Grand Rounds - November 1, 2024
"Malnutrition in the Elderly"

Speaker: Lagomarcino Ledesma, MS, RDN, CSO, CLT. Oncology Dietitian, Cancer Resource Center, UCSF Helen Diller Family Comprehensive Cancer Center.

Objectives

1. List three consequences of malnutrition.
2. Name three or more micronutrients that are commonly low in the aging population.
3. Employ three or more nutritional and supplemental strategies to combat sarcopenia.

Accreditation: St. Charles Health System is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. St. Charles Health System designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)^TM.

The period to claim credit for this activity expires one year after its original publication. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Claim Credit

Target Audience: Physicians, Nurses, Pharmacists, Allied Health Professionals

Accessibility/Program Questions: St. Charles Health System encourages persons with disabilities to participate in its programs and activities. If you anticipate needing any type of accommodation or have questions about the physical access provided, please contact Continuing Medical Education at [email protected].

Oher CME or Clerkship questions: also contact Continuing Medical Education at [email protected].

For many of us, it wouldn’t be fall without having a little creative fun with a pumpkin. We bake with them, we decorate our homes with their fun colors and textures, and we put extra thought into carving our neighborhood’s greatest entryway masterpiece. There’s nothing quite as nostalgic as carving pumpkins.

The majority of the 1.5 billion pounds of fresh pumpkin varieties grown in the United States each year are sold for Halloween. Increasing pumpkin sales during the fall months also means an increase in people visiting the emergency room with hand injuries from slicing into a pumpkin. Various injuries can occur when dealing with a pumpkin’s hard flesh and a sharp cutting utensil. The St. Charles Center’s hand surgeons see several injuries from pumpkin carving every year. Most are minor, but the more serious ones that make it to a hand surgeon can involve injury to your tendons or nerves and require surgery.

Common hand injuries from pumpkin carving 

• Minor cuts or lacerations in the non-dominant hand
• Stab and puncture wounds in the hand
• Severed tendons and ligaments
• Permanent nerve damage in hands and fingers
• Flexor and extensor tendon injuries
• Loss of function and motion in the hand

To avoid hand injuries this fall season, here are some recommendations from the American Society for Surgery of the Hand:

Carve in a clean, dry, well-lit area

Wash and thoroughly dry all of the tools that you will use, including: carving tools, knife, cutting surface, and your hands. Any moisture on your tools, hands, or table can cause slipping that can lead to injuries.

Always have adult supervision

All too often, we see adolescent patients with injuries because adults feel the kids are responsible enough to be left on their own. Even though the carving may be going great, it only takes a second for an injury to occur.

Leave the carving to adults

Never let children do the pumpkin carving. Instead, maybe let kids draw a pattern on the pumpkin and have them be responsible for cleaning out the inside pulp and seeds. When the adults do start cutting, they should always cut away from themselves and cut in small, controlled strokes.

Sharper is not better

A sharper knife is not necessarily better, because it often becomes wedged in the thicker part of the pumpkin, requiring force to remove it. An injury can occur if your hand is in the wrong place when the knife finally dislodges from the thick skin of the pumpkin. Injuries are also sustained when the knife slips and comes out the other side of the pumpkin where your hand may be holding it steady.

Use a pumpkin carving kit

Special kits are available in stores and include small, serrated pumpkin saws that work better because they are less likely to get stuck in the thick pumpkin tissue.

Help for an injury

Should you cut your finger or hand, bleeding from minor cuts will often stop on its own by applying direct pressure to the wound with a clean cloth. If continuous pressure does not slow or stop the bleeding after 15 minutes, an emergency room or urgent care visit may be required.

While most of the injuries from pumpkin carving may only need stitches, others may need to be seen by a hand specialist, such as a hand surgeon, who can restore the hand’s movement and function.

Election Day is right around the corner, and many of you will have already voted by the time you read this. Personally, I love voting. I like how voting often forces me to weigh imperfect options, compelling me along the way to learn more on topics I might otherwise skip and to ask opinions from people I trust. Sometimes the choices are maddening, so I have to think hard on what I believe matters most. And without fail, voting also brings to mind gratitude for those who long ago fought for a right I hope never to take for granted.

