Central Valley Physicians Spring/Summer 2022

Spring/Summer 2022

Serving Fresno, Madera, Kern and King Counties

INSIDE: MICRA Modernization Celebrating Doctors Resident Leaders Recognized Legislative Spring 2022 Advocacy

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“We want to make sure that California’s finest physicians are properly protected.”

A Team Approach to Medical Malpractice Coverage is a Winning Approach for Physicians More than 12,500 physicians rely on the Cooperative of American Physicians (CAP) to protect their practices every day.

Sarah E. Scher, JD Chief Executive Officer

Physician-founded and physician-governed, CAP provides superior medical malpractice coverage and solutions to help California physicians realize professional and personal success.

CAP members also receive risk management services, claims support and a dedicated in-house defense firm, practice management resources, and so much more. Find out what makes CAP different.

CAPphysicians.com

800-252-7706

Medical professional liability coverage is provided to CAP members by the Mutual Protection Trust (MPT), an unincorporated interindemnity arrangement organized under Section 1280.7 of the California Insurance Code.

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Spring/Summer 2022

VOLUME 7, NUMBER 1 • SPRING/SUMMER 2022

{FEATURES}

08 11 13 16 30

MICRA MODERNIZATION

LEGISLATIVE ADVOCACY DAY

COVID 19 TREATMENTS

{DEPARTMENTS} 5 6 20 24

FROM THE EDITOR A MESSAGE FROM THE PRESIDENT DOCTORS WHO MADE A DIFFERENCE THE JOY OF MEDICINE COMPASSION FATIGUE AND THE HELPING PROFESSIONAL

LEADERSHIP AWARDS

CELEBRATING DOCTOR’S DAY

Spring/Summer 2022

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From the Executive Director

This spring, our membership reached an all-time high.

Never before in our history have so many physicians enjoyed the benefits of membership and we are so grateful for each and every one of you.

With increased membership we are continually expanding the services and benefits we offer and enjoy seeing so many of you catching up with colleagues at events like our Doctor’s Day celebration at Gazebo Gardens (page 26-27) the annual Legislative Advocacy Day in Sacramento (page 11-12) and the 71st Annual Yosemite Postgraduate Institute. A very STACY WOODS special addition to this year’s Yosemite Postgraduate Institute was a behind the scenes tour of Ansel Adam’s dark room. It was such an honor to stand in the room where so much of the magic of Ansel Adams photography began.

We appreciate Dr. Michael Adams and Ian and Evan at the Gallery for making this such a special evening.

There are many more CME opportunities coming this year including our annual Cardiology, Nephrology and Diabetes Symposiums and a few new programs through partnerships with California Bridge, Fresno County Department of Public Health and more (see page 15).

PRESIDENT – John Moua, MD PRESIDENT ELECT – Marina Roytman, MD VICE PRESIDENT – Jennifer Davies, MD TREASURER –Pamela Kammen, MD PAST-PRESIDENT – Don Gaede, MD BOARD OF GOVERNORS Mark Alson, MD Nicole Calvillo, MD Karen Dahl, MD Farah Karipineni, MD Brent Kane, MD Farah Karipineni, MD Richard Mendoza, MD Anne Prentice, MD Jesus Rodriguez, MD Toussaint Streat, MD Greg Simpson, MD Tousaint Streat, MD Benjamin Teitelbaum, MD Jai Uttam, MD CMA Trustee - Ranjit S. Rajpal CENTRAL VALLEY PHYSICIANS Editor – Farah Karipineni, MD Assistant Editor – Karen Dahl, MD Managing Editor – Stacy Woods EDITORIAL COMMITTEE

In addition to attending CME activities, there are many ways to get involved with FMMS through committees, CME planning, Connect the Docs, Joy of Medicine, the Board of Governors and seats on the district delegation to the California Medical Association House of Delegates. If you are interested in participating, please call the office at 559-224-4224 to find out more about current opportunities. The Nominations Committee will be meeting soon to discuss open positions on the Board of Governors and 2023 Committees in preparation for the General Society Meeting this September.

Farah Karipineni, MD, Chair Don Gaede MD Karen Dahl, MD Roydon Steinke, MD Michael Mcmillon, MD CREATIVE DIRECTOR prime42: DESIGN | MARKET | HOST prime42.com CONTRIBUTING WRITERS Farin Jacobson, Sarah Holzmann, Yusur Alsalihi, Simon Paul, MD, Aimee Moore, MS, APCC, Christy Oberholtzer, RN CONTRIBUTING PHOTOGRAPHERS Anthony Imirian CENTRAL VALLEY PHYSICIANS is produced by Fresno Madera Medical Society

Stacy Woods

PLEASE DIRECT ALL INQUIRIES AND SUBMISSIONS TO Central Valley Physicians 255 W Fallbrook Avenue Suite 104; Fresno, CA 93711 Phone: 559-224-4224 | Fax: 559-224-0276 Email address: swoods@fmms.org MEDICAL SOCIETY STAFF Executive Director – Stacy Woods Marketing Coordinator – Casey Nagle

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Spring/Summer 2022

A message from our Editor > Farah Karipineni, MD

Going In They said you might die if I did the operation you needed to save your life a truly impossible situation That couldn’t be helped I carefully calculated the risk/benefit ratio Of resecting your wild tumor Spewing four times the normal amount of epinephrine What would happen to your so fragile state When I manipulated such a volatile thing I turned over this problem in my head A million times Thought of a million questions Which I then sought answers for Leading to a million plans Which I then put in place As I often do When rolling such dice To make the best decision To not have your blood on my hands I could operate, of course Or simply walk away But both ways ended with blood on my hands So I decided on surgery Because despite your almost dead heart you are only 32 with four kids ABOUT THE AUTHOR Farah Karipineni, MD, MPH, is board certified in General Surgery and fellowship trained in Endocrine Surgery. She is currently practicing in Fresno as an Assistant Clinical Professor for UCSF. Dr. Karipineni earned her medical degree from University of California, Irvine School of Medicine. Her residency in General Surgery was completed at Albert Einstein Medical Center, and she completed her fellowship in Endocrine Surgery at Johns Hopkins School of Medicine.

Dr Karipineni has been published in journals including The American Surgeon, the International Journal of Surgery and the Journal of Surgical Education.

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In the operating room Things intensified As they often do But faster than I wanted them to I brought in numerous consultants But the decision was mine alone To be “brave” To make the “right call” (Which I still don’t know if I did) Because even when there seem to be many possibilities The outcome is always 100% one thing And for all I knew It could go so many ways On this one The surgery itself had to be perfect Because nothing else was And only by the grace of God You did not arrest as we knew you might You did not have kidney failure as we knew you might You did not stay intubated as we knew you might You did not require emergency heart surgery as we knew you might Mercifully You opened your eyes from sleep after the operation And told me you were going to be ok (I believed you more than all your numbers I was obsessively evaluating) And because you are now safely home We said I made the right call And I feel some relief But not for a second do I forget How easily the outcome could have been different And instead of brave We would call me reckless And instead of saving your life We would say I killed you But by the grace of God We delivered you home instead of to the morgue To your 4 girls and wife And it was always to be so But of course You and I Didn’t know that Going in

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A message from our President > John Moua, MD

We are living during an unprecedented time.

ABOUT THE AUTHOR John Moua, MD is board certified in Pediatric Pulmonology and specializes in Cystic Fibrosis, asthma, chronic lung disease, recurrent respiratory infections and Valley Fever. Dr. Moua serves as Chief, UCSF Fresno Pediatrics, Vice-Chair, Department of Pediatrics, UCSF, Associate Center Director, Cystic Fibrosis Program, UCSF Fresno, Medical Director, CRMC Pediatrics Specialty Center and President, Fresno Madera Medical Society.

Dr. Moua grew up in the Central Valley graduating from Computech Middle School and Edison High School. He earned a BS in Human Biology from Cornell University and his medical degree from UC Davis. Dr. Moua completed his residency at UCSF Fresno and a Pediatric Pulmonology Fellowship at UC Irvine.

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By now, we have all heard of the saying: we are living during an unprecedented time. Two years ago, society came to a screeching halt with the declaration of the COVID pandemic. Hospitals, clinics, and health care workers scrambled to find personal protection equipment. “Non-essential” businesses shuttered their doors—some of them permanently. Schools closed down, forcing many parents to try to find a balance between teaching, childcare, and their full-time jobs. Elective surgeries were canceled, and patient clinic visits were converted to telehealth.

And sadly, many of us have lost family members, friends, and colleagues over the last year to COVID. The COVID pandemic exposed the cracks in our healthcare systems, spotlighted the health disparities in our communities, and revealed how much work we, as physicians, and the medical community still need to do for our patients and their families.

Last year, multiple physician leaders in the community have shared with me that FMMS has become much more engaged and involved with issues affecting our medical community. Since joining the FMMS board in 2019, I would have to agree. This is in part thanks to the leadership of both Drs. Birnbaum and Gaede, executive board members, and Executive Director Stacy Woods.

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I’d like to highlight some of the work that FMMS has done over this past year.

• FMMS with the California Medical Association provided PPE to local physicians and their medical offices when the COVID pandemic began.

• FMMS collaborated with Dr. Rais Vohra and the Fresno County Department of Public Health on crafting public service announcements about masking, social distancing, and COVID vaccinations.

• FMMS facilitated townhall meetings to discuss the shifting healthcare landscape and implications for primary care and graduate medical education in the valley.

• FMMS partnered with the Central Valley Opioid Safety Coalition to present CME webinars on Safe Prescribing Practices and helped with Narcan distribution.

