenulum has yet to be elucidated, there are some practi- feeding difficulty. Initially, breastfeeding difficulties are tioners performing maxillary frenotomy or frenuloplasty. best managed with lactation consultation. If breastfeeding Frenotomy is usually done to improve newborn latching difficulties continue despite intervention by a lactation spe- during breastfeeding. Others have suggested that mitiga- cialist, practitioners should assess for the presence of an- tion of a dental diastema may be justification for the proce- kyloglossia. The HATLFF assessment has good inter-rater dure. The maxillary frenulum configuration at birth may be reliability and can be used to determine which infants with unrelated to its configuration once teeth start to erupt since ankyloglossia should undergo surgical intervention. If fre- the alveolar ridge lengthens as the patient grows. While notomy is deemed appropriate, otolaryngology consultation the presence of a dental diastema is generally considered should follow. The procedure is generally minor, although to be of no clinical significance, and is evepected in normal adverse outcomes have been reported. Frenotomy has been primary dentitions, it has been associated with periodon- shown to improve breastfeeding outcome measures, and tal disease in permanent dentition by gingival recession generally requires minimal follow-up.15, 22 On the other if attached too close to the dentogingival junction.31 The hand, an adequate method of diagnosing problems with mechanics of breastfeeding suggest that an appropriate the maxillary frenulum in infants is absent, and the conse- flanging of the upper lip to allow for sufficient latching dur- quences of an abnormal maxillary frenulum on breastfeeding feeding may be impeded by a short maxillary frenulum. ing are unclear. Maxillary frenotomy has not been shown to Therefore, incision of the maxillary frenulum is thought to improve breastfeeding outcomes, and is not without risk. improve latch quality, improving breastfeeding; however, Given the lack of evidence to support maxillary frenotomy, evidence to support release of the maxillary frenulum to surgical intervention for cases of breastfeeding difficulties is aid in newborn latching is anecdotal at best.29 One study inappropriate and puts the patient at unnecessary risk. Cli- reported an increase in maternal and infant breastfeeding nicians should be familiar with these clinical entities and be outcome measures following surgical release of upper lip able to counsel parents appropriately regarding appropriate tie; however, all of those undergoing the procedure had a management. Kotlow class III or IV maxillary frenulum, and many also References underwent ankyloglossia release, which further confounds 1. Section on Breastfeeding. Breastfeeding and the use of 32 the validity of the findings. human milk. Pediatrics 2012;129:e827-841. Procedure and Risks 2. Ballard J, Chantry C, Howard C. Protocol # 11: Guide- Surgical intervention for abnormalities of the superior labi- lines for the evaluation and management of neonatal ankyloglos- al frenulum includes frenectomy and frenotomy. These pro- sia and its complications in the breastfeeding dyad. Am Acad cedures may be performed through a number of techniques, Breastfeed Med Protoc. 2004. 3. Douglas P. Rethinking “posterior” tongue-tie. Breastfeed including excision with a scalpel, electro-surgery, and CO2 Med 2013;8(6):503-506. laser, and the wound may be closed by primary intention, 4. Segal L, Stephenson R, Dawes M, et al. Prevalence, secondary intention, or using a Z-plasty technique. In the diagnosis, and treatment of ankyloglossia: methodologic review. simplest procedure, the frenal attachment is anesthetized Can Fam Physician. 2007;53(6):1027-1033. with lidocaine containing epinephrine. A hemostat is used 5. Power R, Murphy J. Tongue-tie and frenotomy in infants to isolate the frenulum superiorly up to the gingival buccal with breastfeeding difficulties: achieving a balance. Arch Dis sulcus. An incision is then made through the tissue crushed Child. 2015;100(5):489-494. by the hemostat to free the attachment, and blunt dissec- 6. Hogan M, Westcott C, Griffiths M. Randomized, con- tion is used to remove remaining attachments. Sutures may trolled trial of division of tongue-tie in infants with feeding prob- then be placed to close the labial mucosa.33 Although gener- lems. J Paediatr Child Health. 2005;41(5-6):246-250. 7. Hall D, Renfrew M. Tongue tie. Arch Dis Child. ally thought to be a minor procedure, release of the superior 2005;90(12):1211-1215. labial frenulum is not without associated risk, most com- 8. Walsh J, Links A, Boss E, Tunkel D. Ankyloglossia and monly bleeding scarring, local burns, and complications of lingual frenotomy: national trends in inpatient diagnosis and laser use. One case report described an incidence of hemor- Management in the United States, 1997-2012. Otolaryngol Head rhagic shock requiring a blood transfusion in a 13-month Neck Surg. 2017;156(4):735-740. old following release of her maxillary frenulum; on further 9. Coryllos E, Watson Genna C, Salloum A. Congenital work-up, this child was not found to have any coagulopathy tongue tie and its impact on breast feeding. AAP Sect Breast-

