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Jeﬀrey Dugas, MD
The battle against brain cancer is a personal one for Christopher Jahraus MD, a radiation oncologist with Shelby Baptist Medical Center. When Jahraus was a fourthyear resident in his specialty, his father was diagnosed with glioblastoma, a highly malignant tumor ... 5
Social Media: A Public Health Threat?
Instagram, Facebook, Snapchat, Twitter, YouTube – social media has become a pervasive part of the way Americans share information ... 13
UAB Engages Blue Light Imaging in Bladder Cancer By Jane ehrharDt
New Treatment Lengthens Survival in Glioblastoma Patients
Research, AMA Policies Raise Red Flag on #Overuse
DECEMBER 2017 / $5
special photodynamic diagnostics (PDD) system, the doctor inserts a long, thin tube into the bladder “If this was a prostate cancer that emits both normal white light tool, 90 percent of surgeons would and a blue light. Under the blue be using it,” says Jeffrey Nix, MD, light, the dosed malignant cells assistant professor in the UAB Defluoresce. partment of Urology, about blue “You see that fluorescence light cystoscopy in bladder cancer like a neon light from a restausurgeries. rant sign,” Nix says. It can reveal The optical imaging agent smaller satellite tumors associated known as Cysview, or hexamiwith the more obvious larger tunolevulinate hydrochloride, has mors along with tumors that are been approved by the FDA for the atypical in appearance. “And you detection of non-muscle invasive see the edge of distinction between cancer of the bladder since 2010. normal and malignant tissue with UAB began using it in 2014 and incredible precision.” still remains the only facility offerJeffrey Nix, MD Clearly identifying the ing it in Alabama. boundary makes PDD even more The process is simple. About valuable to novice urologists. “It’s easy for nurses to learn and an hour before the cystoscopy, the imaging agent is delivered into the bladder and gets absorbed by the cancerous tissue. Using the (CONTINUED ON PAGE 8)
A World without Antibiotics By laura Freeman
Few people alive today remember a time when there were no antibiotics. Before penicillin arrived on the front lines of World War II, many lives and limbs were lost not on the battlefield, but in the days after when even small wounds could become lethal infections. As the public began to think of antibiotics as cure-alls that would always be there to protect us, we began to use or misuse them in ways that taught germs to be smarter and more dangerous. Today, the CDC lists antibiotic resistance near the top of the ten most serious concerns facing public health. “There will always be emerging infections, but the big challenge today is microbes that become resistant to antibiotics. We are running out of drugs to fight them,” Peter Pappas, MD, chair of UAB’s Antimicrobial Stewardship Program, said. “There are a few new antibiotics, but most of them are combinations of other drugs. We’re not seeing much that would be a game changer in the pipeline. “New antibiotics are expensive to develop, and since they are typically used only a short time, it is hard to risk the investment of time and money. We need other incentives to encourage new antibiotic
(CONTINUED ON PAGE 12)
Peter Pappas, MD
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Dugas Brings Sense of Urgency to Orthopedic Recovery By Cara D. Clark
At first glance, a ballet dancer and a wrestling superstar seem the ultimate juxtaposition. Closer scrutiny reveals the similitude of performance arts and athleticism. And a deeper dive shows even more commonality through relationships with Jeffrey Dugas, MD, an orthopedic surgeon with Andrews Sports Medicine and physician to the Alabama Ballet and the WWE. Dugas, who specializes in elbow, knee and shoulder surgery, treats injuries across the spectrum from globally renowned wrestling stars to local cheerleaders, high school standouts and average Joes. An avid baseball fan, Dugas took that passion with him in fellowship training with Dr. James Andrews. Working with a surgeon whose patients include Troy Aikman, Charles Barkley, Roger Clemens, Bo Jackson, Michael Jordan and Jack Nicklaus was undoubtedly a good gig. It got even better a when Andrews asked Dugas and cohort Lyle Cain, MD to join him in partnership, creating a synergy between the surgeons that has lasted more than two decades. Dugas says their recruitment of like-minded orthopedic specialists who share their work ethic has been a key to excellence. Dugas, a graduate of Duke Medical School, did his residency at the Hospital for Special Surgery in New York and says that training with the best in the world set him on the track for what he is doing. And what he’s doing is revolutionary. Five years ago, he established an alternative elbow surgery, UCL Repair with Internal Brace Construction. The groundbreaking procedure is returning athletes to play far sooner than the Tommy John method. After observing varying degrees of damage in thousands of ligaments during cadaver research, Dugas was confident he could conserve recovery time, but he needed a perfect storm to prove it. “I needed a high school senior with an injury who didn’t have 12 months to get better,” Dugas said. “They would either be done playing or would have to have a procedure.” In 2013, 17-year-old Mark Johnson walked into Dugas’ exam room. Dugas performed the procedure and Johnson was back on to the baseball diamond to pitch his entire senior year. His total down-time was just five months, less than half the time of the previous gold standard of repair. “Now we’ve done over 200 and the results are as good or better than Tommy
Above: Professional wrestler, John Cena (left), with Jeffrey Dugas, MD. Left: Dugas examines a Vestavia player.
John,” Dugas said. “Over the last four years, some of the larger elbow centers in the country have adopted this method. The sports medicine community looks to us to be leaders and advance the profession. That’s our responsibility, and we take that very seriously.” Dugas focuses on quick recovery time for patients from all walks of life. Whether a grandmother or a linebacker, no one has time to be sidelined by an injury. “Not all of our patients wear numbers on their backs, but we treat everybody with a sense of urgency,” Dugas said. “We aren’t often dealing with life or death problems –more quality of life issues. We take on the patient’s desire to get back to the quality of life they knew.” For Bobbie Nelson, sister of country music icon Willie Nelson, that urgency arose on a Sunday when Dugas got a call to an unconventional exam room — a tour bus. Dugas took his son, Chris, along for the unexpected medical consult 12 years ago. “When we got there, Willie was doing paperwork and watching TV,” said Dugas, describing Nelson as one of the warmest, most collegial people he’s met. “While I was talking to Bobbie about her knee, Willie grabbed Chris and asked if he would like to watch cartoons.” The surreal scene continued to unfold with the arrival of Bob Dylan, and Dugas witnessed the remarkable vignette of his five-year-old sitting between legendary musicians, watching Tom and Jerry. Dugas takes his brushes with largerthan-life figures in stride. His presence is mandatory each year at WrestleMania, the smack-down Super Bowl of the sport. He treats wrestling celebs such as John Cena, Bray Wyatt, Finn Balor, Seth Rollins, the Undertaker and the female contin-
gent of the arena, the Divas. He also serves as team doctor for USA Cheer, Vestavia Hills High School, Troy State University and the Birmingham Barons Ushering his patients through recovery gives Dugas ample opportunity to get
to know them. “Sports medicine is not just about surgery,” Dugas said. “Unlike most other branches of medicine, we have a lot of coaching involved. We guide them through the process for months after we operate. It becomes more of a personal relationship.”
DAVID – for
David Sorrells, Practice Manager for Urology Centers of Alabama, is retiring after 31 years of service. Thank you for your dedication, hard work and guidance! We wish you many more years of fun, happiness and relaxation. We’ll miss you. Happy Retirement!
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DECEMBER 2017 • 3
Low-Dose CT Scans Help Decrease Lung Cancer Mortality By Ann B. DeBellis
According to the American Cancer Society, one out of every four cancer deaths is attributed to lung cancer, making the disease the leading cause of cancer death among men and women. Princeton Baptist Medical Center has joined other hospitals in the Brookwood Baptist Health System in the fight against the disease by offering low-dose lung CT scanning. 85 percent of lung cancers in the United States are directly related to smoking, and the risk continues even after the person stops smoking. In 2013, the US Preventative Task Force (USPTF) recommended low-dose CT scans for the early detection of lung cancer. Patients in numerous studies who received low-dose CT scans showed a 20 percent decrease in lung cancer mortality and, based on collected study data, the USPTF suggested that low-dose CT screening should begin at age 55 and continue until age 80. The lung cancer screening program is activated at all five Brookwood Baptist Health hospitals, including Brookwood, Citizens, Princeton, Shelby, and Walker Baptist medical centers. The Princeton Baptist screening program started in September. “Our goal is to screen patients who are at the highest risk for the future development of lung cancer in such a way
Patient undergoes non-invasive, low-dose CT scan to detect lung cancer.
that we catch the cancer early but don’t deliver a large dose of radiation,” says Allen Groves, MD, Radiologist and Chief of the Low Dose Lung CT Program at Princeton Baptist Medical Center. CT scans of the chest provide more
detailed pictures than chest x-rays and are better at finding small abnormal areas in the lungs. Low-dose CT of the chest uses lower amounts of radiation than a standard chest CT and does not require the use of intravenous contrast.