As I complete my ballot this year, I’m also struck by how my concerns and hopes for health care in Central Oregon are influencing my thinking, and how the choices we make today will inevitably impact our future, often in unpredictable ways. So as you vote, I hope you too will think about how local, state and federal policies impact health care.

I realize health care may not be top of mind for you this cycle. It isn’t top of mind for most Oregonians. A recent opinion poll conducted by DHM Research showed that people believe the most important problem in Oregon is houselessness, followed by drugs, housing affordability, cost of living and crime.

Health care didn’t even make the list. But when you think about it, access to quality health care — particularly behavioral health care — impacts all of the issues listed above.

Many of us don’t think much about health care or our options for care until they are gone. We take for granted that hospitals will always be there when we have an accident, when pneumonia strikes or when it's time to welcome a new baby.

Increasingly, communities across the country are learning what happens when their local hospitals suddenly close their doors. Not only do they have to travel farther for care — incurring additional transportation and lodging expenses — they also feel the pain of tangential things like the hospital’s support of local youth programs, health fairs, flu shots and more. These challenges fall disproportionately on rural communities.

At St. Charles, more than 75% of what we are paid comes directly from Medicare and Medicaid (Oregon Health Plan), which means government reimbursements ultimately dictate the level of care and service we are able to provide. And those reimbursements are not keeping up with the inflationary costs of providing care. On average, the Oregon Health Plan pays hospitals 70 cents for every dollar of care provided. In 2022, this formula resulted in a $1.1 billion gap between what it costs Oregon hospitals to care for OHP members and how much those hospitals were paid for that care. Last year, 54% of Oregon hospitals lost money. I learned recently that nearly one out of three Oregonians now relies on OHP for insurance coverage. I’m proud to live in a state that values coverage so highly in principle, and at the same time I’m concerned we don’t follow up that commitment with a plan to pay for it. Well-intended government actions also add administrative cost and burden, further complicating and straining an already over-stressed system.

While St. Charles has had a modest financial rebound since the pandemic, we are not immune to the challenges all hospitals and physician practices face. Due to our geographic isolation, we are also increasingly worried about the small, private medical providers in the region — like The Center — who are having trouble retaining physicians and meeting the community’s needs for care.

We already know OHP reimbursement and administrative burden will be hot topics during the 2025 legislative session, and we are looking forward to working with our elected officials to address root causes and build a more sustainable model for hospitals and clinics in our state.

Which leads me back to the original intent of this month’s column — please vote. And please think about access to health care and the health of our communities as you do.

Sincerely, 
Steve

When babies are born, they are at risk of developing jaundice, which causes a yellow hue of the skin and can lead to serious issues. This is because their livers aren’t developed enough to break down bilirubin — a waste product from red blood cells — out of the body.

Historically, providers have treated many cases of neonatal jaundice pre-emptively because very high levels of bilirubin can be harmful to the brain. But not all babies need to undergo treatment, which can disrupt family bonding and breastfeeding, said Dr. Suzanne Mendez, St. Charles’ Medical Director of Pediatrics.

“There's a movement in medicine and pediatrics toward what we call ‘safely doing less’ or ‘choosing wisely,’ so that all the interventions and tests that we do on patients are warranted,” she said. “We don't want to unnecessarily burden patients with extra tests or treatments that they don't need, but we also want to be safe and make sure they are still getting the care they need.”

In 2022, the American Academy of Pediatrics sought to shift jaundice treatment practices and sponsored a new quality improvement project called Learning and Implementing Guidelines for Hyperbilirubinemia, or LIGHT for short. (Hyperbilirubinemia is a big word for jaundice.) The goal of the LIGHT project is to limit treatment to newborns who are truly at risk of complications.

The typical treatment for jaundice is blue-light therapy (phototherapy), where newborns are placed in a crib flooded with blue light that can break down bilirubin in the skin, allowing the body to flush it out. In addition to phototherapy, providers may administer IVs and will run tests with blood draws. While the treatment itself is relatively painless and benign, it means newborns spend more time in cribs and less time being held by family.

The American Academy of Pediatrics has acknowledged how disruptive that can be to babies and families alike and it put together updated guidelines and criteria for providers to gauge when babies need treatment and when it’s safe to let the condition clear on its own. More than 100 health care sites nationally, including St. Charles, were tapped to receive training on the new guidelines.