• The Joy of Medicine program, which is aimed to empower our physicians to achieve the highest level of professional and personal wellbeing, continued the Connect the Doc events, such as pickle ball, planting your spring garden, and learning how to grill meats.

• FMMS has continued to make available resiliency consultations to our members through Roubicek and Thacker Counseling.

• In collaboration with other medical societies in California, FMMS was able to provide over 150 units of CME last year alone.

will be protected. The newly modernized MICRA will provide predictability and affordability of medical liability insurance rates for many years to come. We are grateful for the hard work and forward thinking that brought about the modernization of MICRA. (You can read more about the Modernization of MICRA beginning on page 8.) We are now able to focus on other challenges including physician recruitment, physician retention, and Medicare/ MediCal reimbursement rates among other important issues. If you are interested in advocating on behalf of your fellow physicians, there are positions available on the FMMS Legislative Committee. To convey your interest, please reach out to Committee Chair Mark Alson, MD or Stacy Woods at the FMMS office. In the months ahead, I look forward to working with the 2022 FMMS executive members, board members and many of you collaborating on projects, bridging gaps, and supporting initiatives to address issues that we face as a community.

With best regards, John Moua, MD

FMMS President 2022

As our community recovered from the Omicron wave of the COVID pandemic and our society returned to some level of normalcy, the Fairness for Injured Patients Act, also known as FIPA, was our main focus. This measure aimed to overturn the protections of MICRA and would have been on the November ballot, if not for the valiant advocacy efforts of Californians Allied for Patient Protection (CAPP) supported by CMA, FMMS and hundreds of organizations across California. Those efforts led to the introduction of AB 35 which passed the legislature with nearly unanimous bipartisan support. FIPA has been withdrawn, and the next generation of physicians can rest assured that both physicians and injured patients

Spring/Summer 2022

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Common Ground Historic MICRA modernization law puts patients first and prioritizes the stability of affordable access to health care.

Governor Gavin Newsom on May 23, 2022, signed Assembly Bill 35 into law, and in doing so put an end to a decades-long political battle and ushered in a new era of stability around malpractice liability.

The bill, which passed through the California Legislature with nearly unanimous support, will ensure that health care is accessible and affordable, while balancing compensation for Californians who have experienced health care related injury or death. The modernized law will also bring greater accountability, patient safety and trust by making it possible for physicians and patients to have a full and open conversation after an unforeseen outcome.

“This historic moment happened because the two sides of the ballot measure campaign put differences aside, found common ground, and recognized a rare opportunity to protect both our health care delivery system and the rights of injured patients,” said California Medical Association (CMA) President Robert E. Wailes, M.D. “We are immensely grateful to the Legislature and Gov. Newsom for helping to codify this landmark agreement in law.”

A Landmark Achievement

Since California’s landmark medical malpractice reforms – the Medical Injury Compensation Reform Act (MICRA) – were enacted almost 50 years ago, they have successfully struck a balance between compensatory justice for injured patients while maintaining an overall health care system that is accessible and affordable for Californians. California’s physician and provider communities have repeatedly defended MICRA through expensive battles at the ballot, in the courtroom and in the legislature.

This year, we were again facing another costly initiative battle. The so-called Fairness for Injured Patients Act, which had qualified for the November 2022 ballot, would have

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obliterated existing safeguards for out-of-control medical lawsuits and would have resulted in skyrocketing health care costs.

But for the first time in a generation, we were met with an opportunity to achieve a meaningful consensus between competing interests through a revised framework that would protect both the rights of injured patients while keeping MICRA’s essential guardrails solidly in place for patients and providers alike.

Californians Allied for Patient Protection (CAPP), the Consumer Attorneys of California, Nick Rowley—author and primary funder of the November ballot measure—and both sides of the initiative fight worked together with the Legislature and Gov. Newsom to craft an agreement that puts patients first and prioritizes the stability of affordable access to health care.

“CMA is proud to have been part of this landmark achievement for the benefit of all Californians,” said Dr. Wailes. “We look forward to a new era of long-term stability around MICRA that will allow California’s physician and provider communities to focus on other ways to improve access to care and public health for all Californians.”

As part of the agreement, FIPA’s proponents removed it from the November ballot, precluding another costly and unpredictable ballot fight in November.

Modernizing the MICRA Cap

Under the modernized MICRA law reflected in AB 35, which will go into effect on January 1, 2023, the underlying principles of MICRA were preserved – ensuring access to care and protecting our health care delivery system from runaway costs. Important guardrails of MICRA will continue unchanged, including advance notice of a claim, the one-year statute of limitations to file a case, the option of binding

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arbitration, early offer of proof for making punitive damage allegations and allowing other sources of compensation to be considered in award determinations.

institution can only be held liable for damages under one category regardless of how the categories are applied or combined. The new categories include:

The element that has garnered the most interest surrounds changes to the limit on noneconomic damages in medical malpractice cases, which has been $250k since 1975. As opposed to the ballot measure, which would have effectively eliminated the cap on noneconomic damages, under the agreement:

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One cap for health care providers (regardless of the number of providers or causes of action)

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One cap for health care institutions (regardless of the number of institutions or causes of action)

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One cap for unaffiliated health care institutions or providers at that institution that commit a separate and independent negligent act

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Cases not involving a patient death will have a limit of $350k on the effective date of January 1, 2023, with an incremental increase over the next 10 years to $750k and a 2.0% annual inflationary adjustment thereafter.

Cases involving a patient death will have a limit of $500k on the effective date of January 1, 2023, with an incremental increase over the next 10 years to $1 million and a 2.0% annual inflationary adjustment thereafter.

Under FIPA, the cap would have immediately jumped to $1.35 million, and would have at least doubled malpractice premiums overnight. This would have had a chilling impact on the entire health care system, creating a trickle-down effect that would be borne primarily by lowincome patients who would face higher costs and restricted access to care.

The new law will also create three separate categories for a total of three possible caps in each case. A health care provider or health care

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Other critical MICRA guardrails that will remain in place with modest updates include the ability to pay awards of future damages over time and limits on plaintiff’s attorney’s contingency fees.

New Protections

AB 35 also establishes new protections that allow physicians to convey expressions of sympathy, apologies and statements of fault, to transform the existing culture of blame and punishment that suppresses information, into a culture of safety that focuses on openness and information sharing.

Often, a patient’s decision to file a medical malpractice lawsuit is triggered by a failure in communication, not negligence. The modernized framework establishes new evidentiary protection for all pre-litigation expressions of sympathy, regret or benevolence, including statements of fault, by a health care

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provider. Allowing physicians and patients to have a full and open conversation after an unforeseen outcome leads to greater accountability, patient safety and trust.

Shifting Focus

CMA and the provider community remain united and committed to the principle of high-quality health care that is accessible and affordable to all Californians. For decades, we accomplished those goals in part by focusing our political resources on protecting MICRA against regular attacks. By creating long-term stability around MICRA, we can shift our focus, political influence, and resources to affect other positive changes for physician practices and improve access to care and public health for all Californians.

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Sidebar: MICRA vs. FIPA

The AB 35 MICRA modernization is a balanced proposal that preserves its essential guardrails, strengthens provider protections and provides for fair compensation for injured patients. This chart below provides an at-a-glance look at the protections of AB 35 versus what physicians would have faced had FIPA been approved by voters.

Learn more at cmadocs.org/micra.

Spring/Summer 2022

Legislative Advocacy Day 2022 by: Sarah Holzmann and Yusur Alsalihi

On Tuesday, April 19th, members of the American Medical Association (AMA) and California Medical Association (CMA) Chapter of the California Health Sciences University (CHSU) College of Osteopathic Medicine visited Sacramento for the 2022 CMA Legislative Advocacy Day. The student attendees included the authors of this article, Sarah Holzmann (OMS-II) and Yusur Alsalihi (OMS-II), as well as Rajvarun Grewal (OMS-I). Student Doctor Holzmann is the founder and President of CHSU’s AMA and CMA Chapter and the university’s delegate at the June 2022 national AMA meeting. She also serves as a

member of the AMA Committee for Health Information Technology.

Student Doctors Alsalihi and Grewal recently ran for and were elected to serve as the Medical Students Section’s Vice-Chair of Legislative Affairs and the Vice-Chair of Policy, respectively.

Thanks to the Fresno Madera Medical Society (FMMS), we had the pleasure to meet with Representative Frank Bigelow. He is serving in California State Assembly for District 5, encompassing the central Sierra Nevada area.

During this meeting with Assemblymember Bigelow, our goal was to advocate specifically for SB 250 and AB 2132; the former is a comprehensive approach to reforming the prior authorization process. The latter seeks to promote individuals from diverse, underrepresented communities to fund their education from college to residency.

Following an excellent introduction of the two bills from Dr. Ranjit Singh Rajpal, a CMA trustee and interventional cardiologist in Madera, Mr. Bigelow shared a personal account of a recent medical field encounter that captured the essence of the first issue at hand. He spoke openly to the group about the excessive number of authorizations he had to go through to achieve proper medical care for a simple inpatient procedure, highlighting how excessive authorization forms hinder effective and timely access to care. We then discussed why this bill is especially crucial for our county. There is a demonstrable administrative burden placed on physicians that is exacerbated when fewer doctors are practicing per capita.

Through SB 250, we hope that physicians will have more time to care for patients without unnecessary delay and interference from health plans.