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Each screening includes a consultation, personalized risk assessment and a physical evaluation along with the a painless, non-invasive, low-dose CT scan. Results and recommendations are available within 72 hours of screening, and patients have ongoing communication with referring physicians. Medicare and many insurance plans cover lung cancer screening for patients who meet the criteria. Patient eligibility criteria is: • Age 55-80, • Current smoker • Former smoker within the last 15 years • 30 pack per year history or more • Smoking cessation counseling has been performed “The person being scanned must be able to lay flat with his arms above the head for a short time and must not have metal rods or bullet fragments in the midback. The person also must be free of any signs of active lung infections or lung cancer and must be willing to go forward with additional tests and procedures if necessary,” Groves says. “These are strict guidelines, but our nurse navigator does a good job screening orders and speaking with patients by phone to make sure all criteria are met.” According to the American Cancer Society, about one in four screening tests will show something abnormal in the lungs or nearby areas that might be cancer. Most of these abnormal findings will not be cancer, but more CT scans or other tests will be needed to be sure. “In the case of an abnormal finding, both the patient and physician will receive a letter about additional testing or a possible referral to a pulmonologist or thoracic surgeon depending on what they find. The nurse navigator will call them also,” Groves says. “We will make sure the patient undergoes the next step, whether it is a diagnostic exam, a biopsy or another kind of procedure. Our steering committee meets quarterly and we discuss patients who have positive results and have been referred for a next exam in a different health care system. We still want to make sure they are getting the best next step in their care.” Groves appreciates the help of all who have worked to establish the screening programs in the various hospitals. “Our nurse navigator has worked hard to get the program up and running and to make sure the rest of us are doing our jobs correctly,” Groves says. “I am grateful for the help of our steering committee which consists of an oncologist and a thoracic surgeon. Everyone has been supportive and has pitched in to help establish these programs.”
New Treatment Lengthens Survival in Glioblastoma Patients By Cara D. Clark
The battle against brain cancer is a personal one for Christopher Jahraus MD, a radiation oncologist with Shelby Baptist Medical Center. When Jahraus was a fourth-year resident in his specialty, his father was diagnosed with glioblastoma, a highly malignant tumor. “I had said this is the one disease I hope no one in my family ever gets,” Jahraus said. “I knew how much suffering these tumors cause and that this is a really devastating disease with a miserable survival.” Despite surgery and cutting-edge treatment at Massachusetts General Hospital, Jahraus’ father died within a year from the aggressive tumor’s growth. Now there is a treatment that might have given him more time. Just a year ago, Jahraus attended a Cleveland Clinic conference and learned about Tumor Treating Fields (TTF), a ground breaking new method to prevent malignant brain tumor cells from reproducing. “I’d never heard of it, and neither had many others in our field,” Jahraus said. “It’s a remarkable thing. It’s not a replacement for any current therapy, but an adjunct to chemotherapy and radiotherapy.” Even patients who battle glioblastoma with surgery, chemotherapy and radiation have a median survival rate of only about 15 months. The American Association for Cancer Research’s 2017 data demonstrates more than a doubling of survival in patients with glioblastoma treated with TTF at four and five years, when compared to standard therapy. “Patients survive an average of five months more using this,” Jahraus said. “When you have this short time left, five months is a big deal. How great is it to be able to give patients a realistic shot at a longer survival and not to have to travel some place to do it?” Treatment is delivered via electrodes on the patient’s scalp through which a low-energy current creates a field to prevent brain tumor cells from reproducing. The current, imperceptible to the patient, alters the ability of sub-cellular structures or microtubules to assemble, which is necessary for cancer cells to divide and grow. “Organisms have to organize in a certain way in order to grow, and the charge field aligns them to prevent that,” Jahraus explains. “It doesn’t affect normal cells. They are not dividing to the degree as cancer cells. The patient feels nothing, but it’s enough to arrest the growth of these glioblastoma cells.” When Jahraus prescribes the treatment, Novocure sends a professional to the patient’s home to train them on using the system. Shelby Medical treated its first
Jahraus with his first Optune patient on the treatment planning system.
patient in August using Novocure’s Optune. “Patients do the best if they wear the active system for 18 hours a day. “It seems a like a lot, but they carry on about their normal business,” Jahraus said. “What’s remarkable about this is that when I was in training 14 years ago, the typical sur-
vival was 12 months with radio therapy and other treatment.” Shortly after he finished school, Jahraus remembers reading the New England Journal of Medicine’s account of a discovery that could potentially add three months to a patient’s life using the chemotherapy drug Temozolomide (TMZ). TTF, says
Jahraus, is the first real stride forward in that arena since that time, and Shelby is at the forefront of technology. “Cancer patients are near and dear to my heart,” Jahraus said. “To see this treatment available to my patients shows our commitment to deliver the best we can to our patients. I wish to goodness something like this had been around for my dad. Brain tumor patients’ lives are already so affected and they endure so much. The potential to keep them going is exciting stuff. That’s the art of oncology — giving a patient a treatment that interferes with life minimally but offers them a meaningful chance of survival.” The treatment is approved only for glioblastoma, but Jahraus said he hopes the potential for the low-energy electricity in other applications is on the horizon. “You wonder in your heart of hearts if this could turn into cures one day, but you hesitate to put it in those words,” Jahraus said. “You don’t want to put out false hope, but we are getting incredible outcomes. As data matures into the future, who knows? “This treatment shows 30 percent improvement in the length of survival. That’s meaningful. It blows the socks off Temozolomide that was heralded as the most significant advance in the past 20 years. When we look on this someday, we may see that it was the next big step.”
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“It’s potentially revolutionary,” says Luciano Costa, MD, PhD, about chimeric antigen receptor (CAR) T-cell therapy — a newly approved gene therapy for blood cancers. “This is almost like science fiction comes to reality.” The positives of CAR T-cell therapy include not only a solid success rate with a one-time treatment, but a potential cure without irradiation and many other transplant-related toxicities Luciano Costa, MD, PhD by harnessing the patient’s own T cells, the killer cells d of the immune system. Filtered from a pint of the patient’s blood, T cells are isolated and transfected with a specific protein (a chimeric antigen receptor or CAR) that targets an antigen found on most leukemia cells, such as the CD19 protein. “Then it’s purified and grown in culture, while the patient undergoes chemotherapy to be able to receive those cells,” says Costa, who serves as an associate professor of medicine at UAB Division of Hematology and Oncology. The entire engineering process takes two to three weeks. “Then the cells are infused into the patient,” Costa says. Not only do the engineered T cells then latch on to the leukemia cell and destroy it, but they are triggered to expand and proliferate, allowing them to seek out and annihilate the remaining cancer cells. In August, Novartis’s tisagenlecleucel (Kymriah) became the first approved CAR T-cell therapy in the U.S. The FDA approval covers only pediatric use of the gene therapy in ages up to 25 for those with relapsed or refractory B-cell acute lymphoblastic leukemia (ALL). An estimated 3,100 patients under the age of 21 are diagnosed with ALL each year, accounting for around 34 percent of all childhood cancers, according to the National Cancer Institute. The newly approved CAR T-cell therapy showed unprecedented results in those with dire diagnoses, with 83 percent of patients achieving complete remission within three months. For adults with large B-cell lymphoma — around 24,000 adults in the U.S. each year – Gilead Pharmaceuticals’ axicabtagene ciloleucel (Yescarta) garnered the FDA nod in October. It became the second gene therapy approved in the country and the first for certain types of
non-Hodgkin lymphoma. This adult CAR T-cell therapy treatment will be available to those who did not respond to or who relapsed after at least two other kinds of treatment. In trial, 51 percent of those who received Yescarta achieved complete remission and 39 percent of those were still in remission after almost nine months. Administering the gene therapy is as straightforward as a blood transfusion. “What can get complicated is management of those patients for the days and weeks to come as those cells do what they’re meant to do and attack cancer cells,” Costa says. During the first week, the patient can face cytokine release syndrome (CRS). In the pivotal trial of tisagenlecleucel, almost half of the patients struck by CRS intensified into a cytokine storm. In trials of Yescarta, around 13 percent progressed into these severe symptoms. “It’s a very acerbated inflammatory reaction,” Costa says. The patient becomes very sick with a high fever, a drop in blood pressure, and it becomes life-threatening in about half of the patients. Treatment calls for administering anti-IL6 agents. “These drugs existed to treat another autoimmune disease that had nothing to do with cancer, but they have had a potent effect in controlling this syndrome,” Costa says. To specifically treat CRS, the FDA expanded approval this year of the rheumatoid arthritis drug Actemra (tocilizumab). After only one or two doses of the drug, nearly 70 percent of patients completely resolved their CRS in two weeks. The FDA now requires hospitals administering the T-cell therapies to have this immunosuppressant drug on-hand. The other concerning side effect to CAR T-cell therapy is neurologic toxicity, which developed in 44 percent of the Kymriah patients and 87 percent of those utilizing Yescarta. “This is more of a syndrome without a clear mechanism,” Costa says. Patients can be confused, lose their ability to speak, become comatose, or even die. However, most recover when treated with high doses of steroids. “This is not the first time that cells are used to treat cancer,” says Costa, who also heads the bone marrow transplant and cell therapy program at UAB. “Bone marrow transplant essentially uses cells to treat cancer too.” Costa warns that not enough longterm data on CAR T-cell therapy exists yet, whereas bone marrow transplant has (CONTINUED ON PAGE 8)
Reducing Risk by Rethinking Weight The Link between Obesity and Cancer By CINDY SANDERS
Diabetes, heart disease, high blood pressure, osteoarthritis, sleep apnea – the list of health concerns linked to obesity is long and well known. The connection between cancer and weight, however, still takes many by surprise … including some healthcare providers. Nigel Brockton, PhD, director of Research for the American Institute for Cancer Research (AICR), recently returned from the annual Obesity Week Conference, a joint meeting of The Obesity Society and the American Society for Metabolic and Bariatric Surgery. Attending numerous scientific Nigel Brockton, PhD sessions, Brockton said the defining moment for him was when cancer researcher Stephen Hursting, PhD, MPH, simply and compellingly stated: “We need to stop asking, ‘Is obesity a risk factor for cancer?’ Yes. It is. Now we need to focus on how to reduce the impact of obesity on cancer risk and outcomes.” Brockton added the research community has spent the last few decades looking
at the link between weight and cancer. “We now know 11 cancer sites where obesity is strongly associated with risk,” he said. Research has provided sound evidence that overweight and obesity directly influence risk for esophageal, liver, kidney, stomach, colorectal, advanced prostate, post-menopausal breast, gallbladder, pancreatic, ovarian, and endometrial cancers. Additionally, an October 2017 report by the Centers for Disease Control and Prevention (Vital Signs: Trends in Incidence of Cancers Associated with Overweight and Obesity – United States, 2005-2014) found increasing rates of most cancers associated with overweight and obesity, with the exception of colorectal cancer. From 2005-2014, incidence rates of cancers not known to be related to weight declined by 13 percent, but cancers linked to overweight and obesity rose by 7 percent during that timeframe when excluding colorectal cancer (which saw a significant decrease of 23 percent, possibly tied to increased screening). Although not new knowledge, Brockton said it’s important to remember fat tissue is metabolically active and affects the whole body. “It’s not this sort of inert, storage substance,” he pointed out. “Excess adipose tissue … fat tissue … is a major source of hormones and growth factors in the body.”
