Summer 2008 - Vol.3, No.2


Lawrence I. Bonchek, M.D., F.A.C.S., F.A.C.C.



In one of those sacred rituals that administrators at effective and efficient organizations are fond of, Lancaster General has asked Gina and me to review the progress of the Journal toward meeting our goals for the previous fiscal year, and to set forth our goals for the coming year. (Readers should be assured that this request has no bearing on our editorial content, for which I and the Editorial Board remain solely responsible.)

This new request had a salutary effect, as it has encouraged us not only to assess our progress during the past year, but to organize what could easily have become an amorphous set of goals for the near future. Also, and not to be discounted, it provides the impetus for this article about some of the challenges the Journal has met, and the directions it hopes to go. (My summary below deals only with matters visible to readers, and omits all the administrative details that affect the production and printing of the Journal; details that are enormously important and can be even more complex because we cannot control them as readily as we can control content.)

Following are some of the challenges we met during fiscal 2008:

  • Made it much easier to revamp and enhance the layout and design of our website by changing from being hosted by an external vendor to being managed in-house. (Please indulge us by remembering that this is a work in progress.)
  • Obtained ISSN numbers (International Standard Serial Numbering) for the printed and on-line versions so they are now indexed by the Library of Congress.
  • Surveyed a sample of our readers.
  • Cultivated the independent writing capabilities of our medical staff and minimized the use of professional writers. Conducted regular prewriting conferences and post-writing reviews.
  • Published timely articles about topical health crises: (e.g. Community–acquired MRSA).
  • Developed a plan and policy about advertising in the Journal.
  • Reconsidered our policy of restricting authorship to members of our Medical Staff.

For the coming year, we hope to:

  • Meet the requirements for acceptance by Medline.
  • Expand staffing for the Journal with a part-time assistant.
  • Obtain advertisers and complete contracts for Journal advertising.
  • Develop the capability to monitor activity on our website.
  • Design a readership survey that will:
    • help determine the cost/benefit of limiting circulation of the print journal and/or the physical CD;
    • comprehensively assess reader interest in the different features of the Journal.
  • Promote submissions to the Journal from non-staff physicians.
  • Develop another issue of the Journal devoted to a single topic.
  • Promote contributions of articles from additional LGH departments.
  • Reassess the value of providing CME questions.
  • Develop a regular Clinico-Pathologic-Conference under the auspices of the
    Department of Pathology.

These are ambitious goals, and with our current staffing some are clearly unobtainable. But we will pursue as many as possible, and welcome your advice and support in doing so.

Now, as to the content of this issue, I first must commend the timeliness of our two featured review articles by Drs. Gottlieb and Gibas. Dr. Gottlieb’s review of alternatives to conventional heparin comes just when we need it. (Though he writes in the setting of deep venous thrombosis, his primer on newer heparins is widely applicable.) A contaminant in heparin from China, which has been tied to hundreds of allergic reactions and to more than 20 deaths, has been identified as “over-sulfated chondroitin sulfate,” which costs $9/lb instead of heparin’s $900/lb. Shockingly, it may therefore have been used intentionally for financial reasons. The Chinese factory in which it was introduced to the supply chain apparently has never been inspected by the FDA, which only has enough personnel and funding to inspect around 7% of foreign drug-making facilities in any given year. Baxter International is not the only supplier of heparin, but they alone apparently distribute about 100,000 vials of heparin daily.

Dr. Alexandra Gibas’ comprehensive and detailed article on Hepatitis C is made even more topical by the frequent recrudescence of reports of clustered cases, which occur against a persistent background incidence of this often insidious and therefore persistent disease. In May, 2008, the CDC reported an outbreak at a Las Vegas endoscopy clinic. Apparently, when sedated patients required a supplemental dose of sedative, the same syringe was re-used to draw up more drug from the vial, without considering that if the patient had Hepatitis C, the syringe could have been contaminated by backflow when the first injection was made. Even though the syringe would not be used for another patient, its reentry into the vial could contaminate the vial, which could pass along the virus when drug was withdrawn from the vial for the next patient. The number affected by this error is hard to determine, because although hundreds of infected patients were identified at the clinic, it was recognized that the majority probably were infected by other sources such as drug use, etc.

Equally timely is the thoughtful and analytical article by our COO Marion McGowan, about the essential role that we as physicians will have to play in helping administrators to develop an integrated health care system that will take us into the next phase of health care delivery in the United States.

Next, regular readers of the Journal will recall that in Spring 2007 (Vol.2; No. 1) I interviewed Dr. Ray Foley, Chief of Gastroenterology at LGH, about Project Access Lancaster County (PALCO), which was then in its initial stages. In this issue Dr. Foley provides us with a much more comprehensive overview and an update about this innovative program which he and several other key physician-organizers and many more participating practitioners have developed into a comprehensive provider of health services to the uninsured.

PALCO has transformed the healthcare scene for those Lancastrians who fall into the crevasse (it’s far more than a crack) between the poor who qualify for Medicaid, and those whose incomes are less than twice the federally determined poverty level. There are large numbers of people, as Dr. Foley explains, who often are only without coverage temporarily and need help avoiding financial catastrophe while bridging the gap to resumption of coverage by an employer.

I particularly want to draw your attention to the article by Dr. Cathy Rommel on pledget mydriasis. The specifics may not interest you unless you are an ophthalmologist, but what should interest you is that meticulous clinical research can be designed and carried out in a community hospital setting. Though it addresses a seemingly specialized matter, the time to maximum mydriasis, it has practical and far-reaching consequences for the O.R. schedule’s efficiency.

Our interviews this month are also notable. Dr. Nick Zervanos, Founder and long-time Director of our famed Family Practice residency talks about his objectives in starting the program and its accomplishments over the years. (Recall that we interviewed the current Director, Dr. Stephen Ratcliffe, in the third issue of Volume 1 - Winter 2006-2007.) Then, I talk with Dr. Mark Johnston of Lancaster Gastroenterology Inc., about the technique he developed for cryo-ablation of Barrett’s epithelium in the esophagus.

Finally, if readers from outside the LGH staff wonder why Dr. Peterson’s regular articles have only occasional references, it’s because they are an outgrowth of the popular formula he uses in his Family Practice Family Newsletter. As in that weekly communiqué, he is digesting multiple sources of information for us, and presenting a thoughtful summary of the topic that is influenced by his own clinical insight and opinion, and is not intended as an annotated reference work.

I hope you enjoy this issue.