“We were excited to be selected to participate,” Mendez said.

After learning about the new guidelines, providers spent the next year implementing them, then compared data on jaundice treatments from a year before and a year after the LIGHT project’s changes. St. Charles was recognized for its excellent work with two “HighLIGHT” awards: One for limiting necessary treatment to babies above a certain risk threshold, and another for not using unnecessary blood tests post-treatment for babies who received phototherapy.

Another way St. Charles excelled in jaundice treatment was by using a non-invasive screening tool, a skin meter that measures bilirubin. By using the tool, providers reduced the number of babies receiving jaundice-related blood work by 70%, Mendez said.

The Pediatrics Department will continue to integrate the new guidelines and is reviewing data through July 2024 to see how the project has been sustained.

“It's always a balance,” Mendez said. “We want to make sure we keep babies safe, but we don't want to subject every baby to phototherapy, if we can help it.”

If you’ve ever been to St. Charles’ Bend South Family Care clinic, chances are you’ve at least seen and maybe met Mark Welch, a patient service representative there for about eight years.

He’s hard to miss, in part because he’s good at his job.

“When we’d been open about a year (clinic manager) Daggi Stafford came to me and said, ‘You know, you’re the face of this place. You keep smiling and doing what you’re doing out there,’” he said. “And that’s what I’ve done.”

He’s also a veteran of the United States Navy, where he served for 20 years on submarines patrolling the Pacific Ocean. He’d go weeks at a time without seeing sunshine, so when it came time to settle down, he wanted to go somewhere “where the seasons change and the people are friendly,” he said.

He found it in Central Oregon.

“One of the things I really enjoy here is that you’re close to all kinds of outdoor opportunities — from the beach and the mountains, fishing, skiing, hiking, the middle of the desert,” Welch said. “You’re four hours from anything!”

As you can probably tell, he’s young at heart, too. Which is why it took him about 10 years after leaving the military to realize he was a veteran.

“Veterans were those guys in World War II,” he joked. “They were recognizing veterans at an event and my wife poked me and told me to stand up. That’s when it finally hit me that I was a veteran.”

Welch says working in patient access at St. Charles is his second favorite job ever. At the top of that list: Machinist mate and engineering laboratory technician on Naval submarines, which essentially means he was the on-board nuclear chemist and radiation specialist. He also earned his “Dolphins” — a qualification pin given to those with the ability to operate every system on the ship.

“We’d go out for weeks or even months at a time, and if somebody got injured, everybody was able to step up and do anybody else’s job,” he said. “So when you went to sleep after your shift, you had full trust that the guy who was awake was going to save your life if needed.”

When his submarine would dock for a while, Welch had a chance to visit a number of different countries, where he would skip the bars and other entertainment offered near the port and head into the adjacent neighborhoods to learn about the local culture. Ever since he was a kid in a family that moved around a lot — 17 different schools from Kindergarten to 6th grade, he said — Welch has had a curious mind and an affinity for meeting new people.

“I came home from a new school one time and my mom said, ‘Did you make any new friends?’” he said. “I said, ‘Well, they’re the same old friends with new faces.’”

That’s an approach he carries through to his current job at the clinic.

“At the front desk, I figure when somebody's coming in that front door and they’re worried about their daughter or they’re low on gas or they have a bill to pay or whatever, it’s my job to get a smile on their face and make them feel better,” he said. “That way, when you get in front of the doctor, you can talk about why you’re here and not all those other problems you’ve got.”

He continued: “This is probably the first job where I love to get up in the morning because I know I'm coming to work to make a difference in somebody's day.”

With Veterans Day on the horizon, however, Welch is also thinking about the job he used to have — and that millions of others had, and still have, too.

“Veterans Day is the day I get to say thank you to my fellow veterans for being willing to write a check for these United States (and) for their sacrifice for their country, including being willing to give their life,” he said. “And to know that no matter what branch we all served in we always had each other's back. I was and am a part of the greatest military on our planet.”

