Medical Staff Newsletter

On August 11, St. Joseph Hospital performed the very first positron emission tomography (PET) scan in greater Nashua. PET is an advanced technology that provides patients with better cancer care. This minimally invasive diagnostic imaging procedure is a single exam that evaluates the whole body with the mission of detecting cancerous cells the size of a pea. PET studies focus on cellular activity to diagnose, stage, evaluate treatment and detect recurrent cancer. PET is the only modality that can accurately image multiple organs at once to diagnose malignancy and even provide information about whether cancer has spread to other parts of the body. Very early detection of cancer is one important benefit of PET scans. According to

Mary Voltz, MD, board-certified oncologist and hematologist at The Oncology Center at St. Joseph Hospital, “PET helps physicians identify cells that grow at a very fast rate, which is the case with cancer cells.” In many cancer types, early detection of the cancer has been directly linked to the patient’s successful recovery. “Other imaging methods only provide anatomical views, whereas PET allows us to see how the body is functioning,” said Beth Balmer, Director of Diagnostic Imaging.

In addition to finding cancer, physicians need to know if the disease has spread to other parts of the body and where.

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A Q u a r t e r l y N e w s l e t t e r p u b l i s h e d b y t h e S t . J o s e p h H o s p i t a l M e d i c a l S t a f f

This Issue:This Issue:This Issue:This Issue:This Issue:This Issue:This Issue:This Issue:This Issue:This Issue:This Issue:This Issue: ��Can Doctors Learn

Communication Skills? ��St. Joseph Hospital Plans

for Expansion ��The Cardiovascular Center

Receives Award ��Physician News

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Metformin (Glucophage®) is a biguanide oral antihyperglycemic agent used to treat patients with non-insulin-dependent diabetes mellitus. Metformin seems to act by decreasing hepatic glucose production and enhancing peripheral glucose uptake as a result of increased sensitivity of peripheral tissues to insulin. It does not cause hypoglycemia. The most significant adverse effect of metformin therapy is the potential for the development of metformin-associated lactic acidosis in the susceptible patient. Metformin-associated lactic acidosis is estimated to occur at a rate of 0.084 cases per 1000 patient years. Patient mortality in reported cases is about 50%. However, in almost all reported cases, lactic acidosis occurred because one or more patient-associated contraindications for the drug were overlooked - especially cases having several comorbid factors - most often cardiovascular or renal disease. Metformin is excreted unchanged by the kidneys, probably by both glomerular filtration and tubular excretion. Approximately 90% of the absorbed drug is eliminated by the renal route within the first 24 hours. Renal insufficiency, then, is a major consideration.

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PET SCANS: PET SCANS: PET SCANS: AAADVANCEDDVANCEDDVANCED C C CANCERANCERANCER D D DETECTIONETECTIONETECTION T T TECHNOLOGYECHNOLOGYECHNOLOGY

172 Kinsley Street Nashua, NH 03060

NEW EMTALA NEW EMTALA NEW EMTALA RULESRULESRULES

The new Emergency Medical Treatment and Labor Act ( E MTA L A) r u l es a r e scheduled to be published in the Federal Register this month. The overall effect of this final rule will be to "reduce the costs of compliance for hospitals and doctors without weakening the protection of patients," said Thomas Scully, administrator of CMS, in an article. The new rule limits the scope of the 1986 EMTALA law and ex-pands the number of situa-tions in which hospitals would be exempt from the federal requirements. The Bush administration drafted the new rule after hearing complaints from hospitals and doctors who said the old standards were onerous and confusing, exposed them to lawsuits and fines, and encouraged people to seek free care in emergency rooms. The new rule gives hospitals greater discretion in arranging for on-call coverage.