26 West Virginia Medical Journal ©2020, West Virginia State Medical Association feed. 2004. Facts and myths regarding the maxillary midline frenum and its 10. Drazin P. The Assessment Tool for Lingual Frenulum treatment: a systematic review of the literature. Quintessence Int. Function (ATLFF): Use in a Lactation Consultant Private Practice. 2013;44(2):177-187. J Hum Lact. 1994;10(1):54. doi:10.1177/089033449401000135. 29. Pransky S, Lago D, Hong P. Breastfeeding difficul- 11. Amir L, James J, Donath S. Reliability of the Hazelbaker ties and oral cavity anomalies: The influence of posterior an- Asssessment Tool for lingual frenulum function. Int Breastfeed J. kyloglossia and upper-lip ties. Int J Pediatr Otorhinolaryngol. 2006;1(3):1-6. 2015;79(10):1714-1717. 12. Ingram J, Johnson D Copeland M, Churchill C, Taylor H, 30. Kotlow L. Diagnosing and understanding the maxillary Emond A. The development of a tongue assessment tool to assist lip-tie (superior labial, the maxillary labial frenum) as it relates to with tongue-tie identification. Arch Dis Child Fetal Neonatal Ed. breastfeeding. J Hum Lac. 2013;29(4):458-464. 2015;100(4):344-348. 31. Minsk L. The frenectomy as an adjunct to periodontal 13. Messner A, Lalakea M, Aby J, Macmahon J, Bair E. treatment. Compend Contin Educ Dent. 2002;23:424-428.32. Ankyloglossia: incidence and associated feeding difficulties. Arch Devishree, Gujjari S, Shubhashini P. Frenectomy: A review Otolaryngol Head Neck Surg. 2000;126(1):36-9. with the report of surgical techniques. J Clin Diagn Res. 14. Ballard J, Auer C, Khoury J. Ankyloglossia: assessment, 2012;6(9);1587-1592. incidence, and effect of frenuloplasty on the breastfeeding dyad. Pediatrics. 2002;110(5):e63. 15. Ghaheri B, Cole M, Fausel S, Chuop M, Mace J. Breast- feeding improvement following tongue-tie and lip-tie release: a prospect cohort study. Laryngoscope. 2017;127(5):1217-1223. 16. Kummer A. Ankyloglossia: to clip or not to clip? That’s the question. The ASHA Leader. 2005;10(17):6-30. 17. Messner A, Lalakea M. The effect of ankyloglossia on speech in children. Otolaryngol Head Neck Surg. 2002;127(6):539-45 18. Lalakea M, Messner A. Ankyloglossia: does it matter? Pediatr Clin North Am. 2003;50(2):381-397. 19. Francis D, Krishnaswami S, McPheeters M. Treatment of ankyloglossia and breastfeeding outcomes: a systematic review. Pediatrics. 2015;135(6):e1458-1466. 20. Chinnadurai S, Francis D, Epstein R, Morad A, Koha- nim S, McPheeters M. Treatment of ankyloglossia for reasons other than breastfeeding: a systematic review. Pediatrics. 2015;135(6):e1467-1474. Figure 1. Ankyloglossia: Lingual frenulum attachment is 21. Toner D, Giordano T, Handler S. Office frenotomy for just posterior to the tongue tip, with a notching of the tip neonates: resolving dysphagia, parental satisfaction and cost- effectiveness. ORL Head Neck Nurs. 2014;32(2):6-7. visible when the tongue is extended. 22. Baker A, Carr M. Surgical treatment of ankyloglossia. Operative Techniques in Otolaryngology-Head and Neck Surgery. 2015;26(1):28-32. 23. Klockars T, Pitkäranta A. Pediatric tongue-tie division: technique and patient satisfaction. Int J Pediatr Otorhinolarngol. 2009;73(10):1399-1401. 24. Genther D, Skinner M, Bailey P, Capone R, Byrne P. Airway obstruction after lingual frenulectomy in two infants with Pierre-Robin Sequence. Int J Pediatr Otorhinolaryngol. 2015;79(9):1592-1594. 25. Tracy L, Gomez G, Overton L, McClain W. Hypovolemic shock after labial and lingual frenulectomy: A report of two cases. Int J Pediatr Otorhinolaryngol. 2017;100(1):223-224. 26. Henry S, Levin M, Tsaknis P. Histologic features of the superior labial frenum. J Periodontol. 1976;47(1):25-28. 27. Santa Maria C, Aby J, Truong M, Thakur Y, Rea S, Mess- ner A. The superior labial frenulum in newborns: what is normal? Figure 3. Maxillary frenulum: Superior labial frenulum Global Pediatric Health. 2017;4:1-6. attachment into the anterior papilla. 28. Delli K, Livas C, Sculean A, Katsaros C, Bornstein M.