The second bill, which was put forth by Assemblymember Carlos Villapudua, has the ultimate goal of creating a physician workforce that reflects our state’s patient population. AB 2132 also incorporates a commitment to practice in a rural or medically underserved area after residency, which addresses the physician shortage, particularly in areas with the greatest need. As students, we sought to attend a university whose mission includes “inspiring a diverse student body to commit to careers that serve our region,” thus, we were highly motivated to share our perspectives on this critical topic. SD Alsalihi spoke out about her status as underrepresented in medicine (URM) and how students like herself struggle to meet the high costs required to finance their medical education. These financial barriers strongly disincentivize URM students from accepting lower-paying practice opportunities and specialties in underserved areas. Although students like us are proud to be a part of CHSU and its mission, we recognize that our actions can only go so far without adequate support from the state.

In addition to the privilege of advocating on behalf of a brighter future for medical practice, we also had the pleasure of learning about Bigelow’s younger days driving a race car and what drives his ambition to lead. Even in the first few minutes of meeting with the representative, it was evident that despite his physical presence in the capital, or technically the “swing-space” a few blocks away while the government building is under construction, his heart remains in the Central Valley. The stories he shared about his 40+ years of experience as a volunteer firefighter further highlighted his passion for serving our area. As one example, he shared a recent memory from when he stepped up to provide his assistance during a wildfire. While on the phone with a current fire department leader, he offered to 12

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drive down from his office back to our district in a swift attempt to rescue hundreds of cows belonging to a local rancher.

With only so much time allotted to discuss these critical issues and the policies’ potential solutions, we left the assembly member’s office. We made our way back to the conference. Our disappointment quickly transformed into enthusiasm when the Attorney General of California was welcomed to the stage of the banquet hall. In his keynote speech, Robert Andres Bonta spoke of his background.

A day after his birth, the Philippine president signed a proclamation that placed the Philippines under Martial Law. The Bonta family then moved to California when he was two months old. During his address, he joked that when they moved to the states, his mother would simultaneously plan his birthday parties alongside protests to celebrate the first occasion and express continued dissent for the latter. The true impact of the speech came when AG Bonta spoke about the impact the affordable care act has on everyday California and how the act has helped provide coverage to more of the state’s population. His speech highlighted recent efforts to minimize and overthrow the act and how his office and neighboring states have acted to protect the Affordable Care Act. His speech left the crowd in a standing ovation, reminding us why we were there and of all the work still to be done.

In light of a first-year neurology midterm and all of the histology relevant to nephrotic syndrome awaiting our second year, we returned to Clovis not even 24-hours later. Still, our journey did not come to a halt there. Before the end of the academic year, our chapter plans to host a virtual meeting to discuss the same policies with different members of the House or Senate. We aim to continue educating our peers and the public about these issues to convey their importance for the future of medicine.

COVID-19 Treatment After the Omicron surge recedes, the landscape for COVID response in the future will look significantly different. For physicians seeing patients with COVID infection, outpatient treatment of COVID will play a much larger role. Until now the availability of COVID treatment has been limited in comparison to the number of COVID cases, so for many providers treatment has remained in the background of their awareness. For example, there are large numbers of immunosuppressed patients at risk for COVID who may not respond to vaccination. These patients can be protected for up to six months with a single long-acting monoclonal antibody injection. However, at present many counties are turning away their allotments of Evushield due to the lack of uptake by providers and limitations on eligibility. As production of medications increases and decreasing case rates reduce demand, availability of COVID treatment is going to become a reality for outpatient COVID management. As programs such as Governor Newsom’s COVID SMARTER response, and President Biden’s plan to coordinate testing and treatment at testing sites gain are rolled out, these programs will lead to a significant increase in demand from the public for COVID treatment. Providers will need to know how to prescribe these treatments, and during this time of changing availability, for whom to prescribe, and if the medications are currently available in our area.

ABOUT THE AUTHOR Simon Paul graduated from Cornell University Medical College and completed residency in Internal Medicine at Parkland Memorial Hospital. After completing an NIH Physician-Scientist Fellowship at Rockefeller University he began work as an HIV specialist—initially at New York Hospital-Cornell and then at the UCSF-Fresno Internal Medicine Department until 2020. In 2020 he was appointed as the Public Health Officer for Madera County.

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Who will prescribe these treatments?

COVID treatment is most effective when started as quickly as possible after infection. This timing will require coordination of testing sites with treatment providers.

To date, a significant portion of COVID testing has been carried out at large testing sites and pharmacies. Similarly, a significant proportion of COVID vaccination has also been carried out at mass vaccination sites and pharmacies. With the goal of providing widespread access, and of connecting testing and treatment, the Biden administration and CDPH plans will continue this movement of COVID treatment to less traditional providers (pharmacies with clinical providers and test-to-treat sites with telehealth providers).

However, the increasing availability of rapid COVID antigen tests will also make it possible for many outpatient offices to provide diagnosis and treatment at a single visit. The ability for providers to offer a careful clinical assessment in addition to covid testing and treatment, will be critical for those who most need treatment: older patients and those with medical conditions that place them at high risk for COVID complications. These patients may prefer to see their regular provider for care and may also need more assessment than a pharmacy testing and treatment site can provide. In addition, a large number of ill patients will still head to urgent care centers and emergency rooms for evaluation; providing rapid tests and prescribing treatment at these sites may be critical for improving COVID outcomes and decreasing hospitalizations.

Planning and preparation now may make providing access to COVID treatment in outpatient and urgent care settings straightforward if cases surge again in the future.

ORAL COVID TREATMENT:

Paxlovid (nirmatrelvir and ritonavir) is currently the best treatment option for COVID. Unfortunately, until now it has been the least available. Paxlovid contains nirmatrelvir--an inhibitor of the COVID protease enzyme.

Treatment is 90% effective at preventing hospitalization and death. Importantly, with the COVID variants to date, mutations have been largely in the COVID spike protein— these mutations do not affect the COVID protease enzyme structure and make no change to the effectiveness

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of Paxlovid. Paxlovid also contains a “booster”—the cytochrome p450 inhibitor ritonavir that allows high drug levels to be maintained. This booster is responsible for the many drug interactions of Paxlovid—most any other medications that are metabolized through the p450 system can be affected to varying degrees. However, treatment is only for five days, and many common interacting medications such as statins can be held and restarted 3 days after completing Paxlovid therapy. Excellent resources are available to quickly assess drug interactions; one of the most user friendly is the Liverpool COVID interactions checker [https://www.covid19-druginteractions.org/ checker]. Availability of Paxlovid is has been limited to certain pharmacies, however, new locations are often added. Up-to-date information on availability is viewable at https://covid-19-therapeutics-locator-dhhs.hub.arcgis. com/ . As COVID case numbers decrease and medication availability increases it is likely that providers will only need to check on local availability infrequently.

Molnupiravir is the other oral medication for COVID treatment. Unfortunately, this is currently the least effective treatment option with only a 30% decrease in severe outcomes. However, if the preferred Paxlovid or IV therapies are not available, there is widespread availability of Molnupiravir at many pharmacies. Molnupiravir induces viral RNA mutations making the virus unable to replicate.

Due to this mechanism of action, concerns have been raised about the possibility of this mutagenesis leading to new COVID variants; post-approval surveillance of genomic databases is planned to address this concern.

Molnupiravir is also not recommended in pregnancy or for children.

INTRAVENOUS COVID THERAPY:

A range of monoclonal antibodies (designed to bind to the COVID spike protein) and remdesivir (an inhibitor of the viral RNA polymerase) are also available. As few outpatient settings will keep these medications on hand, the key to prescribing them is to know where patients can be sent for infusions and the referral criteria for these sites. Location of infusion sites is usually posted on county health department websites; obtaining information on the referral process for a nearby site ahead of time can make this process simple when a patient tests positive and needs treatment. The effectiveness of monoclonal antibody

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treatments can change drastically as new COVID variants arise, as many new variants have significant changes to the spike protein—the target of the monoclonal antibodies.

Infusion centers are kept up to date on which therapies to prioritize based on local variants and treatment availability.

Remdesivir is not affected by variants of the COVID spike protein, however, this treatment requires infusions daily for three days and for that reason is less frequently used.

COVID PREVENTION

Evushield is a modified monoclonal antibody designed to persist in the circulation at an effective level for over 6 months (a “long-acting monoclonal antibody”).

Patients who are unable to mount an immune response to COVID vaccines or patients that would likely not survive a COVID infection are candidates for preventive therapy.

Many of these patients (such as oncology patients) already have infusion clinic appointments for other medications.

Surprisingly, while Evushield could simply be added on to the medications at any infusion clinic appointment, we have seen almost no use of Evushield in the Central Valley area—perhaps due to a mistaken impression that this medication is difficult to access. Care givers for these immunosuppressed patients should be aware that, going forward, if a patient such as an immunosuppressed oncology patient is hospitalized with COVID, the question will increasingly be raised as to why the patient was not offered preventive treatment. As availability of Evushield is increasing, eligibility criteria are expanding and may include a wider range of immunosuppressed patients, such as rheumatology patients on immunomodulating medications. Again, county health department websites and the CDPH websites listed below are excellent resources for current locations to obtain Evushield, and for eligibility criteria as both are changing rapidly.