More Research Needed While research has clearly uncovered ties to cancer, not all results have been as expected. The Continuous Update Project (CUP), a joint effort of AICR and the World Cancer Research Fund (WCRF), has found being overweight between the ages of 18-30 actually has a slight protective factor when it comes to pre- and post-menopausal breast cancer. “But from a public health point of view, it’s a very tricky message to navigate,” noted Brockton, adding the research also shows that women who continue to be overweight past 30 increase their risk for the cancer type. Alice Bender, MS, RDN, director for Nutrition Programs at AICR, pointed out significantly improved treatments for breast cancer mean women have to consider other health concerns that come along with weight gain that far outweigh any Alice Bender, MS, RDN slight protective gain. “Many survivors don’t die from recurrence of breast cancer but from heart disease,” she said of the reality for many
women. “And we know that losing weight will help with those health outcomes.” Other areas that need to be explored when it comes to weight and cancer research include residual effects of losing weight on prevention, active treatment and survival. Similarly, Brockton said differences between the impact of being overweight vs. obese need to be more thoroughly vetted and stratified by cancer site. “In overweight and obesity, we don’t know if being formerly obese has the same effect as being formerly a smoker,” he pointed out. “We need more research done, and the CUP reports have helped identify which aspects we need to address more carefully.” Bender noted results are beginning to be published from researchers who have put the AICR/WCRF’s 10 recommendations for cancer prevention (see box) to the test with promising results. Since the release of the evidence-based steps, researchers have analyzed the impact on populations in ongoing studies of diet, activity and disease risk. Consistently, the findings have shown adherence to the AICR recommendations cuts cancer risk, improves the health of cancer survivors
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(CONTINUED ON PAGE 8)
DECEMBER 2017 • 7
Reducing Risk, continued from page 7 and protects against other chronic diseases. And new evidence is coming online all the time. “In our latest CUP report on colorectal cancer, whole grains stood out with particularly strong evidence of decreasing risk,” she said.
Empowering Patients & Providers Despite the established evidence that compels providers to enhance patient education on the relationship between weight and cancer, there remains a disconnect across the country. “We know that surveys find half of Americans are not aware of the link between obesity and cancer risks,” said Bender. Providers, she continued, could help bridge the gap. “It’s a really tough conversation to have, but we help equip doctors and healthcare providers to know how to start those conversations,” she said, noting AICR has brochures, infographics, and other helpful tools to get the ball rolling. Brockton added, “It’s important for healthcare providers to know that second to smoking, obesity is the most important lifestyle issue for preventing cancer.” He continued, “I think it’s important to position it in a way that empowers the patient to make those changes.” Bender said AICR also has tools to do just that. The aicr.org website includes a quiz to assess current diet, information on establishing a cancer-protective diet, nutrition facts, healthy recipes and easy-tofollow information on the positive impact of phytochemicals in food and the negative effects of too much processed meat, sugar and alcohol. Twice a year, Bender continued, the organization hosts ‘The New American Plate Challenge,” a 12-week online program that encourages participants to fill two-thirds of the plate with plant-based foods and only one-third or less with food from animals. In addition, there are a
UAB Engages Blue Light, continued from page 1
series of weekly challenges to encourage healthier eating and increased physical activity. The next round starts February 2018. By participating in the fun, interactive cancer prevention challenge, Bender concluded, “You are well on your way to a diet that can lower your risk for cancer and other chronic diseases.”
easy to implement. You basically just push a button,” Nix says. He shows the family the images from the blue light illumination because this can often make the tumor easily visible and understandable to them. The process does not get used in every surgery. “However, in the majority of cases of non-muscle invasive bladder cancer, we use this enhanced technique. It is imperative to treatment that all of the tumors are removed,” Nix says. Missed tumors during surgery is one of the proposed theories for the high rate — 50 to 80 percent— of bladder recurrence, making it the highest recurrence rate of any form of cancer. That rate drops by 15 to 20 percent when the blue light is employed and time to recurrence also lengthens significantly. “The expense of bladder cancer is because the recurrence is so high and you have to follow up with patients forever,” Nix says. “But if you spend a little extra money to do blue light to decrease that recurrence rate, then you save a lot more money by doing fewer future procedures.” Nix uses the PDD in about 90 percent of his patients. “I haven’t heard a single patient complain about the extra charge,” he says. CMS and private insurers have not covered Cysview as a separate fee initially, but only as part of an outpatient bundled payment which does not fully cover its cost. “We know it’s beneficial, but insurers are almost always slow to move the needle. The hospitals had to eat part of that cost initially.” Things may change in 2018. Photocure, the makers of Cysview, met with Medicare officials this year. Though CMS purportedly said they will not pay separately for Cysview, the administration proposed new add-on billing codes that ultimately could pay more for procedures that use the fluorescing agent. Despite the benefits of the blue light cystoscopy, few urologists utilize it. “I
Ten Recommendations for Cancer Prevention • Be as lean as possible without becoming underweight. • Be physically active for at least 30 minutes a day and limit sedentary habits. • Avoid sugary drinks and limit consumption of energy-dense foods. • Eat a variety of vegetables, fruits, whole grains and legumes. • Limit consumption of red meats and avoid processed meats. • If consumed at all, limit alcoholic drinks to two for men and one for women a day. • Limit consumption of salty foods and foods processed with sodium. • Don’t use supplements to protect against cancer. • For new moms, it’s best to breastfeed exclusively for up to six months and then add other liquids and foods. • For cancer survivors, follow the recommendations for cancer prevention after concluding treatment. • And a bonus rule for all – don’t smoke or chew tobacco. Source: American Institute for Cancer Research: aicr.org
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don’t think it’s because of a misunderstanding about it,” Nix says. “It is simple to use and valuable for the patients.” The problem appears to be awareness. Bladder cancer ranks as the fourth most common cancer in men, who are about three to four times more likely to contract it during their lifetime than women, according to the American Cancer Society. Around 79,030 new cases and about 16,870 deaths from bladder cancer are estimated for this year. But the average age at the time of diagnosis is 73. “75 and 80-year-olds, in my experience, tend to question their doctors a little less, unlike younger patients who are more apt to research their conditions and treatment options” Nix says. “Very few of my patients say they came to me for the blue light tech. They don’t know it’s something they want. “If this was breast cancer, every surgeon would use it. We need to raise awareness of blue light cystoscopy among primary care physicians and patients in order for to increase utilization. If patients start to push for it, they will get it.”
First Approved Gene Therapy Fights, continued from page 6
been used for decades and has proven to be effective in about half of patients. “Be careful not to discard treatment that has safety and efficacy proven over time in favor of something that is quite promising, but potentially more toxic and for which we do not know the longevity of therapy,” he says. A downside of the promising CAR-T cell therapy is the prohibitive cost. Gilead Sciences has set the one-time treatment price for Yescarta at $375,000. Novartis set the price for Kymriah at $475,000, but will not charge for patients who do not achieve remission within three months. However, the alternative treatment of a bone marrow transplant using the patient’s cells hits a similar range at around $350,000. For a child, however, that drops to $75,000 ranging up to $200,000. “CAR T-cell therapy could potentially become a safer, more attractive option than bone marrow, but we’re not there yet,” Costa says, though he admires the mechanics of gene therapy. “It’s a concept that has been dreamed of for decades — to essentially use your own immune system to reprogram itself and fight the cancer without affecting normal organs.”