www.wvsma.org 1st Quarter 2020 | Vol. 116 27 Figure 2. Algorithm for management of infants with breastfeeding problems and ankyloglossia.

Breastfeeding Difficulties

↓

Lactation Consultation ↓

Continued Breastfeeding

Difficulties

↓

HATLFF > 11 or HATLFF >11 and ← → Appearance Score <8 Assess for Ankyloglossia Appearance Score = 10 ↓ ↓

Consult Otolaryngology Surgical Intervention for Surgical Intervention Inappropriate

28 West Virginia Medical Journal ©2020, West Virginia State Medical Association Table 1. Classification Systems for Ankyloglossia Coryllos Classification Scale9 Type I: Attachment of the frenulum to the tongue tip, in front of the alveolar ridge Type II: Attachment of the frenulum 2-4 mm behind the tongue tip Type III: Attachment of the frenulum to the mid-tongue/middle floor of the mouth Type IV: Attachment to the base of the tongue Hazelbaker Assessment Tool for Lingual Frenulum Function (1998 version) 11 Appearance Items Appearance of tongue when lifted 2: Round or Square 1: Slight cleft in tip apparent 0: Heart-Shaped Elasticity of frenulum 2: Very elastic (excellent) 1: Moderately elastic 0: Little or no elasticity Length of lingual frenulum when tongue lifted 2: More than 1 cm or embedded in tongue 1: 1 cm 0: Less than 1 cm Attachment of lingual frenulum to tongue 2: Posterior to tip 1: At tip 0: Notched Attachment of lingual frenulum to inferior alveolar ridge 2: Attached to floor of mouth or well below ridge 1: Attached just below ridge 0: Attached at ridge Functional Items Lateralization 2: Complete 1: Body of tongue but not tongue tip 0: None Lift of tongue 2: Tip to mid-mouth 1: Only edges to mid-mouth 0: Tip stays at alveolar ridge or rises to mid-mouth only with jaw closure Extension of tongue 2: Tip over lower lip 1: Tip over lower gum only 0: Neither of above, or anterior to mid-tongue humps Spread of anterior tongue 2: Complete 1: Moderate or partial 0: Little or none

www.wvsma.org 1st Quarter 2020 | Vol. 116 29 Cupping 2: Entire edge, firm cup 1: Side edges only, moderate cup 0: Poor or no cup Peristalsis 2: Complete, anterior to posterior (originates at the tip) 1: Partial: originating posterior to tip 0: None or reverse peristalsis Snapback 2: None 1: Periodic 0: Frequent or with each suck © Alison K. Hazelbaker, MA, IBCLC July 1 1998 14 = Perfect score (regardless of Appearance Item score) 11 = Acceptable if Appearance Item score is 10 <11 = Function impaired. Frenotomy should be considered if management fails. Frenotomy necessary if Appearance Item score is <8. Table 2 Kotlow Classification of Maxillary Frenulum Kotlow Classification Scale30 Class I: Minimally visible attachment Class II: Attachment primarily into the gingival tissue Class III: Inserts just in front of anterior papilla Class IV: Attachment just into the hard palate or papilla area

30 West Virginia Medical Journal ©2020, West Virginia State Medical Association Moving from Surveillance to Supporting the Medical Home: A Health System Intervention for West Virginia Infants with Neonatal Abstinence Syndrome