For further information: CDPH therapeutics site—information for both patients and providers. For providers there are links to the NIH treatment website, factsheets for all COVID treatments, and a therapeutics locator website: https://covid-19-therapeutics-locator-dhhs.hub.arcgis.com/ test to treat site locator: https://aspr.hhs.gov/TestToTreat/Pages/default.aspx NIH outpatient COVID management site: https://www.covid19treatmentguidelines.nih.gov/management/clinicalmanagement/nonhospitalized-adults--therapeutic-management/

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Nephrology Symposium Saturday, August 13, 2022 8:00 am - 2:00 pm 4.5 CME 8:00 am

Welcome Dr. Hemant Dhingra Program Director

8:15 am

The Testosterone Controversy: A Clincial Update Saeed Sandhu, MD

9:00 am

Recent Advances in Kideny Transplant Management Ram Peddi, MD

9:45 am

SGLT2 Inhibitors - Current Status In Heart Failure and Chronic Kidney Disease Richard Glassock, MD

8:00 am

Registration, Exhibits & Continental Breakfast

8:30 am

Welcome and Introduction Ranjit Singh Rajpal, MD, Program Director

8:40 am

Cardiovascular Sequelae of COVID-19 in Adults.

Myocarditis and Other Myocardial Improvement, Post-Acute Sequelae of SARS-COV-2 Infection and Return to Play Ty J. Gluckman, MD

9:30 am

Intersections of Antiplatelet and Anticoagulant Therapy - What To Do When A Patient Needs Both Ty J. Gluckman, MD

10:30 am

Break & Exhibits

10:45 am

2022 AHA/ACC/HFSA Guidelines for the Management of Heart Failure: Expert Eldrin F. Lewis, MD

11:45 am

TAVR vs. SAVR Update 2022 Comparative Indications - Pit Falls and Proper Selection of Patients Raj R. Makkar, MD (virtual)

12:30 pm

Lunch & Exhibits

1:00 pm

Moderator: Alfred Valles, MD

1:40 pm

Short and Ultrashort: DAPT Strategies After Stent Implantation. What Do We Know and Where Are We Going?

Joseph L. Thomas, MD

10:00 - 10:15 am Break and Exhibits 10:15 am

How to Delay Dialysis Initiation in the Era of Vallue Based Kidney Care Models Kam Kalantar, MD

11:00 am

Preemptive Kidney Transplant Why and How Yihung (Eric) Huang, MD

11:45 am

Patient Care Implications of Obesity Paradox and Reverse Epidemiology: Assocation Fallacy or Biologic REality?

Kam Kalantar, MD

12:15 pm

Doubling Kidney Transplants by 2030- Can We Do It? Yihung (Eric) Huang, MD

1:00 pm

Lunch

Platinum Sponsor Horizon Therapeutics Gold Sponsor

Bayer Pharmaceuticals

2:30 pm

Silver Sponsors

Aurinia Pharma CareDx Fresno Kidney Foundation Vifor Pharma

3:30 pm

Spring 2022

Transcatheter Mitral and Tricuspid Valve Interventions: Status Update Raj R. Makkal, MD (virtual)

Register at FMMS.org or by calling 559-224-4224 CENTRAL VALLEY PHYSICIANS

15

Each year the Fresno Madera Medical Society recognizes a graduating resident from each of the three Graduate Medical Education programs for their exceptional leadership throughout residency. The Steven N. Parks, MD Leadership Award was originally established to honor a resident or fellow from UCSF Fresno Medical Education Program who demonstrates outstanding leadership qualities, takes initiative, and exceeds expectations.

The UCSF Fresno award was named for Dr. Parks who was known for his vision, leadership, and guidance during his 35 years of practice in Fresno. Dr. Parks made outstanding contributions to the medical community, the profession, Fresno Madera Medical Society, and other professional organizations.

In 2021, the Fresno Madera Medical Society Board of Governors elected to extend the FMMS Leadership Award to include Saint Agnes Graduate Medical Education and the Valley Children’s Pediatric Residency Program.

This year’s recipients include Heather Chow, MD (UCSF Fresno), Rafael Gonzalez, MD (Valley Children’s) and Manpreet Singh, MD (Saint Agnes).

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RAFAEL GONZALEZ, MD

HEATHER CHOW, MD

Dr. Karen Dahl, member of the Fresno Madera Medical Society Board of Governors presented the FMMS Leadership Award during the Valley Children’s Hospital Graduation Ceremony to Rafael Gonzalez, MD. Dr. Gonzalez was nominated for this award based on his involvement in the community, dedication to fellow residents and to the underserved children of the Valley.

Dr. Gonzalez is from Salinas and chose Valley Children’s Hospital for residency based on his eagerness to be part of a team that makes such a profound impact on the youth of California’s Central Valley. Deeply aware of both the physician shortage and existing health disparities, he is eager to help change both. Dr. Gonzalez has been very involved in the community during residency. He mentors high school pre-med students and numerous fellow residents in the program and across the Central Valley. Dr. Gonzalez has a passion for serving medically disadvantaged populations, particularly the Latino/a population which led him to create a COVID-19 Vaccine Clinic from scratch and work with the Residency Diversity Council to ensure the residents of Cutler-Orosi, specifically the children, had access to vaccines. 247 total vaccines were administered including 148 vaccines for children aged 5 to 17 in the first of multiple clinics in the area.

Dr. Gonzalez contributed in many ways, whether in a clinical setting or creating a memorial tribute in celebration of Dia de Los Muertos collaborating with the Residency Diversity Council, CLAS committee and DEI Subcommittee that was showcased in the Guilds Hall.

Dr. Gonzalez matched in the Pediatric Subspecialty Fellowship Match and will be completing a fellowship in Gastroenterology at Stanford Medicine in the Division of Gastroenterology, Hepatology and Nutrition.

Dr. John Moua, president of the Fresno Madera Medical Society presented the Steven N. Parks, MD Leadership Award to Heather Chow, MD in recognition of her leadership in the academic setting, clinical setting and in the greater community. Dr. Chow not only excelled in her own medical education and professional development but provided mentorship and guidance through the Court Appointed Special Advocate (CASA) program to youth in foster care.

Originally from San Francisco, Dr. Chow earned a Bachelor of Science degree in Molecular, Cell and Developmental Biology from the University of California, Los Angeles before earning her MD from the Touro University Nevada College of Osteopathic Medicine.

Dr. Chow won the Pediatric teaching award in 2020 and the Pediatric Hospitalist Award in 2021 for her strong clinical team leadership skills and her commitment to evidence-based, patient-centered care. In addition to this clinical work, Dr. Chow also produced meaningful scholarly work. She helped organize UCSF Fresno’s 2021 Pediatric ECHO project that sought to improve screening for lead exposure in children in our community.

She also collaborated and co-published a paper in the Pediatric Clinics of North America Journal, “COVID-19 in Children: Clinical Manifestations and Pharmacologic Interventions Including Vaccine Trials.”

Dr. Chow has been an active member of the Pediatric Program Evaluation Committee and helped to ensure a successful transition from the traditional in-person interview process to a virtual format. In addition to her outstanding work within the UCSF Residency Program and CASA, Dr. Chow led a school-supply collection drive for underserved youth and an annual winter holiday toy drive where she solicited donations, organized collection, and wrapped and distributed the gifts.

Dr. Chow will remain at UCSF Fresno this coming year as a Chief Resident.

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17

SINGH MANPREET, MD Saint Agnes Graduate Medical Education Dr. Jennifer Davies, Vice President of the Fresno Madera Medical Society presented the FMMS Leadership Award during graduation ceremonies at Saint Agnes to Dr. Manpreet Singh in recognition of his demonstrated leadership throughout his residency.

Dr. Singh grew up in Orange Cove after moving to the United States from India as a child. He graduated from Reedley College, obtained a Bachelors in Biological Sciences form UC Irvine and attended Ross University School of Medicine.

In his role as Chief Resident, Dr. Singh facilitated all current resident lecture attendance, didactic curriculum and master rotation development and schedule coverage/ changes. As Chief Resident, Dr. Singh provided strong leadership for 48 Internal Medicine residents and 12 transitional year residents in the Saint Agnes Graduate Medical Education program. During his three years at Saint Agnes, Dr. Singh shined as a leader having been selected by his peers to be the GMEC resident representative during the 2020-2021 academic year, served as resident forum leader for the Internal medicine and transitional year program and advocated successfully for and helped create a designated ICU rounding space for residents.

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As a PGY2, Dr. Singh assisted the program coordinator in onboarding lectures for 21 interns including “internal Medicine Policies and Procedures Overview”, “Chief Resident Expectations”, and “Intern Survival Guide”. Dr. Singh was a nominee for the 2022 Saint Agnes Medical Center Champion in Care award. The Champion in Care award was created in 2009 by nursing as a way to recognize those physicians who demonstrate a team spirit and a desire to work collaboratively with Saint Agnes team members, as well as patients and families, to provide exemplary patient care. Although he didn’t win, being a resident nominated by nursing is a huge accomplishment.

Dr. Singh has been accepted into Harbor-UCLA Medical Center for a Nephrology Fellowship. His longterm goal is to stay in the Central Valley while providing exceellent medical care to the residents of Fresno and the small surrounding communities.

Spring 2022

KidsVaxGrant Opportunity Exclusively for VFC Providers Application deadline extended to July 15, 2022, or when all funds are disbursed.

The State of California is offering grant funding to medical organizations enrolled in the federal Vaccines for Children (VFC) Program, serving eligible children from birth through 18 years of age. Administered by Physicians for a Healthy California (PHC), the California Department of Public Health (CDPH) is investing approximately $10 million to fund the KidsVaxGrant.

VFC providers newly enrolled in California's COVID-19 vaccine program (myCAvax) could be eligible for $10,000 to support enrollment and launching a vaccination center. Those that enroll in myCAvax from December 17, 2021, through July 15, 2022, will qualify for the grant.

