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     Family Physician News                                                                                                                                      acofp
                        JUNE 2 0 0 6                                                                                                           Special Pain Issue

                      VOLUME 6
                                                                                                Pain Assessment                                                                                             CME
                      NUMBER 6

              w w w. a c o f p . o r g
                                                                                                in Elderly Adults
                                                                                                Reducing pain intensity
Providing scientific information,
practice management strategies                                                                  improves cognition and reduces
and ACOFP news for the                                                                          behavioral problems
community of osteopathic
family physicians                                                                               By Liliya Gekhman DO, and Janet Lieto, DO

                                                                                                        ain assessment is an important   neuralgia. Elderly

                                                                                                        issue in the management of       cognitively-impaired
                                                                                                        elderly patients. Statistics     patients may
                                                                                                suggest that as many as 80 percent       experience pain
                                                                                                of elderly adults have pain, and very    differently from
                                                                                                often this pain goes under-              younger patients.
President’s Perspective                                                                         diagnosed.(11) Undiagnosed and           Some research
                                                                                                under-treated pain may lead to           suggests that
Reins of Leadership         PA G E 3                                                                                                     demented patients
                                                                                                depression, cognitive and functional
                                                                                                decline. Reducing pain intensity         have decreased
Washington Update                                                                               improves cognition and reduces           perception of pain.
                                                                                                behavioral problems.(11)                 However, there is
Senate Fails Again to                                                                                                                    disagreement on
                                                                                                    The goal of pain management in
Approve Medical Liability                                                                                                                this issue.(1)
                                                                                                elderly adults is improved function
Reform Legislation     PA G E                                                  4
                                                                                                that leads to improved activities of
                                                                                                daily living, socialization, sleep and
Case Study                                                                                      not necessarily the complete absence
                                                                                                                                         continued on page 12 =
                                                                                                of pain. Elderly patients are
Necrotizing Fasciitis                                                                           underrepresented in pain-related
Presenting As Arm,                                                                              research. Less than one percent
Shoulder and Upper                                                                              of all annual publications
Back Pain                 PA G E 1 6                                                            regarding pain are related to               A Case Study and Clinical
                                                                                                pain in the elderly.(4)
                                                                                                    Health care providers may con-
                                                                                                                                            Review of Clostridium tetani
                                                                                                tribute to underdiagnosis and under-
                                                                                                treatment of pain in elderly patients.
                                                                                                                                            Tetanus isn’t necessarily a thing of the past in the United States
                                                                                                This may result from concerns
                              Arlington Heights, IL 60005
                              330 E. Algonquin Rd., Suite One
                                                                Osteopathic Family Physicians
                                                                American College Of

                                                                                                                                            By Troy M. Smith, DO
                                                                                                regarding the safety of pain medica-
                                                                                                tions and misconceptions regarding

                                                                                                                                                  etanus is an illness characterized by an acute onset of
                                                                                                pain perception in the elderly.
                                                                                                    Malignancy is a frequent cause of             hypertonia, painful muscle contractions (usually of the neck
                                                                                                chronic pain in the elderly. Elderly              and jaw) and generalized muscle spasms without other
                                                                                                adults also commonly suffer from                  apparent medical etiologies.
                                                                                                chronic pain of musculoskeletal                                                    The toxin, tetanospasmin,
                                                                                                origin due to osteoarthritis,                                                   which is released by the
                                                                                                degenerative joint disease and                                                  germinating spores of the
                                                                                                previous bone fractures. Such pain is                                           bacterium, Clostridium tetani,
                                                                                                common, since virtually everyone                                                causes the disease. This obligate
                                                                                                has evidence of degenerative changes                                            anaerobic gram-positive bacillus
                                                                                                in weight-bearing joints by middle                                              forms spores, which are resistant
                                                                                                age. In later life, these changes may                                           to heat, desiccation and
                                                                                                manifest as stiffness and pain with                                             disinfectants. If the spores enter
                                                                                                physical activity.(2)                                                           a wound that penetrates the skin
                                                                                                    Other common reasons for                                                    under anaerobic conditions, they
                                                                                                chronic non-malignant pain in the                                               germinate and release the
                          Permit No. 6112

                                                                                                elderly are neuropathic pain, central
                          Non-Profit Org.
                           U.S. Postage
                            Chicago, IL

                                                                                                post-stroke pain and post-herpetic                                                            continued on page 6 =
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2   O S T E O PAT H I C FA M I LY P H Y S I C I A N N E W S J U N E 2 0 0 6
   OFP NEWS                                                       president’s
   Osteopathic Family Physician News
   provides scientific information,                                      P E R S P E C T I V E
   practice management strategies, and
   ACOFP news for the community of
   osteopathic family physicians.                                 Take Hold of the
   Thomas N. Told, DO, FACOFP dist.
                                                                  Reins of Leadership
   Douglas J. Jorgensen, DO, CPC                                                                he final leg of our ACOFP triangle brand is Leadership. Like the reins
   Editor                                                                                       on a bridle, Leadership provides direction for the ACOFP, as well as
                                                                                                guidance for the membership on issues affecting osteopathic family
   Kenneth T. Lajoie, DO, MPH
                                                                                                physicians and their patients.
   Associate Editor
                                                                                             Leadership isn’t just a job for the Board of Governors or the state officers.
   Peter L. Schmelzer, CAE                                                               Leadership includes every member of ACOFP. John Quincy Adams once said,
   Executive Director                                                                    “If your actions inspire others to dream more, learn more, do more, and
                                                                                         become more you are a leader.” By viewing Leadership from that perspective,
   Mark E. Paulson                                                                       each of us can assume a unique role in this great organization.
   Manager, Communications & Marketing                           Thomas N. Told, DO,
                                                                 FACOFP dist.
                                                                                            I would like to encourage you to do more than simply pay your dues and
   Stacy E. Jacobs                                                                      wait for services to flow your way. Step up and take hold of the reins of
   Publications & Web Site Designer                              Leadership, along with your state and national officers. Let them know how you think the ACOFP
                                                                 can more effectively expand its services and benefits to the entire membership.
   Editorial Advisory Committee                                     Take the time to seek out local osteopathic family physicians who may not be ACOFP members.
                                                                 You may find that, in many cases, they may have trained outside our profession. If you do, let them
   Jan D. Zieren, DO, FACOFP, Dept. Chair                        know that as fellow family physicians they will always be welcome in our ranks, and that their
   J. Robert Mannino, DO, FACOFP dist., Chair                    thoughts and views are important to us.
   Steven R. Blasi, DO                                              Join the osteopathic family physicians in your state society to form resolutions for presentation
   Harold M. Friedman, DO                                        during our Congress of Delegates in Kissimmee, Florida next March. Indeed, make the effort to
   Linda I. Greenspan, DO, FACOFP
                                                                 become an ACOFP Congress Delegate or Alternate in order to put your views forward and to vote
   Steven D. Kamajian, DO
                                                                 your conscience.
   Donald E. Kotoske, DO, FACOFP dist.
                                                                    Become familiar with the history of
   Katarina Lindley, DO
   Christopher J. Mehallo, DO                                    the ACOFP and your state chapter. Pearl
   Harry J. Morris, DO                                           S Buck once said, “One faces the future
   Robert N. Pedowitz, DO                                        with one’s past.” It is essential that we               Leadership isn’t just a job for the
   Eric J. Sheflin, DO, FACOFP dist.                             review the events and backgrounds of
                                                                 those who formed the ACOFP. When                        Board of Governors or the state
   Joel D. Stein, DO
   Alice J. Zal, DO, FACOFP                                      we perform this very small task, we gain                officers. Leadership includes every
                                                                 greater insight into challenges and
   ACOFP Headquarters Office                                     solutions our founders saw. Armed with                  member of ACOFP.
   330 E. Algonquin Road, Suite 1                                those insights, we can navigate more
   Arlington Heights, IL 60005                                   easily through many of the same
   (ph) 800-323-0794 (fax) 847-228-9755                          problems that will face us again
   Web site:                                       in the future.                                           Leadership is projecting a positive image of family practice to students, residents and the
                                                                 members of your community. Though the percentage of students choosing family practice as a
   Advertising Sales                                             profession is declining slightly, we are producing more family doctors than ever before. New
   Michael Minakowski                                            residency programs are being added every year, and our training programs are being refined to be
   11 Penn Plaza, Suite 1003                                     more useful to physicians entering practice. We need to let students know that for a health care
   New York, NY 10001                                            system to be cost-effective and user-friendly, it must contain family physicians.
   (ph) 215-860-0912 (fax) 215-860-0913                             Family physicians are the bridge for integrating patients into the oft-times confusing world of
   (e-mail)                                   sub-specialization and high-tech medical care. We need to equip residents with the latest in practice
                                                                 management skills and tools to enter practice with confidence.
   Instructions for Authors                                         And finally, we need to accept the responsibility of Leadership in educating our patients
   Articles submitted for publication must be original in        regarding the proper use of available health care resources. When we achieve responsible resource
   nature and may not be published in any other periodical.      utilization, we will gain more resources to build a more responsive health care delivery system.
   Materials for publication should be of clinical or didactic      Yes, do take hold of the reins of Leadership, for in doing so you will find a deep satisfaction that
   interest to osteopathic family physicians. Any reference to
   statistics and/or studies must be footnoted. Material by      can only comes from service to others. And continue to ride with the ACOFP Brand – Advocacy,
   another author must be in quotations and receive              Education, Leadership!
   appropriate attribution. The ACOFP reserves the right to
   edit all submissions. Submit typed copy to the address
   above or via e-mail to                Osteopathically yours,
   All opinions expressed in OFP News are those of the
   authors and not necessarily those of the editors, the
   ACOFP, or the institution with which the authors are
   affiliated, unless expressly stated.
                                                                 Thomas N. Told, DO, FACOFP dist.
Advertisers’ Index
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                                                                                                           O S T E O PAT H I C FA M I LY P H Y S I C I A N N E W S J U N E 2 0 0 6   3
      U P D A T E

Senate Fails Again to Approve Medical
Liability Reform Legislation
The focus now turns to smaller medical liability reform
bills that protect smaller groups of physicians
By Marcelino Oliva, DO, and Shawn Martin

