San Antonio Medicine December 2015

MEDICINE SAN ANTONIO

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DECEMBER 2015

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VOLUME 68 NO. 12

MEDICINE SAN ANTONIO

THE OFFICIAL PUBLICATION OF THE BEXAR COUNTY MEDICAL SOCIETY

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Men’s Health

DECEMBER 2015

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VOLUME 68 NO. 12

San Antonio Medicine is the official publication of Bexar County Medical Society (BCMS).

All expressions of opinions and statements of supposed facts are published on the authority of the writer, and cannot be regarded as expressing the views of BCMS. Advertisements do not imply sponsorship of or endorsement

by BCMS.

Brachytherapy and IMRT — Radiation Alternatives to Surgery for Early Prostate Cancer

By Michael F. Sarosdy, MD ........................................12

EDITORIAL CORRESPONDENCE: Bexar County Medical Society 6243 West IH-10, Suite 600 San Antonio, TX 78201-2092 Email: editor@bcms.org

Treating Depression Disorders in Men

By Malathi V. Koli, MD, FAPA .....................................16

Male Cosmetic Surgery on the Rise

MAGAZINE ADDRESS CHANGES: Call (210) 301-4391 or Email: membership@bcms.org

By Dr. Kenneth C.Y. Yu ..............................................20

Osteoporosis in Men: Less frequent, but more lethal

SUBSCRIPTION RATES: $30 per year or $4 per individual issue

By Aruna Venkatesh, MD...........................................22 BCMS President’s Message ...........................................................................................................8 BCMS News ..................................................................................................................................10

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BCMS Legislative News ...........................................................................................................................26 Adventures in Flying: A recollection By Fred H. Olin, MD .......................................................................27 Nonprofit: FTD Confidential By Sarah Oxford, Executive Director FTLDA ...................................28 UTHSCSA Dean’s Message By Francisco González-Scarano, MD ........................................................30 Legal Ease: Who’s responsible when a crime happens? By George F. “Rick” Evans Jr. ........................32 Business of Medicine: Electronic Health Records (EHRs) and Interoperability in Healthcare Today by Joseph (Joe) P. Gonzales, MHA, FACHE ...........................................................34 BCMS Circle of Friends Services Directory .............................................................................................37 In the Driver’s Seat ...................................................................................................................................43 Auto Review: 2015 BMW 740d, By Steve Schutz, MD.............................................................................44

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BOARD OF DIRECTORS

OFFICERS James L. Humphreys, MD, President Leah Hanselka Jacobson, MD, Vice President Maria M. Tiamson-Beato, MD, Treasurer Adam V. Ratner, MD, Secretary Jayesh B. Shah, MD, President-elect K. Ashok Kumar, MD, Immediate Past President

DIRECTORS Jorge Miguel Cavazos, MD, Member Josie Ann Cigarroa, MD, Member Kristi G. Clark, MD, Member John Robert Holcomb, MD, Member John Joseph Nava, MD, Member Carmen Perez, MD, Member Oscar Gilberto Ramirez, MD, Member Bernard T. Swift, Jr., DO, MPH, Member Miguel A. Vazquez, MD, Member Francisco Gonzalez-Scarano, MD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative Carlayne E. Jackson, MD, Medical School Representative Col. Bradley A. Lloyd, MD, Military Representative Rebecca Christopherson, BCMS Alliance President Gerald Q. Greenfield Jr., MD, PA, Board of Censors Chair Donald L. Hilton Jr., MD, Board of Mediations Chair George F. "Rick" Evans Jr., General Counsel

CEO/EXECUTIVE DIRECTOR Stephen C. Fitzer

CHIEF OPERATING OFFICER Melody Newsom Mike W. Thomas, Director of Communications August Trevino, Development Director Brissa Vela, Membership Director

COMMUNICATIONS/ PUBLICATIONS COMMITTEE Fred H. Olin, MD, Chair Jay S. Ellis Jr., MD, Member Karl W. Janich, MD, Member Karen C. McQueen, Alliance Member Jeffrey J. Meffert, MD, Vice Chair Esmeralda Perez, Community Member Rajam S. Ramamurthy, MD, Member J.J. Waller Jr., MD, Member Kenneth C.Y. Yu, MD, Member

6 San Antonio Medicine • December 2015

PRESIDENT’S MESSAGE

Gratitude and recognition for a successful year

By James L. Humphreys, MD 2015 BCMS President

As we head into the holiday season and wrap up 2015 I am struck by how quickly this year seems to have vanished before my eyes. This is not a new phenomenon for me and seems to have only gotten worse every year since my daughter was born.

It still seems to me that it was only a year or two ago that she was peddling around our living room and kitchen on a tricycle despite the fact that she is actually a teenager in middle school this year. Suffice it to say, it has been a hectic but rewarding year.

Thanksgiving has come and gone by now but I want to take this opportunity to recognize some folks and express my gratitude to them. First, I need to thank the BCMS staff for doing an amazing amount of work on our behalf that often goes unremarked by our membership. They are hardworking, dedicated people who handle essentially all of the legwork to help us pull off nice events for the membership, take care of the needs of the membership, and keep the organization afloat. Steve and Melody do an excellent job at managing and operating the society for us and I can’t thank them and the rest of the staff enough for their efforts.

Next I want to recognize the other officers of the society and the members of the board and the committees in the society. These are members who step up to commit extra time and work on behalf of us all to bring the value and relevance of the society to the membership. Thanks to all of you for making the society a living organization of and by

8 San Antonio Medicine • December 2015

the physicians of Bexar county. It is an honor for me to know and be associated with you.

Lastly, let me thank all of you for giving me the opportunity to spend a year as president of the society. It is a tremendous honor to be the nominal leader of a group that has meant so much to me over the last 10 years (or more, I lose track of things like that these days). It is a privilege for me to be a member of the medical community here in San Antonio and to have such fine colleagues to guide me and help me be a better and smarter physician.

I am looking forward to an excellent new year with Jayesh Shah as our new president and to offering him any and all assistance during his year. We will start off with a bang in our brand new building that will be finished on time and in budget thanks to the careful stewardship of Steve Fitzer and the excellence of our selected builder who has really come through for us on this project.

If you haven’t ever really gotten involved in the society, make this the year to do so. I have been paid back many times already above and beyond for my investment of time in BCMS and am confident that you will be as well. Have a safe and restful holiday season this month and my best wishes to us all for a prosperous and healthy new year.

James L. Humphreys, MD, is the 2015 president of the Bexar County Medical Society. He is a pathologist with Precision Pathology in San Antonio.