VFC providers already enrolled in myCAvax, who are expanding operating hours could be eligible for $15,000. Eligible providers must expand hours of operations by a minimum of 15 hours to provide additional time options for working families.

Expanded hours must be outside of normal or existing clinic

Proud Recipient of #KidsVaxGrant

hours, and they must be completed within 60 days of the application’s approval (not retroactive).

Spring 2022

Apply today at KidsVaxGrant.org CENTRAL VALLEY PHYSICIANS

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Doctors Who Made A Difference

Cardiac surgery techniques that seem run-of-the-mill in today’s hospitals were pioneered in the late1960 s and1970 s –and it may not be widely known that Fresno was ahead of its time when it came to complex heart surgeries.

One man on the forefront of innovative techniques was the late Dr .Sathaporn Vathayanon ,affectionately known as Dr. Sam.

D

r. Sam, who had privileges at Valley Children’s, Fresno Community, and St. Agnes hospitals, is credited with performing several of the Central Valley’s firsts: the first coronary bypass operation, first coronary bypass graft using an internal mammary artery, and first Fontan palliative procedure.

“The Central Valley was there early in this whole trajectory of heart surgery science,” said Dr. James Prochazka, a pediatric cardiologist at Valley Children’s Hospital who worked alongside Dr. Vathayanon for many years. “And it was continued with many new techniques introduced by Dr. Vathayanon, who, by the way, was meticulous and skilled and beloved by his patients.”

Dr. Vathayanon was born in Bangkok, Thailand on April 25, 1934. Through the encouragement of his mother, Sewan Vathayanon, he broke from his family military tradition to pursue a career in medicine.

He graduated with a B.S. degree in 1952 and received his M.D. and graduated Cum Laude in 1956 from

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by: Farin Jacobson

Chulalongkorn University in Bangkok, Thailand.

His post graduate training included an internship and residency at Maryland General Hospital from 196064, and a residency in thoracic surgery at the University of Michigan Medical Center from 1964-66.

From 1966-69 Dr. Vathayanon was an instructor of thoracic surgery at the University of Michigan School of Medicine and a staff thoracic-cardiovascular surgeon at University of Michigan Medical Center.

Dr. Vathayanon had intended to return to Thailand, as he was very close with his mother, but upon completion of medical school decided to stay in his adoptive country and became a naturalized citizen of the United States.

He was recruited from University of Michigan by Dr. Byron Evans to practice medicine at Valley Children’s Hospital in 1969.

The progression of cardiology in Fresno was documented in an article compiled by the late Dr. Fitzalbert M. Marius, a pioneer cardiologist in the Valley,

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called “Forty Years of Open Heart Surgery in Fresno.”

Of the document, Dr. Prochaska said, “That’s the only archive that really exists showing, I think, how Fresno was way ahead of the time in starting complex surgery as we know it today, and that Dr. Sam, I’ll call him, also tried very hard to carry out that innovation.”

Dr. Vathayanon performed Central California’s first coronary bypass operation in January 1970 – a double bypass graft on patient Frank Nakamura.

In 1974, Dr. Vathayanon performed the first coronary

One of Dr. Sam’s proudest memories was on June 11, 1985, when as chief surgeon he performed a lifesaving operation on a 7-year-old Honduran Indian boy who had a rare but fatal heart defect.

The patient was born in a remote village in Honduras with tricuspid atresia, where the valve that controls blood flow from the right upper chamber of the heart to the right lower chamber of the heart doesn’t form.

“That’s lethal,” Dr. Prochazka explained. “ And Dr. Sam did the first operation to bypass that

“And Dr. Sam did the first operation to bypass that chamber to allow blood to adequately flow into his lungs.” bypass graft in the area using an internal mammary artery.

Internal thoracic (mammary) artery (ITA) grafts became and are still the most commonly used bypass grafts, with the best long-term results.

Dr. Sam pioneered some of the first steps in cardioprotection during bypass surgery by introducing the use of nitroglycerin injection into the heart in 1973, according to the Dr. Marius’ “Forty Years of Open Heart Surgery in Fresno.”

“He brought the concept back from Texas where he had seen Denton Cooley crush nitroglycerine pills, which he placed into solution and then injected into the cardiac circulation of a patient whose heart would not start,” reads the document. “The Valley Children’s team was using injectable nitroglycerine before it was officially approved by the FDA and long before any of the drug companies was producing the solution. Its use facilitated and improved getting the patients off of the pump.”

Dr. Vathayanon was also instrumental in the change from using old disc oxygenators, which were cumbersome and inefficient, to the disposable Bentley oxygenator during open heart surgeries, according to Dr. Marius’ work.

Dr. Vathayanon also introduced priming the pump with Ringer’s solution (commonly seen in IV fluid bags) instead of blood. He was the first cardiac surgeon in this area to accept and to operate on Jehovah’s Witness patients without any blood product transfusions. So-called “bloodless” surgeries are still performed today for patients of Jehovah’s Witness faith.

Spring/Summer 2022

chamber to allow blood to adequately flow into his lungs.”

Called the Fontan palliation procedure, at the time it was so rarely used, a heart specialist team might perform it only once a year and even more rare on a pediatric patient.

It was the first time this procedure was performed in Fresno, Dr. Prochazka said.

Dr. Sam was described as a sweet and gentle man with a big heart. According to his obituary, it was not uncommon for former patients and their relatives to approach Dr. Sam to thank him for giving them more time with their loved ones.

Not only was he instrumental in heart surgery innovations and the progression of heart medicine, he was also a humanitarian. He served in Asian tsunami relief efforts in 2004 in his native country of Thailand. Dr. Sam stayed in Phuket for two and a half weeks, seeing up to 75 patients per day.

Dr. Vathayanon was a beloved member of the Fresno community for more than 50 years. He spent his off time relaxing at his Arabian horse ranch in Santa Ynez and enjoying scenic nature walks. He had a passion for photography, writing, classical music and the arts. “Dr. Sam” passed away peacefully in his sleep on Sept. 18, 2021.

CENTRAL VALLEY PHYSICIANS

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Study of Health Impacts of Drought, Wildfire Smoke and Excessive Heat Underway

The Fresno Madera Medical Society (FMMS) is pleased to announce the start of a grant-funded project called FUERTE (Fresno Understands Environmental Resilience Through Equity). This unique project is wholly funded by the Bay Area Council Foundation’s California Resilience Challenge Grant Program.

The information gathered through the FUERTE project will be invaluable in helping to understand and guide health priorities as our community deals with ever increasing health impacts from challenges such as drought, wildfires, flooding, and extreme heat. Results will help physicians and preparedness officials understand the impact of the climate crisis on underserved urban and rural communities in Fresno County.

FMMS will be the lead organization for this community-engaged vulnerability and adaptation assessment within the County of Fresno and will coordinate the involvement of multiple agencies and consulting organizations. These partners include clinicians from UCSF Fresno, researchers from UCLA, community advocates from Central California Environmental Justice Network, and policy experts from the Public Health Institute. Although the Fresno County Department of Public Health was originally going to

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spearhead the project, it will now participate in a limited advisory capacity.

“During the last few wildfire seasons, and throughout the COVID pandemic, there have been many gaps in our understanding of the ways our most vulnerable communities will need to prepare and adapt to the intensifying effects of a more unpredictable environment here in Central California,” stated project lead Rais Vohra, MD. “I was excited to participate in the FUERTE Project because this is a first step in helping fill in those gaps, through the use of stakeholder surveys and direct community interaction. The insights gathered from this work will help us develop better preparedness and mitigation plans for our local county residents, and the agencies who serve them. The goal is to ensure that people stay healthy wherever they live, work and enjoy time with their families in our beautiful county.”

“FMMS is honored to be part of this essential work and thanks the FUERTE Team for their leadership and foresight in developing this unique and vital project,” stated John Moua, MD President of the Fresno Madera Medical Society and a pediatric pulmonary specialist.

“This project will gather essential information to guide the complicated work of mitigating health impacts during a rapidly changing era, and ensure equity is prioritized as we build a network for education, advocacy, preparedness and surveillance related to the environmental adversities our patients now face.”

Funding for the FUERTE Project is being provided by the Bay Area Council Foundation’s California Resilience Challenge Grant Program. The program provides help to communities across California struggling to improve resilience to the effects of historic droughts, intense wildfires, heatwaves, sea level rise, and destructive flooding.

A total of 176,000 is allocated to complete the FUERTE project, which will be completed over 2 years.

Spring/Summer 2022

11:30 AM - 1:30 PM HR Hot Topics Your Questions Answered Wednesday, September 21, 2022 12:00 PM - 1:30 PM Sponsored by

Spring 2022

CENTRAL VALLEY PHYSICIANS

23

Compassion Fatigue and the Helping Professional: Aimee Moore, MS, APCC Associate Professional Clinical Counselor, APCC# 6691 Under supervision of Michael Roubicek, PhD, LCSW

ABOUT THE AUTHOR As a registered Associate Professional Clinical counselor, Aimee enjoys working with couples, individuals and young adults experiencing anxiety, depression or difficulties within their relationships. She operates from an attachment-perspective to build a safe, non-judgemental environment to support clients in an exploration of self and how they connect with others.

Aimee strives to provide a space that allows her clients to feel fully supported through gentle guidance and reflection; she is passionate and committed to helping her clients become the best version of themselves by tailoring her therapeutic approach to best fit their unique needs and goals. Aimee is an LGBTQIA+ affirming therapist and is mindful of how our individual, societal and diverse experiences impact our connection with ourselves and with others.