                                                          n May 8, the United States Senate considered        for any reason. House Leadership is considering moving
                                                          two medical liability reform bills, the “Medical    the legislation to the full House in June.
                                                          Care Access Protection Act” (S. 22), introduced         The “Community Health Center Volunteer Physician
                                                by Sen. John Ensign (R-NV), and the “Healthy                  Protection Act of 2005” (H.R. 1313/S. 1058), introduced
                                                Mothers and Healthy Babies Access to Care Act” (S.            by Rep. Tim Murphy (R-PA) and Sen. Rick Santorum
                                                23), introduced by Sen. Rick Santorum (R-PA). Both            (R-PA), extends liability protections to physicians who
                                                bills included limits on non-economic damages based           volunteer their services at community health centers. The
                                                upon the Texas law established in 2003.                       proposal aims to increase the numbers of physicians,
                                                    Under the Texas model, non-economic damages are           especially those that may be retired, who are willing to
                                                limited to $250,000 for physicians, $250,000 for a            provide patient care at CHCs.
                                                hospital, and $250,000 for a second institution — for a           Both the House and Senate may consider
                                                total of $750,000 in non-economic damages. Leading            comprehensive medical liability reform legislation again
                                                up to the vote, many supporters expressed hope that the       prior to the adjournment of the 109th Congress. Exact
                                                “trifurcated” approach was more appealing politically,        timing of these votes is uncertain, but they likely would
                                                and might blunt criticism that $250,000 was an unfair         occur in the fall.
                                                and outdated monetary award.
                                                    S. 22 was a broad bill applicable to all physicians and   Medicare Enrollment and the National
                                                health care services, while S. 23 narrowed the scope to       Provider Identifier
                                                only services related to obstetrical care. Unfortunately,         Medicare’s recently revised enrollment application
                                                both bills failed to secure enough votes to be approved       (Form 855) requires physicians and other health care
                                                by the Senate. The vote on S. 22 was 48-42. Forty-eight providers to list their National Provider Identifier (NPI).
                                                Republicans voted in favor of the bill. Thirty-nine           If you are planning to enroll in Medicare or change your
                                                Democrats and three Republicans voted against the bill. current enrollment using the revised form, you must
                                                Ten Members did not vote. The vote on S. 22 was 49-           obtain your NPI first.
                                                44. Forty-nine Republicans voted in favor of the bill.
                                                Democrats and             Of the Members not voting, Senators Burns, Brownback, Coburn
                                                three Republicans
                                                voted against the         and McCain have supported routinely comprehensive medical liability
                                                bill. Seven Members reform legislation. Their failure to cast a vote prevented the vote
                                                did not vote.
                                                    Of the Members total from reaching the majority margin predicted.
                                                not voting, Senators
                                                Burns, Brownback, Coburn and McCain have supported                The Centers for Medicare and Medicaid Services
                                                routinely comprehensive medical liability reform              (CMS) has clarified that physicians applying may
                                                legislation. Their failure to cast a vote prevented the vote continue to use the 2001 version of Form 855, which
                                                total from reaching the majority margin predicted.            does not require the NPI, until June 2. After June 5,
                                                (Please see the complete listing of the Senate vote that      only the revised Form 855 will be accepted by CMS.
                                                accompanies this article.)                                        CMS continues to work to resolve problems
                                                    With the Senate failing to approve comprehensive          associated with the submission of the new forms and the
                                                medical liability reform legislation, the focus now turns to NPI. For more information, visit the CMS website at
                                                smaller medical liability reform bills that provide liability
                                                protections to a smaller group of physicians. These bills
                                                include proposals that would provide liability protections    House Approves Budget Resolution
                                                for physicians responding to natural and manmade                  On May 17, the House of Representatives approved
                                                disasters, and liability protection for physicians who        a $2.7 trillion FY 2007 budget resolution. Prior
                                                volunteer their services in community health centers.         attempts to adopt the plan were postponed for lack of
                                                    The House Judiciary Committee approved the                votes over the level of discretionary spending, especially
                                                “Disaster Relief Volunteer Protection Act of 2006”            funding for health care and medical research programs.
                                                (H.R. 4698) on March 15. The legislation, introduced          Members successfully petitioned for increased
                                                by Judiciary Committee Chairman James Sensenbrenner discretionary funding, and a $3.1 billion reserve fund for
                                                (R-WI), provides protections for licensed physicians          health and education programs. Combined with funds
                                                whether they are providing care in the state they are         shifted from defense and foreign aid accounts, the
                                                licensed in or not. However, the bill does not provide        resolution provides an additional $7.1 billion overall for
                                                protections for those who are not licensed, who are on a      programs in the Departments of Labor, Health and
                                                probationary status or have allowed their license to lapse Human Services, and Education.

4   O S T E O PAT H I C FA M I LY P H Y S I C I A N N E W S J U N E 2 0 0 6
         U P D A T E

   The increased funding brings funding levels closer to those approved by the
Senate in its FY 2007 plan. The House Budget Resolution also includes non-binding
legislation encouraging Congress to approve increased funding for physicians
participating in the Medicare program. Under current law, physicians will have their
Medicare reimbursements cut by 4.6 percent on January 1, 2007.

Marcelino Oliva, DO, FACOFP chairs the ACOFP Committee on Federal Legislation.
Shawn Martin serves as ACOFP’s Director of Government Affairs. ACOFP members can
contact Mr. Martin at 800-962-9008, extension 228, or by e-mail at

 Senate Votes on the “Medical Care Access Protection Act” (S. 22) and the “Healthy Mothers and Healthy Babies Access to Care Act” (S. 23).
         FIRST         LAST        PARTY   STATE   S. 22        S. 23                  FIRST       LAST            PARTY       STATE         S. 22             S. 23
  Sen.   Daniel        Akaka       D       HI      No           No              Sen.   James       Inhofe          R           OK            Yes               Yes
  Sen.   Lamar         Alexander   R       TN      Yes          Yes             Sen.   Daniel      Inouye          D           HI            No                No
  Sen.   Wayne         Allard      R       CO      Yes          Yes             Sen.   Johnny      Isakson         R           GA            Yes               Yes
  Sen.   George        Allen       R       VA      Yes          Yes             Sen.   James       Jeffords        I           VT            Not Voting        Not Voting
  Sen.   Max           Baucus      D       MT      No           No              Sen.   Tim         Johnson         D           SD            No                No
  Sen.   Evan          Bayh        D       IN      No           No              Sen.   Edward      Kennedy         D           MA            No                No
  Sen.   Robert        Bennett     R       UT      Yes          Yes             Sen.   John        Kerry           D           MA            No                No
  Sen.   Joseph        Biden       D       DE      Not Voting   Not Voting      Sen.   Herbert     Kohl            D           WI            No                No
  Sen.   Jeff          Bingaman    D       NM      No           No              Sen.   Jon         Kyl             R           AZ            Yes               Yes
  Sen.   Christopher   Bond        R       MO      Yes          Yes             Sen.   Mary        Landrieu        D           LA            No                No
  Sen.   Barbara       Boxer       D       CA      No           No              Sen.   Frank       Lautenberg      D           NJ            No                No
  Sen.   Sam           Brownback   R       KS      Not Voting   Not Voting      Sen.   Patrick     Leahy           D           VT            No                No
  Sen.   Jim           Bunning     R       KY      Yes          Yes             Sen.   Carl        Levin           D           MI            No                No
  Sen.   Conrad        Burns       R       MT      Not Voting   Not Voting      Sen.   Joseph      Lieberman       D           CT            No                No
  Sen.   Richard       Burr        R       NC      Yes          Yes             Sen.   Blanche     Lincoln         D           AR            No                No
  Sen.   Robert        Byrd        D       WV      No           No              Sen.   Trent       Lott            R           MS            Yes               Yes
  Sen.   Maria         Cantwell    D       WA      No           No              Sen.   Richard     Lugar           R           IN            Yes               Yes
  Sen.   Thomas        Carper      D       DE      No           No              Sen.   Mel         Martinez        R           FL            Yes               Yes
  Sen.   Lincoln       Chafee      R       RI      Yes          Yes             Sen.   John        McCain          R           AZ            Not Voting        Not Voting
  Sen.   Saxby         Chambliss   R       GA      Yes          Yes             Sen.   Mitch       McConnell       R           KY            Yes               Yes
  Sen.   Hillary       Clinton     D       NY      No           No              Sen.   Barbara     Mikulski        D           MD            No                No
  Sen.   Tom           Coburn      R       OK      Not Voting   Yes             Sen.   Lisa        Murkowski       R           AK            Yes               Yes
  Sen.   Thad          Cochran     R       MS      Yes          Yes             Sen.   Patty       Murray          D           WA            No                No
  Sen.   Norm          Coleman     R       MN      Yes          Yes             Sen.   Ben         Nelson          D           NE            No                No
  Sen.   Susan         Collins     R       ME      Yes          Yes             Sen.   Bill        Nelson          D           FL            No                No
  Sen.   Kent          Conrad      D       ND      Not Voting   Not Voting      Sen.   Barack      Obama           D           IL            Not Voting        No
  Sen.   John          Cornyn      R       TX      Yes          Yes             Sen.   Mark        Pryor           D           AR            No                No
  Sen.   Jon           Corzine     D       NJ      No           No              Sen.   Jack        Reed            D           RI            No                No
  Sen.   Larry         Craig       R       ID      Yes          Yes             Sen.   Harry       Reid            D           NV            No                No
  Sen.   Mike          Crapo       R       ID      No           No              Sen.   Pat         Roberts         R           KS            Yes               Yes
  Sen.   Mark          Dayton      D       MN      No           No              Sen.   John        Rockefeller     D           WV            Not Voting        Not Voting
  Sen.   Jim           DeMint      R       SC      Yes          Yes             Sen.   Ken         Salazar         D           CO            No                No
  Sen.   Mike          DeWine      R       OH      Yes          Yes             Sen.   Rick        Santorum        R           PA            Yes               Yes
  Sen.   Christopher   Dodd        D       CT      No           No              Sen.   Paul        Sarbanes        D           MD            No                No
  Sen.   Elizabeth     Dole        R       NC      Yes          Yes             Sen.   Charles     Schumer         D           NY            No                No
  Sen.   Pete          Domenici    R       NM      Yes          Yes             Sen.   Jeff        Sessions        R           AL            Yes               Yes
  Sen.   Byron         Dorgan      D       ND      No           No              Sen.   Richard     Shelby          R           AL            No                No
  Sen.   Richard       Durbin      D       IL      Not Voting   No              Sen.   Gordon      Smith           R           OR            Yes               Yes
  Sen.   John          Ensign      R       NV      Yes          Yes             Sen.   Olympia     Snowe           R           ME            Yes               Yes
  Sen.   Michael       Enzi        R       WY      Yes          Yes             Sen.   Arlen       Specter         R           PA            Yes               Yes
  Sen.   Russ          Feingold    D       WI      No           No              Sen.   Debbie      Stabenow        D           MI            No                No
  Sen.   Dianne        Feinstein   D       CA      No           No              Sen.   Ted         Stevens         R           AK            Yes               Yes
  Sen.   Bill          Frist       R       TN      Yes          Yes             Sen.   John        Sununu          R           NH            Yes               Yes
  Sen.   Lindsey       Graham      R       SC      No           No              Sen.   Jim         Talent          R           MO            Yes               Yes
  Sen.   Charles       Grassley    R       IA      Yes          Yes             Sen.   Craig       Thomas          R           WY            Yes               Yes
  Sen.   Judd          Gregg       R       NH      Yes          Yes             Sen.   John        Thune           R           SD            Yes               Yes
  Sen.   Chuck         Hagel       R       NE      Yes          Yes             Sen.   David       Vitter          R           LA            Yes               Yes
  Sen.   Tom           Harkin      D       IA      No           No              Sen.   George      Voinovich       R           OH            Yes               Yes
  Sen.   Orrin         Hatch       R       UT      Yes          Yes             Sen.   John        Warner          R           VA            Yes               Yes
  Sen.   Kay Bailey    Hutchison   R       TX      Yes          Yes             Sen.   Ron         Wyden           D           OR            No                No

                                                                                                 O S T E O PAT H I C FA M I LY P H Y S I C I A N N E W S J U N E 2 0 0 6    5
pain                                                                                  Article
      S P E C I A L             I S S U E