BCMS NEWS

UNSUNG HERO NOMINEE Brandy Dominguez, office manager for Certified Allergy and Asthma of San Antonio, was nominated for the Unsung Hero Award by Dr. Robert Ramirez.

"As the office manager, Brandy exceeds the team expectations in many ways. She not only handles employee affairs but also supervises billing duties efficiently and professionally.

She has always maintained a positive attitude towards employees and more importantly, our patients. She has excellent bargaining skills which helped tremendously with our recent renovation project. Brandy also led the initiative to attain OSHA and HIPAA compliance training. As a leader with good work ethic and personal values, she has earned the respect of everyone in the office as both a manager and mentor."

— Dr. Robert Ramirez From left to right: Victoria Ranard, Anya Perez, Brandy Dominguez, Ron Waller, Allison Gill, Jaimie Weathers, Dr. Robert Ramirez, Yvette Coronado, and Carrie Delacruz.

WOMEN IN MEDICINE 2015 The Bexar County Medical Society held its 23rd Annual Women in Medicine Event on Saturday, Nov. 1, 2015.

The Women In Medicine Committee honored Dr. Rajam Ramamurthy and Dr. Diana Burns-Banks and recognized their leadership as the first two female past president leaders of the Bexar County Medical Society.

Guests also enjoyed a fashion show sponsored by Dillard’s La Cantera. Female physicians and Circle of Friends sponsors participated as fashion show models. Dr. Jorge Alvarez performed as Sherlock Holmes — an attendee favorite! Special thanks go out to all of the sponsors and shopping spree vendors.

We are looking forward to seeing everyone at the 24th Annual Women in Medicine Event on Nov. 5, 2016.

From L-R Dr. Leah Jacobson, 2017 BCMS Elected President, Dr. Diana Burns-Banks, BCMS Past President and Dr. Rajam Ramamurthy, BCMS Past President.

10 San Antonio Medicine • December 2015

MEN’S HEALTH

Brachytherapy and IMRT

Radiation Alternatives to Surgery for Early Prostate Cancer Michael F. Sarosdy, MD

Figure 1: Plain X-ray of the pelvis showing contrast in the bladder with I-125 elements just implanted in the prostate.

12 San Antonio Medicine • December 2015

MEN’S HEALTH Adenocarcinoma of the prostate, or “prostate cancer,” remains the No. 1 cancer diagnosed among American males as well as the second most common cause of cancer deaths among American men.

Despite the emergence of robotic radical prostatectomy, radical prostatectomy is still associated with high rates of mild to severe incontinence (up to 20 percent or more) and erectile dysfunction (up to 50 percent), as well as failure to cure, with at least biochemical failure and/or progression of clinical disease in 20-50 percent depending on individual risk factors and stage at diagnosis. Those that progress after prostatectomy then usually receive adjuvant external radiation and some progress to androgen blockade and often second-line treatments for advanced disease.

Treatment options Two commonly used radiation options are available, namely Intensity Modulated Radiation Therapy (IMRT) and Low Dose Rate (LDR) Trans-perineal Brachytherapy, often referred to as a “seed implant.”

IMRT represents the evolution of 1990’s “external beam” to CT-guided gating or blocking of the beam at the margins of the target area to better avoid radiating surrounding tissues (bladder and rectum). However, IMRT still requires 9 weeks of daily treatment and the dose delivered (75 Gray) is only slightly higher than the dose required to kill prostate cancer (65-70 Gray). Attempts to increase the dose to 80 Gray were aborted due to high rectal toxicity.

Low Dose Rate Brachytherapy, introduced in 1986 and refined since, remains a highly effective modality in treating localized prostate cancer, with meta-analyses showing higher biochemical freedom from relapse than with surgery or external radiation (Figure 1).

Brachytherapy has the distinct advantage of being delivered by a single outpatient treatment, requiring about one hour in the operating room to implant the radioactive elements, with most patients able to return to work or nearly full activities the next day. The physics treatment plan is individually designed using an outpatient trans-rectal ultrasound study in which a 3-dimensional model of the prostate is created. Titanium-encapsulated I-125 (Iodine) or Pd-103 (Palladium) elements (or “seeds”) are stranded together and preloaded into needles that are delivered to the facility for implantation by the team, including both a radiation oncologist and a urologic oncologist working together in the OR. After the one hour implant procedure, most patients are dis-

charged catheter-free in 2-3 hours. With a half-life of 60 days for the more commonly-used I-125, there is a slow release of localized radiation over 8-10 months conforming to the prostate, biologically very well-suited for a slow growing cancer like prostate cancer. Increased voiding symptoms and a slight increase in stool frequency last several months in most, but incontinence is uncommon, and long term erectile dysfunction is less likely with brachytherapy than with surgery or IMRT. Brachytherapy is particularly well-suited for the patient who lives an hour or more away from a treatment center, or those not wanting to disrupt their work or social schedule by the longer treatment time of IMRT or the time for recovery after surgery.

Myths that younger men should have surgery instead of brachytherapy are not supported by any published literature.

With a post-treatment positive biopsy rate of < 1 percent in experienced hands, local disease recurrence is uncommon, with biochemical failures usually due to disease that was outside the treatment field at the time of treatment.

Part of the success of brachytherapy is likely due to the extended range and margins of the treatment field compared to IMRT or radical prostatectomy. The latter two are roughly limited to the capsule of the prostate. Brachytherapy, because of the low dose rate nature, allows a margin of 4-5 mm outside the prostate that is at 145 Gray, with a margin of 8-10 mm that is delivered at 110 Gray. Thus, much higher doses are delivered outside the prostate than with IMRT, likely treating what might be microscopic disease that would otherwise be recognized as “positive margins” after prostatectomy, or rising PSA and biochemical failure after IMRT. Figure 2 (following page) shows one of several figures from a huge meta-analysis by the Prostate Cancer Treatment Foundation showing biochemical cure with different treatment modalities from all published papers since 2000 culled for quality, this one showing freedom from biochemical recurrence (rising PSA post treatment) in “low risk” disease. Similar stratification is noted in “intermediate” and “high risk” disease patients. For all three risk levels, meaning good, moderate, or bad and aggressive cancers, brachytherapy results published in peer-reviewed literature were superior to external radiation and surgery. These are readily available on an interactive web-page at www.pctrf.org.

National trends How does all this translate to current treatment paradigms?

National trends over the last 10-12 years have seen a decrease in continued on page 14 visit us at www.bcms.org

13

MEN’S HEALTH continued from page 13

Figure 2: Biochemical progression-free survival after treatment for low-risk prostate cancer from peer-reviewed papers since 2000. The colored ellipses are mathematically derived according to plotted points for each treatment modality. Each point is referenced and can be clicked on and the citation detailed at www.pctrf.org.

brachytherapy, with an increase in surgery and IMRT, but these changes were not based upon peer-reviewed evidence.