Fall/Winter 2003 Fall/Winter 2003 Fall/Winter 2003 Fall/Winter 2003

Medical Staff Newsletter - St. Joseph Hospital, Nashua NH

Fall/Winter 2003

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Also, factors that depress the ability to metabolize lactate, such as liver dysfunction or alcohol abuse, or increase lactate production by increasing anaerobic metabolism (e.g., cardiac failure, cardiac or peripheral muscle ischemia, or severe infection) are contraindications for the use of metformin. Intravenous administration of contrast media to a patient taking metformin is a clinical concern. Of metformin-associated lactic acidosis cases reported worldwide between 1968 and 1991, 7 of the 110 patients received iodinated contrast material before developing lactic acidosis. The U.S. Food and Drug Administration-approved metformin package insert states that metformin should be withheld temporarily in patients undergoing radiological studies using intravenous iodinated contrast media. If acute renal failure or a reduction in renal function were to be caused by the iodinated contrast media, an accumulation of metformin could occur, with resultant lactate accumulation. The major clinical concern, then is confined to patients with known, borderline, or incipient renal dysfunction. The risk of contrast media-induced dysfunction is lessened by limiting the amount of contrast medium administered and hydrating the patient; both of these measures should be considered in patients with renal dysfunction. Therefore, metformin should be discontinued before or at the time of the procedure, withheld for 48 hours after the procedure, and be reinstated only after renal function has been re-evaluated and found to be normal. Communication between the radiologist, the patient’s clinician, and the patient will be necessary to establish the procedure for reassessing renal function and restarting metformin after the contrast examination.

References:References:References:References: Bailey CJ, Turner RC. Metformin. New England Journal of Medicine 1996; 334:574-579. Bailey CJ. Biguanides and NIDDM. Diabetes Care 1992; 15:755-772.

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This is called staging the patient. “At St. Joseph Hospital we provide the patients and the oncologist with additional information about the disease,” said Brian Hu, MD, (board-certified in Diagnostic Radiology at St. Joseph Hospital.) “For example, we can tell not only if there is cancer but also other critical facts such as where the cancer is and how aggressive it is.” PET can be used to determine if cancer has been successfully treated or it has returned. “This kind of information gives out patients a greater peace of mind,” said Ms. Balmer.

Physicians can see all this information without having to put the patient through invasive surgical procedures. PET is a safe and painless procedure with no known side effects. This scan usually takes about an hour and a half to complete. For more information about PET scanning services at St. Joseph Hospital, call Beth Balmer, Director of Diagnostic Imaging, at 882-3000 ext. 67101.

CCCANANAN D D DOCTORSOCTORSOCTORS L L LEARNEARNEARN CCCOMMUNICATIONOMMUNICATIONOMMUNICATION S S SKILLSKILLSKILLS???

Apparently so, according to an article in the September 3 issue of JAMA (Journal of the American Medical Association). "Effect of Communications "Effect of Communications "Effect of Communications "Effect of Communications Training on Medical Student Training on Medical Student Training on Medical Student Training on Medical Student Performance"Performance"Performance"Performance" reports the results of a three-year study conducted at three medical schools: New York University, University of Massachusetts, and Case Western Reserve University. The purpose of the study was to determine whether communications training for medical students improves specific competencies known to affect outcomes of patient care. Comprehensive communica-tions curricula were developed at each school using an estab-lished educational model for teaching and practicing core communication skills and engaging students in self-reflection on their performance. Standardized patients assessed student performance on 21 skills related to 5 key patient care tasks: relationship develop-ment and maintenance, patient assessment, education and counseling, negotiation and shared decision making, and organization and time manage-ment. The study concluded that the additional training signifi-cantly improved third-year students' overall communica-tions skills and tasks that are important to positive patient outcomes. Improvements were observed at each of the 3 schools despite adaptation of the intervention to the local curriculum and culture.

For more information, follow this link: http://jama.amahttp://jama.amahttp://jama.amahttp://jama.ama----assn.org/assn.org/assn.org/assn.org/

Medical QuotesMedical QuotesMedical QuotesMedical QuotesMedical QuotesMedical QuotesMedical QuotesMedical QuotesMedical QuotesMedical QuotesMedical QuotesMedical Quotes “A physician is obligated to consider more than a diseased organ, more even than the whole man - he must view the man in his world.” ~ Harvey Cushing “Winning is overemphasized. The only time it is really important is in surgery and war.” ~ Al McGuire, Basketball coach

Dr. Brian Hu

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Medical Staff Newsletter - St. Joseph Hospital, Nashua NH

Fall/Winter 2003

Planning continues for the new ambulatory care facility at St. Joseph Hospital, designed to meet the

demands of a growing population and the increasing number of ambulatory/outpatients we serve. The new

building will be constructed adjacent to the front of the hospital and will be connected by an atrium. The atrium will be the central destination for patients and visitors who enter and exit the hospital, and will house central registration, admitting, the gift shop, a café area, a retail pharmacy, phlebotomy, and family waiting areas. The new building will be two stories high and the first floor will house the Cardiovascular Center and Oncology Center. The second floor will house the Surgi-Center and endoscopy. There will be renovations to much of the first floor of the hospital as well, particularly in Diagnostic Imaging and the Emergency Department which will expand to allow a separate Fast Track area. Plans also call for a new two-level parking deck to be built on the south side of campus. The parking deck will be built and completed prior to the construction of the new building, which is expected to start next Spring. There are 11 separate “user groups” comprised of employees and physicians who represent various departments. The user groups have been meeting periodically with the architects of Lavallee/Brensinger, PA to develop detailed programmatic plans for each area. Updates about the hospital’s expansion plans will continue to be published in this quarterly newsletter as well as online at www.stjosephhospital.com