A Case Study and Clinical Review
of Clostridium tetani
= continued from page 1

                                                tetanospasmin toxin, which ranks               Physical examination revealed a     recovery, he was eventually
                                                with botulism toxin as the most            temperature of 101° F, heart rate of    discharged to home with near-
                                                potent known microbial poison.             104 bpm, blood pressure 124/64 and      full recovery of his previous
                                                   An estimated one million infants        respiratory rate of 18. The patient     functional ability.
                                                die of tetanus in developing               was alert and oriented times three          As this near-fatal case illustrates,
                                                countries each year because of poor        and was in no acute respiratory         it is important to consider tetanus
                                                hygiene. Since childhood                   distress. His cardio-pulmonary exam     in the differential diagnosis of cases
                                                immunization laws were passed in           was unremarkable. His neurological      with unexplained neurological
                                                                                           exam revealed intermittent,             symptoms. The balance of this
                                                                                           involuntary muscle spasms of the        article provides an overview of
                An estimated one million infants die of                                    left upper extremity of                 the pathophysiology, history and
                                                                                           approximately five seconds in           clinical features, management and
                tetanus in developing countries each year                                  duration. He demonstrated an            prevention of tetanus.
                because of poor hygiene.                                                   occasional left facial grimace with
                                                                                           the spasms. He also had diffuse         Pathophysiology
                                                                                           weakness of the left upper extremity.       The toxin, tetanospasmin, which
                                                                                           His deep tendon reflexes were           is released by the germinating spore
                                                                                           symmetric and sensation was intact.     of the tetanus bacillus to
                                                                                               He was admitted to the hospital,    underlying tissue, circulates via the
                                                the United States in the 1970s, only       and evaluated by the neurology and      lymphatic and vascular circulation,
                                                about 50 cases a year are reported in      infectious disease services. He         where it diffuses to the end plates
                                                this country.(1) Presently, tetanus is a   underwent extensive diagnostic          of all nerves. The circulating toxin
                                                severe disease of primarily older          studies, which revealed normal          cannot cross the blood-brain
                                                adults who are unvaccinated or             CBC, VDRL and CSF studies. His          barrier, and therefore does not
                                                inadequately vaccinated. The               metabolic labs were normal, except      enter the central nervous system
                                                following case study involves an           for a low sodium finding of 131.        directly, except at the fourth
                                                individual who was eventually              His serologies including Lyme and       ventricle.(2) The toxin binds to the
                                                diagnosed and treated for a tetanus        West Nile antibodies, and others        gangliosides at the neuromuscular
                                                infection in March of 2004.                were negative. His chest x-ray and      junction, and is transported along
                                                                                           CT of the head were negative. His       the axon in a retrograde direction
                                                Case Study                                 EEG was reported as mildly              into the neurons of the central
                                                    This 75 year-old Caucasian male        abnormal, non-specific cerebral         nervous system. The transport in
                                                was driving back to Michigan               dysfunction with mild                   the motor nerve takes from two to
                                                following a six-month stay in New          encephalopathy. His clinical            14 days to reach the CNS.(2)
                                                Mexico. He began to notice                 condition deteriorated and he               The toxin affects the inhibitory
                                                difficulty holding a coffee cup and        developed progressive dysarthria        neurons, preventing the release of
                                                some weakness in his left arm. He          and dysphagia. He continued to          GABA and glycine, leading to
                                                wasn’t concerned, because he had           have dystonic movements to his          failure of inhibition of motor reflex
                                                experienced on-and-off weakness            face and upper extremeties. He          responses to sensory stimulation.
                                                since experiencing a CVA three             required intubation with mechanical     This causes muscle rigidity and the
                                                years prior. Four days later, he began     ventilation as well as a PEG tube       characteristic generalized
                                                to experience twitching in his left        placement. He was also treated for      contractions of a tetanic spasm,
                                                arm, with spasms to the left side of       an upper GI bleed and developed         along with autonomic instability.
                                                his face. Retrospectively, he gave         PSVT and atrial flutter.                Once the toxin binds to neurons, it
                                                history of having fallen twice, and of         The etiology for his progressive    cannot be neutralized by antitoxin.
                                                progressive weakness of his upper          neurologic decline was uncertain.       The length and course of illness is
                                                extremities. He then presented to an       He was suspected to have had a          influenced by the amount and
                                                emergency room for evaluation.             possible toxin exposure. On further     location of the bound toxin. The
                                                    His medical history was                questioning of his family, they         usual clinical course of tetanus
                                                significant for mild emphysema             revealed he had dental work             usually ranges from two to four
                                                with a 20-pack-per year history of         performed in Mexico two weeks           weeks, and is influenced by the age
                                                cigarette smoking, hyperlipidemia, a       prior to his admission. The             of the patient and the development
                                                prior cerebral vascular accident in        neurologist suspected generalized       of complications.(3)
                                                2001, and partial gastric resection        tetanus, and empirically treated him
                                                for peptic ulcer disease in 1965. He       with a diphtheria-tetanus
                                                                                                                                   History and Clinical
                                                related a history of moderate              vaccination and 6,000 units of
                                                                                           tetanus immune globulin.                Features
                                                alcohol use. He lived in a suburban                                                   The diagnosis of tetanus requires
                                                area of Detroit, Michigan, and                 During the next few days, the
                                                                                           patient’s clinical status began to      a high index of clinical suspicion, as
                                                traveled every winter to New                                                       there are no specific laboratory tests
                                                Mexico. He related no known                improve. He required continued
                                                                                           supportive care and inpatient           for its diagnosis. In 15 to 30 percent
                                                recent immunizations or previous                                                   of cases, there is neither a history of
                                                military service.                          rehabilitation. After a prolonged
                                                                                                                                   injury, nor a source of infection.(4)

6   O S T E O PAT H I C FA M I LY P H Y S I C I A N N E W S J U N E 2 0 0 6
pain                                                                  Article
   S P E C I A L   I S S U E

                               The mechanism of injury is commonly contamination of            As the disease progresses, muscle rigidity becomes
                               a wound, burn or animal bite but atypical cases from         the major manifestation. Muscle rigidity spreads from
                               middle ear infection, dental caries, septic abortion and     the jaw and facial muscles to the extensor muscles of the
                               intramuscular injections have been reported.(2)              limbs during the next 24 to 48 hours. Persistent
                                  Tetanus may occur in three clinical forms: localized,     contraction of facial musculature may occur, producing
                               generalized or cephalic. Local tetanus is characterized      the classic sneering grin expression known as risus
                               by muscle spasm near the site of inoculation. It may         sardonicus.(3) Reflex spasms develop in most patients,
                               precede generalized tetanus, but by itself, is usually       and can be triggered by minimal external stimulation
                               resolved without sequelae after several weeks. Cephalic      such as light, touch or noise. They may last seconds to
                               tetanus is a rare manifestation that involves introduction   minutes, and as the disease progresses, may cause
                               of the Clostridium tetani bacterium in the head and          fractures, dislocations, apnea and rhabdomyolysis. In
                               neck region. The most common affected cranial nerve is       severe cases of tetanus, autonomic dysfunction occurs,
                               the facial nerve.                                            which is often the cause of death.
                                  Generalized tetanus is the most common form seen             One bedside diagnostic test is known as the spatula
                               in 80 percent of cases. The onset may be insidious, but      test.(5) A spatula or tongue blade is used to touch the
                               typically presents with trismus (i.e. lock jaw) in 75        posterior pharynx. This usually elicits a gag reflex and
                               percent of the cases. Other presenting complaints            the patient tries to expel the tongue blade. This is a
                               include dysphagia, stiffness, neck rigidity, restlessness    negative test. In tetanus, the patient develops a reflex
                               and reflex spasms.                                           spasm of the masseters and bites the spatula. This is a

                                                                                                                                       continued on page 8 =

                                                                                        O S T E O PAT H I C FA M I LY P H Y S I C I A N N E W S J U N E 2 0 0 6   7
pain                                                                                        Article
        S P E C I A L            I S S U E

A Case Study and Clinical Review
of Clostridium tetani
= continued from page 7

                                                  positive test. In 400 patients this       The recommended dose is 500 to          anaerobes including C. tetani.(2) The
                                                  test had a specificity of 100 percent, 3000 U. A patient also should receive recommended dose is 500 mg
                                                  and sensitivity of 94 percent. No         tetanus toxoid to prevent recurrent     intravenously every eight hours for
                                                  adverse sequelae were reported from disease. Therapy also includes                seven to 10 days.
                                                  this test. This test can be performed antibiotics and wide wound                     Patients should be monitored in
                                                  in a patient presenting with                                                                          an intensive care
                                                  trismus to help aid in the                                                                            setting, and
                                                  early diagnosis of tetanus and The diagnosis of tetanus requires a high index                         prophylactic
                                                  to hasten appropriate               of clinical suspicion, as there are no specific                   intubation
                                                  therapeutic intervention.                                                                             should be
                                                                                      laboratory tests for its diagnosis.                               considered in all
                                                  Management                                                                                            patients with
                                                      Since there is no way to                                                                          moderate to
                                                  remove the toxin once it is bound to                                                                  severe clinical
                                                  nervous tissue, the only specific         debridement under anesthesia            manifestations. Patients also require
                                                  treatment is to eradicate the bacteria    when a wound is identified.             minimal external stimulation.
                                                  from the wound and neutralize the             Penicillin had previously been      Sedation and muscle relaxation
                                                  circulating toxin, and to provide         the traditional antibiotic for tetanus, should be instituted, usually with
                                                  appropriate supportive care. Specific     but it was shown to be a GABA           diazepam (0.1-0.2 mg/kg IV q 4-6
                                                  therapy includes administration of        antagonist, which could aggravate       hours).(3) Maintenance of adequate
                                                  intramuscular human tetanus               tetanus spasms. It has been replaced hydration, nutrition and
                                                  immune globulin HTIg to neutralize with metronidazole (Flagyl), which             oxygenation is also required. Often,
                                                  any residual circulating antitoxin.       is bactericidal against obligate        these patients require parenteral

This micrograph depicts a group of Clostridium tetani bacteria, responsible for causing tetanus in humans.
Image courtesy of The Center for Disease Control

8    O S T E O PAT H I C FA M I LY P H Y S I C I A N N E W S J U N E 2 0 0 6
pain                                                           Article
   S P E C I A L   I S S U E

                                         nutrition due to the lengthy disease process.  protection in childhood. Additional boosters
                                         The main goal of therapy is to prevent and     should be given each decade throughout
                                         treat complications.                           life, with further tetanus prophylaxis after
                                            New treatment options to consider reported  acute wounds.
                                         to avoid artificial ventilation and sedation are   Individuals who have received a full
                                         dantrolene, baclofen and magnesium.            primary immunization and appropriate
                                         Magnesium therapy has the advantages           boosters need only local wound care for clean
                                         of controlling spasms and sympathetic          and minor wounds. However, they should
                                         hyperactivity without sedation. Studies have   receive a tetanus toxoid booster after a dirty,
                                                                                                        tetanus-prone wound if the
                                                                                                        most recent dose was received
                               Since there is no way to remove the toxin once it is                     more that five years previously.
                                                                                                        Patients who have not
                               bound to nervous tissue, the only specific treatment                     completed a primary series
                               is to eradicate the bacteria from the wound and                          require a tetanus toxoid
                                                                                                        booster after any penetrating
                               neutralize the circulating toxin, and to provide                         wound, and TIG after a
                               appropriate supportive care.                                             tetanus-prone injury. The
                                                                                                        prophylactic dose of TIG
                                                                                                        is 250-500 U, given
                                        concluded that magnesium should be used as          Although tetanus is uncommon in the
                                        a first line therapy in the routine management  U.S., it could be minimized by updating and
                                        of tetanus.(2)                                  maintaining tetanus immunizations. With
                                            The main predictors of prognosis are the    tetanus being such a preventable disease, it
                                        quickness of symptom onset from exposure        is important to ask patients about their
                                        and the rate of progression from trismus to     immunization histories and to update them
                                        severe spasms. In general, shorter intervals    when possible. In addition, vaccination
                                        indicate more severe tetanus and a poorer       programs need to be expanded worldwide
                                        prognosis. Most patients usually survive        to decrease this highly preventable disease.
                                        tetanus and return to their predisease state of
                                        health, but recovery is slow and usually occurs Troy M. Smith, DO, is a 1990 graduate of the
                                        during a two- to four-month period.             University of Osteopathic Medicine and Health
                                                                                        Sciences-College of Osteopathic Medicine and
                                        Conclusion                                      Surgery in Des Moines, Iowa. He completed a
                                            The best treatment for tetanus is           Family Practice residency at Garden City
                                        prevention. The cost of immunization            Osteopathic Hospital in 1993. He is Board-
                                        is negligible, compared to the costs of         certified in Family Practice and Geriatric
                                        treating a prolonged case of tetanus. Active    Medicine. He is a Clinical Assistant Professor of
                                        immunization with tetanus toxoid is the         Family Medicine at Michigan State University,
                                        most effective means of prevention. Tetanus     East Lansing, Michigan.
                                         toxoid is one of the safest and most effective
                                         vaccines available.(7) Serious vaccine
                                         complications are rare, with anaphylaxis
                                                                                                                 Print this article with references at
                                         occurring one in one million cases.(8) The
                                         primary series of tetanus toxoid, administered
                                         as DTP vaccine at two, four and six months,
                                         and a booster 12 months later, ensures

                                                                              O S T E O PAT H I C FA M I LY P H Y S I C I A N N E W S J U N E 2 0 0 6    9
     S P E C I A L            I S S U E

Ohio University Study Indicates Higher
Diabetes Rates for Seven Counties in
Southeastern Ohio
Ohio University survey says one-quarter of those responding were taking
neither insulin or other diabetes medication to help treat the disease