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2017 Healthcare Year in Review by
Howard E. Bogard
If the 2017 healthcare environment could be summed up in one word, it would be “uncertainty.” With the largely unexpected election of Donald Trump as President, the multiple, unsuccessful attempts by the Republican controlled Congress to repeal and replace the Affordable Care Act (“ACA”), and the recent Executive Orders by President Trump that could destabilize the health insurance markets, payers, providers and patients are trying to plan for an uncertain future. In addition, Alabama healthcare providers of all sorts and sizes face increased cyber security threats, a new Medicare Administrative Contractor beginning the first quarter of 2018, and changes to Medicare payment and performance initiatives. In these uncertain times, I present to you my top ten healthcare developments of 2017 for Alabama healthcare providers. 10. Physician Practice Settles with the Government for Failure to Return Credit Balances. On October 13, 2017, it was announced that First Coast Cardiovascular Institute, P.A. (“First Coast”), a Florida physician practice, had agreed to pay $448,821 to resolve allegations that it violated the False Claims Act by knowingly delaying repayment of more than $175,000 in credit balances owed to Medicare, Medicaid,
TRICARE, and the Department of Veterans Affairs. The settlement stemmed from a qui tam lawsuit brought by a former employee of First Coast. While the total dollar amount of the settlement is relatively small compared to other False Claims Act cases, the application of a 2.5x multiplier of single damages is on the high end. It is widely expected that the government will increase its investigation and prosecution of providers who fail to return credit balances or other overpayments owed to federal payers. Pursuant to the ACA, a provider or supplier who has received an overpayment from a federal payer must return the overpayment within the latter of: (1) 60 days after the date on which the overpayment was “identified,” or (2) the due date of a corresponding cost report, if applicable (the socalled “60-Day Rule”). An overpayment is “identified” once a provider or supplier has or should have, through “reasonable diligence,” quantified the overpayment. This investigation period cannot exceed six months from receipt of credible information of the overpayment, absent extraordinary circumstances. 9. Alabama Pill Mills. As a byproduct of the Opioid Crisis (see paragraph 2 below), the government has stepped up its investigation and prosecution of physician practices that prescribe narcotics for illegitimate purposes, so
called “pill-mills”. In March of this year, two pain management physicians in Mobile, Alabama were convicted of running a pill-mill following a seven-week trial. The physicians received lengthy prison sentences and forfeited virtually all of their personal assets, including several houses, beach condos, and 23 luxury cars. In addition, each physician was ordered to pay a $5 million judgment to the government, as well as $15 million in restitution. A few months after the conviction, U.S. Attorney General Sessions announced a nationwide takedown of 120 doctors, nurses, and pharmacists, entitled “Operation Pilluted,” who were charged with various federal offenses related to their alleged “unlawful distribution of opioids and other prescription narcotics.” Recently, a special prosecutor has been assigned to the Northern District of Alabama in Birmingham for the sole purpose of investigating providers that illegally prescribe narcotics. 8. Changes to Medicare Bundled Payment Initiatives. On August 15, 2017, the Centers for Medicare & Medicaid Services (“CMS”) announced a proposed rule to reduce the number of mandatory geographic areas participating in the Center for Medicare and Medicaid Innovation’s Comprehensive Care for Joint Replacement model from 67 to 34. CMS also proposed to cancel the Epi-
sode Payment Models (“EPM”) and the Cardiac Rehabilitation (“CR”) incentive payment models, which were scheduled to begin on January 1, 2018. The EPMs and the CRs were designed as mandatory payment models to test the effects of bundling payment for complex cardiac and orthopedic care that the federal government believes could benefit from improvement in care coordination and other care redesign efforts. Moving forward, CMS expects to increase opportunities for providers to participate in voluntary initiatives rather than large mandatory episode payment models. 7. MACRA Changes. On November 2, 2017, CMS published a Final Rule outlining changes for the 2018 performance year of the Quality Payment Program under the Medicare Access and CHIP Reauthorization Act (“MACRA”). Under MACRA, eligible Medicare providers can take part in the Merit-based Incentive Payment System or the Advanced Alternative Payment model tracks. The Final Rule makes multiple changes to MACRA, including exempting physician practices with less than $90,000 in Medicare revenue or fewer than 200 unique Medicare patients per year. The Final Rule can be found at https://www.federalregister.gov/ documents/2017/11/16/2017-24067/ (CONTINUED ON PAGE 10)
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2017 Healthcare Year in Review, continued from page 9
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medicare-programs-cy-2018-updates-tothe-quality-payment-program-and-quality-payment-program-extreme. 6. Cyber Security Threats. From January through August of this year, the healthcare sector reported 75 breach incidents involving cyber -attacks, with 1,684,904 patient records impacted. The breach reports came from just about every imaginable type of healthcare provider, from small physician and dental offices, and DME companies to large health systems, academic medical centers, as well as a State Medicaid agency. According to National Public Radio, the average breach costs health care providers $355 per stolen record. Cyber security threats to healthcare providers, including ransomware attacks, are expected to increase in the coming year. 5. Alabama has a New MAC. On September 7, 2017, CMS awarded Palmetto GBA (“Palmetto”) a new contract for the administration of Medicare Part A and Part B Fee-for-Service claims in the States of Alabama, Georgia, and Tennessee. Palmetto will replace Cahaba Government Benefit Administrators, which held the contract since September of 2014. Palmetto will provide Medicare services to more than 400 hospitals, 52,000 physicians, and 2.5 million Medicare beneficiaries, equating to more than $17 billion in Medicare benefit payments annually. The new contract includes a base year and four option years, for a maximum duration of five years. According to Palmetto, Part A providers will transition effective January 29, 2018, and Part B providers on February 26, 2018. To support the performance of the newlyawarded MAC contract, Palmetto will open an office in Birmingham, Alabama. 4. Alabama Medicaid Ends RCOs. Legislation passed in 2013 and 2014 called for Alabama to be divided into regions and for community and providerled regional care organizations (“RCOs”) to coordinate the health care of Medicaid patients in each region, with each RCO ultimately bearing the risks of contracting with the State of Alabama to provide that care. The State won a waiver from federal regulators and up to $700 million in grants to help implement the program, which was set to launch in October of this year. However, just a few months before the launch date State officials abandoned the RCOs finding the program too expensive. While State lawmakers earmarked more than $105 million from the BP oil settlement to Medicaid, with some of that money going to the RCOs, the funding would have only lasted until 2018, creating future funding uncertainties for the RCO program. 3. President Trump Moves to Disrupt the ACA. With Congress having failed to repeal and replace the ACA, on October 12 President Trump issued an Executive Order directing the Departments of Health and Human Services, Labor and the Treasury to develop rules aimed at allowing small businesses and individuals to purchase less expensive
plans with fewer benefits. As a result, younger and healthier individuals could move away from the health insurance exchanges resulting in increased premiums for the sicker individuals that remain in the exchanges. The White House also indicated that it would halt federal payment of cost-sharing reductions to insurers, which help insurers offset the cost of providing coverage to lower income individuals who purchase insurance through the exchanges. The payments total about $7 billion this year. Without the payments it is widely expected that insurance premiums will quickly rise, with many insurers pulling out of the insurance exchanges in 2018. Within days of the announcement, the Attorneys General for 18 States as well as Washington D.C. filed a lawsuit against the Trump administration in an effort to block its decision to cut subsidy payments. 2. Opioid Crisis. It has been reported that in 2016 more Americans died of drug overdoses than killed in the Vietnam War. In total, more than 170 people are estimated to die from overdoses every day in the United States, and most of the deaths are linked to opioids. According to the Center for Public Integrity, in 2015 Alabama had the highest per capita number of opioid prescriptions of any state in the country, with a rate of 1.2 prescriptions for every resident. In August of this year, Governor Ivey signed an Executive Order establishing the Alabama Opioid Overdose and Addiction Council to advise the Governor on a comprehensive strategy to combat Alabama’s opioid crisis. The Council is required to report its findings by the end of this year. In October, President Trump declared the opioid epidemic a national public health emergency, but did not request any additional funding to combat the problem. Without additional funding at both the State and Federal levels, it is hard to imagine how any real progress will be made to address this growing and deadly crisis. 1. Republicans Fail to Repeal and Replace the ACA. Despite controlling both chambers of Congress and the White House, the Republicans failed to deliver on a seven year promise to repeal and replace the ACA. The process began in March of this year and ended in September when the Graham-Cassidy bill died as three Senate Republicans announced they opposed the effort. After the latest attempt failed, the Republican leadership has, for now, abandoned any overhaul of the ACA and has shifted focus to the nation’s tax system. May all of you have a happy, healthy and successful 2018! Howard E. Bogard is Chair of the Health Care Practice Group at Burr & Forman LLP and exclusively represents health care providers in regulatory and corporate matters.
Responding To Disaster By Laura Freeman
â€œAfter 9/11 and the anthrax letters made it clear that we needed to gear up our caThree devastating hurpabilities to respond to public ricanes and the threat of a health emergencies, congress cholera outbreak from convoted funding of grants to help taminated water; wildfires all 50 states and the US terrinear Gatlinburg and Califortories improve their preparania wine country; outbreaks tions to respond to terrorism,â€? of Zika and Ebolaâ€”it all reMcCormick said. â€œHurricane minds us that bad things can Katrina taught us that we also happen anywhere. needed more robust capabiliWhen we see the human ties to respond to other types misery from recent megaof disasters, so there was a quakes in Mexico, we have push to expand preparation to consider that fault lines caprograms to all hazards, with pable of an eight-point quake a network of organizations are as near as Memphis and working together. Each speSouth Carolina. The continucialty is set up to take the lead, ing barrage of mass shootings Public health students taking water samples in the Coosa river as part of a clean depending on whether the diand vehicle attacks by ter- water project. saster was related to weather, rorists make us ask how such infectious diseases, fire, earthquake, things could happenâ€”and could they Lisa C. McCormick DrPH, MPH, Direcchemical contamination, or another happen here? Are we ready to respond? tor of the Deep South hazard.â€? With all the bad news out there, the Biosafety and Infecâ€œSome threats, especially infectious good news is that public health and emertious Disease Response diseases, need preparation that goes begency response teams arenâ€™t just waiting Worker Training yond regional and national boundaries for the next disaster to happen. They are Program, and Rubin with more international cooperation to working to prepare for whatever may Pillay, PhD, medical help rapidly identify, contain and treat come. futurist and Professor outbreaks,â€? Pillay said. â€œWith air travel, Two people at the center of efforts to of Healthcare Innoinfections can go from one remote vilimprove preparation and response to revation and EntrepreRubin Pillay, PhD lage to the most populous cities around gional and global health emergencies are neurship at UAB.