SSSTTT. J. J. JOSEPHOSEPHOSEPH H H HOSPITALOSPITALOSPITAL P P PLANSLANSLANS FORFORFOR E E EXPANSIONXPANSIONXPANSION

T T THEHEHE C C CARDIOVASCULARARDIOVASCULARARDIOVASCULAR C C CENTERENTERENTER R R RECEIVESECEIVESECEIVES A A AWARDWARDWARD On November 12, The Anticoagulant Clinic in the Cardiovascular Center was awarded the D.R.E.A.M. (Dream of Reaching Excellence in Anticoagulation Management) Award from Roche Diagnostics. The award recognizes organizations in the New England area for their excellence in improving the quality of care for patients receiving anticoagulation therapy. St. Joseph Hospital is the only hospital in the New England area to receive this award. The Anticoagulation Clinic was founded in January 2002, and currently has 317 active patients. The clinic sees an average of 450 patient visits each month. The goal of the clinic is to provide exceptional quality of care to their patients, thus making the clinic staff advocates for their patients. By working collaboratively with their patients and reinforcing teaching, the Anticoagulation staff have found that their patients have a better outcome as evidenced by the percent of patients whose INR is in the therapeutic range. For more information regarding Anticoagulant services, call The Cardiovascular Center at 595-3971.

The American Academy of Pediatrics (AAP) recently certified John Kukay, MD, FAAP, a pediatrician with Nashua Pediatrics, as a Fellow. Fellows of the American Academy of Pediatrics (AAP) are recognized by

their colleagues and the organization’s Board of Directors as demonstrating excellence in training – leading to Board Certification – as well as demonstrating high ethical and professional principles and conduct. Organized by 35 pediatricians in Detroit in 1930, the AAP now has more than 55,000 members. Of these members, nearly 40,000 have earned the designation of Fellow, allowing them to use the credentials FAAP. The mission of the American Academy of Pediatricians is to attain optimal physical, mental and social health and well-being for all infants, children, adolescents and young adults. John Kukay, MD, FAAP, practices at Nashua Pediatrics, located at 155 Kinsley Street in Nashua, as well as additional locations in Merrimack and Milford.

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MMMMMMMMMMMMARKETINGARKETINGARKETINGARKETINGARKETINGARKETINGARKETINGARKETINGARKETINGARKETINGARKETINGARKETING N N N N N N N N N N N NEWSEWSEWSEWSEWSEWSEWSEWSEWSEWSEWSEWS ~ You are invited to participate in Healthy Choices, Healthy Choices, Healthy Choices, Healthy Choices, Healthy Choices, Healthy Choices, Healthy Choices, Healthy Choices, Healthy Choices, Healthy Choices, Healthy Choices, Healthy Choices, News for Healthy Living, News for Healthy Living, News for Healthy Living, News for Healthy Living, News for Healthy Living, News for Healthy Living, News for Healthy Living, News for Healthy Living, News for Healthy Living, News for Healthy Living, News for Healthy Living, News for Healthy Living, an informational column published every Tuesday on page three in The Telegraph. Drs. Bonenberger, Hu, and Wingate have recently been featured in the column. If you wish to participate, please contact Mary Carbonneau at 882-3000 ext. 63205 or mcarbonneau@sjh-nh.org.

Continuing Medical Education Programs 2003Continuing Medical Education Programs 2003 Optimal Antiplatelet Therapy for Acute Coronary Syndrome Management, December 3, 12-1:00 p.m. (Carl Amelio Room) James L. Januzzi, MD, Department of Cardiology, Massachusetts General Hospital Department of Pediatrics: Managing Decisions in Community Acquired Pneumonia, December 4,12:30-1:30 p.m. (CAR) Edward J. O’Rourke, MD, Assistant Clinical Professor of Pediatrics, Harvard Medical School; Medical Director, Infection Control, Children’s Hospital Boston Comprehensive Treatment of Cutaneous Melanoma, December 10, 12-1:00 p.m. (CAR), Wayne Stadelmann, MD Private Practice - Plastic Surgery, Member, Department of Surgery, Concord Hospital SARS Update and Next Steps, December 17, 12-1:00 p.m. (CAR) Elizabeth C. Clark, MD, Infectious Disease Associates of Nashua and Manchester Department of Psychiatry: Agitation of Gero-Psychiatric Patients, December 19, 12:00-1:00 p.m. (CAR), Lynn A. Villemaire, MD Assistant Professor of Psychiatry, Dartmouth Medical School Tumor Conference Tumor Conference – December 12, Karen Krag, MD, North Shore Cancer Center- (7:30-8:30 a.m. SJH Board Room)