                                                        he prevalence of diabetes      (blindness); kidney disease; nerve    United States Department of
                                                        throughout seven counties of   damage; amputations; dental           Health and Human Services.
                                                        southeastern Ohio may be       disease; pregnancy problems; and         Dr. Schwartz and other health-
                                                almost twice as high as the state and  sexual dysfunction.                   care professionals and educators are
                                                national averages, according to a         According to the Centers for       among those leading the fight
                                                survey by the Appalachian Rural        Disease Control and Prevention’s      against diabetes in Southeastern
                                                Health Institute (ARHI) at Ohio        2004 Behavioral Risk Factor           Ohio. The ARHI study was
                                                University. The seven counties         Surveillance System (BRFSS) survey, conducted under the auspices of
                                                surveyed were Jackson, Meigs,          the nationwide prevalence of diabetes Ohio Governor Robert Taft’s
                                                Morgan, Perry, Ross, Washington        was 7.2 percent; the rate was 7.8     Appalachian Diabetes Initiative by
                                                                                       percent for Ohio. Perry County,       Ohio University’s Voinovich Center
                                                and Scioto. Perry
                                                                                                                                           for Leadership & Public
                                                and Morgan
                                                                        If people have to choose between putting food                      Affairs, and was funded
                                                counties were
                                                                                                                                           in part by the Ohio
                                                first and second,       on the table to feed their families or having their
                                                                                                                                           Diabetes Prevention and
                                                respectively, for
                                                                        medications, they choose to support their families. Control Program. Both
                                                the highest
                                                                                                                                           have helped fund
                                                prevalence of           They don’t realize the implications of not taking
                                                                                                                                           ARHI’s Diabetes
                                                diabetes. Results       their medications until something happens, and                     Initiative, of which the
                                                from all seven                                                                             Diabetes/Endocrine
                                                counties were           they’re taken to the hospital
                                                                                                                                           Center plays the leading
                                                higher than state                                                                          role. ARHI was created
                                                and national diabetes rates.           according to the ARHI study, had a    by the College of Osteopathic
                                                    The survey also found that         rate of 14.2 percent. Ross County     Medicine and College of Health
                                                almost one-quarter of those who        was the lowest, at 10.2 percent.      and Human Services in 2003.
                                                responded were taking neither          ARHI’s survey methodology parallels      ARHI held its quarterly
                                                insulin nor other diabetes             that of the BRFSS.                    conference of diabetes educators and
                                                medication to help treat the disease.     “Within Appalachia there are       health-care professionals
                                                    “The results of this survey        clusters of counties that are at      Wednesday, June 6, 2006 at Ohio
                                                indicate that persons in Appalachian higher risk, and they tend to be        University. The quarterly sessions,
                                                Ohio have prevalence rates for         more devastated economically and      which focus on the research and
                                                diabetes equivalent to those           have lower group socioeconomic        work in progress toward developing
                                                reported for high risk ethnic groups   status,” said Dr. Schwartz.           more comprehensive diabetes care
                                                in the country,” said Frank               Schwarz said that many of Ohio’s and outreach programs in
                                                Schwartz, MD, director of ARHI’s       29 Appalachian counties have a        Appalachia Ohio, are an outgrowth
                                                Diabetes/Endocrine Center and          disproportionately high number of     of ARHI’s Diabetes Initiative.
                                                OU-COM associate professor of          people who live at or near poverty    Wednesday’s conference examined
                                                endocrinology. Schwartz was the        level, have lower education levels,   barriers to diabetes care in
                                                principal investigator for the study.  suffer from obesity and lead          Appalachia and unveiled the results
                                                    Diabetes is a disease in which the unhealthy lifestyles.                 of the ARHI study.
                                                body does not adequately produce          Currently, there is no cure for       The goal at the College of
                                                or utilize insulin, which stimulates   diabetes. According to the            Osteopathic Medicine and Ohio
                                                the transport of blood glucose         American Diabetes Association         University, said Dr. Schwartz, “is to
                                                (sugar) into body cells. Unchecked     (ADA), there are almost 21 million    have a research and clinical diabetes
                                                or untreated diabetes leads to         Americans with diabetes, of which     program that goes from the scientific
                                                hyperglycemia — highly elevated        almost six million are unaware of     bench to the patient’s bedside” for
                                                levels of blood glucose. The           their disease. Dr. Schwartz believes  southeastern Ohio. In order to
                                                complications of untreated and/or      that there could be higher            accomplish that, he said you need not
                                                long-term diabetes comprise a          prevalence rates of diabetes in the   only scientists and clinicians treating
                                                number of life-impairing and life-     seven counties than even the ARHI     diabetes at the molecular and patient
                                                threatening illnesses such as heart    study indicates. This is possible,    care levels, you must work to put into
                                                disease and stroke, which account      considering ADA statistics and that place educational and social networks
                                                for roughly 65 percent of diabetes-    these people are residents of         and coalitions that bring together all
                                                related fatalities; high blood         counties that are classified as       those who are involved with diabetes
                                                pressure; diabetic retinopathy         medically underserved by the          care in this region.

10   O S T E O PAT H I C FA M I LY P H Y S I C I A N N E W S J U N E 2 0 0 6
pain                                                                                                 All the benefits you need.
      S P E C I A L        I S S U E
                                                                                                     All the support you want.
                                                                                                     Continuing Education
                                                                                                     Keep up with medical advances
                                                                                                     • AOA/ACOFP 111th Annual Convention & Exhibition,
    “We started out as a group of diabetes educators. We were the zealots. Now we’re                   October 16-20, 2006, Las Vegas, Nev.
adding anyone who is involved in the delivery of health care and chronic care in                     • Center for Excellence in Procedural Medicine Regional
southeastern Ohio. These are people who are involved with helping those at every                       Workshops on dermatologic skills
socioeconomic level through the region. We are seeking to work with governmental                     • Center for Excellence in Procedural Medicine Regional
agencies, county extension agencies and the school systems, as well. We’re all                         Workshops on joint and trigger point injections
participating in this process to fashion effective ways of intervening from the                      • Center for Excellence in Procedural Medicine Regional
standpoint of governmental policies and outreach health-care programs, to preventing                   Workshops on spirometry
diabetes at the molecular level.”                                                                    • Intensive Update and Board Review in Osteopathic
    Carole Merckle has been part of this developing network for more than a year.                      Family Medicine
Merckle is the director of health education for the Perry County Health Department,                  • Relief of Persistent Pain Online Education Course
the county with the highest reported diabetes prevalence rate.                                       • Osteopathic Family Physician News CME Quizzes.
    “In Perry County diabetes is a near epidemic in almost every age group now,” said
Ms. Merckle. “We’re seeing high incidences of diabetes across the board. We’re seeing                Online Communities
more children with diabetes in our schools. We’re seeing more adults that aren’t                     Stay connected from your home or office
receiving care.”                                                                                     • DO Connect: Online Family Physician Community
    The obesity epidemic has fueled the rise in diabetes, said Ms. Merckle. “We’ve got               • OFP Coding Discussion Forum
an epidemic of Type 2 diabetes. We’ve got huge numbers of adults with diabetes. It’s                 • Job Bank
not just Perry County. Unfortunately, our rates are higher than the other counties.”                 • Online Membership Directory
    Complicating the proper treatment and care of the rising numbers of those with                   • ACOFP State Societies
diabetes, said Merckle, are social and economic issues that affect the ability and
willingness of diabetics to properly manage their diabetes and that limit the kinds of               Advocacy
care that they are going to seek out and be able to afford.                                          Be heard on key physician issues
    “If people have to choose between putting food on the table to feed their families or            • Medical Liability Reform
having their medications, they choose to support their families. They don’t realize the              • Physician Payment Policies
implications of not taking their medications until something happens, and they’re                    • Protect Physicians Ability to Practice Medicine
taken to the hospital.                                                                               • Promote and Protect Physicians’ Ability to Care
    “Too many diabetics don’t believe they have diabetes unless they are taking insulin.               for Patients
I’ve had patients over the years tell me, ‘Oh, I’ve just got a touch of diabetes. Or I’ve            • Patient Access to Quality Medical Care
just got a little bit of diabetes.’ If they were on oral medications, they really didn’t             • Graduate Medical Education
think they had diabetes. This is because of a lack of education about diabetes.
    “And too many people don’t have money to pay for medications or can’t afford to                  Leadership Opportunities
pay for their medications on a regular basis.”                                                       Give back to the osteopathic community
    Almost one-quarter of those responding to the survey in Perry County said they                   • Volunteer for a national committee or task force
were unable to regularly see a health-care provider because of cost.                                 • Earn recognition at the highest level with the
    What’s needed, said Ms. Merckle, is funding to pay for diabetes medication and                     designation of Fellow or Distinguished Fellow
educational programs in Perry County for the uninsured and underinsured.                             • Become an osteopathic family physician Mentor
    “Diabetes is a day-to-day disease. You’re living with it day in and day out of your              • Become a Preceptor
life. It’s not like high cholesterol. You can eat a big steak at one meal, and it won’t              • Submit an article to the Osteopathic Family
make a huge impact on your overall cholesterol if you’re properly monitoring what you                  Physician News
eat otherwise. With diabetes that’s not the case. If you’re diabetic and load up on
carbohydrates in one meal, you’re going to have a reaction to that. If your blood sugar              Professional Resources
goes too high or too low, you suffer the consequences. It’s a very hard disease. You can’t           Get help to grow your practice
get away from it for an hour or two. It’s with you all the time.”                                    • PDA downloads
                                                                   “Most diabetics in my             • Osteopathic forms central download
                                                                area did not test their blood        • OMT Procedures
Many of Ohio’s 29 Appalachian counties                          sugar every day,” said               • Osteopathic Practice Management Online
                                                                Norma Torres, RN, former               Information Center
have a disproportionately high number of
                                                                health commissioner for              • Osteopathic Family Physician News
people who live at or near poverty level,                       Meigs County, who
                                                                attended the conference.             Coding
have lower education levels, suffer from
                                                                “And if they test it — and           • Coding education tools
obesity and lead unhealthy lifestyles.                          they should test it four or          • Coding Search & Rescue
                                                                five times a day — they              •
don’t write it down.” And not all physicians use the A1C test, she said, which is a
much better indicator of blood sugar levels.                                                         Financial Services
    “A lot more education is needed. We need a lot more professionals to get involved                • Physician reimbursement services
in diabetes education. I believe we need to have a diabetes educator in every county,                • Group insurance plans
someone who could be available and accessible in a manner similar to the patient                     • College loan consolidation
navigators employed by the American Cancer Society.” This is someone who can call and                • Real Estate and Moving Resources
who would provide you with the needed resources and help available, Ms. Torres said.                 • Credit cards through MBNA America
    “In the laboratory we could come up with the best cure for diabetes,” said Jack                  • Moving services
Bantle, Ph.D., vice president for research at Ohio University, “but if you can’t get the             • Rental car discounts
patient to take it when he or she is supposed to take it, it won’t work. You really have
to understand (the issues of ) care — from the bench to the bedside.”                                If you have questions about your Membership,
    And with the help of ARHI’s Diabetes Initiative, there are dozens of health-care                 please call 800-323-0794.
educators and professionals, such as Merckle and Torres, preparing to take on the as
yet incurable but treatable disease of diabetes.