The arrival of fellowship-trained surgeon Dr. Neil O’Kelly means breast cancer patients in Central Oregon now have the option of undergoing breast reconstructive surgery at St. Charles — and getting the care they need closer to home.

Dr. Linyee Chang, senior medical director of Cancer Services at St. Charles, says the arrival of O’Kelly is a milestone worth celebrating.

“Bringing Dr. O’Kelly to the Cancer Center shows our commitment to serving breast cancer patients in our community. We are thrilled to have such a well-trained, exceptional surgeon join us to help complete this incredible team,” said Dr. Chang. “I want our community to know that they can come to us for all things breast cancer — this is our area of expertise.”

O’Kelly’s arrival late last summer is the latest point of growth for the breast cancer program, which now includes early detection, genetic counseling, medical oncology, radiation oncology, a high-risk clinic and more. Breast cancer is the most common kind of cancer in Central Oregon, and St. Chares cares for about 200 patients every year.

The team will continue to grow to serve the community’s needs with the opening of the St. Charles Cancer Center in Redmond in 2026, where St. Charles will also offer a full complement of breast cancer services. Expansion of clinical trial options is also in the works, which will ultimately lead to a launch of the St. Charles Cancer Institute next year.

Dr. Caitlyn Truong, a fellowship-trained breast surgeon, joined the St. Charles team more than a year ago to support patients needing mastectomies and tumor removal surgeries. O’Kelly and Truong now work hand-in-hand — they even share an office — to support breast cancer patients who need surgery. After the cancer is removed, O’Kelly performs the reconstruction, a service that is in high demand. Prior to O’Kelly’s arrival, it was common for patients to travel out of the area for reconstructive surgery.

Kim Brinson, a 39-year-old breast cancer patient from Redmond, was “very grateful to have a reconstructive surgeon” in Central Oregon, she said. Brinson found a lump in her breast during a self-exam and ended up needing a mastectomy. She worked with O’Kelly to determine her options and ultimately underwent a double mastectomy and then a bilateral DIEP flap reconstruction.

O’Kelly says the reconstruction is a delicate surgery, in which he uses abdominal tissue to reconstruct a patient’s breasts.

“I would hate to travel for surgery,” said Brinson. “Having access in the area is amazing. O’Kelly is warm and caring and everything I would hope for in a doctor.”

She says the surgery removed her cancer with clean margins and she’s hopeful to not need any more treatment, so she can focus on spending time with her husband and two kids.

“I’m definitely feeling much better and am feeling relieved and ready to get back to regular life,” said Brinson.

The need in the community is one of the reasons that O’Kelly wanted to come to Central Oregon, after having studied at Johns Hopkins University for a microsurgery fellowship. “It’s hard to imagine having to travel out of state, while you are battling cancer, to have access to breast reconstruction," he said. "That’s a challenging path and I’m hopeful that people will find it a comfort and relief in having options closer to home.”

O’Kelly found his passion for plastic surgery during a rotation as a medical student at Georgetown University. “I like the wide array of surgeries that could be performed, especially with reconstruction.”

He quickly became interested in breast reconstruction specifically when he realized the powerful, positive impact his work could have on breast cancer patients.

“It gives us an opportunity to help the patient by restoring form after the removal of tissue to combat cancer. I am able to really help someone with a medical problem,” said O’Kelly. “A mastectomy or lumpectomy can be very challenging for patients to go through and breast reconstruction offers patients (a chance to) restore their self-image, which can have a big impact on quality of life after cancer. These reconstruction surgeries can have tremendous value for patients.”

If a woman chooses to undergo a mastectomy and desires reconstruction, she has many options including implant-based, tissue flap or free flap using microsurgical reconstruction with tissue from a patient’s body, often the abdomen. O’Kelly can perform all of these options and says it’s a partnership between the patient and surgeon to determine an individualized approach based on goals and preferences.

“It’s an extremely personal choice and it’s important to be able to offer all of the different options so that patients can select what will make them happiest in the long run,” said O’Kelly.

He also said he enjoys working alongside Truong and the team at the Cancer Center.

“Dr. Chang has built an amazing team of doctors in the center, who are very knowledgeable," he said. "Every single caregiver I’ve worked with has been wonderful.”

The plan is to treat several breast cancer patients per week in the Operating Room.