PPPHYSICIANHYSICIANHYSICIAN N N NEWSEWSEWS

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David Brignall, MD David Brignall, MD David Brignall, MD David Brignall, MD David Brignall, MD David Brignall, MD David Brignall, MD David Brignall, MD David Brignall, MD David Brignall, MD David Brignall, MD David Brignall, MD is relocating from SJ Family Medical Center on Amherst Street to the Hudson SJ Family Medical Center located at 290 Derry Road. This change is effective on December 1.

Pierre Dionne, MD and Peter Seviour, MD Pierre Dionne, MD and Peter Seviour, MD Pierre Dionne, MD and Peter Seviour, MD Pierre Dionne, MD and Peter Seviour, MD Pierre Dionne, MD and Peter Seviour, MD Pierre Dionne, MD and Peter Seviour, MD Pierre Dionne, MD and Peter Seviour, MD Pierre Dionne, MD and Peter Seviour, MD Pierre Dionne, MD and Peter Seviour, MD Pierre Dionne, MD and Peter Seviour, MD Pierre Dionne, MD and Peter Seviour, MD Pierre Dionne, MD and Peter Seviour, MD have announced the opening of their new practice, Hudson Medical Associates, Hudson Medical Associates, Hudson Medical Associates, Hudson Medical Associates, Hudson Medical Associates, Hudson Medical Associates, Hudson Medical Associates, Hudson Medical Associates, located at 290 Derry Road, Hudson, N.H. Drs. Dionne and Seviour specialize in family medicine and have more than 20 years of combined experience treating patients who range from infancy to the senior years.

Leonard Block, MD, FACS, Leonard Block, MD, FACS, Leonard Block, MD, FACS, Leonard Block, MD, FACS, Leonard Block, MD, FACS, Leonard Block, MD, FACS, Leonard Block, MD, FACS, Leonard Block, MD, FACS, Leonard Block, MD, FACS, Leonard Block, MD, FACS, Leonard Block, MD, FACS, Leonard Block, MD, FACS, recently received a three-year appointment as Cancer Liaison Physician for the Hospital Cancer Program at St. Joseph Hospital. The Cancer Liaison Program is an integral part of the Commission on Cancer of the American College of Surgeons.

Dr. Block is among a national network of over 1,600 volunteer Cancer Liaison Physicians who provide leadership and support to the commission of Cancer Approval Program.

Deborah Galla Berger, MD Deborah Galla Berger, MD Deborah Galla Berger, MD Deborah Galla Berger, MD Deborah Galla Berger, MD Deborah Galla Berger, MD Deborah Galla Berger, MD Deborah Galla Berger, MD Deborah Galla Berger, MD Deborah Galla Berger, MD Deborah Galla Berger, MD Deborah Galla Berger, MD has joined St. Joseph Hospital’s Radiology Department. Dr. Berger received her medical degree from the State University of New York Health Science Center at Syracuse and completed her fellowship in Interventional Radiology at the New York University Medical Center. She is a member of the Society of Interventional

Radiology, Radiologic Society of North America and the American Medical Association. She is board certified in Radiology and specializes in Interventional Radiology.

Brian P. Fawcett, MD, MPH Brian P. Fawcett, MD, MPH Brian P. Fawcett, MD, MPH Brian P. Fawcett, MD, MPH Brian P. Fawcett, MD, MPH Brian P. Fawcett, MD, MPH Brian P. Fawcett, MD, MPH Brian P. Fawcett, MD, MPH Brian P. Fawcett, MD, MPH Brian P. Fawcett, MD, MPH Brian P. Fawcett, MD, MPH Brian P. Fawcett, MD, MPH has joined St. Joseph Hospital Business & Health, Occupational Health Services. Dr. Fawcett received his medical degree from Marshall University School of Medicine in Huntington, West Virginia and completed his residency in Occupational Medicine at the University of Minnesota in Minneapolis/St. Paul.

His prior medical experience includes directing occupational health programs, managing corporate surveillance programs, treating work-related injuries and case management. Dr. Fawcett is a member of the American College of Occupational and Environmental Medicine and the American College of Sports Medicine. He is board eligible in Occupational Medicine.