                                                                                                O S T E O PAT H I C FA M I LY P H Y S I C I A N N E W S J U N E 2 0 0 6   11
pain                                                                               Article
     S P E C I A L            I S S U E

Pain Assessment in
Elderly Adults
= continued from page 1

                                                    Pain assessment is an essential      scale was superior for pain           behaviors to express the presence of
                                                part of pain management. Com-            assessment in older patients with     pain, such as grimacing, rocking,
                                                monly, pain assessment is based on       mild-to-moderate cognitive            withdrawing, hyperkinesis and
                                                self-report. Some elderly patients       impairment (MMSE 13-22) in a          hypokinesis. Interpretation of these
                                                may underreport pain because of          subacute care
                                                fatalism, denial, the philosophy of      setting. The study
                                                the “good patient,” fear of adverse      provided
                                                                                                                 Undiagnosed and under-treated pain
                                                effects, fear of addiction or loss of    supportive
                                                independence.(1) Although there are      evidence for the        may lead to depression, cognitive and
                                                multiple instruments available for       ability of this
                                                                                                                 functional decline.
                                                pain assessment, elderly patients        group of patients
                                                with significant cognitive               to rate pain
                                                impairment may have difficulty           reliably. This study
                                                using these scales.                      excluded patients with severe         behaviors may be complicated by
                                                    It has been shown that nursing       cognitive impairment and with a       the fact that pain may manifest
                                                home patients with mild to               pre-existing diagnosis of dementia.   totally differently in different
                                                moderate cognitive impairment are            The physiological responses to    people, depending on how they react
                                                able to report pain at the moment,       pain, which include increased heart   to pain and their mechanisms for
                                                although their recall of pain is less    rate and decreased variability in     coping with pain.(3, 10)
                                                reliable.(3) Patients with Alzheimer’s   respiration, are poor indicators of       In one study, nurse ratings of
                                                                                                                               elderly demented patient pain did
                                                                                                                               not correlate with patient ratings
                                                                                                                               and underestimated pain relative to
                                                                                                                               patients reports.(9) The mini mental
                                                                                                                               status score of patients did not affect
                                                                                                                               these results. It has also been
                                                                                                                               reported that physician and nursing
                                                                                                                               assessments of pain correlated with
                                                                                                                               patient’s assessment, and probably
                                                                                                                               can be used as a valid surrogate to
                                                                                                                               self-assessment by the patient.(12)
                                                                                                                               These inconsistent findings limit use
                                                                                                                               of behavioral observation for pain
                                                                                                                                   Pain perceptions, and the ability
                                                                                                                               to describe pain in cognitively-
                                                                                                                               impaired patients, may depend on
                                                                                                                               the nature of the neuropathological
                                                                                                                               process responsible for cognitive
                                                                                                                               impairment. AD versus vascular
                                                                                                                               dementia (VD) may affect different
                                                                                                                               areas in the brain responsible for
                                                                                                                               pain perception. Patients with VD
                                                                                                                               commonly have an increase in the
                                                                                                                               affective component of the pain
                                                                                                                               experience, while patients with AD
                                                                                                                               may demonstrate a decrease in the
                                                                                                                               affective response to pain.(8)
                                                                                                                               Thalamic nuclei are unlikely to be
                                                                                                                               significantly affected in patients
                                                                                                                               with AD, which may result in
                                                                                                                               preserved discriminative ability of
                                                disease (AD) may have specific           pain in nonverbal patients.(13)       pain perception. It has been
                                                difficulties with visual tests because   Improved physical and psychosocial    suggested previously that demented
                                                these patients are prone to visual       functioning, and change in mood       subjects may have impairments of
                                                agnosia.(14)                             and cognition, may help to assess     body perception and localization of
                                                   One study compared a five-point       pain relief in these individuals.     stimulus.(13)
                                                verbal rating scale, a seven-point           Behavioral observations have also     Many studies have attempted to
                                                faces pain scale, a horizontal 21-       been used for pain assessment in      elucidate pain perception in elderly
                                                point box scale and two vertical 21-     elderly patients with dementia.(7)    individuals, but there are many gaps
                                                point box scales.(6) It was              Cognitively-impaired elderly          in understanding how elderly
                                                demonstrated that the 21-point box       patients may develop specific         patients with cognitive impairment

12   O S T E O PAT H I C FA M I LY P H Y S I C I A N N E W S J U N E 2 0 0 6
pain                                                                        Article
      S P E C I A L        I S S U E

The goal of pain management in
                                                          • There would be a strong, positive correlation
elderly adults is improved function                         between self-report of pain by patients with
                                                            cognitive impairment and caregiver report
that leads to improved activities
                                                          • Patients with cognitive impairment are able
of daily living, socialization, sleep                       to use a diagram of the human body used in
                                                            the Brief Pain Inventory for pain assessment
and not necessarily the complete
absence of pain.                                       Methods

                                                       Data Collection and Analysis
perceive pain. The present study is designed to            The study participants included 10 patients
address this issue.                                    and 10 caregivers from the Center for Aging at
   The primary objective of this study is to           UMDNJ/SOM. The study was approved by the
investigate the ability of elderly cognitively-        Institutional Review Board (IRB). Participants
impaired adults to indicate they have pain, and to     were asked by a triage nurse if they have pain now
identify where on their body they are experiencing     or within the previous week. If they answered
this pain. The secondary objective of this study is    “yes” to either question, they were asked if they
to investigate validity of common pain assessment      would consider participating in a pain research
scales for pain assessment in elderly patients with    project. If they agreed, then the principal
cognitive impairment.                                  investigator (PI) met with the patient and the
                                                       caregiver, and explained the purpose of the study.
   The hypotheses to be tested are:                    If a participant and a caregiver agreed to
   • Pain location, as reported by patients with       participate in the study, the participant’s ability to
     cognitive impairment, will correspond to the      sign an informed consent were assessed using a
     location of pain predicted by medical diagnosis                                  continued on page 14 =

                                                                                          A d v e r t i s i n g

                                                                                   Family Medicine – Wisconsin
                                                                                   The Wisconsin Office of Rural Health(WORH) has detailed information
                                                                                   on over 90 Family Medicine positions located throughout the state in both
                                                                                   rural and urban communities ranging in population from 1,000 – 250,000.
                                                                                   These positions are mainly with multi-specialty medical groups and
                                                                                   healthcare systems, although there are also some independent clinics as
                                                                                   well. There are outpatient-only positions, urgent care positions, and
                                                                                   emergency room positions also listed. WORH is a not-for-profit
                                                                                   organization located at the University of Wisconsin School of Medicine &
                                                                                   Public Health in Madison. Our Physician Placement Program has been
                                                                                   assisting primary care physicians find rewarding and satisfying positions
                                                                                   here in Wisconsin for over 26 years. For a complete listing of all Family
                                                                                   Medicine positions currently available, please contact: Randy Munson,
                                                                                   Wisconsin Office of Rural Health, 310 North Midvale Blvd, Madison,
                                                                                   Wisconsin, 53705. 1-800-385-0005; 608-261-1893(fax); e-mail:

                                                                                                  To place a classified advertisement in this
                                                                                                  publication, contact Michael Minakowski
                                                                                                  11 Penn Plaza, Suite 1003
                                                                                                  New York, NY 10001
                                                                                                  (ph) 215-860-0912
                                                                                                  (fax) 215-860-0913

                                                                                                  O S T E O PAT H I C FA M I LY P H Y S I C I A N N E W S J U N E 2 0 0 6   13
pain                                                                                    Article
     S P E C I A L            I S S U E

Pain Assessment in
Elderly Adults
 = continued from page 13

                                modified version of the test                                    Data from Pain Faces Scale were      research studies,(16, 17) and these scales
                                described by V.D. Buckles.(18) The                           compared with data from the             are extensively used in both clinical
                                participants and their caregivers                            Numeric Intensity Scale for each        practice and research.
                                completed research questionnaires.                           participant. Then, the pain rating by        The Brief Pain Inventory was
                                   The PI screened the medical                               the participant was compared to the     developed by Charles S.Cleeland,
                                records of the enrolled participants                         pain rating by his or her caregiver     PhD, and includes questions about
                                for pain syndromes and diagnoses                             for each scale. Responses of the        pain, pain relief and how pain
                                associated with the pain syndrome,                           participants, who were able to          interfered with a range of activities.(20,
                                                        such as                              localize pain on a diagram from             Patients are also asked to locate the
                                                        osteoarthritis,                      the Brief Pain Inventory, were          pain on a diagram commonly used in
Some elderly patients may underreport pain              degenerative                         compared with the presence of a         hospital and ambulatory care pain
                                                        join disease,                        corresponding medical diagnosis         assessment scales.
because of fatalism, denial, the philosophy of
                                                        previous                             of a painful condition and with a
the “good patient,” fear of adverse effects,            fracture and                         caregiver response.                     Results
                                                        spinal                                                                          The total sample included 10
fear of addiction or loss of independence.(1)
                                                        stenosis.                            Instrumentation                         participants with mild to moderate
                                                        MMSE,                                   The pain assessment form             dementing illness and their
                                                        Geriatric                            included two different well-            corresponding caregivers. . Ninety
                                Depression Scale (GDS) results and                           established pain scales (Pain Faces     percent of the participants were
                                demographic data were obtained                               Scale and Numeric Pain Intensity        females, with an average age of 80.1
                                from medical records review.                                 Scale) and a diagram of the human       (standard deviation of plus or minus
                                Participants with MMSE scores                                body from the Brief Pain Inventory.     3.24) years. None of the participants
                                between 18 and 30 were included in                           In addition, an item asking to          had met criteria for possible
                                the study. All caregivers were in                            describe the pain is included in the    depression, according to the GDS.
                                contact with the participants on a                           Pain Questionnaire. The sensitivity     MMSE scores were between 18 and
                                daily basis, and were familiar with                          and specificity of both scales have     28. The most common medical
                                the patient’s complaints of pain.                            been demonstrated in multiple

                    Table 1. Pain Location as reported on the Human Body Diagram and a Medical Diagnosis

                            ##                      MMSE                         Human body diagram                   Reported pain              Medical Diagnosis

                             1                         22                               Left arm                          Left arm                       OA, DJD

                             2                         23                           Left hip, left arm                   Low back                           OA

                             3                         18                      Shoulders, arm, abdomen                Right shoulder                        OA

                             4                         22                              Right foot                            Foot                        Foot Sx

                             5                         25                      Shoulders, back, knee, hips               Low back                        OA, OP

                             6                         22                              Knee, arm                            Knee                            OA

                             7                         28                               Hip, knee                            Hip                            OA

                             8                         25                         Low back, knee, feet                       Leg                         Foot Fx

                             9                         28                                  Eye                           Eyes pain                          OA

                            10                         23                              Low back                          Low back                           OA

                 The table illustrates pain complaints of the ten participants. The second column “MMSE” shows MMSE score for each participant.
                 The third column “Human body diagram” describes a pain location as it was marked by a participant on a Diagram of the Human Body.
                 The fourth column “Reported pain” indicated pain as it was reported verbally by a participant. The fifth column “Medical diagnosis”
                 contains a list of medical diagnosis as it was documented in the participant’s medical record.
                 OA – osteoarthritis, DJD – degenerative joint disease, Sx – surgery, Fx – fracture, OP - osteoporosi

14   O S T E O PAT H I C FA M I LY P H Y S I C I A N N E W S J U N E 2 0 0 6
pain                                                                Article
     S P E C I A L      I S S U E