Men are less threatened with surgery when it involves “the robot,” as it sounds technically advanced and does allow for faster recovery. But the published data show that curative results are equivalent to or no better than open surgery.

The upsurge in IMRT reflects the merging of small groups of urologists into larger groups starting in 2003 so they could afford to bring the IMRT in-house and benefit from the hugely higher reimbursement for IMRT compared to either surgery or brachytherapy (Wall Street Journal, Dec. 7, 2010). Due to 14 San Antonio Medicine • December 2015

the huge economic burden of IMRT that suddenly developed, CMS has been aggressively reducing reimbursement over the past 5-10 years, and it is unlikely that there will be further proliferation of IMRT for that reason.

Brachytherapy remains an effective, patient-friendly modality with superior results at centers of excellence throughout the United States and should continue to be an option offered to all patients that have to deal with the prospect of treatment of early, localized prostate cancer, regardless of age or risk status. All treatments for prostate cancer result in morbidity and lifestyle issues, but brachytherapy is the smallest bump in the road for most.

MEN’S HEALTH

Treating Depression Disorders in Men

By Malathi V. Koli, M.D. F.A.P.A

Depression is a leading cause of disability and a major health problem in the U.S. and throughout the world. It is estimated that 5 percent to 8 percent of the general population is affected by major depression in their lifetime.

As of 2013, there were 40,000 deaths by suicide in the U.S., making it the 8th leading cause of death. There is evidence of serious somatic symptoms and physical illness linked to depression. Recent studies have found depression in elderly patients is a predictor of negative cardiovascular events, including myocardial infarction stroke and death.

When depression is detected early and well treated, it can reduce the risk of suicide, adverse physical health and will increase productivity.

The estimated economic loss due to depression ranged from $83.1 billion in 2000 to $210.5 billion in 2010.

Symptoms and factors Now let us examine the symptoms of major depressive disorder.

Five or more of the following symptoms are needed to be present for at least two weeks: 1. Feeling sad, blue 2. Loss of interest in things one usually enjoys 3. Changes in appetite — up or down with weight loss or weight gain 4. Trouble sleeping — too little or too much 5. Loss of energy or feeling tired all the time 6. Feeling sluggish, psycho-motor retardation 7. Difficulty concentrating or making decisions.

8. Feeling worthless and guilty 9. Thoughts of death or suicide Not all patients display all symptoms. Symptoms can be categorized as emotional and physical. Among these symptoms suicidal 16 San Antonio Medicine • December 2015

ideation is the most serious one. Many depressed patients experience thoughts of death, ranging from transient feelings that others would be better off without them, to actual planning, and implementing to commit suicide.

Major depression accounts for 50 percent of suicides. Hence early detection of depression and effective treatment interventions are imperative. For each 8-10 deaths by suicide, 18-20 suicide attempts are made.

Factors associated with elevated risk for suicide: 1. Males — older than 45 especially over 65 age group 2. Caucasian males 3. Protestant 4. Divorced or widowed 5. Recent severe loss 6. Poor prognosis with serious physical illness 7. Prior suicide attempts 8. Family history of suicide 9. Unwillingness to accept help 10. Lack of support system 11. Alcohol or drug abuse 12. Depression with psychotic symptoms Compared to males, more female patients attempt to commit suicide, however male patients are higher in completing suicide.

Depression comes in a variety of forms due to different etiology.

Other medical illnesses can present with depression simultaneously.

Differential diagnosis, to mention a few Hypothyroidism Secondary to cardiovascular disease, MI Multiple sclerosis Secondary to stroke: Pancreatic Cancer Dementia Lyme disease Parkinson disease Chronic Fatigue Syndrome continued on page 17

MEN’S HEALTH continued from page 16 Depression can be significant in other psychiatric disorders including post-traumatic stress disorder, bipolar disorders, schizophrenia, panic disorders. Often a time, Bipolar Disorder type II with depression gets misdiagnosed as Major Depression Disorder. Patients are prescribed antidepressants, especially SSRIs (Selective Serotonin Reuptake Inhibitors) which are counterproductive and may precipitate a manic episode; long term use of these SSRIs may even cause them to be rapid cyclers between mania and depression.

These groups of patients are very difficult to treat. When a patient presents with the complaint of depression, always rule out any history of mania. In spite of treatment with pharmacotherapy and psychotherapy remission rate after an episode of depression is only about 33 percent.

Current mode of treatment for Major Depression Antidepressants — SSRIs, SNRIs ECT Psychotherapy supportive, cognitive behavioral Electroconvulsive therapy was first introduced by Cerletti and Bini in 1938, and was tried for various patients with affective disorder and schizophrenia. Now it is generally recognized as one of the effective treatment modalities for major depression. ECT may be the treatment of choice where rapid actions are required: examples include psychotic depression, post-traumatic depression and depression with very high suicidality, elderly patients with multiple organ system problems and taking a large amount of medicines and poor tolerance/response to antidepressants. There is also maintenance ECT with treatment once monthly or so for relapse prevention.

Research studies show no significant advantage between different SSRIs. They vary only in their Behavioral Therapy (CBT) and individual psychotherapy being beneficial.

Labs There is no specific lab test to diagnose depression, however basic metabolic panel, blood count, urine analysis and thyroid studies are routine to rule out other causes.

Neuro Imaging Anatomical changes of decreased prefrontal cortex, especially left side.

Functional impairment of increased activity in amygdala and decreased blood flow and glucose metabolism (found in pet studies).

Genetics: 1. Affective Disorder concordance among monozygotic twins is 40 percent and among dizygotic twins is 11 percent.

2. Depression starting in younger age, alcoholism and sociopathy among the relatives of patients with major depression.

3. Associations between mood and monoamines, serotonin, and norepinephrine were first discovered in the 70’s (James Maas18 San Antonio Medicine • December 2015

Biogenic amines and depression 1975) serendipitously by the mood altering effects of isoniazid (anti tuberculosis medicine) which is a monoamine, oxidase inhibitor. Now we know that all anti-depressants affect post synaptic signaling of serotonin and no-epinephrine or both at the post synaptic membrane. This led to the hypothesis that depression is caused by a neurotransmitter deficiency and anti-depressants treat this imbalance.

4. Homocysteine hypothesis Lack of co-enzymes that are necessary for monoamine production among genetically predisposed individuals. These patients have elevated Homocysteine which reduces the monoamine production causing depression.

Hence depression is a medical illness, not a character weakness.