“There’s a tremendous need in the community," said O'Kelly, "and we are going to get busier and busier over time.”

In the world of sports, physical preparation is only half the battle. Athletes who consistently perform at their best understand that mental preparation is just as crucial. In competitive environments, the ability to focus and manage performance anxiety can be the key differentiator between winning and losing. This article delves into effective sports psychology techniques that athletes can use to enhance focus and control anxiety, leading to improved performance in competition.

Why mental preparation matters in sports

Sports psychology focuses on optimizing an athlete’s mental health and emotional well-being, which directly impacts performance. Elite athletes consistently practice mental strategies alongside physical training to ensure they are prepared for the pressure of competition. Whether it's managing the pressure of a final game or maintaining concentration during high-stakes moments, mental preparation can significantly influence an athlete's success.

Common challenges in sports psychology

Athletes often face two major mental challenges during competitions:

1. Performance anxiety – The fear of failure or disappointing others can lead to nervousness, tense muscles, and mistakes on the field or court.
2. Lack of focus – Distractions, self-doubt, or external factors can lead to a loss of concentration, making it difficult for athletes to stay “in the zone.”

Sports psychology techniques for improving focus 

Here are several mental techniques athletes can implement to improve focus and maintain peak performance:

1. Visualization (mental imagery)

Visualization involves mentally rehearsing the actions and outcomes of a performance. By vividly imagining successful execution of skills, athletes can "train" their minds to react calmly and instinctively during competition. Studies have shown that visualization can help improve motor skills and confidence, making it a powerful tool for focus. Tip: Before a game or event, spend 10-15 minutes visualizing various game scenarios, including successful plays, winning moments, and handling unexpected challenges.

2. Mindfulness meditation

Mindfulness meditation helps athletes stay present by focusing on the current moment, rather than worrying about the past or future. This technique enhances focus by teaching athletes to control their attention and avoid distractions. Mindfulness is especially effective for athletes in sports requiring sustained concentration, such as golf, tennis, or shooting. Tip: Practice mindfulness for 5-10 minutes daily. Focus on breathing, bodily sensations, and your surroundings. If your mind wanders, gently bring it back to the present.

3. Routine and ritual

Establishing a pre-performance routine can help athletes signal to their minds that it’s time to focus. Whether it’s a specific warm-up, listening to a particular playlist, or practicing a certain movement, routines can help athletes block out distractions and get into the right mental state for peak performance. Tip: Develop a consistent pre-game routine that includes both physical and mental preparation. Stick to it before every competition.

Managing performance anxiety in sports

Performance anxiety can cripple an athlete's confidence and ability to perform under pressure. The following techniques can help manage anxiety and keep nerves in check:

1. Breathing exercises

Deep, controlled breathing helps lower heart rates and reduce stress, bringing an athlete back to a calm, focused state. Breathing exercises are easy to practice, even during a competition, making them one of the most accessible tools for anxiety management. Tip: Practice box breathing—inhale for 4 seconds, hold for 4 seconds, exhale for 4 seconds, and hold for another 4 seconds. Repeat until you feel more relaxed.

2. Positive self-talk

The language athletes use to talk to themselves plays a major role in how they perform. Negative thoughts can amplify anxiety, whereas positive self-talk can boost confidence and reduce fear. Replace phrases like “I can’t” or “What if I fail?” with affirmations such as “I’ve got this” or “I am prepared and capable.” Tip: Write down a few positive phrases or affirmations and read them aloud before competing. Repeat them in your head whenever you feel nervous or doubtful.

3. Progressive Muscle Relaxation (PMR)

Progressive muscle relaxation involves tensing and then relaxing muscle groups in a systematic manner. This technique reduces physical tension that often accompanies anxiety and brings a sense of control over one’s body. Tip: Practice PMR by tensing a muscle group (e.g., your shoulders) for 5-10 seconds, then slowly releasing the tension. Move through your body, focusing on each muscle group.

The role of a sports psychologist

While self-practiced techniques can greatly improve focus and manage anxiety, working with a sports psychologist can provide a more personalized approach. Sports psychologists offer tailored mental training plans based on an athlete’s unique needs, and they help develop coping strategies for high-pressure situations.