                                                                                                                        previously reported in the literature,
                                                                                                                        OA and previous fractures are
                                                                                                                        common causes for pain in
                                                                                                                        the elderly.
                                                                                                                           It was confirmed that a caregiver
                                                                                                                        who interacts with a cognitively-
                                                                                                                        impaired patient on a daily basis was
                                                                                                                        able to accurately estimate the
                                                                                                                        location and intensity of the pain
                                                                                                                        experienced by the patient.
                                                                                                                           There is a strong correlation
                                                                                                                        between the pain assessments of the
                                                                                                                        caregiver and the patient using a
                                                                                                                        Numeric Pain Intensity Scale and a
                                                                                                                        diagram of human body from the
                                                                                                                        Brief Pain Inventory. However, the
                                                                                                                        correlation between the caregiver’s
                                                                                                                        report of pain on the Faces Pain
                                                                                                                        Scale and the patient’s report on
                                                                                                                        that scale was low. It was also
                                                                                                                        observed that participants required
                                                                                                                        more time to complete a Faces Pain
                                                                                                                        Scale. This is consistent with
                                                                                                                        previous reports of lower completion
                                                                                                                        rates for Faces Pain Scale as
                                                                                                                        compared to the Numeric Pain
                                diagnosis responsible for pain                The third hypothesis was to test          Intensity Scale.(19)
                                was osteoarthritis (80 percent            if patients with cognitive                       Our responders were able to use
                                of participants).                         impairment are able to use a                  a diagram of the human body from
                                   Six (60 percent) of the                diagram of the human body from                the Brief Pain Inventory for pain
                                participants reported the same            the Brief Pain Inventory for pain             assessment.
                                intensity of pain on both Faces and       assessment. We found that all
                                Numeric scales. One participant           responders were able to use the               Conclusion
                                (MMSE 18) was unable to complete          diagram. Nine (90 percent) of                     Elderly adults with mild dementia
                                the Faces scale. Only five (50            responders marked the same pain               are able to accurately report their pain
                                percent) of caregivers reported the       location marked by their caregivers.          using formal pain assessment scales.
                                same intensity of pain on both the            The one patient with a MMSE               On the basis of this study, our elderly
                                Faces and Numeric scales.                 score of 18 was not able to complete          patients are able to remember their
                                   The first hypothesis addresses         The Faces Pain scale. That patient            pain complaints.
                                pain location reported by patients        was able to complete the Numeric                  There is a need for a larger study
                                verbally and by marking a diagram         Pain Scale.                                   to evaluate a possible correlation
                                of the human body as compared to                                                        between MMSE score and the
                                the location of pain that can be          Discussion                                    ability to use formal pain scales.
                                expected on the base of a medical            Formal instruments for pain                There is a need to verify the
                                diagnosis. Table 1 illustrates the        assessment may present some                   findings of the present study using
                                                        results. All of   difficulties when used with                   a larger sample.
                                                        the patients      cognitively impaired participants.
It has been shown that nursing home patients reported pain                This study showed that most elderly
                                                        in the            participants with mild to moderate            Liliya Gekhman, DO, is in private
with mild to moderate cognitive impairment              locations that    cognitive impairment (MMSE 22-                practice at the Wycoff Heights Medical
are able to report pain at the moment,                  can be            28) were able to complete Numeric             Center, Brooklyn, New York.
                                                        expected          Pain Intensity Scale and Pain Faces
although their recall of pain is less reliable.(3)      from their        Scale at least with the same accuracy         Janet Lieto, DO, is a Fellowship
                                                        medical           as their caregivers. However, subjects        Program Director (Geriatrics/Family
                                                        diagnoses.        with more advanced cognitive                  Medicine Track) at the University of
                                                            The           impairment appeared to encounter              Medicine and Dentistry of New Jersey
                                second hypothesis assessed the            difficulties using the formal pain            School of Medicine – School of Osteopathic
                                correlation between self-reports of       assessment instruments used in this           Medicine, Stratford, New Jersey.
                                pain by responders with cognitive         study, as it was seen with our patient
                                impairment and by caregivers’             with MMSE score of 18.
                                reports. Pearson Correlation                 Pain location as reported by
                                Coefficient demonstrated a 0.688          elderly patients on the Human Body
                                correlation for the Numeric scale         Diagram corresponded to the                         Print this article with references at
                                and .166 for the Faces scale between      location of pain predicted by             
                                pain, as reported by responders, and      medical diagnoses. As was
                                by caregivers.

                                                                                         O S T E O PAT H I C FA M I LY P H Y S I C I A N N E W S J U N E 2 0 0 6   15
pain                                                                                Article
      S P E C I A L           I S S U E

Necrotizing Fasciitis
Presenting As Arm, Shoulder
and Upper Back Pain
An exploration of the so-called “Flesh-Eating Disease”
By Douglas S. Buffington, DO

                                                         ecrotizing Fasciitis (NF) is a    Lungs were clear bilaterally. Heart    32, creatinine 1.7. LFTs were
                                                         rapidly progressing               was regular without murmur. Her        within normal limits.
                                                         infectious process that is        abdomen was soft, but mildly              The patient was admitted for
                                                often polymicrobial. Mortality             distended with some LLQ                treatment and further workup,
                                                estimates range from 20 to 40              tenderness. Rectal examination was     and was placed on broad-
                                                percent and survival is often              negative for masses with guaiac        spectrum antibiotics. The
                                                accompanied by severe morbidity.           negative stool. Musculoskeletal        following day, surgical services
                                                Patients often present with localized      examination was within normal          were consulted to evaluate the
                                                tense, exquisitely tender skin, which      limits. She had several open lesions   patient. The lower back began to
                                                may often be misdiagnosed as               on her digits of both hands.           develop bilateral flank ecchymoses
                                                                                           Admission laboratory values were as    with skin breakdown on the left
                                                                                           follows: WBC 8.3 with 45 bands,        side. A CT of her abdomen and
                                                   Early diagnosis of NF is critical.
                                                                                           hemoglobin 13, hematocrit 39,          pelvis showed large bilateral
                                                The mainstays of treatment are
                                                                                           sodium 132, potassium 4.2, BUN         subcutaneous fluid collections
                                                broad-spectrum antibiotics and wide
                                                surgical debridement. This case
                                                involves a patient whose presenting
                                                chief complaint was tenderness in
                                                an area other than the involved site.

                                                Case Presentation
                                                    A 62 year-old female presented
                                                to our facility with a history of chills
                                                and rigors that, two days later,
                                                developed into myalgias, malaise,
                                                nausea, vomiting and diarrhea. She
                                                subsequently developed severe left
                                                arm, shoulder and upper back pain.
                                                Her family related that she had
                                                developed purulent skin erosions
                                                over the joints of both her hands
                                                two weeks prior to presentation.
                                                The patient had treated these
                                                lesions with an over-the-counter
                                                antibiotic ointment.
                                                    The patient’s previous medical
                                                history was significant only for
                                                menopause, Cesarean section and
                                                aspiration of a right breast cyst. She
                                                took only hormone replacement

Early diagnosis of NF is critical. The mainstays of
treatment are broad-spectrum antibiotics and wide
surgical debridement.

                                                therapy (HRT), and had no known
                                                drug allergies. The patient denied
                                                any use of tobacco or ethanol. She
                                                worked as a hairdresser.
                                                   On presentation, her
                                                temperature was 99° F, BP 83/50,
                                                pulse 97 and respirations 20. Her
                                                head was normocephalic. Neck
                                                showed no JVD or adenopathy.

16   O S T E O PAT H I C FA M I LY P H Y S I C I A N N E W S J U N E 2 0 0 6
pain                                                                      Article
     S P E C I A L   I S S U E

                                                                           toes, as well as resection of the distal       and cardiac disease, diabetes,
                                                                           phalanx of her middle and index                chronic renal failure, post-operative
                                                                           fingers of her right hand, secondary           wound complications, cutaneous
                                                                           to gangrene.                                   disease and subcutaneous injections.
                                                                              The patient stabilized and was                 Worldwide, rates of the disease
                                                                           transferred to a skilled rehabilitation        increased from the mid-1980s to the
                                                                           facility. She was eventually weaned            early 1990s. Rates have stabilized
                                                                           from the ventilator and her                    during the past decade in the
                                                                           tracheotomy tube was removed. She              United States, with approximately
                                                                           showed steady clinical progress and            8,800 cases of invasive disease
                                                                           was eventually discharged home.                (including Toxic Shock Syndrome, NF,
                                                                                                                          bacteremia, pneumonia) occurring in
                                                                           Discussion                                     2000. Only six percent of these
                                                                               Dr. Joseph Jones, a Confederate            cases were NF. Reported average
                                                                           Army surgeon, is credited with the             mortality rates range from 20 to 40
                                                                           first description of NF during the             percent. However, survival appears
                                                                           American Civil War. At that time, it           to be related to early detection and
                                                                           was referred to as “hospital                   aggressive surgical excision.
                                                                           gangrene.” The current descriptive                Patients generally present two to
                                 in her flanks and dilated loops of        term “necrotizing fasciitis” was first         four days after the initial insult.
                                 small bowel.                              used in 1952.                                  Gastrointestinal and influenza-like
                                     The patient was taken to the              This disease process is a life-            symptoms may be present, and the
                                 operating room for incision and           threatening, invasive infection that           skin is tense and shiny. There can be
                                 drainage (I&D) of the fluid               causes a rapidly-developing necrosis           areas of localized necrosis,
                                 collections, as well as exploratory       of subcutaneous tissue and fascia.             secondary to thrombosis. The
                                 laparotomy and lysis of adhesions.        Subsequent multisytem organ failure            presentation can easily be confused
                                 Her flank wounds were copiously           may ensue within
                                 irrigated and packed with                 hours to days, and
                                 providone-iodine soaked dressing.         amputations are
                                     Post-operatively, the patient         common. Group A
                                 developed septic shock and renal          streptococcus (S.
                                 failure. She underwent emergent           pyogenes) is the
                                 continuous veno-venous                    most common
                                 hemodialysis. She developed               isolate cultured
                                 respiratory failure, and required         from the blood and
                                 intubation. She also developed acute      wounds of NF
                                 tubular necrosis (ATN) and became         patients. Severity
                                 dialysis dependent. She also              of the disease is
                                 required high doses of IV fluids in       associated with
                                 order to maintain blood pressure.         increases in
                                     Blood and wound cultures grew         prevalence of the
                                 beta-hemolytic Streptococcus and          more virulent
                                 the patient received several courses      strains of the
                                 of antibiotics. She failed to wean off    bacterium (M-1
                                 of the ventilator and consequently        and M-3
                                 required a tracheotomy. Her flank         serotypes).
                                 wounds were managed with                  However,
                                 frequent dressing changes and             polymicrobial
                                 bedside debridement. The patient          synergistic
                                 required parenteral nutritional           infection with
                                                                           aerobic, anaerobic,
Dr. Joseph Jones, a Confederate Army surgeon,                              gram positive and
                                                                           gram negative
is credited with the first description of NF during
                                                                           bacteria also
the American Civil War. At that time, it was                               occurs. NF can
                                                                           also occur in
referred to as “hospital gangrene.”
                                                                           association with
                                                                           streptococcal toxic
                                                                           shock syndrome.
                                 support and a gastric feeding tube.           The groin, abdomen and                     with cellulitis. However, exquisite
                                 The patient was transfused due to         extremities are the most frequent              and unrelenting pain that is out of
                                 anemia and heme positive stools.          sites of involvement in this disease.          proportion to physical findings is a
                                    Approximately seven weeks after        Predisposing factors to NF include             hallmark sign of this disease.
                                 her initial presentation, the patient     immunosuppression, obesity,                       Routine blood work, as well as
                                 underwent amputation of all 10            malnutrition, chronic respiratory              wound and blood cultures should be

                                                                                                                                             continued on page 18 =

                                                                                           O S T E O PAT H I C FA M I LY P H Y S I C I A N N E W S J U N E 2 0 0 6   17
pain                                                                           Article
     S P E C I A L            I S S U E

Necrotizing Fasciitis Presenting As Arm,
Shoulder and Upper Back Pain
 = continued from page 17

                                obtained. Metabolic derangements are common in these         complaint of sever left arm, shoulder and upper back
                                patients, due in part to massive fluid sequestration. CT     pain. Our patient’s cutaneous manifestations were not
                                scans should also be obtained, which can show abscess        on these areas, but were, in fact, on her flanks. She
                                or areas of vascular thrombosis or of gas accumulation       eventually required amputation of several digits, and
                                (if a gas-producing organism is present).                    her fingers may have, in fact, been the source of her
                                                          Early recognition, antibiotic      disease process. However, these areas did not initially
                                                      coverage and timely surgical           show signs of NF.
Early recognition, antibiotic coverage                intervention are essential                Although excisional debridement is recommended,
                                                      components of care for these           our patient’s flank abscesses were incised and drained of
and early surgical intervention are                   patients. Delayed treatment can        moderate amounts of purulent material and debris.
essential components of care for these                have devastating consequences. A       Evidently, this procedure, along with broad-spectrum
                                                      delay of greater than 24 hours is      antibiotics, copious bactericidal irrigation and further
patients. Delayed treatment can have                  associated with a 70 percent           bedside debridement sufficiently decreased bacterial
devastating consequences.                             mortality rate, versus 36 percent      load at the wound site.
                                                      for treatment initiated within 24
                                                      hours. One small series cites a 53     Dr. Buffington is in private practice in Elysburg,
                                percent mortality among patients in whom the                 Pennsylvania.
                                diagnosis was missed at initial outpatient evaluation.
                                    Broad-spectrum antibiotic coverage, consisting of
                                high-dose penicillin and clilndamycin should be
                                initiated immediately after cultures are obtained. Wide
                                excisional debridement (versus I&D) is recommended.                                    Print this article with references at
                                    In our case, the patient presented after three days of                   
                                symptoms. Unique to this case is the presenting