Recovery with proper treatment is the rule not the exception. The risk of recurrence is 50 percent after one episode, 70 percent after two episodes, 90 percent after three episodes. Patients who experience residual subthreshold depressive symptom – painful somatic symptom are likely to relapse three times more and they have had shorter duration of time to relapse, than asymptomatic patients with full remission. However primary mode of treatment is psycho pharmacological.

Most patients with depression present themselves to their primary care physician, OBGYN, neurologists and internists, because there is still a great deal of stigma in the society about mental illness and “being a mental patient.” A thorough physical exam, mental status exam, family history and previous history of depression/suicidality, previous history of treatments are a must.

Depression is a biological event with superimposed psycho-social stressors that aggravate the condition. It is recommended that pharmacological treatment should continue for at least 6-8 months after full remission in order to reduce the relapse rate.

Treatment approach should address Bio-psycho-social aspect of the disease Anti-depressants Psychotherapy ECT Enhance support system Life style changes Most patient’s fair well with combined treatment approach.

visit us at www.bcms.org

19

MEN’S HEALTH

Male

Cosmetic Surgery on the Rise

By Dr. Kenneth C.Y. Yu

20 San Antonio Medicine • December 2015

Historically, female patients have outnumbered male patients in getting cosmetic surgery. For women — the fairer sex — looking young and beautiful is a product of history and sociologic influences. For men, while similar motivations to look young and handsome are present, many male patients are turning to cosmetic surgery to maintain competitiveness in the workforce. The working age continues to rise, and many older men find that good jobs are going to younger counterparts. As people are living longer due to better health (through advances in healthcare and better diet and exercise), men are able to extend their careers. Men, like women, just want to look as good as they feel inside. The American Society of Aesthetic Plastic Surgery reported there’s been a 273 percent increase in the number of procedures performed on men since 1997.

What are the most common cosmetic procedures done by men? In 2014, the top surgical procedures were rhinoplasty, liposuction, blepharoplasty, and facelifts. Men also had minimally invasive procedures. The common injectable treatments we hear in public are also popular with men, and include Botulinum toxin injections (Botox or Dysport), soft tissue fillers, laser hair removal and skin resurfacing procedures.

Injectable treatments are increasingly popular with men.

Botox can selectively weaken facial muscles and help men look more relaxed, less angry and tired. Forehead and glabellar wrinkles (the “angry 11’s” between the brows) are common areas that men want softened. In contrast to women, who place a priority on smooth skin, men often just want a more relaxed look but also want to keep some wrinkles. This helps present an appearance of experience. Deepening nasolabial folds is a common sign of aging, and this is another area where men are looking for improvement. Various fillers (i.e. hyaluronic acid fillers like Juvederm or Restylane or calcium hydroxyapatite like Radiessse) can effectively fill in the depression and achieve a more youthful look.

Another interesting finding discovered recently is the observation that many people (both men and women) are selfconscious about their submental fullness or fat. This gives one a “double chin” look. With the popularity of taking selfies with smart phones, more people are seeking treatment for this area. Traditionally, options included surgery (lipectomy) or liposuction. However, the recently FDA-approved Kybella injections offer patients a nonsurgical, minimally invasive in-

MEN’S HEALTH jectable treatment that is done in the clinic. Researchers involved in the trials were surprised to find more men than usual participate in the trials. Men may be more averse or hesitant to undergo surgery than women, and are keen to find procedures that can be done quickly with minimal downtime. Kybella injections destroy fat cells and can be quite effective in improving the jawline and neck profile.

While minimally invasive procedures are effective, some patients will benefit more from surgical options. In men, the most common facial cosmetic surgeries include rhinoplasty, liposuction, blepharoplasty and facelifts. Men may have crooked noses from trauma or sports injuries. Accompanied with nasal obstruction, a rhinoplasty is often the only effective treatment. The surgeon must be knowledgeable with ideal male aesthetics when performing a rhinoplasty so as to not produce a feminine nose that does not look good on a male. Many older men suffer from upper eyelid hooding that will obstruct their visual fields. In these cases, injections won’t help, and an upper blepharoplasty is the best option. Like rhinoplasties, surgeons must not apply female principles when performing upper blepharoplasties. The goal is to remove the obstructing skin while keeping a natural male look.

Placing incisions incorrectly or over-resecting skin can result in

unnatural looks. We’ve all seen the unfortunate results in celebrities who look worse after these surgeries — Kenny Rogers comes to mind. Bruce Jenner’s eyes also looked unnatural on him. However, since the announcement he was undergoing gender transformation, one can argue that maybe his result is actually acceptable, since his goal was to become a woman. Some men have facial skin and neck laxity that can’t be improved with fillers, and a lower facelift and neck lift offer the best option. In performing a face and neck lift, the surgeon must take into consideration hair bearing areas of skin when planning incisions so as to camouflage scars and not bring hair into the ear.

In the past, people were very private about advertising that they had any cosmetic procedures done. But as mainstream media — with the help of more celebrities becoming more open about these procedures — brings attention to the benefits of cosmetic surgery, cosmetic procedures are gaining acceptance in the general public.

While women still remain the largest group to undergo these procedures, we’re seeing more men signing up.

Kenneth C.Y. Yu, MD, FACS is a facial plastic & reconstructive surgeon in private practice in Stone Oak.

visit us at www.bcms.org

21

MEN’S HEALTH

Osteoporosis in Men: Less frequent, but more lethal

By Aruna Venkatesh, MD

In the United States, about 1.5 million men over age 65 years have osteoporosis and another 3.5 million men are at risk. Lifetime risk of osteoporotic fracture is about 25 percent for a 60 year old man. By age 90, one of every six men will have a hip fracture. While the prevalence of osteoporotic fractures is lower – a third to a fifth of that seen in women – mortality rates are higher in men.

Osteoporosis is characterized by low bone mass and fragility of the skeleton, resulting in an increased risk of fracture especially at the spine, hip and wrist.

Diagnosis: DXA measurements of the spine and hip are recommended.

DXA stands for dual-energy X-ray absorptiometry which is a means of measuring bone mineral density or BMD. Diagnosis is based on the lowest T–score measured. Hip BMD (bone mineral density) has the highest predictive value for hip fracture, while spine BMD has less variability and can detect responses to therapy earlier than hip BMD. World Health Organization diagnostic thresholds based on BMD at the hip for men over the age 50 are DXA T–score ≤ – 2.5 for osteoporosis and T–score between –1 and –2.5 for osteopenia. For those younger than 50, clinical history of fragility fracture and/or other risk factors for osteoporosis are used for diagnosis.