the globe in a matter of days.â€? Now that high speed genetic sequencing allows faster identification of diseases and the DNA fingerprint of particular strains, western countries with advanced technology resources are in a better position to respond to outbreaks and develop new treatment approaches when needed. â€œUnfortunately, so many of the emerging diseases like Ebola, resistant strains of Malaria, and other contagious diseases show up first in poor countries that donâ€™t have the resources to identify and treat the disease in time to stop it,â€? Pillay said. â€œNot only for their sake, but to protect people everywhere, we need a stronger cooperative international effort.â€? McCormick is Director of the Office of Public Health Practice for the UAB School of Public Health. She teaches disaster and emergency management and preparedness policy, and has coauthored three text books on the topic. She is also Lead Evaluator for the Region IV Public Health Training Center in assessing response capacity and community resiliency of interorganizational networks. â€œWe have to be able to reach across organizational and geographic boundaries (CONTINUED ON PAGE 12)
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DECEMBER 2017 â€˘ 11
A World without Antibiotics, continued from page 1 development. Meanwhile, our best hope is protecting the effectiveness of the antibiotics we have. “In antimicrobial stewardship, we face two different challenges. In an inpatient hospital setting, patients tend to be sicker and may encounter almost any type of microbe. In outpatient settings, patients often come to a physician’s office expecting a prescription for an antibiotic even for viral infections an antibiotic can’t help. If a prescription has to be written before the infection can be identified and the patient doesn’t come back to the office for months, changing treatment can be complicated. Even when an antibiotic is appropriate, it is difficult to verify that the patient is being compliant.” UAB’s Antimicrobial Stewardship Program has been in operation for more than a dozen years and has expanded to include UAB West and a hospital in Anniston. Hospitals in Alexander City and Sylacauga are gearing up to join the program. “The emphasis is on teaching our residents and patients how to use antimicrobials judiciously. In urgent situations where we have to begin treatment before we can identify the infection, that also means being
ready to adjust the treatment plan if we find the germ isn’t sensitive to the drug or if we need a different combination of medications,” Pappas said. MRSA is a classic case of what can happen when antibiotics are used inappropriately. “We started out with gowns and gloves when we detected MRSA,” Pappas said. “It was originally a hospital acquired infection, but it is now so widespread that patients can pick it up anywhere. We’re trying to keep other microbes from doing the same, but we are already seeing resistant strains of malaria, tuberculosis, salmonella and typhoid. Antivirals are under less pressure because they are used less often, but multiresistant herpes and CMV are a threat. “One of our biggest concerns now is a hospital acquired fungal infection, Candida auras, which has been found in India and Pakistan with a few cases in the US. It causes fever, sepsis and death. If it gets out on a global basis, it could be devastating.” UAB’s Antimicrobial Stewardship Program has been quite successful, and Pappas hopes that the residents trained in the judicious use of these drugs will take what they have learned with them as they
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go into practice. “We hope to develop an outpatient program soon to help local medical practices,” Pappas said. “Physicians are under tremendous pressure to prescribe antibiotics for viral infections. Some patients feel shortchanged when they don’t get an antibiotic, even when it won’t help. They don’t understand what antibiotics are for and what can happen if they are misused. “Patients need to know that an unnecessary antibiotic isn’t just an unnecessary expense. It can affect their microbiome and leave them open to other infections.
Responding To Disaster, continued from page 11 to respond to many different types of events that can be different in nature, magnitude and the capabilities required to deal with them,” McCormick said. “Most states and county health departments have emergency plans in place. In Alabama, the state health department takes lead on managing emergencies in most counties. Jefferson and Mobile Counties also have emergency management at the county level.” Resources ready to respond can vary by the size of the city, and by the most likely risks. Along the coast, the impact of a hurricane is a direct threat. Further inland, tornado outbreaks can affect the entire state. Birmingham’s large population, multiple interstates and rail lines converging, tall buildings, wide range of manufacturing and warehousing, prominence as a regional healthcare referral center, and geography of heavily forested mountains and flood-prone valleys along with frequent extremes in climate create its own unique threat profile. “The CDC lists 15 capabilities states should develop in order to be ready for a crisis event,” McCormick said. “This includes emergency services like fire and hazardous materials response, mass fatality management, and access to medical services during disruption. Ice storms
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They need to understand why they should take antibiotics as prescribed when they do need them. If they stop when they are feeling better but before the infection is gone, they are teaching the germ to become smarter. Next time, if their antibiotic no longer works, they may have to step up to a more powerful drug. Some of these stronger antibiotics can be extremely expensive and have their own side effects. “We need more awareness of antibiotic resistance. We don’t need antibiotics for every illness, but when we do, we need antibiotics that work.”
would be an example where people who need oxygen, dialysis and essential medications may need help. Facilities management and coordination between hospitals is necessary to see that those who need care are taken to the nearest facility with beds and staff available. “We have many health professionals in Birmingham who respond to health emergencies in other areas and other countries. When volunteers return home, the health department monitors their status to make sure that any symptoms they develop are managed and don’t open up the possibility of transmitting a dangerous infection to the community.” Pillay also pointed out that public health professionals are playing a role behind the scenes to protect everyday necessities we take for granted. “Food and water security are big issues around the world,” he said. “The safety of our food and water supply are concerns for everyone. Our public health teams are working to prevent food borne illnesses and remove the threat before it spreads. “Vaccinations have brought down the death toll in third world countries and are increasing life expectancy. Unfortunately, misinformation is reducing vaccination rates here at home and allowing outbreaks of preventable diseases. We need to get the facts out so parents can make informed decisions.” Pillay also warned against slow motion outbreaks of diseases like cancer, neurological disorders, metabolic disorders, heart and lung diseases that may be partially linked to preventable causes like air and environmental quality, nutrition, and the lack of preventive care. Some progress has been made in preparing to respond to terrorist attacks since 2001, but terrorism threats continue to evolve. Home grown mass shooters have emerged with increasing frequency and higher death tolls, and we as a nation still haven’t come to consensus on how prevent rather than just respond. But with many of the dangers we face, we have the assurance of knowing that public health responders are making it their business to save lives and protect health around the world. Perhaps the best strategy for living in an uncertain world is to prepare for the worst, expect the best, and savor in full measure the joy in every day.
Social Media: A Public Health Threat? Research, AMA Policies Raise Red Flag on #Overuse By CINDY SANDERS
Instagram, Facebook, Snapchat, Twitter, YouTube – social media has become a pervasive part of the way Americans share information. While there are many admirable outcomes – from being able to keep up with friends and family across the country or around the globe to rapidly deploying breaking news – research increasingly links use to less desirable outcomes including significant increases in depression, anxiety, and accidents. At the recent Interim Meeting of the American Medical Association, the national physician organization adopted two new policies directly addressing the growing concerns attached with social media overuse. The new policies join an earlier call to action to dissuade distracted driving, walking, or machinery use while operating hand-held devices. The earlier policy came out of the AMA’s 2015 Annual Meeting. “The AMA has recognized that both distracted driving and distracted walking are preventable hazards,” said AMA Board Secretary Jesse M. Ehrenfeld, MD, MPH. “We had previous policy to support educational efforts around those issues.” The two new policies coincide with increasing evidence regarding the behavioral health impact of spending too much Jesse M. Ehrenfeld, MD, MPH time in front of screens or on social media channels. “One of the concerns we have is there is new data that demonstrates as screen time goes up in children, there’s an increase in health problems, depression and anxiety,” said Ehrenfeld, adding the link between social media and these issues are what drove adoption of the new policies. In addition to behavioral health concerns, too much screen time is associated with upticks in sleep issues and childhood obesity, which can lead to a host of other health problems. Ehrenfeld and colleagues recognize digital devices play an important role in society but have called on physicians, public health officials, and policymakers to become more active in finding a balance between screen time and other activities. “Mobile phones and tablets undoubtedly have educational and recreational benefits,” said Ehrenfeld, “but it is critical, particularly for young people, that screen time be balanced with physical activity and sleep.” The new policy, he continued, encourages more content in the health education
curricula of primary and secondary schools addressing the current imbalance. “But also importantly, we think primary care physicians ought to assess their patients and talk to parents about the need to balance screen time and physical activity,” he continued. “To improve the health and wellbeing of young people, all of us must do more to address the harmful effects of screen time.” The other new policy adopted in midNovember focuses on the negative health impact of social media usage. The AMA pointed to recent statistics showing 68 percent of adults and 71 percent of teenagers use Facebook with many users checking social media every day … often multiple times a day. Citing several recent studies that have found a notable link between increased use of social media and increased levels of anxiety and depression, the new policy urges schools to provide safe and effective educational programs to help students identify and mitigate the onset of mental health impacts from social media. “According to research conducted by Pew, across the country, nearly a quarter of teens are online ‘almost constantly,’ and 92 percent go online every day,” said Ehrenfeld. “Social media has the power to bring people closer together and to build communities, but research also is showing a link between increased social media use and an uptick in anxiety and depression. In addition to increasing awareness of these dangers among parents and teens, we must do more in our schools to identify and address them as early as possible.” He added the AMA is looking to develop tools and protocols around digital media. “The AMA wants to make sure that we’re partnering with the right organizations to make sure we understand the impacts of social media usage,” Ehrenfeld noted of taking a collaborative approach to tackling the issue in both youth and adults. Colleagues in the American Academy of Pediatrics, for example, have created social media guidance for pediatricians and have developed a toolkit and a number of policy statements to address media usage in children and adolescents. “If, as a physician, we can identify someone who may be at risk, then we can intervene,” Ehrenfeld pointed out. He added the new policy calls for creating screening tools to help identify warning flags for negative physical and behavioral health impacts. When it comes to the ubiquitous use of digital media, he concluded, “We know these tools are important for lots of reasons including educational purposes, but the key is to balance their usage and to make sure the usage is safe and not detrimental to the person who has the device.”