18   O S T E O PAT H I C FA M I LY P H Y S I C I A N N E W S J U N E 2 0 0 6
Calendar of Events
June 2006                                                   September 2006
June 22-25, 2006                                            September 20-23, 2006                                                             National Calendar
Ohio Osteopathic Association Annual Convention “Family
Practice Day”
                                                            32nd Annual Capital Region Healthy Review Conference
                                                            28.5 1-A AMA/AOA CME credits anticipated
Sawmill Creek Resort on Lake Erie                           Capital Plaza Hotel, Jefferson City, MO
Sandusky, OH                                                Call William D. Smittle, DO, at 573-635-8100 for more                             October 16-20, 2006
Contact or call 614-299-2107 for regis-   information
tration information
                                                                                                                                              AOA/ACOFP 111th Annual Convention
                                                            October 2006                                                                      Las Vegas Convention Center/ Hilton Hotel
June 29-July 2, 2006
93rd Annual Northwest Osteopathic convention                October 16-20, 2006
                                                                                                                                              Las Vegas, Nevada
20 1-A CME Credits pending AOA approval                     AOA/ACOFP 111th Annual Convention
Resort Semiahmoo                                            Las Vegas Convention Center
Blaine, WA                                                  Hilton Hotel
Contact Kathleen Itter, 206-937-5358 for reservation        Las Vegas, NV
information                                                                                                                                        AOBFP Calendar
                                                            November 2006                                                                          2006
July 2006
                                                            Illinois Osteopathic Medical Society Annual Winter                                     Family Practice Certification/
July 26-30, 2006                                            Scientific Seminar                                                                     Recertification Exam
Texas ACOFP State Society Annual Meeting                    30 1-A Credits Anticipated                                                             Location: Grapevine, Tex.
28 1-A CME hours anticipated                                DoubleTree Hotel                                                                       Dates: March 21-22, 2006
Dallas-Ft. Worth Airport Marriott Hotel                     Oakbrook, IL                                                                           Deadline: December 2, 2005
8440 Freeport Parkway                                       Call Elizabeth Harano at 800-621-1773, or via e-mail eha-
Irving, TX 75063                                   for registration information                                      Family Practice Certification/
Call 972-929-8800 for room reservations                                                                                                            Recertification Exam
Contact or call 888-892-2637 for regis-    December 2006                                                                          Location: Las Vegas, Nev.
tration information                                                                                                                                Dates: October 14-15, 2006
                                                            December 1-3, 2006                                                                     Deadline: July 7, 2006
July 27-30                                                  25th Annual Winter Update
Florida Society ACOFP 26th Annual Convention & Family       Marriott Hotel
Practice Update                                             Indianapolis, IN
30 1-A Credits Anticipated                                  Call Michael Claphan at 800-942-0501, or via e-mail
Hyatt Regency Grand Cypress Resort                 for registration information
Orlando, Florida
Call 850-531-8385 for more information

July 27-30
                                                                          To submit an item, send an e-mail message to
Michigan Association of Osteopathic Family Physicians
Summer Family Practice Symposium & Risk Management
23 hours of AOA Category 1-A CME credit anticipated
Hagerty Center, Traverse City, MI
                                                                                                  NUAL CONVEN
Call Sara Carson at 800-657-1556, or via e-mail at scar- for more information                                             TH
                                                                                             AN                         TI                   Save the Date


August 2006

                                                                                                                                             ACOFP 44th Annual

August 3-6, 2006
California ACOFP Society 30th Annual Scientific Seminar
                                                                                                                                             Convention & Exhibition
                                                                                                                                             Kissimmee, Florida!
                                                                                                                                  I TI O N

34-36 1-A CME credits anticipated
Disneyland Hotel
1150 West Magic Way
                                                                                             ACOFP 2OO7                                      March 14-18, 2007
Anaheim, CA 92802

Call 714-778-6600 for hotel room reservations
Call 866-522-2637 or 916-786-5908 for registration                        t’s not too early to begin making your plans to attend the American College of
information                                                               Osteopathic Family Physicians’ 44th Annual Convention & Exhibition, to be held from
                                                                          Wednesday, March 14 through Sunday, March 18, 2007 at the Gaylord Palms Resort
August 10-13, 2006                                                        & Convention Center in Kissimmee, Florida.
Colorado ACOFP
Breckinridge, CO
                                                                      During the event, you’ll be able to attend the full range of educational sessions, meetings
August 11-13, 2006                                                    and social events that you’ve come to expect, including osteopathic manipulation therapy
Pennsylvania ACOFP                                                    demonstrations, Fun Night, the Awards Luncheon, House of Delegates sessions, and much
Hershey, PA                                                           more. And of course, you’ll see the latest in medicines, technology and services in the
                                                                      educational exhibition.
Saturday, August 12, 2006
Illinois ACOFP State Society
8-10 1A CME anticipated                                               And while you’re not increasing your professional knowledge or networking with your peers
Collinsville Holiday Inn                                              in the practice of osteopathic family medicine, you’ll be right in the middle of one of the
Collinsville, IL                                                      great resort areas of the United States, Kissimmee, Florida! You and your family will be able to
                                                                      take in such world-class attractions as Disney World, Universal Studios Florida, Gatorland and
                                                                      SeaWorld Orlando, and if you’re not into theme parks, shopping, beaches, restaurants,
                                                                      antiquing and more are right at hand.

                                                                      Information about the program, social events and keynote speaker
                                                                      will appear in future issues of Osteopathic Family Physician News.
                                                                                                                                                                           Advocacy u Education u Leadership

                                                                                                                         O S T E O PAT H I C FA M I LY P H Y S I C I A N N E W S J U N E 2 0 0 6               19
      H I G H L I G H T S

Poster Presentations Displayed
During Grapevine Convention

       wenty-one Poster Presentations, covering                  R. C. Moore, DO                                       William J. Burke, DO
       such diverse topics as diabetes, exercise                 UMDNJ-SOM                                             Doctors Hospital
       and osteopathic medical school curricula                  Medical Students’ Knowledge and Attitudes about       An Interdisciplinary Curriculum Regarding Care of
were on display during the 43rd Annual                              Health Literacy                                      Aging Feet
Convention & Exhibition in Grapevine, Texas.
   The 2006 Poster Presentation, sponsored by                    M. E. Papa, DO                                        Dirck A. Curry, DO
the ACOFP’s Osteopathic Clinical and Research                    Christiana Care Health System                         BroMenn Family Health Clinic
Committee, featured the work of students,                        Do Group Healthcare Visits for Patients with Type     Use of an Electronic Medical Record to Standardize
Residents and osteopathic medical school faculty                   2 Diabetes Improve Outcomes?                           Osteopathic Manipulation Medical
members. Students and Residents received cash                                                                             Documentation for Clinical Research Projects
prizes of up to $500 for winning presentations,                  Rajan Mitchell, DO
while winning faculty members received special                   UMDNJ-SOM                                             Winners
recognition during the event.                                    Values That Affect Specialty Choices of Medical       Students
                                                                    Studies                                            1st place $500
Students                                                                                                               Scott Reineck, BS, OMS II
Scott Reineck, BS, OMS II                                        Faculty
Ohio University College of Osteopathic                           Joseph Allgeier, DO                                   2nd place $250
  Medicine                                                       Florida Hospital East Orlando                         Danesh S. Modi, OMS II
Diabetes Report Card 2004 for an Academic                        Objectively Assessing the Core Competencies
  Medical Institution                                               Utilizing a Video Monitoring Process               Residents
                                                                                                                       1st place $500
Danesh S. Modi, OMS II                                           Joshua Coren, DO, MBA                                 Rajan Mitchell, DO
UMDNJ-SOM                                                        UMDNJ-SOM
Patient Knowledge and Perception of Upper                        The Use of Web-CT in a Third Year Family              2nd place $250
   Respiratory Infections, Antibiotic Indications and               Medicine Clerkship                                 Michaeleen N. Wilson, DO
                                                                 Donald J. Sefcik, DO, MBA, FACOFP                     3rd place $100
                                                                 Midwestern University, Chicago College of             Brian J. Jones, DO
                                                                   Osteopathic Medicine
Irina Benyaminova, DO                                            Curriculum Revision: A Report on the Correlation      Faculty
Wyckoff Heights Medical Center                                     and Divergence of Faculty Opinions at One           1st place
A Case of Child Abuse vs. Cafffey’s Disease: Possible              Medical School                                      Dirck A. Curry, DO
   Psycho-Social Ramification                                                                                          BroMenn Family Health Clinic
                                                                 Allen F. Clowers, DO                                  Use of an Electronic Medical Record to Standardize
Rebecca Brice, DO                                                UMDNJ-SOM                                                Osteopathic Manipulation Medical
Saint Joseph Community Hospital                                  Simulation Exercises to Augment New Residency            Documentation for Clinical Research Projects
The Impact of Osteopathic Curriculum on the                         Training Programs in Family Medicine
   Opinion of Allopathic Residents Regarding                                                                           2nd place
   Osteopathic Manipulative Treatment                            Frank A. Filipetto, DO                                Adarsh K. Gupta, DO, M.Engg.
                                                                 UMDNJ-SOM                                             UMDNJ-SOM
Michaeleen N. Wilson, DO                                         From Solo to Team: An Interdisciplinary Training      Knowledge, Skills and Attitudes of Practicing
Conemaugh Memorial Hospital                                         Program                                              Primary Care Physicians about Evidence-Based
The FMC Fitness Challenge: An Experiential                                                                               Medicine and its Application in Clinical Settings
  Approach to Teaching Physicians about Weight                   Frank A. Filipetto, DO
  and Health Management                                          UMDNJ-SOM                                             3rd place
                                                                 Development of E-Learning Courses to Implement        Allen F. Clowers, DO
Mirela Carnaru, DO                                                  New Residency Training Programs in Family          UMDNJ-SOM
Wyckoff Heights Medical Center                                      Medicine                                           Simulation Exercises to Augment New Residency
Health Literacy: Use of the Internet in an Urban                                                                          Training Programs in Family Medicine
  Primary Care Setting                                           Adarsh K. Gupta, DO, M.Engg.
Michelle Kane, DO                                                Medical Informatics in Headache Management and
UMDNJ-SOM                                                          its Long Term Effects on Diagnosis and
Retrospective Analysis of Pesticide Use in a Small                 Treatment of Headaches
  Rural Community and Their Effect on the
  Prevalence of Hypothyroidism                                   Adarsh K. Gupta, DO, M.Engg.
Brian J. Jones, DO                                               Knowledge, Skills and Attitudes of Practicing
Wilson Memorial Regional Medical Center                            Primary Care Physicians about Evidence-Based
Mandatory OMM Training during Clerkship                            Medicine and its Application in Clinical Settings
   Rotations in Influencing Students Attitude in
   Practicing OMM

20    O S T E O PAT H I C FA M I LY P H Y S I C I A N N E W S J U N E 2 0 0 6
       H I G H L I G H T S

Five Receive ACOFP Distinguished Service
Award during 2006 Convention & Exposition

         utgoing President Glenn G. Miller, DO, FACOFP, presented the                board, as Chair of the of the Membership Committee and as Chair of the
         ACOFP’s Distinguished Service Award to five osteopathic family              Preceptorship Committee.
         physicians during the 2006 Annual Convention and Exposition in                 Dr. Harvey Spector was cited for his service to the ACOFP Congress of
Grapevine, Texas.                                                                    Delegates and his membership on the Awards Committee.
   The ACOFP Distinguished Service Award is presented by the President                  Dr. T. Eugene Zachary was recognized for his 18 years of service as the
and the Awards Committee to persons in recognition of their meritorious              ACOFP’s Congress of Delegates Speaker, as well as his years of service to
service and dedication to the profession of osteopathic family practice.             both the Texas Osteopathic Medical Association (TOMA) and the
   Recognized were Alan Brewer, DO, FACOFP, of St. Joseph, Missouri;                 American Osteopathic Association (AOA).
Harvey Spector, DO, FACOFP, Philadelphia, Pennsylvania; T. Eugene                       Dr. Donald Peterson was honored as TOMA’s Family Physician of the
Zachary, DO, FACOFP, Colleyville, Texas; Donald M. Peterson, DO,                     Year in 1986, and for his service to the profession of osteopathic family
FACOFP, Dallas, Texas; and T. Robert Sharp, DO, FACOFP, Dallas, Texas.               medicine as a residency program director and as the first osteopathic physician
   Dr. Alan Brewer, described by Dr. Miller as a “jack-of-all-trades”                elected to the Board of the American Medical Peer Review Association.
volunteer, served as advisor to the ACOFP’s national student executive                  Dr. T. Robert Sharp served as the 18th president of the ACOFP, and was
                                                                                     presented the ACOFP’s Family Physician of the Year award in 1972.
Distinguised Service Award Recipients
                                                                                       Distinguised Service Award Recipients

Dr. Harvey Spector, left, and Dr. Alan Brewer receive their                            Dr. T. Robert Sharp, left, Dr. Donald Peterson, center, and Dr. T. Eugene Zachary pause
ACOFP Distinguised Service Awards.                                                     after receiving their Distinguised Service Award during the Awards luncheon.