Aimee was born and raised in Colorado. She graduated from Grand Canyon University, Phoenix, AZ with a Master’s in professional clinical counseling. Aimee has spent the past two years serving those with extensive trauma and disrupted attachments.

Prior to becoming a Professional Clinical Counselor, Aimee spent two years as a high school educator. She has completed Gottman Institute Level 1 training and plans to become a certified Gottman Therapist in the future.

Awareness, Resilience, and Prevention

The recent events of the past two years have undoubtedly been an incredible test of our resilience. For those of us in the helping professions, we are afforded the task of supporting our patients and clients in the uncertainty of current times, while also trying to navigate this journey ourselves.

At one point in time, most would argue that compassion fatigue was most commonly seen amongst healthcare professionals; their daily workplace environment exposing them to extreme stress or trauma. However, with the 24hour news cycle right at our fingertips, the exposure, and saturation of tragedy is at an all time high, leaving everyone at risk.

Merrium Webster defines compassion fatigue as “the physical and mental exhaustion and emotional withdrawal experienced by those who care for sick or traumatized people over an extended period of time.” Often mistaken for burnout, which is associated with too much work and/or too many responsibilities with no adequate outlets, compassion fatigue is a secondary traumatic stress or indirect exposure to trauma by helping others.

As much as we pride ourselves in our dedication and ability to extend our empathetic, caring hearts, to our patients and clients, we must recognize our own vulnerabilities and limitations. Honoring the self by caring for our own emotional well-being is critical to ensuring longevity in our professional and personal lives.

Simply put, the helping professional should adhere to the same instructions given by flight attendants: “Secure your own oxygen mask, before helping others”.

According to the American Institute of Stress be aware of the following signs and symptoms of compassion fatigue: • • • • • • • • • •

Nervous system arousal (Sleep disturbance) Emotional intensity increases Cognitive ability decreases Behavior and judgment impaired Isolation and loss of morale Depression and PTSD (potentiate) Loss of self-worth and emotional modulation Identity, worldview, and spirituality impacted Beliefs and psychological needs-safety, trust, esteem, intimacy, and control Loss of hope and meaning=existential despair Anger toward perpetrators or causal events

© Can Stock Photo / 4774344sean

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In the helping profession, it is a universal truth that we are able to do our best work in caring for others, by first caring for ourselves. We do our clients and patients a disservice when we do not: (1) recognize our own needs and (2) ask for support. Often, healthcare professionals’ psychological distress goes unnoticed, untreated or is minimized due to stigma associated with a professional asking for help. The helping professional must prioritize self-care, and do our best to attend to our physical and mental health.

Try to stay mindful and incorporate these safeguards into your day and weekly routine: Maintain consistent sleep, physical fitness and healthy eating patterns Stay rested and well-fueled by maintaining a healthy diet filled with fruits and vegetables followed by a restful sleep (7-8 hours). Do this by meal planning, eating healthy snacks throughout the day, staying hydrated and setting a consistent bedtime. Incorporate a component of exercise or physical fitness into your daily routine. This could be as simple as taking your dogs for a walk every evening, dancing in the kitchen while you cook or going to the gym or completing a home workout routine.

Avoid an increase in alcohol or drug consumption Although it may be tempting to alleviate stress through alcohol or drug use, it is only a short-term fix which can also be a slippery-slope to dependency.

Utilize your social support networks When we are feeling overwhelmed or stressed, it is easy for us to isolate and disengage. Be sure to keep contact with your family and friends through regular phone calls, zoom meetings or weekend get-togethers. Utilize your colleagues and supervisors to decompress regarding mutually understood work stressors.

Remember, you are part of a team; you do not have to do things alone.

While practicing and incorporating these safeguards into your routine may be helpful in reducing compassion fatigue, in some cases, you may need additional support by working with a mental health professional. Connecting with a licensed mental health therapist will allow you the space to process current stressors, as well as provide an opportunity to identify coping skills to support your functioning in both your professional and personal life.

Many psychiatrists, psychologists, and counselors are now offering services by phone or through HIPAA-compliant telehealth platforms; some offering weekend and evening hours to accommodate busy work schedules.

In today’s world, the helping professional is as essential as ever before, leaving us more at risk for burnout and compassion fatigue. Caring for yourself is critical when caring for others.

Spring/Summer 2022

Need on the spot, immediate, assistance throughout your day to manage stress?

Here are some quick tips to help you decompress and get you back to what you do best, helping others: Breathing Exercises: When we are in the midst of stressful moments, we tend to tense up, causing our breath to become shallow and constrained. Work on deep breathing, focusing on your breath entering into and out of your abdomen instead of your chest.

Progressive Muscle Relaxation Like our breath, in stressful situations, our muscles become tense which can contribute to headaches, backaches and overall fatigue. Progressive muscle relaxation is a systematic way to relieve tension from various areas in your body. Some of my favorite examples to illustrate this comes from my work with kids: 1. Hands and Arms: Pretend you have a lemon in your right hand, and begin to squeeze the lemon, as if you are attempting to squeeze all of the juice out. Take deep breaths, count to ten. Release. Repeat with your other hand 2. Jaw: Pretend you have a giant bubble gum jawbreaker in your mouth. It’s very hard to chew. Bite down as hard as you can, letting your neck muscles help you.

Now relax, letting your jaw hang loose, dropping the top of your tongue from the roof of your mouth.

Breathe deep. Repeat.

Resources https://www.merriam-webster.com/dictionary/ compassion%20fatigue https://www.apa.org/topics/covid-19/compassion-fatigue https://www.stress.org/military/for-practitionersleaders/ compassion-fatigue https://store.samhsa.gov/sites/default/files/SAMHSA_Digital_ Download/PEP20-01-01-016_508.pdf

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by: Christy Oberholtzer, RN, MPH

EMBRACING AN OPPORTUNITY FOR THE CENTRAL VALLEY

The Central Valley does not often have the opportunity to lead the way in healthcare, research, or policy so when the occasion arises we embrace it. This is the story of that process and an invitation to join.

The Patient-Centered Outcomes Research Institute (PCORI) funds comparative clinical effectiveness research that will “improve the quality and relevance of evidence available to help patients, caregivers, clinicians, employers, insurers, and policy makers make betterinformed health decisions.”

In 2019, PCORI awarded funding to the University of California San Francisco (UCSF) to work with California State University Fresno’s Central Valley Health Policy Institute (CVHPI) to implement the ongoing EMBRACE Prenatal Care Study. EMBRACE (Engaging Mothers & Babies; Reimagining Antenatal Care for Everyone) is comparing 1,300 women that receive individual prenatal care with 1,300 women that receive group prenatal care.

Study participants who meet the financial qualifications (Medi-Cal eligibility) and gestational age requirements (prior to 24 weeks) are assigned to a prenatal care

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comparator based on their provider’s randomization schedule and their due date. Participants will also complete three questionnaires throughout their study enrollment and share birth-related medical records.

Participants receive stipends for their time completing the questionnaires.

Among study participants assigned to individual versus group prenatal care we will compare: • preterm birth rates (Aim 1) • changes in depressive and anxiety symptom severity (Aim 2) • perception of respectful care and satisfaction with prenatal care (Aim 3) • Aim 3 also includes an in-depth qualitative component to explore experiences of care among Black and Latina women.

When reviewing the EMBRACE proposal, one PCORI reviewer wrote, “This is the type of quality research initiative for which PCORI was created.” We agree and believe that with the participation of enough prenatal

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care providers in Fresno County and throughout the Central Valley and continued engagement with community members and stakeholders, we will find answers on the effectiveness of enhanced prenatal care on pregnancy experiences and outcomes. Our findings will be disseminated widely, contributing to policy recommendations, and complementing the increased focus and efforts around improving maternal child health outcomes in California and across the nation.

EMBRACE presents an opportunity for Central Valley clinicians that deliver prenatal care to participate in landscape changing research as providers and, if desired, as co-investigators. For more information on coinvestigator opportunities, we encourage you to contact Principal Investigator Miriam Kuppermann, PhD, MPH at miriam.kuppermann@ucsf.edu.

What is required to participate in EMBRACE as a provider?

• Delivery of prenatal care to a Medi-Cal eligible population • Willingness to offer group prenatal care While individual prenatal care and Comprehensive Perinatal Services Program (CPSP) are routinely offered, we know that group prenatal care is a paradigm shift for the delivery of prenatal care. For this reason, First 5 Fresno County facilitates the Glow! Group Prenatal Care comparator. First 5 Fresno County and their partner agencies offer a staff facilitator who facilitates group sessions with the participating provider. The staff facilitator handles the coordination of group sessions and all non-clinical components, working with the office staff as needed. This design was intentional and a result of the insights of many local prenatal care providers and their experiences during the development and implementation of Glow! prior to EMBRACE. Fabiola Gonzalez, Executive Director of First 5 Fresno County, shares why they are committed to enabling providers to offer group prenatal care. “We know a healthy pregnancy requires a village - of people, places, and policies all supporting the pregnant parent-to-be as baby grows strong and has a successful full-term birth.

Glow! is a key component of that village; providing group

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prenatal care and wrap-around services innovatively and comprehensively allows more time for patients to engage with their medical provider in a safe and respectful setting, while building community and learning how to better advocate for their healthcare. For this reason, we at First 5 Fresno County remain committed to being part of the village needed to ensure a healthy pregnancy and thus committed to investing in innovative programs like Glow!”.