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For Providers, 2017 Draws to a Close with Regulatory Burdens and Promises of IRS Enforcement By Colin Luke
Last year drew to a close with promises for the swift repeal and replacement of the Affordable Care Act after the inauguration of Donald Trump. Whether the result of partisan rancor, intraparty discord, or both, however, “repeal and replace” stalled in 2017. Proposed reform measures like the American Health Care Act, the GrahamCassidy bill and the Alexander-Murray all fell short of passage because they either went too far or they didn’t go far enough. This means that healthcare providers look to 2018 with most of the same concerns they had when 2017 began. And many of these concerns focus on the substantial regulatory burdens that take valuable time away from patient care. The American Hospital Association (AHA) recently published a report titled “Regulatory Overload” that provides some insightful data to support what hospitals, physicians and other providers already know: there’s a struggle to regulatory compliance demands with “the clinical, operational and financial activities necessary to fulfill their clinical missions.” The report pegs the cost of regulatory compliance industry wide at nearly $39 bil-
lion a year. This figure equates to an average annual cost of $1,200 per admitted patient or $47,000 per hospital bed. Collectively, healthcare providers must comply with more than 600 discrete regulatory requirements with the greatest number found in the areas of Conditions of Participation, Privacy and Security Rules, and Quality Reporting. To address this monumental compliance challenge, the report notes that an average size hospital dedicates 59 employees to regulatory compliance. Advocating policy changes on behalf of the nearly 5,000 hospitals, health care systems, networks, other providers represented by the AHA, the document puts forth a number of bold recommendations that could influence healthcare legislative conversations in both the short and long terms. Notable among these are the AHA calls to: Cancel Stage 3 of meaningful use of electronic medical records. The AHA report claims “burdensome and unnecessary” meaningful use regulations provide “no clear benefit to patient care” and will only become “more onerous when Stage 3 begins in 2018.” Suspend all regulatory requirements that mandate submission of electronic clini-
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cal quality measures. The report cites acknowledgment from CMS that “electronic test submissions by hospitals and physicians do not accurately measure the quality of care provided” and charges that CMS regulations “will double the electronic clinical quality measure reporting requirements for hospitals for 2017.” Prohibit enforcement of burdensome requirements mandating “direct supervision of outpatient therapeutic services that “could harm access to care in rural and underserved communities” Create new exceptions and safe harbors for clinical integration arrangements under the Stark law and the Anti-Kickback Statute respectively that create. While providers look for the loosening of regulatory tethers, there are other taxing issues to look forward to in the new year. In October the Internal Revenue Service announced that it would – for the first time – reject electronically filed tax returns if information is not provided indicating the individual’s healthcare coverage. This news was followed in November by an announcement that the IRS has begun enforcing – again, for the first time – the employer mandate under which companies with at least 50 full-time employees must
offer affordable health insurance to their employees or else face significant tax penalties. As we were going to press, updated tax reform legislation was released by Senate Republicans that includes a provision to repeal the individual mandate established by the Affordable Care Act. It remains unclear, however, if there are enough votes to pass the revised tax bill or if we’ll be seeing new versions with new provisions as the calendar turns to 2018. The IRS, in the meantime, has publicly stated that it is “obligated to enforce” elements of the Affordable Care Act with respect to the individual mandate and employer shared responsibility provision. What happens next is an open question, but change is almost certainly on the horizon for healthcare providers in 2018. For now, though, all we can do is keep a watchful eye on healthcare regulatory developments in Washington, D.C. and across the country. Colin Luke is a partner with Waller Law where he serves as Practice Group Leader for Healthcare Compliance and Operations.
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The Literary Examiner BY TERRI SCHLICHENMEYER
Supernormal: The Untold Story of Resilience by Meg Jay, PhD; c.2017; $28.00; 400 pages A lot goes into building a great kid. “Resilience,” says Jay, quoting the It takes several yards of solid foundaAmerican Psychological Association, “is tion; a straight frame with ground-floor adapting well in the face of adversity, rules. You put up walls where appropriate, trauma, tragedy or significant ongolocks where needed, you ing stressors.” In her work create doors to the world as a clinical psychologist, and windows of opportushe says that many resilient nity. Do it right, as in the people don’t think they posnew book Supernormal: The sess those traits when, in fact, Untold Story of Adversity and they learned long ago how Resilience by Meg Jay, PhD, to cope with issues they’ve and you’ll have a kid with endured. They’ve been able fortress-strength. to “make something out of Into every life, a little nothing” in their resilience rain must fall – in other and yet, they have appeared words, nothing can be all to pass almost unnoticed. good. Terrible events hap“Beating the odds,” Jay pen to perfectly wonderful says, “they live improbable Meg Jay, PhD people but when they haplives, and after decades of pen to children, it’s especially heinous. academic study no one knows quite how.” And yet - don’t children tend to bounce Jay holds up, for example, adults who back easier? were once children of nasty divorce. She Not always, says Jay. Those that do, tells a story of a survivor of parental alcothe kids-cum-adults who appear to be able holism and survivors of kidnapping, who to handle anything, are what she calls “sukept their traumas secret as adults. She pernormal” people, but their ability to explains the empowerment of formerly seem serene and unflappable may come bullied grown-ups, and the selective inat a price. attention and hypervigilance of abused
A biopsy reveals that you have skin cancer. You are not alone. 1.2 million people in the United States are diagnosed with skin cancer each year with the same concerns as you.
children. Jay looks at adults who, as children, were orphaned, neglected, isolated, and depressed. They coped – but when they couldn’t, Jay says, “strong, resilient people do go to therapy.” It took me awhile to understand exactly what Supernormal was offering here. Its pseudonymous clinical examples were interesting and readable, but what was author Meg Jay trying to say? In the end, it was all about perseverance. Before you get to that, though, it may seem that the stories in Supernormal are awfully bleak. Many have outcomes that aren’t happy. Yes, Jay says, some people will battle their demons forever. Fortunately, this sorrow is finely balanced by irresistible, lively historical and scientific background, and other information to support the tales themselves and their (sometimes positive) outcomes.
In chapters when those good-vs.-bad battles are more of the latter, readers still get a feeling of inspiration from the strength that Jay’s subjects displayed. We’re also left believing that the hurt children within these resilient adults have finally gotten the comfort and care they deserved, even years later. For anyone who has endured childhood trauma, who feels they’re living a disingenuous life, or who loves that person, this book offers advice and compassion. It’s recommended for doctors and laypersons alike. For you, Supernormal helps build understanding. Terri Schlichenmeyer is a professional book reviewer who has been reading since she was 3 years old and she never goes anywhere without a book.
It is important for you to know that your skin cancer is the most curable of all cancer types and we are well prepared to help you. Dr. Gary Monheit trained with Dr. Frederic Mohs, the originator of the Mohs procedure, and has 40 years of experience treating our patients. He performs over 2,000 procedures per year and is well prepared to treat your problem. It is our goal to provide personal and compassionate care in our state-of-the-art surgical center with tools and techniques that will provide you the best treatment and cure you expect.
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DECEMBER 2017 • 15
Social Security Disability Insurance and Supplemental Security Income: The Basics By Janet CoX
There is a lot of confusion about Social Security Disability Insurance and Supplemental Security Income, the two types of disability benefits that can be received from Social Security. The definition of disability is the same under both programs, but that is where the similarity ends. The following is a very basic description of the disability programs provided under the Social Security Act, titles II and XVI.
Social Security Disability Insurance Security Disability Insurance (SSDI) is a benefit that is available to workers and
certain family members if he has worked long enough and paid Social Security taxes (via wages or self- employment taxes).
Is ﬁnancial need considered in entitlement to SSDI? No. There is no means test. Assets, financial worth and unearned income have no bearing on entitlement. What is the beneﬁt rate for a disabled worker? A disabled worker will draw a benefit amount approximately equal to the amount she would draw at normal retirement age. When the individual reaches normal retirement age, the benefit is con-
verted over to retirement benefits.
What are the other beneﬁts that go along with SSDI? A worker who is approved for SSDI also gets a “period of disability” meaning the work record is frozen for the duration of the disability. Years of no earnings due to disability are not counted in the averaging formula used to calculate the monthly benefit amount. Everyone is focused on the disability income. Few know the benefits of having the years of “zero” earnings excluded from their benefit calculations and the determination of work credits for benefit entitlement. What about medical insurance?
A disabled worker is entitled to Medicare. However, there is a waiting period. Medicare coverage begins after the worker has been entitled to disability benefits for 24 consecutive months. Medicare covers only the disabled worker and does not extend to family members.