Pathogenesis: Decreased bone mass results when • Peak bone mass achieved is low • Bone resorption exceeds bone formation during remodeling • All these processes may contribute Peak Bone mass depends on • Normal pubertal sex steroids secretion • Timing of puberty – constitutional delay in puberty results in significant reduction in bone density Ethnicity African Americans have higher BMD followed by Whites. Asian and Hispanic Americans have lower BMD but may have lower hip fracture rates especially among Hispanics.

Environmental factors Physical activity during childhood enhances and maintains bone mass and density. Chronic diseases during childhood adversely influence attainment of peak bone mass.

22 San Antonio Medicine • December 2015

• Malnutrition • Muscle deficits • Decreased physical activity • Chronic inflammation • Chronic glucocorticoid use Age related bone–loss is the single largest risk factor for fragility fractures but the risk begins about 10 years later than women Secondary causes can be identified in 40–60 percent of men with osteoporotic fractures • Hypogonadism • Chronic glucocorticoid therapy • Malabsorption • Vitamin D deficiency • Anti–convulsant therapy • Hypercalciuria • Alcohol abuse and smoking

Who should be tested?

• Routine testing of BMD in men is generally not recommended (some specialty organizations recommend testing in men over age 70) • DXA BMD for • Clinical manifestations of low bone mass • radiographic osteopenia • history of low trauma fractures • loss of more than 1.5 inches in height, • Risk factors for fracture • long–term glucocorticoid therapy • androgen deprivation therapy for prostate cancer • hypogonadism • primary hyperparathyroidism • intestinal malabsorption disorders

MEN’S HEALTH • Markers of bone formation and resorption – only confirm accelerated bone loss may be useful in monitoring response to therapy

Treatment Includes life style measures and drug / hormone therapy Lifestyle measures • Weight–bearing exercises • Limit /Avoid smoking and excess alcohol use • Adequate Calcium intake: 1000 to 1200mg /day and Vitamin D 600–800 IU /day Treatment of secondary causes and avoiding offending agents where possible: glucocorticoids, smoking and alcohol

Candidates for pharmacotherapy: • Men with osteoporosis ( T–score ≤ –2.5 or fragility fracture ) without symptomatic hypogonadism or when testosterone therapy contraindicated • High risk men with low bone mass T–score –1.0 to –2.5 based on Fracture Risk Assessment Tool (FRAX) with a 10–year probability of hip fracture or combined major osteoporotic fracture of ≥3.0 or ≥205 respectively. www.shef.ac.uk/FRAX/

Choice of therapy

Evaluation • Hypogonadism, Glucocorticoid excess may be apparent in the initial history and physical examination.

• Routine biochemical evaluation should include • Hepatic and renal function • Complete blood count • Serum testosterone • Calcium/albumin • Phosphorus and Alkaline phosphatase • 25 OH Vitamin D • 24hr urine calcium and creatinine • Additional testing guided by abnormal results or unexplained bone loss • Parathyroid hormone • Estradiol • Tissue transglutaminase antibodies, especially if Vitamin D or Urinary calcium levels are low) • Serum and urine electrophoresis prompted by anemia or vertebral fractures • 24hr urine free cortisol • Serum Tryptase to rule out Mastocytosis

BISPHOSPHONATES • Oral weekly alendronate or risedronate are initial therapy of choice based on efficacy cost and longterm safety data and annual IV Zolendronic acid for those intolerant or with contraindication to oral therapy.

• Effective in reducing risk of vertebral fractures • Administration first thing in the morning, fasting improves bioavailability. Calcium and Vitamin D that can interfere with absorption should be delayed at least one hour.

• Should be taken alone on an empty stomach first thing in the morning with at least eight ounces of water • Should remain upright and not eat any food or drink for at least 30 min to an hour • Enteric coated delayed risedronate is taken immediately after breakfast with four ounces of water Side effects and precautions • Reflux, esophagitis and ulcer if improperly administered • Should not be given to patients with active Upper GI disease • Should be stopped if patients develop symptoms of esophagitis • Esophageal cancer – conflicting data • Follow up of 46,000 bisphosphonate uses in a case cohort study did not find an increased risk of esophageal or gastric cancer • Nested Case control analysis of 15,000 adults with GI cancer, found an increased risk esophageal cancer with bisphosphonate use at 1.3 relative risk.

• FDA recommendation to not use in patients with Barrett’s esophagus continued on page 24 visit us at www.bcms.org

23

MEN’S HEALTH continued from page 23

Osteoporosis in Men • Flu–like symptoms • Seen as acute–phase reaction (low grade fever, myalgia’s , arthralgia) 24 to 72 hrs after IV bisphosphonates, responsive to ibuprofen or acetaminophen and decreasing occurrence with subsequent infusions • Clinically significant hypocalcemia only with IV bisphosphonate or in the setting of VIT D or PTH deficiency • Rare but persistent severe musculoskeletal pain • Renal – contraindicated with Creatinine clearance below 35 ml/min • Osteonecrosis of the jaw • Risk 1 in 10,000 to 100,000 patient– years • IV bisphosphonate, cancer, anti–cancer therapy, duration of exposure (>4 years), dental extractions and implants, poor fitting dentures, glucocorticoid therapy and smoking are risk factors • Discussion of risk, dental hygiene and regular dental visits are encouraged • The American Association of Oral and Maxillofacial Surgeons recommends stopping bisphosphonate therapy for two months in patient s requiring dental extraction or implants if they have received therapy for >4 years or use concomitant glucocorticoids. No restrictions for less than four years use • Atrial Fibrillation • Risk is small if any, seen with IV Zolendronic acid • Atypical Femur Fractures • Related to decrease in bone turnover with prolonger therapy leading to adynamic /frozen bone • Long term use (~7 years ) increases the relative risk though absolute risk is low 3.2–>50 cases per 100,000 person years) • Risk declines with stoppage of bisphosphonates • Typical presentation is mid–thigh or groin pain, plain radiograph may show cortical thickening, to be confirmed on MRI Duration of therapy • Drug holiday after five years of oral alendronate or three years of annual Zolendronic acid in in the setting of stable BMD, no h/o fragility fracture. Treatment resumption if significant reduction in follow up at two yearly BMD or new fragility fracture

PARATHYROID HORMONE PTH 1–34 Teriparatide is an anti–resorpitive anabolic agent that stimulates bone formation and bone remodeling.