       H I G H L I G H T S

Robert N. Pedowitz, DO, Presented
Young Physician Leadership Award
                                                   obert Pedowitz, DO, of Bordentown, New Jersey,        Latimer, their daughter, Ree-Ree, and their
                                                   was presented the ACOFP’s first annual Dr.            grandchildren, Gabriella and Vincent.
                                                   Michael F. Avallone, Jr., Young Physician of the         In presenting the award, Dr. Porcelli noted that Dr.
                                            Year Award during the 2006 Annual Convention and             Pedowitz was the first resident elected to the ACOFP
                                            Exposition in Grapevine, Texas.                              Board of Governors as Resident Academic Member,
                                               This annual award is presented in recognition of the      and that he has served on the ACOFP’s Editorial
                                            early contributions and leadership potential in an           Committee and the Marketing and Public Relations
                                            ACOFP member who has been in practice from two to            Committee. He has also served as Chair of the Young
                                            10 years. The award is named in memory of Michael F.         Physicians Committee, where he has worked to expand
                                            Avallone, Jr., DO, FACOFP dist., President of the            effective communication with residents and young
                                            ACOFP during the 1991–92 term.                               physicians across the United States.
                                               Presenting the award was M. Jay Porcelli, DO,                “Rob Pedowitz truly demonstrates what it means to be
                                            FACOFP dist., Chair of the ACOFP’s Education and             a young physician leader in the profession of osteopathic
                                            Research Foundation. Also on hand for the presentation       family medicine,” said Dr. Porcelli, “and he vastly deserves
 Dr. Robert Pedowitz displays
                                            was Dr. Avallone’s widow, Regina, her sister, Joyce          the recognition from his peers in that profession that this
 his award.
                                                                                                         award represents.”

                                                                                                      O S T E O PAT H I C FA M I LY P H Y S I C I A N N E W S J U N E 2 0 0 6    21
        M A T T E R S

Loan Deadline Approaching for
Student Loan Borrowers

         n Saturday, July 1, 2006, student loan                          they always remain variable; the interest          • Interest rate reductions vs. cash rebates:
         interest rates will increase significantly,                     rate changes quarterly with the 91 Day                Many lenders offer interest rate reductions
         to rates as high as 6.91 percent. In                            Treasury Bill. You may not know that by               as a benefit for consolidating. In many
2005, rates were at a historic low; this year, the                       consolidating HEAL Loans with your                    cases, if you miss one payment your interest
fourth-lowest in history at 4.7 percent for                              other federal loans, the interest rate will           rate reduction is taken away and you can’t
borrowers in their grace period, and 5.3 percent                         only change annually. By consolidating                earn it back. Make sure you are signing up
for borrowers already in repayment.                                      HEAL Loans now, while rates are still low,            for a benefit that you can obtain…and keep.
                                                                         you may be able to save money in interest.            Many borrowers prefer cash rebates because
                                                                      4. When you consolidate your loans,                      they receive their full benefit faster.
Here’s what you may not
                                                                         most lenders offer financial incentives.           You have already incurred significant costs to
already know                                                             Unfortunately, some of these financial          become an osteopathic family physician; you
     1. Many ACOFP members have already                                  incentives may not turn out to be in your       shouldn’t have to pay more in interest. Make sure
        consolidated their student loans before, but                     best interest. Make sure you investigate        you lock in the rate on all of your federal student
        may have left some loans out of the                              these important items before choosing           loans before time runs out on today’s low rates!
        consolidation. Any loans that are                                a lender:
        unconsolidated remain at a variable interest                  • Be sure you read the fine print: Some               College Loan Corporation has partnered with
        rate, and will be subject to the interest rate                   lenders are in the business of selling loans.   ACOFP to offer debt management assistance and
        increase on July 1. For example, if you                          Make sure you identify if your potential        special benefits to ACOFP members. You can speak
        have a $20,500 loan that is not yet                              consolidator sells loans. If your loan will     with a VIP counselor to help you lock in this year’s
        consolidated, you can save $2,593 in                             be sold and you want to proceed, find out if    low rate by calling (800) 863-8771 or visit
        interest by consolidating before rates go up                     you have life of loan servicing and ensure
        on July 1 (see chart below). Be sure to                          your benefits are preserved.
        double-check your loans to make sure they
        are all consolidated before the deadline.
     2. The average ACOFP member owes                                                                      Total Savings by Refinancing before July 1, 2006*
        $140,000 in student loan debt. If you have
                                                                          $20,500 student loan debt                               up to $2,593 in interest
        never consolidated before, you can save
        $17,598 in interest by consolidating before                       $100,000 student loan debt                              up to $12,570 in interest
        July 1 (see chart below).
     3. You may have utilized the HEAL Loan,                              $140,000 student loan debt                              up to $17,598 in interest
        a special type of government loan for health
        professionals, to help pay for your                                                                                 *For estimate purposes only – calculations assume
        education. HEAL Loans are different                                                                              projected rates as of 4/12/06 for an unconsolidated
        from the Federal Stafford Loans in that                                                                          Stafford Loan in grace.

       N E W S

LECOM Introduces Three-Year
Medical Degree Curriculum

                                                                          he Lake Erie College of Osteopathic Medicine (LECOM) has announced its Primary Care
                                                                          Scholars Pathway (PCSP) that will reduce the time it takes to become a family physician. The
                                                                          PCSP will condense four years of medical education into three years in order to graduate more
                                                                   family doctors sooner and to save these students one year of expenses that adds to the mounting debt
                                                                   held by medical college graduates.
                                                                      The LECOM PCSP has received approval from the American Osteopathic Association
                                                                   Committee on Osteopathic College Accreditation and backing of the American College of
                                                                   Osteopathic Family Practice.
                                                                      “LECOM proposed this innovative curricular pathway in response to the declining interest in
                                                                   primary care and particularly family practice,” explained John M. Ferretti, DO, LECOM President.
                                                                   “We hope to attract new students by offering them a shorter path to a medical degree without
                                                                   jeopardizing their education in the areas needed to train a family physician.”
                                                                      LECOM will select its first PCSP class in the fall of 2007 from a group of candidates after they
                                                                   complete the first twelve weeks of Gross Anatomy. Medical students who enter PCSP that October
                                                                   will graduate with a Doctor of Osteopathic Degree in 2010. Graduates will continue their post-
                                                                   graduate education through a three-year residency program at selected hospitals.

22     O S T E O PAT H I C FA M I LY P H Y S I C I A N N E W S J U N E 2 0 0 6
state                                                                                                          ACOFP’s Intensive
     N E W S
                                                                                                               Update & Board Review
TOMA Honors Members for                                                                                        in Osteopathic Family
Service in House of Delegates
                                                                                                               See You in September!

      everal members of the American College of Osteopathic Family Medicine (ACOFP) were
                                                                                                               Join us Thursday, September 7 through Saturday,
      honored by the Texas Osteopathic Medical Association (TOMA) for their service as delegates
                                                                                                               September 9, 2006 for the ACOFP’s Intensive
      to the group’s House of Delegates during its 61st Annual Meeting of in Austin, Texas.
   Recognized were David R. Armbruster, DO, FACOFP, of Pearland; Jack McCarty, DO,                             Up d a t e & B o a r d R e v i e w i n O s t e o p a t h i c F a m i l y
FACOFP dist., Lubbock; Robert L. Peters, Jr., DO, FACOFP, Round Rock; Daniel W. Saylak, DO,                    Medicine, where you can refresh your knowledge
FACOFP, Bryan; Merlin L. Shriner, DO, FACOFP, Fairfield; George N. Smith, DO, FACOFP,                          of family medicine topics, or prepare for the
West; Rodney M. Wiseman, DO, FACOFP, Whitehouse; and T. Eugene Zachary, DO, FACOFP,                            American Osteopathic Board of Family Physicians’
Colleyville.                                                                                                   Recertification Exam.
   TOMA’s House of Delegates is the policy-making body of the more than 2,000-member
association, and represents the delegated powers of the group’s 19 district societies in state affairs.        This Intensive Review presents comprehensive
                                                                                                               instruction of important topics in contemporary
                                                                                                               osteopathic family medicine such as nephrology,
                                                                                                               hypertension, diabetes and other topics,
                                                                                                               presented by family physician faculty with
                                                                                                               expertise in specific topic areas.*

                                                                                                               For those planning to take certification or
                                                                                                               recertification examinations, you also will
                                                                                                               have the opportunity to participate in hands-on
                                                                                                               workshops for osteopathic manipulative
                                                                                                               technique (OMT).

                                                                                                               Save the Date!
                                                                                                               ACOFP members will receive registration
cme                                                                                                            information in the mail after July 1.
   R E S O U R C E                                                                                             Online registration will also be available
                                                                                                               on that date at
  OFP News Offers                                                                    CME
                                                                                    Article                    The Chicago Marriott O’Hare Hotel is offering
  1-B CME                                                                                                      room rates of $129 (plus tax) for either single-
                                                                                                               or double-bed rooms during the event.
                                                                                                               Contact the hotel at 1-800-228-9290 for more

           COFP members who read the Osteopathic Family Physician                                              information and to make your reservations.
           News can receive two hours of Category 1-B continuing
                                                                                                               This event is supported in part by a grant from
           medical education credit for completing quizzes in the
                                                                                                               the West Allegheny Physicians’ Association (WAPA)
  journal and its supplements.                                                                                 Fund of the Pittsburgh Foundation.
     Take the quizzes via by logging on to and clicking                                                          * This program anticipates being approved for
  on to the link titled ‘June 2006 CME Quiz’ that launches the .pdf file.                                      AOA Category 1- A CME credits, pending approval
                                                                                                               by the AOA CME.

                                 May CME Quiz Answers                                                           Intensive Update and Board Review
                       1. c, 2. b, 3. d, 4. a, 5. b, 6. d, 7. b, 8. a, 9. a, 10.c                                 in Osteopathic Family Medicine
                                                                                                                             September 7 - 9, 2006
                                                                                                                     Chicago Marriott O’Hare Hotel
                                                                                                                               8535 W. Higgins Rd.
                                                                                                                                   Chicago, Illinois

                                                                                                                              330 E. Algonquin Road, Ste. 1
                                                                                                                               A r lington Heights, IL 60005

                                                                                              O S T E O PAT H I C FA M I LY P H Y S I C I A N N E W S J U N E 2 0 0 6       23
                                                     Group Insurance Plans
                                                   designed specifically for members of the
                                                       American College of
                                                   Osteopathic Family Physicians
                                                  for more information and to get a quote.
                                                            Or call 800-503-9230
                                                                                                 also apply for coverage for
                                                    Your membership in the                       their employees at
                                                    American College of Osteopathic     Or,

                                                                                                 members may phone Marsh Affinity
                                                    Family Physicians provides you               Group Services' Customer Service
                                                    with the opportunity to obtain               Department at 877-886-0110.
                                                    comprehensive protection for

                                                    yourself, your staff and your                CATASTROPHE MAJOR
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                                                    to you – no salesperson will call.           all eligible expenses for up to five full
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        Please send me more information             $1,000,000 in life insurance coverage.       ance. This Plan is perfect for recent col-
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     10-year group term life insurance plan         DISABILITY INCOME PLAN                       easy on your budget. You are eligible to
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