What about beneﬁts for the worker’s family? Dependent minor children and a spouse caring for those children may be entitled to monthly benefits. These benefits are subject to a “family maximum” which is derived from the worker’s benefit rate and earnings record. Can family members draw a disability beneﬁt from the worker’s record? A widow(er) or divorced widow(er) may be entitled to an early survivor benefit off the earnings record of a deceased worker if he is disabled, is between the age of 50 and 60, is unmarried and meets certain other non-disability requirements. A child of the wage earner may be entitled to a disability benefit if the child is unmarried, is under a disability that began before age 22 and is dependent on the wage earner. This benefit can be paid during the life of the worker if she is receiving disability or retirement income. It is available to a surviving disabled adult child after the worker’s death. Supplemental Security Income Supplemental Security Income (SSI) is a disability benefit that can be received by an adult or child under age 18 who is disabled and has limited income and resources. Financial need is a key criteria. Applications are screened for financial qualifications before the application proceeds to a disability evaluation. In adult claims, excluded resources include the claimant’s home, one automobile and up to $2,000 in countable resources. Income and “in kind” income such as food and shelter can reduce the SSI benefit to which the claimant is otherwise eligible. Benefit rates are the same for all claimants and are set by statute and regulations. The maximum rate for SSI can be reduced by earned income, unearned income and “in kind” income such as food and shelter. There are no family benefits. Only the disabled individual can receive a monthly benefit.
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Is medical coverage provided? Medicaid provides medical coverage. An individual receives Medicaid coverage for any month in which they are eligible for SSI disability. (CONTINUED ON PAGE 17)
16 • DECEMBER 2017
Birmingham Medical News
Robotic Surgery: How, When and Why? By Justin B. Gerth MD
Robotic assisted surgery has exploded in use since it was first introduced 20 years ago with over four million procedures performed. Although minimally invasive laparoscopic surgery has been around longer, certain limitations existed within this field. Laparoscopic surgical instruments lack wristed movement, essentially forcing surgeons to operate with chop sticks. This resulted in difficulty performing certain procedures and working at difficult angles. Robotic surgery allows wristed action of the instruments, better optics, surgeon control of the camera, and better ergonomics. While there is not any significant change in long-term outcomes, there are studies that suggest decreased pain and shorter hospital stays. As a resident, I was not trained in robotic general surgery even though the OB/GYN and Urology residents used it routinely. I began to see the potential uses early in my career and began my training and early adoption of the techniques. Over the last four years, I have performed over 450 robotic surgeries ranging from hernias, colon resection, splenectomy, adrenalectomy, and stomach. I still use the traditional laparoscopic technique at some of the hospitals where I practice because no robotics system is available. Rural hospitals and outpatient surgical centers have generally not acquired robotic platforms. The console and robot
Social Security, continued from page 16
SSI is available to disabled children. Children may be eligible for SSI if they meet a separate (very strict) test for disability that is based very heavily on medical criteria. The financial eligibility is determined by family composition, household income, and assets and resources of the child and parents. Special needs trusts can be established to create eligibility for a disabled child or adult where assets otherwise would prevent eligibility. The Social Security Act is complex and there are many exceptions to almost every rule. Social Security has a helpful website with a wealth of general information and downloadable PDFs. The website also publishes a toll free number for those who wish to speak with a live representative. The wait times to get a live person on the phone can be very long and the quality and accuracy of the information varies from one representative to another.
cost over one million dollars and yearly maintenance contracts can cost hundreds of thousands of dollars. With limited healthcare dollars, hospitals don’t always have the resources available for a robotics program. There is no increased compensation for performing a procedure robotically. However, most larger hospitals have adopted robotic surgical platforms for their surgical departments. Patient selection is always a critical component in determining which surgical platform to use. Patients with higher BMIs tend to be great candidates for robotic surgery. This surgical population can make laparoscopic surgery more complex due to poor equipment maneuvering and surgeon discomfort. Robotics helps overcome this with the wristed action of the instruments and surgeon comfort at the console.
However, low BMI patients are not always great candidates for robotic surgery because of the need to space out the instruments appropriately and avoid arm collision. Also, patients undergoing surgery may require additional tools to be used in their surgery. Robotics allows the use of ICG dye to help identify critical bile duct structures during difficult gallbladder surgeries. Also, the ICG dye can be used to assess blood flow while performing colon resections and anastomosis. While most surgeries due not require these advanced tools, they can prove pivotal in difficult operations. Technology has allowed vast advancement in surgical options for surgeons and their patients. Which platform to use depends on surgeon training and preference as well as patient’s choice. Ex-
perience and comfort with robotics is necessary to achieve optimal outcomes. The quick adoption of robotics into general surgery has been much faster than laparoscopic. At its peak, laparoscopic inguinal hernia repair was only used about 33 percent of the time compared with open surgery. Where technology takes us next and what the next generation of surgery will look like is anybody’s guess. However, I am sure it will be exciting to see what comes next. Justin B. Gerth MD practices with Eastern Surgical Associates.
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Birmingham Medical News
DECEMBER 2017 • 17
When an IT Manager Goes Rogue By Jennifer Lagutin
Your business’ data could be compromised by the most unlikely of sources -- your own IT manager. Over the past couple months, I’ve encountered multiple chilling examples of IT staff gone rogue. Of course, this isn’t happening every day. But when it does, it’s especially damaging to organizations with a one-person IT department. These lone IT managers often hold the keys to the kingdom. No one person - IT expert or not - should ever have complete control over passwords, access, processes, etc. Why? Consider these two recent incidents: A healthcare company with a one-
dent. Next, he quietly began moving things around in their system creating weaknesses, vulnerabilities and a potential takedown. The business owner lost a lot of sleep over this guy. Ironically, the company president never intended to eliminate the IT manager’s position but provide him additional resources from an IT company. At another business with a oneman tech department, the IT director was fired for ethical violations outside of his role in IT. However, even after his termination, he used a password only he knew to gain remote access to the company’s systems and move files around. What’s worse is he made it look like someone else had done it; lawsuit pending. We get it. Historically it made sense
person IT department has seen a lot of growth recently. As a result, the IT manager has had a difficult time keeping up with the many demands of the developing business. This manager heard rumors that the company was considering outsourcing their IT, and he suddenly stopped cooperating or responding to the company presi-
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to hire the very best IT expert a company could find to manage the network infrastructure (i.e. everything that plugs in), but today companies are benefiting more by sharing their risks with a partner company. We suggest seeking out an IT provider who is experienced in your industry and is willing to customize the best solution for your business and security needs. Jennifer Lagutin is a Technical Solutions Manager with TekLinks. Email her at firstname.lastname@example.org.
Hepatitis C Screening for Primary Care Physicians By David M. Fettig, MD
An estimated 3.5 million people in the United States are infected with Chronic Hepatitis C Virus (HCV). Many of these people do not know they are infected and are not receiving care. The CDC estimates that while Baby Boomers (born 1945-1965) comprise only 27 percent of the US population, they account for approximately threefourths of all HCV infections. Therefore, they are at greatest risk for hepatocellular carcinoma and other HCV-related liver disease. HCV is now the leading cause of liver transplantation and liver cancer in the US. The CDC, USPSTF, and AASLD recommend the one-time screening of all Baby Boomers regardless of liver enzyme levels, symptoms, or risk factors. Other at-risk patients who should be screened are: persons who have ever injected illegal drugs, HIV-infected patients, recipients of tattoos from unlicensed or unregulated environments, persons on long-term hemodialysis, persons with persistently abnormal alanine aminotransferase levels, persons who received a blood transfusion or organ transplant before 1992, healthcare workers after accidental needle sticks, and children born to a HCV positive mother. Once you identify an at-risk patient, screen with an HCV Antibody test. If the result is negative, no further testing is needed. If the result is positive, diagnosis must be confirmed with an HCV RNA test. If RNA is detected, Chronic HCV Infection is confirmed and the patient can be referred to a gastroenterologist for further evaluation. David M. Fettig, MD practices with Birmingham Gastroenterology Associates.
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Birmingham Medical News
DECEMBER 2017 • 19
Targeting a MicroRNA Shows Potential to Enhance Effectiveness of Diabetes Drugs Over the past 15 years, UAB endocrinologist Anath Shalev, MD has unraveled a crucial biological pathway that malfunctions in diabetes. Her latest discovery in this beta-cell pathway, published in the journal Diabetes, shows the po- Anath Shalev, MD tential to enhance the effectiveness of existing diabetes drugs. In 2013, the UAB researchers found that either diabetes or elevated production of the protein TXNIP induced beta-cell expression of microRNA-204, or miR-204, and this microRNA, in turn, blocked insulin production. The Shalev group has now found another vital role for miR-204 — regulating the cell surface receptor that is the target of many of the newer type 2 diabetes drugs. This drug target is the glucagon-like peptide 1 receptor, or GLP1R. Activation of GLP1R with these drugs helps the beta cell produce and secrete more insulin. Shalev’s new work was performed in rat beta cells, genetically modified
mice, mouse pancreatic islets and human pancreatic islets. Healthy beta cells, which are found in the pancreatic islets, produce insulin to control blood sugar levels; in diabetes the beta cells are impaired and dysfunctional, and have lower GLP1R levels. Shalev and colleagues found that overexpression of miR-204 decreased expression of GLP1R in rat beta cells and in mouse and human pancreatic islets. Conversely, knock-down of miR204 increased expression of GLP1R in those cells and pancreatic islets. Greater GLP1R expression is beneficial because it helps transfer a signal to the beta cell to secrete more insulin, such as after a meal. Also, many of the newer diabetes drugs act as agonists to activate GLP1R. Higher expression can allow use of a lower-drug dose to treat diabetes, thus reducing dose-dependent side effects. In mice, the UAB researchers found that a deletion of miR-204 caused enhanced GLP1R expression, and also better insulin secretion and glucose control. Furthermore, the knockout mice were more responsive to a GLP1R agonist in glucose tolerance tests. When the GLP1R knockout mice were used in a model of diabetes, where beta cells are damaged by low doses of the
toxin streptozotocin, the diabetic mice showed improved glucose control and increased serum insulin levels. These results suggest that downregulating miR-204, now revealed as an upstream regulator of GLP1R, could lead to better treatment of diabetes.