• Administered subcutaneously as daily injections • Indication: T score ≤ –2.5 and at least one fragility fracture and continue to fracture after one year of bisphosphonate or unable to tolerate any other therapy 24 San Antonio Medicine • December 2015

• Previous or current treatment with bisphosphonate “blunts” response to PTH • Baseline and periodic monitoring with s calcium renal profile • Treatment duration for no longer than 24 months • BMD improvement s of 2 percent and 6 percent and fracture relative risk of 0.35 and 0.45 at vertebral and non–vertebral sites respectively

DENOSUMAB An option in the setting of intolerance to bisphosphonate or impaired renal function. Fracture prevention data in men available only for use with androgen deprivation therapy

Hypogonadism • Testosterone therapy: In the absence of contraindications, for individual with clinical features of androgen deficiency and truly low testosterone levels and those with unequivocal diagnoses like Klinefelter and gonadotrophin deficiency. Treatment may improve BMD by 5 to 10 percent and occurs primarily in cortical bone.

• For high risk patients with hypogonadism; that are not responding to testosterone replacement, fracture or therapy, are on concomitant glucocorticoids, or T score below –3, additional treatment with bisphosphonates recommended.

Glucocorticoid induced osteoporosis • Doses of Prednisone or equivalent as low as 2.5–5 mg/day can increase fracture risk within 3–6 months of therapy • All individuals receiving any dose of glucocorticoids for ≥3 month should receive Calcium and Vitamin D supplementation 12000mg/dal and 800 IU /day respectively • Treatment recommendations are guided by age, FRAX score, prednisone dose • Men ≥ 50 yrs. with established osteoporosis should receive pharmacologic therapy.

• Men ≥ 50 yrs. with T–score –1 to –2.5, treatment based on FRAX score • Pharmacotherapy if 10–year probability of hip or combined major osteoporotic fracture of ≥3 percent or 20 percent respectively • If 10 year risk less than above, pharmacotherapy only if prednisone dose >7.5mg for ≥3 months • Men ≤ 50 years with fragility fracture while on >7.5mg prednisone for>3 months, pharmacotherapy recommended • Should probably receive pharmacotherapy if there is evidence of accelerated bone loss(>4 percent/year) • Weekly Alendronate and Risedronate are the bisphosphonates of choice and IV Zolendronic acid for those intolerant to oral agents

MEN’S HEALTH In conclusion Over 5 million men have or are at risk for osteoporosis. Though less prevalent than in women, morbidity and mortality associated with osteoporosis is higher in men and they are less likely to have been evaluated or receive treatment for this condition. So it is important that physicians especially those involved in care of the elderly and men’s health issues adequately screen and treat these individuals.

References Finkelstein JS. Epidemiology and etiology of osteoporosis in men. : UpToDate, Post TW (Ed), UpToDate, Waltham, MA. Finkelstein JS. Treatment of osteoporosis in men. : UpToDate, Post TW (Ed), UpToDate, Waltham, MA. Finkelstein JS. Clinical manifestations, diagnosis, and evaluation of osteoporosis in men. : UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed November 6, 2015) Gennari L, Bilezikian JP. Osteoporosis in men. Endocrinol Metab Clin North Am 2007; 36:399.

Alendronate for the treatment of osteoporosis in men.

N Engl J Med. 2000;343(9):604.

Orwoll E, Teglbjærg CS, Langdahl BL, Chapurlat R, Czerwinski E, Kendler DL, Reginster JY, Kivitz A, Lewiecki EM, Miller PD, Bolognese MA, McClung MR, Bone HG, LjunggrenÖ, Abrahamsen B, Gruntmanis U, Yang YC, Wagman RB, Siddhanti S, Grauer A, Hall JW, Boonen A randomized, placebo–controlled study of the effects of denosumab for the treatment of men with low bone mineral density.

J Clin Endocrinol Metab. 2012;97(9):3161.

Neer RM, Arnaud CD, Zanchetta JR, Prince R, Gaich GA, Reginster JY, Hodsman AB, Eriksen EF, Ish–Shalom S, Genant HK, Wang O, Mitlak BH Effect of parathyroid hormone (1–34) on fractures and bone mineral density in postmenopausal women with osteoporosis.

N Engl J Med. 2001;344(19):1434.

Orwoll E, Ettinger M, Weiss S, Miller P, Kendler D, Graham J, Adami S, Weber K, Lorenc R, Pietschmann P, Vandormael K, Lombardi A

visit us at www.bcms.org

25

BCMS NEWS

BCMS PHYSICIANS AND STAFF VISIT WITH LEGISLATORS

By Mary E. Nava, MBA Chief Governmental Affairs Officer Bexar County Medical Society Recently, several BCMS physicians attended area receptions honoring two of our state representatives and one senator: Rep. Lyle Larson (District 122); Rep. Justin Rodriguez (District 125) and Sen. Jose Menendez (District 26). Many thanks to the following physicians who participated in these events: BCMS President, James Humphreys, MD; Kaashif Ahmad, MD; Michael Battista, MD; Jun Beato, MD; Maria Tiamson Beato, MD; Amy Benedikt, MD; Alejandro Gonzalez, MD; Pam Hall, MD; Alex Kenton, MD; Jesse Moss, Jr., MD and Mary Wearden, MD.

Representing BCMS at a Sept. 30 reception at TopGolf honoring Sen. Jose Menendez were (l-r): Jesse Moss, Jr., MD; Mary Nava; Menendez; Maria Tiamson Beato, MD and Jun Beato, MD. Pausing for a photo with Rep. Justin Rodriguez on Oct. 14 at Club Giraud were (l-r): Jun Beato, MD; Maria Tiamson Beato, MD; Rodriguez; Michael Battista, MD and Mary Nava.

On Oct. 14, BCMS members from Pediatrix Medical Group, led Rep. Lyle Larson on a tour of North Central Baptist Hospital's (NCBH) Neonatal Intensive Care Unit (NICU) and later hosted a luncheon at Silo Restaurant. Joining Rep. Larson (far right) in the Simulation Room of the hospital's NICU were (l-r): Alejandro Gonzalez, MD; Michael Battista, MD and Mary Wearden, MD. 26 San Antonio Medicine â&#x20AC;˘ December 2015

TRAVEL REVIEW

Adventures in Flying: A recollection

By Fred H. Olin, MD Several recent episodes of airliners having problems with landing gear, cross-wind landings, etc., got me to thinking about the non-mishaps I’ve experienced in airplanes. I’ve never been in a crash, never gotten sick, and never been on one that had some sort of dramatic event occur… you know, no sick passenger, no violence, that sort of thing. But, since we live so far from anything not in Texas, flying is a good way to get somewhere. Here are some of my memories.