We are eager to ensure that participating in EMBRACE as a provider is a smooth process. All study recruitment efforts are managed by the study staff and most group prenatal care components are managed by First 5 Fresno Country. Attending a one-time group prenatal care training and willingness to embrace a different model of care are the primary requirements for offering Glow! and participating in the EMBRACE study. For each participant enrolled in the EMBRACE study regardless of assigned comparator, practices receive a stipend to help offset the administrative costs of study participation.

The American College of Obstetricians and Gynecologists Committee Opinion 731 describes, “Group prenatal care models are designed to improve patient education and include opportunities for social support while maintaining the risk screening and physical assessment of individual prenatal care. There is no evidence that suggests that group prenatal care causes harm.

Individual and group care models warrant additional study with a goal of demonstrating differences in outcomes and identifying populations that benefit most from specific care models.”

The Central Valley has an opportunity to embrace the momentum surrounding the push to improve pregnancy and birth outcomes and provide strong scientific evidence on who may benefit from enhanced prenatal care and how to make implementation feasible. Take this opportunity to learn more about how participating in EMBRACE may be possible for your prenatal care practice or patients.

For more information, contact EMBRACE Project Manager Kristin Carraway at kristinc@csufresno.edu or 559-289-8342, or visit embraceprenatalcarestudy. org.

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California Telehealth Resource Center: Serving Patients and Providers with Unbiased Resources for Telehealth Success

Since 2006, the California Telehealth Resource Center (CTRC) has served as a leading source of expertise providing comprehensive knowledge in the development and establishment of telehealth programs. Funded by the U.S. Department of Health and Human Services (HHS) Health Resources and Services Administration (HRSA), CTRC is nationally recognized as one of 14 federally designated Telehealth Resource Centers around the country created to support health care organizations by providing resources, training and technical support to unlock the full potential of telemedicine for both patients and providers.

By focusing our service primarily on the state of California, we have an in depth understanding of the unique needs of this region and its populations. With over 50 years of collective industry experience, our CTRC team has extensive knowledge of supporting the health care for the medically underserved communities, rural and urban providers, and patients and families throughout California who would otherwise be unable to access quality health care due to geographic isolation, language/cultural barriers, disability, lack of insurance, lack of a permanent address, and other challenges. Our work to support telehealth expansion and access is fueled by our organizational values, our connection to our California communities, and our steadfast dedication to ensuring that everyone has a fair opportunity to achieve their full health potential.

CTRC offers a wide range of consultation services and technical assistance to help care teams address clinical

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challenges with ease and efficiency, while ensuring security and peace of mind for the patients they serve via a safe virtual connection. Since CTRC is federally funded, much of what we offer is available at no cost.

We provide: • Expert consultative services, before and during telehealth program development, to ensure program optimization • Resources for organizing and managing telehealth programs – including a comprehensive library of practice guides, policy reports, sample forms, and workflows • On-demand training videos and courses for all provider program team members, including coordinators, administrators, and clinical presenters • A list of continuing education and accredited certification courses offering telehealth schooling • Time-saving resources for patients and families to maximize their telehealth experience • An ever-expanding list of California-based telehealth specialty providers • Access to telehealth-related events, workshops, webinars, and conferences (such as our annual CTRC Telehealth Summit) CTRC understands the larger health care delivery system and works closely with community organizations, corporate and industry leaders, and policymakers to develop an environment that will support the continued

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expansion and optimization of telemedicine and telehealth.

We facilitate conversation, encourage learning, engage with communities, share powerful stories, and partner with like-minded organizations to explore meaningful new approaches. We give California providers access to evidence-based practices and leading-edge solutions—so they can grow and innovate with confidence as the industry evolves.

One of our most popular opportunities for telehealth education and industry networking is the annual CTRC Telehealth Summit. Since its inception in 2012, this highlyanticipated and widely-endorsed event has evolved into the premier telehealth industry conference in California, offering attendees a chance to: • •

Obtain the latest industry insights and best practices from leading experts Connect with peers in similar roles with varied years of telehealth experience

RENTABLE SPACE FOR LEASE

Spruce Medical Complex 1275 E. Spruce Ave., Suite 101 Fresno, CA 93720

•

Engage in peer-to-peer learning through facilitated group discussions Learn proven telehealth program strategies and optimal delivery methods See how other health centers have developed successful and sustainable virtual care programs Explore new solutions and technology advancements with event sponsors

• • •

We invite all health care professionals, telemedicine personnel, administrators, physicians, clinic managers, billing managers, health care IT specialists, and other health care leaders to join us virtually for the 10th Annual California Telehealth Summit, August 9-10, 2022. Visit the event page on the CTRC website (https://www.caltrc.org/ telehealth-summit/2022-telehealth-summit/) for more information and registration.

Tracy Zweig Associates A

REGISTRY

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PLACEMENT

FIRM

Physicians

Nurse Practitioners Physician Assistants

Building totals 9,435.78 sf, single story With underground parking garage Building completed in 2005 Property Types: Medical Offices, Laboratory Available Space #1 = approx. 1,091 sf –Medical/General Office Space

–Medical–2 Offices/3 Treatment Rooms

Locum Tenens Permanent Placement

Please contact the Office Manager, Barbara Cordova,

Voi ce: 800-919-9141 or 80 5-6 41-914 1 FA X : 805-641-914 3

Available Space #2 = approx. 550 sf

for more information: barbara@npimmg.com

Spring/Summer 2022

j nguy e n@tra c y z we i g. c om www. tracyzwei g.com

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Celebrating Doctors Day!

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CENTRAL VALLEY PHYSICIANS

Spring 2022

Spring 2022

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LET'S TAKE IT

OUTSIDE

Spring and summer in the Central Valley are great times to get outdoors. Here are a few local destinations recommended by members for a great day trip escape.

WALK WITH A DOC

Ranjit S. Rajpal, MD

Chhaya Makhija, MD

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CENTRAL VALLEY PHYSICIANS

Spring/Summer 2022

TABLE MOUNTAIN

Don H. Gaede, MD

CHINA PEAK

Gregory Simpson, MD

KERCKHOFF LAKE

Minji Cho MD

PINCUSHION PEAK

Rahil Khasgiwale, OMSII

SPRING SKIING

Marina Roytman, MD

STEVENSON FALLS

The CHSU Wellness and Wilderness Medicine Club Pictured from left to right: Tajinder Singh, OMSI, Emily Johnson, PhD, MPH, RDN, CDE, Sara Goldgraben, MD, MPH, MBA, Laura Gutierrez-Rivera, OMSII, Zachary Josse, OMSII, Helina Saleh, OMSII, and Deion Santander, OMSI

Spring/Summer 2022

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PUT YOUR MEMBERSHIP TO WORK! When you join the Fresno Madera Medical Society, you join the California Medical Association as well.

Together FMMS-CMA can help with the success of your practice.

Your annual dues can be more than offset when using membership services and discounts, and you get personal assistance with practice management and payment recovery issues to improve your bottom line. Join the FMMS to be a better leader for your staff and patients, and to amplify your voice to influence policy and legislation. The FMMS brings together an active community of physicians in order to improve the larger community. Our mission is physician-driven, and we want to help you solve your biggest practice management issue. Join the FMMS today!

BENEFIT Automobile & Homeowners Insurance CAP Cooperative of American Physicians

Car Rentals

Save up to 8% more.

CONTACT Mercury Insurance Group (866) 602-5259 www.mercuryinsurance.com/cma

Member discounts on malpractice protection, risk management and practice management.

Albert Malasig (650) 543-2185 www.CAPphysicians.com

Save up to 25% on car rentals for business or personal travel.

Avis (800) 786-4262 www.cmanet.org/groupdiscounts

Classified Ads

Free classified ads in Central Valley Physicians Magazine

Resiliency Consultations

3 Free, anonymous resiliency consultations yearly through Joy of Medicine Program

Roubicek and Thacker 559-323-8484

FMMS is an accredited provider for Continuing Medical Education providing free and low cost seminars for members.

FMMS: (559) 224-4224 www.fmms.org

Confidential support and assistance to physicians affected by substance abuse, or an emotional or physical problem.

CMA: (650) 756-7787 https://www.cmadocs.org/confidential-line

Discount on hourly consulting fee for practice assessments, valuation, brokerage, partnerships, etc.

Practice & Liability Consultants (415) 764-4800 www.practiceconsultants.net

Driving Emblem

CHP approved emblem provides physicians expemption from speeding laws when en route to an emergency

FMMS (559) 224-4224

Human Resource Services

20% discount plus free consulting calls with HR Business Partner package

Sierra HR Partners, Inc. (559) 431-8090 www.sierrahr.com

Discounts on medical, workers’ comp, dental, disability, long-term care, level term life & business overhead expense.

Mercer (800) 842-3761 www.mercer.com

Free tool kit on quality measures & online tool to create custom MIPS plan.

FMMS (559) 224-4224

CME Seminars

Confidential Hotline

Consultancy Services

Insurance MACRA Assistance 34

CENTRAL VALLEY PHYSICIANS

FMMS: (559) 224-4224

Spring 2022

BENEFIT

CONTACT

Up to 89% off the cover price of hundreds of magazines for your home, office, and waiting and patient rooms.

Consumer Subscription Services (800) 289-6247 www.cmanet.org/magazines

Medical IDs

Discounts on 24-hour emergency identification and family notification services.

MedicAlert Foundation (800) 253-7880 www.medicalert.org/cma

Medical Office Services

Discounts on medical billing. No upfront costs. 1st month free and 2nd month 1/2 price.

Rita Nye (559) 359-6170 www.medicalbillingmos.com

Messaging App

Free secure messaging app for physician-to-physician/care team communication.