Study Finds Dieting Combined with HighIntensity Exercise Helps Reducing Risk of Weight Regain Researchers at UAB have found that combining a calorie-restricted diet with high-intensity interval training could be a solution for reducing weight regain after weight loss. “One of the problems when you restrict calories on a diet is that you lose muscle mass, and as a result, your metabolism slows down to accommodate the restriction of food,” said Eric Plaisance, PhD, assistant professor of exercise science in the UAB School of Education. “80 percent of people who lose weight by dieting gain all of it back in a four- to five-year period.” Moderate-intensity exercise, such as a brisk walk or dancing, has been shown to reduce the lowering of one’s metabolic rate while restricting calories. In a study published in the American
Journal of Physiology, the UAB research team found that in the presence of a calorie-restricted diet, high-intensity exercise training preserved muscle mass and had a greater impact on the way the body uses glucose for energy in mice. High-intensity interval training is a process in which a person performs near maximal exercise for a short period of time, and then performs two to four minutes of active recovery; for example, if someone is on a treadmill they may go from running to walking. Then the person performs another cycle of near maximal exercise and active recovery and continues to do so for four to five cycles. Plaisance says previous research shows that continuous moderate intensity exercise does burn more calories, but further studies have shown that people who perform high-intensity interval training seem to produce the same amount of weight loss doing 20 minutes of exercise as those who do 60 minutes of moderate-intensity exercise. “Most people tell us they do not exercise for lack of time,” Plaisance said. “High-intensity interval training takes about a third of the time as a continuous exercise training.”
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20 • DECEMBER 2017
Birmingham Medical News
Cisco names TekLinks South Collaboration Partner of the Year Cisco recently recognized TekLinks as the South Area Architectural Excellence - Collaboration Partner of the Year. “TekLinks’ innovation, leadership, and flawless execution as a Cisco business partner delivering business outcome solutions across the South earned them this honor,” said Idan Matos, Cisco National Partner Account Manager. Key factors influencing TekLinks’ recognition: • 171 percent YoY growth.
• TekLinks is one of the fastest growing DVARs in the US, nearly doubling their revenue year over year. • Invested in and empowered a Cisco practice lead and TekLinks Collaboration Lead to strengthen the partnership delivering 166 percent Collaboration Growth for FY17. • “Know it, Show it, Sell it” strategy resulted in 220 percent growth in telepresence endpoints and 460 percent growth in telepresence Infrastructure. • Closed the largest Collaboration EA deal with the State of Alabama providing TekLinks an initial revenue opportunity of $20 million.
St. Vincent’s Open Urgent Care in Homewood
DCH Introduces Human Milk Program for Premature Infants DCH Health System has launched a donor breast milk program benefitting premature infants in the neonatal intensive care units (NICUs) at DCH Regional Medical Center and Northport Medical Center. DCH has been a pioneer in providing exclusive human milk nutrition for premature infants in its NICUs and is already using fortifiers made from human milk, as opposed to cow milk. DCH will partner with Prolacta Bioscience to establish the Human Milk Program at DCH Health System. The program uses surplus breast milk of nursing mothers in their community to make standardized donor breast milk made by Prolacta Bioscience. The milk will be distributed to premature infants hospitalized across the country, including the NICUs at both Tuscaloosa County hospitals. “This is an easy and safe outlet for mothers to donate their unused breast milk to babies who need it the most,” said Lorraine Yehlen, vice president of patient care services for the DCH Health System. Prolacta will manage the qualification process of mothers referred from DCH with health screenings and blood testing, along with streamlining the milk collection and shipping process right from donors’ homes. Prolacta’s manufacturing facility will be used to conduct the safety and quality testing before pasteurizing the human milk products for in-hospital use.
St. Vincent’s Health System recently held a ribbon cutting for the opening of its new St. Vincent’s Urgent Care location in Homewood. The location opened October 2, 2017. St. Vincent’s Urgent Care provides walk-in care for minor injuries and illnesses seven days a week. In addition, the location offers online check-in at stvurgentcare. com. The location treats a wide range of conditions, including ear or eye infections, flu, fevers, cuts that may need stitches, allergies, and upper respiratory tract infections. Lynette Zills, MD is the Medical Director of the facility. Zills is board certified in Urgent Care and Family Medicine with over 21 years experience practicing full time Urgent Care Medicine.
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Overstreet Joins Burr Forman Health Law Practice
Providing exceptional real estate advisory services to physicians and medical groups Veritas listens to you, is able to assess your needs, and ﬁnds and implements successful solutions for your practice very effectively and efﬁciently. Rich and his team are tremendous professionals that are the best at what they do. Gregory Bourgeois, MD
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Adam Overstreet has joined Burr & Forman where he will practice with firm’s health care group in Birmingham. After serving more than ten years at the Department of Justice, Overstreet brings extensive experience dealing with white collar criminal Adam Overstreet and civil matters that will enhance the firm’s capacity to successfully serve clients in the health care industry. “With health care a top priority nationally and for the businesses we serve, Adam’s experience within health care litigation supports our ability to counsel clients seamlessly through the everchanging landscape,” said Howard Bogard, leader of Burr & Forman’s health care practice group. “Adam’s substantial background with the Department of Justice adds a unique strength to our team.” Prior to joining Burr & Forman, Overstreet served as the Appellate Section Chief at the Southern District of Alabama’s U.S. Attorney’s Office where he trained Assistant U.S. Attorneys regarding developments in federal criminal law. He has litigated over 100 appeals before the 11th Circuit and orally argued several white-collar cases, including a multi-million dollar “Ponzi” scheme. His additional experience includes serving as the Health Care Fraud Coordinator of the U.S. Attorney’s Office, as well as a member of the Complex Litigation Unit. While serving as the Health Care Fraud Coordinator, he handled all criminal health care fraud (HCF) matters in the office and directed numerous complex HCF investigations. He participated in several parallel civil False Claim Act and qui tam whistle blower investigations. He also successfully reinforced the office’s dormant criminal Health Care Fraud program, which culminated in what was formerly the largest and most complex HCF case in the history of the office. Overstreet earned his undergraduate degree from Auburn University and his law degree from the University of Alabama School of Law.
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DECEMBER 2017 â€¢ 23
WHAT WE DO
At Keep IT Simple, we are experts who have
hired experts, so you get an IT guy who’s capable, precise, thorough and knows that ĐŽŵŵƵŶŝĐĂƟŶŐǁŝƚŚŽƵƌĐůŝĞŶƚƐŝƐĂƐŝŵƉŽƌƚĂŶƚ ĂƐĐŽŶŶĞĐƟŶŐƚŚĞƌŝŐŚƚǁŝƌĞƐ͘<ĞĞƉ/d^ŝŵƉůĞ ŬĞĞƉƐ ǇŽƵƌ ŽĸĐĞ ǁŽƌŬŝŶŐ ĞĸĐŝĞŶƚůǇ ǁŝƚŚ ƉƌĞĐŝƐŝŽŶ͘ We work with over 250 medical ƉƌĂĐƟĐĞƐ ŝŶ ůĂďĂŵĂ ƉƌŽǀŝĚŝŶŐ ƐĞƌǀŝĐĞ͕ ƐƵƉƉŽƌƚ͕ĞƋƵŝƉŵĞŶƚƐĂůĞƐ͕ĂŶĚƐŽŌǁĂƌĞ͘
•ĂƚĂͬ/ŶƚĞƌŶĞƚͬEĞƚǁŽƌŬŽŶĮŐƵƌĂƟŽŶ͕^ĞĐƵƌŝƚǇΘDĂŶĂŐĞŵĞŶƚ •/ŶƚĞŐƌĂƟŽŶŽĨDƵůƟƉůĞ,ĂƌĚǁĂƌĞΘ^ŽŌǁĂƌĞ^ǇƐƚĞŵƐ •ŝWĂĚͬŝWŚŽŶĞͬdĂďůĞƚͬ^ŵĂƌƚƉŚŽŶĞŽŶĮŐƵƌĂƟŽŶΘ^ƵƉƉŽƌƚ •DZͬ,ZǆƉĞƌŝĞŶĐĞ͕^ĞƌǀŝĐĞΘ^ƵƉƉŽƌƚ •KŶƐŝƚĞ>ŽĐĂů/d^ĞƌǀŝĐĞΘ^ƵƉƉŽƌƚ •,/W,/d,ŽŵƉůŝĂŶĐĞ •^ĞĐƵƌĞZĞŵŽƚĞĐĐĞƐƐΘDŽŶŝƚŽƌŝŶŐ •ŶƟͲsŝƌƵƐ͕ŶƟͲ^ƉǇǁĂƌĞ͕ŶƟͲ^ƉĂŵ^ŽůƵƟŽŶƐ •&ŝƌĞǁĂůů͕sWEΘŵĂŝůŶĐƌǇƉƟŽŶ^ĞƌǀŝĐĞƐ
&&KZ>WZ//E' ^hWZ/KZ<EKt>' y>>Ed^Zs/
•KŶƐŝƚĞͬKīƐŝƚĞĂƚĂĂĐŬƵƉWƌŽƚĞĐƟŽŶ •tĞďĞƐŝŐŶ͕,ŽƐƟŶŐΘůŽƵĚ^ĞƌǀŝĐĞƐ •ZĞŵŽƚĞ/d^ĞƌǀŝĐĞΘ^ƵƉƉŽƌƚ
Published on Dec 14, 2017