When I was in the Army stationed in Philadelphia, a close relative died in Chicago at Christmas time 1962. I got permission to go to the funeral, and my wife and I boarded a Lockheed Constellation for the trip. For you younger folks, that was a four-engine propellerdriven airliner with three vertical stabilizers at the back. No problems: departed on time, quiet flight, easy, nighttime approach with holiday lights, smooth landing at O’Hare. It had snowed, and crews were clearing the taxiways, aprons etc. They hadn’t gotten to the taxiway our pilot was directed to use, but he made the turn and headed toward the terminal, and promptly went off the left side of the pavement. There was a shallow ditch there that sloped downward, and so did our side of the plane, at an angle I’d estimate at 10 – 15 degrees. There we sat. Full power did nothing but blow a lot of snow around. The airport mobilized a platoon of guys with snow shovels who dug us out, then one of those tugs came and pulled the plane to the gate.

It was about 1965 when we left San Antonio on Eastern Airlines to go to New England to play tourist and visit my wife’s brother and his family. Our older daughter was still in diapers. We had a stop in Houston before proceeding on to Boston. About halfway there the captain announced that there was thick fog at Hobby (the only airport they had then) and we would fly around for a bit to see if it would clear. A couple of hours later he attempted to land, but at the last minute he decided the fog was too thick and did a “touch and go.” We headed back to San Antonio to refuel. Meanwhile, we were going to run out of diapers before we got where we were going. With some insistence on our part, the personnel arranged for the baggage guys to get one of our suitcases out of the hold and let my wife retrieve a bunch more of that essential supply.

In 1978, I flew American from San Antonio to Chicago to take

my orthopaedic board exam. On the way home, in a Boeing 727, we had barely reached cruising altitude over central Illinois when there was an audible “bang” and a “bump,” sort of what you might feel if you ran over a 2 x 4 on the freeway. The captain came on the P.A. and said, in an Arkansas or East Texas twang, “Frayunds, we have a li’l pro’lem with the num’er two engine, thass the big un’ in the middle, so we’ve shut it daown. We can fly on the other two, so everything’s gonna be ALL right.” About the time we crossed the Mississippi there was another “bang” and “bump.” “Frayunds, now we have turned off the number three engine, but this airplane can fly on one. We’ll drop daown to a lower altitude and fly slower, and the comp’ny wants us to proceed to the repair base at Tulsa, where they’ll have another airplane waiting for us.” No panic among the passengers. A few minutes later over the St. Louis area: “Frayunds, Ah don’ care what the airline says, we’re goin’ to St. Louie.” Applause. He made a very steep, descending left turn and landed almost immediately… obviously the airport had cleared him for an urgent landing. The fire trucks were out, the whole bit. It took a few hours to get everyone on airplanes home, but all’s well…

In the late ‘70s my wife, daughters and I went on vacation to Alaska. We were only going to go to the panhandle area, and our first stop was at Glacier Bay National Park. To get there, we flew to the Gustavus airport… not a big place, Gustavus. Again in a 727, but this time, as we approached the airport the captain told us not to worry, we were going to land with a bump and some heavy brake use. Indeed we did just that. He sort of “pancaked” in and it was a really short stop. I was in a window seat on the right side of the plane, and as we made a left U-turn to get to the terminal (an Aframe shack back then) the wing and I were over grass, and I recall that there was no development off the end of the runway, just some grass and low hills.

There are more, but this magazine has word limits, and I’m pushing it here. Maybe I’ll write about them some time.

Fred H. Olin, M.D. is a semi-retired orthopaedic surgeon whose attitude toward flying is that, even at its worst it beats the heck out of a covered wagon… and no, he doesn’t remember those himself. visit us at www.bcms.org

27

NONPROFIT

FTD

Confidential

by Sarah Oxford, Executive Director, FTLDA

The Frontotemporal Lobar Degeneration Association was founded in San Antonio by Terri Bratton in 2009.

Terri lost her sister, aged 55 and her brother, aged 51 to a disease she had to learn about on her own. While trying to find a doctor who could tell her why her sister was behaving so badly and why her brother who loved his family had withdrawn from everyone, she did a little “light reading”. With a laundry list of symptoms she did some reverse engineering of the disease she discovered to behavioral frontotemporal dementia.

28 San Antonio Medicine • December 2015

Terri’s sister Patsy was always gregarious and outgoing, intelligent and a conscientious, loving mother. But her extraordinary loss of empathy, whacked out judgement, and bizarre dis-inhibition raised a giant red flag. Patsy walked through her bedroom one night and used her sister’s bathroom (leaving the door open), much to her and her husband’s embar-

rassment. But Patsy didn’t seem to give it a thought. Who does that? Why? She once decided to get out of the car WHILE Terri was driving on Loop 410. She was able to grab her arm to keep her from exiting at 60 miles an hour. At the same time, Terri’s brother, a former SAPD detective had retired and moved to his house at Lake LBJ. Sounds ideal, doesn’t

NONPROFIT

it. It would have been except instead of enjoying his family on the lake and barbequing up a storm, instead he retreated into the house with blinds and curtains drawn. When he spoke with his high school aged daughter on the phone she thought his slurred speech was due to his drinking. A few beers he did enjoy, but he never had a problem. His daughter chalked it up to all the awful things he witnessed as a police detective. The formerly affectionate son who doted on his widowed mother even became aggressive and threatening, and afterward acted as if nothing had happened.

The doctors Terri and her mother consulted offered many and sundry explanations, such as bipolar disorder, alcoholism, drug abuse, and once were even blamed for their loved ones problems. Terri did not give up on her quest for an answer, for a diagnosis. She read any medical journal article she could, comparing the symptoms they described to those of her sister and brother.

In the meantime, Patsy was losing control of her entire life. She could no longer hold a job. She would go off without telling anyone and be located days later barefoot in a parking lot. Michael was already retired, but went completely underground, cutting himself off from his sons and daughter who adored him.

The crisis point came when the day after Michael saw a physician at the VA and was told to go home and take two Tylenol, he took his life.

Terri was devastated and feared her sister might follow suit without ever knowing what the problem was. Time was running out.

After contacting some of the authors of the articles she had read she found a community of very curious researchers. They wanted to know more. Terri began to keep a journal of her sister’s behaviors and communicating with several researchers across the country.

Dr. Bruce Miller, Director, Memory and Ageing Center of UC San Francisco was one who offered insight, as did Dr. Paul Schulz, Associate Professor of Neurology, UTHealth-

Houston, Vice Chair of Methodist Hospital Neurology Service, Elected Director of Dementia Clinic, UTHealth-Houston and Director Neuropsychiatry and Behavioral Neurology Fellowship.

Getting her sister on an airplane to fly the short trip to Houston was challenging enough, protesting vehemently that she had not done her nails and would not go. Dr. Schulz concurred with Terri’s suspicion that her sister’s ailment was indeed, FTD. The diagnosis put a real name on the bizarre change in Patsy, but the prognosis was not what anyone wants to hear. There is no treatment to the progressive degeneration, and no cure. But now, Terri and her brother’s family understood it was more than likely the same disease that caused Michael’s death.