Conclusion: Mental training for athletic success

Just as athletes need to condition their bodies for peak performance, mental conditioning is essential to succeeding in sports. Visualization, mindfulness, and pre-game routines can sharpen focus, while breathing exercises, positive self-talk, and muscle relaxation techniques help manage performance anxiety. By integrating these mental techniques into regular training, athletes can optimize their mental game, leading to greater success on the field or court.

Key takeaways:

• Focus on mental as well as physical training to maximize athletic performance.
• Use visualization and mindfulness to sharpen focus and stay present.
• Manage anxiety through controlled breathing, positive self-talk, and relaxation techniques.

By mastering the mental side of competition, athletes can gain the competitive edge they need to excel and thrive under pressure. 

Grand Rounds - October 18, 2024
"Exploring the Essentials of Endoscopic Ultrasound (EUS)"

Speaker: Courtney Walker, MD. Interventional Gastroenterologist. St. Charles Health System.

Objectives

1. Providers will be able to recognize an EUS procedure and key anatomical structures evaluated by EUS.
2. Providers will be able to describe the importance and relevance of EUS in clinical practice.
3. Providers will be able to explain to their patients the basic EUS procedure.
4. Providers will be able to compare the benefits of EUS with other imaging modalities.
5. Providers will be able to evaluate the effectiveness of EUS and understand complications.
6. Providers will be able to appraise when a referral for EUS is appropriate for their patients.

Accreditation: St. Charles Health System is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. St. Charles Health System designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)^TM.

The period to claim credit for this activity expires one year after its original publication. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Claim Credit

Target Audience: Physicians, Nurses, Pharmacists, Allied Health Professionals

Accessibility/Program Questions: St. Charles Health System encourages persons with disabilities to participate in its programs and activities. If you anticipate needing any type of accommodation or have questions about the physical access provided, please contact Continuing Medical Education at [email protected].

Oher CME or Clerkship questions: also contact Continuing Medical Education at [email protected].

Community members with unwanted medications on hand can dispose of them safely during a free event hosted by St. Charles Health System and the Bend Police Department from 10 a.m. to 2 p.m. on Saturday, Oct. 26 at the Bend Police Department, 555 NE 15th St., Bend.

The take-back event is intended to help Central Oregonians safely dispose of medications to protect the environment and fellow community members. During last year’s event, community members brought in 329 pounds of medications and sharps for safe disposal.

No questions will be asked. Individuals can drive through the parking lot and drop off medications right from their car window. Bend Police evidence technicians will accept the medications, then give them to the Drug Enforcement Administration (DEA) to dispose of safely.

Any non-oncology medications will be accepted. Liquids, pills, powders, patches, creams, prescriptions or over-the-counter medicines can be dropped off. In addition, sharps will be accepted if they’re properly packaged in a sharps container for disposal. Representatives from St. Charles pharmacy will also be on-site to answer questions.

Grand Rounds - October 11, 2024
"Menopausal Hormone Therapy - a 'Hot' Topic for Hot Flashes"

Speaker: Kathryn Macaulay, MD. Director, UCSD Menopause Health Program; Clinical Professor of Obstetrics, Gynecology and Reproductive Sciences. UC San Diego Health.

Objectives

1. Identify the latest data and evidence as summarized in the most recent NAMS (2022) Position Statement on Menopausal Hormone Therapy.
2. Describe and discuss the potential risks, benefits, and FDA-approved indications, for menopausal hormone therapy.
3. Describe and discuss the current evidence-based prescribing recommendations for menopausal hormone therapy, in a language that can be readily shared in patient-based discussions.
4. Analyze the evidence for alternative therapies in the treatment of symptoms associated with menopause.

Accreditation: St. Charles Health System is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. St. Charles Health System designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)^TM.

The period to claim credit for this activity expires one year after its original publication. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Claim Credit

Target Audience: Physicians, Nurses, Pharmacists, Allied Health Professionals

Accessibility/Program Questions: St. Charles Health System encourages persons with disabilities to participate in its programs and activities. If you anticipate needing any type of accommodation or have questions about the physical access provided, please contact Continuing Medical Education at [email protected].

Oher CME or Clerkship questions: also contact Continuing Medical Education at [email protected].