DocBookMD www.cmanet.org/docbookmd

Notary Services

Need a document notarized? Members can receive free Notary Services at the FMMS office.

FMMS 255 W Fallbrook Ave Suite 104 (559) 224-4224

Save up to 80% on office supplies and more.

Staples Advantage (800) 786-4262 www.cmanet.org/staples

CMA’s 24-hour Physicians Confidential Assistance hotline. Free and will not result in any form of disciplinary action.

Completely Confidential Doctor - Doctor Assistance (650)756-7787

Help for practices of all sizes: legal handbooks, practice mgmt. guides, patient education materials, etc.

CMA Resource Library www.cmanet.org/resource-library

Magazine Subscriptions

Office Supplies

Physician Assistance

Practice Resources

Premier Valley Bank

Local bank offering comprehensive banking solutions that help make the job of managing finances easier

Premier Valley Bank www.premiervalleybank.com

Regency Investment Advisers

Financial advisors offering services in investment management, financial planning and retirement plans.

Chris Comstock (559) 438-2640 www.regencyinvests.com

Get paid: members receive one-on-one assistance. We have recouped $16 million from payors in the last 10 years.

FMMS: (559) 224-4224 CMA: (888) 401-5911

15% discount on tamper-resistant security prescription pads and printer paper.

RxSecurity (800) 667-9723 www.rxsecurity.com/cma-order

Discounts on website design packages, including mobile-friendly design.

Mayaco (209) 957-8629 www.mayaco.com/physicians

Reimbursement Assistance Security Prescription Pads Website

For information on becoming an FMMS Business Partner call 559-224-4224 Spring 2022

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Dr. Herbert E. Gladen died on March 7th, 2022, surrounded by loved ones following a cardiac event, holding the hand of his beloved. He is survived by his wife of over 50 years; Edna Rose (Kiheri) Gladen, and a large family of kin. Born in Kabekona, near Bemidji, MN on July 1, 1946. Married to Edna on Nov 25, 1967. Air Force until ‘71, He joined the Mayo Clinic’s first medical school class in ‘72. Board Certified in General Surgery in ‘82, then Critical Care in ‘86.He spent 18 years as the Assistant Clinical Professor of Surgery at the University of California at San Francisco in Fresno. American Samoa in 2009, then Colusa CA from 2010-2016. In 2019 they returned to Minnesota to live with Daughter & Grandson.

Potted Spring bulbs (like Daffodils) are welcome, stories and/or pictures to RememberHerbert@gmail.com Dr. Gladen was an FMMS/CMA member for 19 years.

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Spring/Summer Spring 2022

Beloved physician, Dr. A. Paul Mello, died peacefully at his home on January 12, 2022.Having practiced the art of medicine for over 50 years, perhaps it is apt that ultimately it was Dr. Mello’s heart that gave out because he gave it so willingly and generously to his family, his friends, his patients and his profession.Dr. Mello was born in Richmond, California on December 31, 1941 to Dr. John and Ida Mello. He grew up in Pittsburg, California.

Upon graduating from Pittsburgh High School, Dr. Mello attended Santa Clara University and Georgetown University School of Medicine, earning his medical degree in 1967.After graduating from Georgetown, Dr. Mello returned to the Bay Area to pursue an internship at Santa Clara County Hospital. It was there that he met and married the love of his life, Karen, who at the time was a medical technologist.From 1968 to 1970, Dr. Mello served in the U.S. Navy as a commissioned medical officer, stationed first in San Diego and later in the Philippines.

Following his military service, Dr. Mello completed his medical residency in Internal Medicine at Stanford Hospital and at Santa Clara County Hospital, where he was chief resident.Eager to establish roots and start a private medical practice, the Mellos relocated to Fresno, drawn by its solid community and to be near family. Dr. Mello joined the Fresno Medical Group. Later he and fellow colleagues formed Internal Medicine Associates, where he practiced medicine for several decades. Dr. Mello eventually joined Saint Agnes Medical Providers until his retirement in 2019.

Medicine was Dr. Mello’s true calling. He loved being a doctor and cared deeply for his patients and colleagues.

Many in his practice became lifelong friends. Saint Agnes Hospital was like a second home to Dr. Mello. He spent countless hours there — including nights, weekends and holidays — making his rounds and caring for those he lovingly called his “people.” Additionally, and with sincere and generous heart, his door was also always open to share knowledge and perspective, offer guidance and provide Spring 2022 Spring/Summer 2022

love and support to family and friends. So many would refer to him as “The Good Doctor.”Dr. Mello also made time to do the things he loved and to share them with his family. He, Karen and the children traveled extensively throughout the world — his favorite trips being those that involved piling into the family station wagon and driving all over the United States. Dr. Mello was an avid fisherman, hunter and, in his prime, a black diamond-level skier.

He loved the mountains, especially spending time at the family cabin in Pinecrest. Dr. Mello was a master sailor, having crewed on sailboats with friends and colleagues in various races and regattas around California. He inspired two generations of sailors, most recently teaching his grandchildren how to sail on his Hobie Cat.Dr. Mello had a fierce intellect, curiosity and an insatiable thirst for knowledge that was almost as strong as his compassion for people. On any given day, his reading list would include local and national newspapers, the most recent editions of top medical journals and his fiction book of choice. He enjoyed sports and appreciated the arts. His weekends would often include attending Fresno State football games and performances of the Fresno Philharmonic.The very social Dr. Mello loved being with family and friends.

Though he was rarely the first to arrive at a party, he was usually one of the last to leave. He was probably happiest when sharing a glass of red wine and a slice of cheese over good conversation.Above all, Dr. Mello was a loving and devoted husband, father and grandfather. He is survived by his dear wife of 54 years, Karen; his son Branden, his wife Kate and their children Elizabeth and Ansel Paul II; and his daughter Kirsten Years, her husband Stephen and their children Julian, Reagan and Charlotte. He is also survived by his sister, Lesley Harrison, and many beloved nieces and nephews, cousins, in-laws and friends. A service celebrating Dr. Mello’s life will be held February 17, 2022 at 10:30 a.m. at Holy Spirit Catholic Church in Fresno. In lieu of flowers, donations may be made to a favorite charity.

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FMMS Joy of Medicine www.FMMSJoy.org

Remember when medicine was fun?

RECONNECT TO YOUR

Joy of Medicine

RESILIENCY CONSULTATIONS The Fresno Madera Medical Society recognizes the overwhelming stresses and immense workloads that physicians face today.

Stress, anxiety, depression and grief are common, but they can be managed. Resiliency Consultations can provide relief, an increased ability to cope, healing and an opportunity for personal growth.

FMMS sponsors up to four (4) annual sessions with approved and vetted providers confidentially, conveniently and FREE to physicians living and practicing in Fresno and Madera Counties.

Participating in a Joy of Medicine Resiliency Consultation is completely confidential. Neither FMMS, your employer, nor the California Board of Medicine will be notified if you choose to participate.

Participating providers offer a wide range of appointment times that strive to accommodate the unique and busy schedules of physicians.

FMMS sponsors up to four Consultations per year. Providers are paid by FMMS directly, discreetly and anonymously. Insurance will not be asked for or billed.

Physicians have the option of extending their participation at their own expense after the fourth visit.

Make medicine fun again. Call today to schedule a free Resiliency Consultation and begin the process of reconnecting to your Joy of Medicine.

SCHEDULE

AN APPOINTMENT

ROUBICEK and THACKER 559-323-8484

Call and identify yourself as a physician practicing in Fresno or Madera County

Closer to home + enhanced referrals = easier access to world-class care Kelly Haas, M.D., Health Sciences Clinical Professor Specialties: Pediatric Gastroenterology, Pediatric Hepatology, Pediatric Nutrition

UC Davis Health offers nationally ranked expertise — now with added convenience for our referring providers From the most delicate robotic and catheter procedures to the latest precision therapeutics, we’re proud to offer up-to-the-minute diagnostic and treatment options for both adult and pediatric referring providers across Northern California and the Central Valley.

Your referred patients benefit from shorter drives, less traffic gridlock, affordable lodging, and more support from local family and friends. We also offer robust telehealth and telemedicine options, for both initial consultations and follow up care.

Referring your patients to UC Davis Health specialty and subspecialty care is now easier than ever. Our physician referral liaison team is here to serve as direct lines of communication — helping to navigate and expedite referrals.

Our liaisons can also help to: ■

■

■

■

■

Facilitate access to our secure EMR system, PhysicianConnect Arrange meetings and/or webinars with our clinicians Assist with UC Davis Health clinical trials and telemedicine Keep you abreast of new services, providers and research programs Share information about CME and events such as tumor boards, grand rounds, symposiums, etc.

Reach out to your local Physician Referral Liaison today: Joaquin Muñoz | 916-701-7161 | joamunoz@ucdavis.edu

referrals.ucdavis.edu Spring 2022

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Fresno Madera Medical Society 255 W. Fallbrook, Suite 104 Fresno, CA 93711

NON PROFIT ORG U.S. POSTAGE

PAID Permit No. 30 Fresno, CA

The podcast by pediatricians for pediatricians Join Valley Children’s pediatricians and pediatric subspecialists for new episodes every month covering common to complex topics in pediatric healthcare. Our physician hosts discuss a wide range of issues, from physician wellness to complex genetics, advocacy to antibiotics and beyond.

Subscribe for free wherever you enjoy podcasts or visit www.valleychildrens.org/podcast

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@ValleyChildrensMedEd

@ValleyMedEd

Spring 2022

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