For more than two decades, the West Virginia individual level information about infants diagnosed with Department of Health and Human Resources, Bureau NAS was not, until January 2020, shared with pediatric or for Public Health, and West Virginia University School family medicine providers. of Medicine’s Department of Pediatrics have worked In June 2019, West Virginia’s Perinatal Quality together to administer a birth score system for all Collaborative (PQC), the West Virginia Perinatal infants born in the state. This arrangement serves as Partnership, Inc., recommended that Project WATCH a preventive program to identify newborn infants at begin informing pediatric providers about an infant’s risk for post-neonatal mortality, debilitating conditions diagnosis with NAS to ensure proper care and management. and developmental delays. The goals of the birth score The primary objectives relating to the management of system, known as Project WATCH, are to identify infants diagnosed with NAS are the stimulation of normal newborns at greatest risk for death between one week growth and development and minimization of negative and one year of age; and to link high-risk infants with outcomes including physical discomfort, sleep deprivation, physicians for close followup during the first year of life. To accomplish the statutory purpose of Project WATCH, a risk identification scoring tool was developed using weighted multivariate risk score functions comprised of both infant and maternal factors. Data are collected on every infant born in West Virginia birthing hospitals/ facilities as well as most home births. Since late 2016, maternal substance use during pregnancy has been one of the 10 risk factors that encompass the risk scoring system. In late 2016, Project WATCH began collecting discrete surveillance data to calculate the incidence seizures in the infant and impaired maternal bonding, of neonatal abstinence syndrome in West Virginia among others. Moreover, several studies have shown via a standardized case definition. This ongoing infants with NAS who are breastfed are likely to have less NAS surveillance has been essential to informing severe symptoms, require less pharmacologic treatment, public health-related efforts aimed at prevention, but and have shorter hospital stays than formula-fed infants. In general, healthcare professionals lack specific training on the screening and management of pregnant patients

www.wvsma.org 1st Quarter 2020 | Vol. 116 31 with opioid use disorder. This extends into the care of Manuscript Submission Guidelines infants born with NAS. Beginning January ORIGINALITY: Articles submitted for publication become the sole property of the 2020, Project WATCH West Virginia State Medical Association. Prior publication is unacceptable. The Publica- began notifying primary tions Committee reserves the right to edit any material submitted. Scientific articles are care providers of an to be prepared in accordance with the Uniform Requirements for Submission of Manu- infant’s diagnosis of NAS. scripts to Biomedical Journals. Correspondingly, and in coordination with the AUTHORS: A cover letter from the corresponding author, complete with a mailing West Virginia Perinatal address and email address, must be submitted with the manuscript. Persons listed as authors must have participated sufficiently in the work to take public responsibility for the Partnership, Inc., Project concept. No more than six authors will be listed. Please include titles and affiliations for WATCH will facilitate each author. A corresponding author, complete with title, mailing address and email ad- ongoing educational dress must be identified and will be included in the publication. Other contributors may outreach and training for be recognized in an acknowledgement. maternity care, pediatric and family medicine FORMAT: Submit articles in Microsoft Word and as a PDF. Both files should include all providers throughout elements of the article. This includes authors with titles and affiliations, abstract, main ar- the state to highlight ticle, figures with legends, tables with titles and references. Additionally, all figures must opportunities for be attached as separate .jpg files. treatment and prevention The WVSMA publishes a printed, quarterly WVMJ. We for mothers and infants JOURNAL PLATFORMS: also publish case reports online in an Open Access platform—Scholastica. Publishing two as well as plan for needed journals eenables publication of a larger volume of peer-reviewed case reports, review services. articles and original research.

Authors STYLE: Manuscript word count is limited to 3,200 words. Approximate the style adopted James E. Jeffries, MSWest by the American Medical Association as illustrated in JAMA and detailed in the AMA’s Virginia Department of Health and Human Resources Manual of Style. An abstract of 200 words or less must accompany each manuscript, stating Bureau for Public Health the exact question considered, the key points of methodology, key findings, and the conclu- Office of Maternal, Child and Family sion directly supported by the findings. Health VISUALS: No more than five visuals (tables and figures combined). Candice Hamilton, MPH West Virginia University – School of REFERENCES: References should be prepared in accordance with the AMA Manual of Medicine Department of Pediatrics Style. Instructions for authors are available online at www.jama.com. References are to be in superscript and appear AFTER punctuation. Amy N. Tolliver, MS West Virginia Perinatal Partnership PHOTOGRAPHS/FIGURES: Submit digital files, which are at least large enough to fill a 2-3/8 inch space at 100% at 300 dots per inch (dpi). Use arrows to point to areas of interest. Amna Umer, PhD West Virginia University – School of RESUBMISSIONS: Authors must submit a Response to Reviewers document in addition Medicine to the revised manuscript. Department of Pediatrics Revised submissions missing this “Response” document or response documents that do not address all reviewer comments will be rejected without peer-review.

If you need more information, contact John Law at 304-925-0342, ext. 280.

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