How could so many good professionals miss the signs and symptoms of FTD? Easily, most don’t know about FTD. This became Terri’s mission, and the Frontotemporal Lobar Degeneration Association was born.

FTLDA’s mission is simple, to raise awareness of FTD, educate medical professionals and advance research.

What is FTD? FTD is a progressive neurodegenerative disease with an average onset of 57 years of age. There are reports of onset as early as the 20’s. FTD affects as many people as Alzheimer’s disease in the 40-64 age group.

There are several types of FTD: Behavioral variant FTD (bvFTD): A person with bvFTD tends to exhibit marked behavioral changes, such as emotional coldness, distance, stubbornness, selfishness disinhibition and overeating, especially sweets.

Impairment of judgment can lead to financial indiscretions with potentially catastrophic consequences. At times, they may behave inappropriately with strangers, lose their social manners, act impulsively, and even break laws.

Memory is relatively normal, so dementia is often not recognized.

Semantic dementia (SD) People with early semantic dementia usually complain of difficulty coming up with the word or name for something. Words that the person uses a lot may remain available, more unusual words may be replaced by “thingy” or “you know”.

People with moderate SD will have immense trouble understanding what you say to them. They have increasing difficulty recognizing names and faces of people- even family and friends. Reading and writing usually decline but may still be able to do arithmetic.

Progressive nonfluent aphasia (PNFA) Early symptoms include slowed speech and trouble getting words out correctly. The person PNFA will become essentially mute after five years or more and develop Parkinsonian symptoms that overlap with PSP (Progressive Supranuclear Palsy) and CBD (Corticobasal Degeneration).

FTD with motor neuron disease (FTD-MND) The most common form of MND is ALS. Cognitive or behavioral problems, slurred speech difficulty swallowing, muscle wasting or limb weaknesses occur. About 15 percent of ALS patients have FTD on the day ALS is diagnosed another 60 percent have milder degrees of FTD upon diagnosis. More will develop FTD later.

(Source: UCSF Memory and Aging Center) The Frontotemporal Lobar Degeneration Association advances research through monetary support and facilitation of brain donation for families who have a lost a loved one with FTD. FTLDA is also working toward the goal set forth by the NIH meeting of NINDS to establish an international FTD clinical trial network data bank for clinical specimens, family histories and cohorts to speed the clinical trial process.

For more information about FTLDA contact us at: oxford@ftlda.org, or visit our website at: www.ftlda.org. visit us at www.bcms.org

29

UTHSCSA DEAN’S MESSAGE

Hepatitis C Cure & Liver Research

By Francisco González-Scarano, MD

The School of Medicine at the UT Health Science Center is at the forefront of another major medical milestone: a 90 percent cure rate for people with hepatitis C (genotype 1) who have diseased/cirrhotic livers. This cure rate includes liver transplant patients with a recurrence of hepatitis C. This research is immediately transformational in healthcare because these patients have very much to lose and a cure can not only save their lives, but also bring back a quality of life that was unprecedented just a few years ago.

The new treatment is part of the revolution that is taking place in hepatitis C research where just five years ago the cure rates were between 50 and 70 percent and still included significant side effects.

This new research was conducted through the Texas Liver Institute (TLI) which we established in 2012 with the arrival of national experts Fred Poordad, MD, and Eric Lawitz, MD, clinical professors of medicine. The TLI is a multi-center partnership with the School of Medicine and University Health System. Though a non-profit, it generates its own revenues from clinical practice and research grants.

Before working on hepatitis C, Dr. Poordad focused on Fatty Liver Disease (FLD). He realized hepatitis was a much greater problem and began working exclusively on the disease as well as working with liver and kidney transplant patients. Drs. Poordad and Lawitz were fortunate to have some of the first hepatitis C patients in the world that were cured. They were on the forefront of using new di30 San Antonio Medicine • December 2015

rect antiviral agents (DAA) in the research setting long before most were aware of the existence of such revolutionary medications.

Local risk factors South Texas, and Hispanics in particular, suffer from a higher incidence of liver disease and liver cancer, as well as cancers of the cervix, stomach and gallbladder. This makes San Antonio an ideal location for the Texas Liver Institute. The community also shows higher obesity rates, which is also a key risk factor for liver disease.

The pathology of fatty liver disease is similar to that of alcoholism, although there is still much to be learned about the conditions. The most vulnerable group – patients with chronic liver disease or a transplant, combined with hepatitis C – have been the focus of Dr. Poordad’s work and considerable progress over the last two years.

The new regimen is based on a multi-drug cocktail that combines DAAs and uses no interferon – the traditional staple of hepatitis treatments that has many dangerous side effects. Dr. Poordad was the lead author on the multi-site study published in the New England Journal of Medicine in May of 2014 that detailed the treatment of hepatitis C patients with severe liver disorders combined with hepatitis C. Dr. Poordad also presented his data at the International Liver Congress in London last year and as a result of this and other research, the FDA gave the regimen a “Breakthrough Therapy Designation”, recognition that it may substantially im-

UTHSCSA DEAN’S MESSAGE prove upon currently available treatments and allows for an expedited review process. Because of this status, the new DAA cocktail was approved by the FDA earlier this summer.

After decades of little progress and low cure rates in hepatitis C treatment, more significant advances were made in the mid-1990s with cure rates in the 40 to 50 percent range, but much lower for the group with diseased livers. Interferon was a major part of those treatments and it brought an entire range of flu-like side effects such as muscle aches, fever, rashes, as well as other serious symptoms including reduction in brain function, possible thyroid dysfunction, other autoimmune difficulties and even bone marrow suppression.

These side effects were dangerous for patients, especially those facing advanced cirrhosis and other issues.

Progress increased in the late 1990s through the early 2000s; a time of rapid growth and advancement as DAAs were discovered and cure rates began to climb. Boceprevir, the first FDA approved DAA, came onto the market in 2011. In use with interferon, it nearly doubled the cure rates to the 75 percent range; however it also carried all the interferon related side effects. It was within the past few years that researchers began leaving out the interferon and adding the other DAAs after they saw virus counts in chimpanzees (the only other animal that can get hepatitis) were greatly reduced. This led to proofof-concept studies, safety studies and other key measures for an FDA approval track.

Recent treatments have been so effective that the FDA actually allowed the terminology “cure” to be used in approval applications.

Because of recurrences in the virus, they previously would not allow the word to be used. Thanks to the new research, we have also seen advancement in the accepted definition of the word “cure.” Currently, a cure for hepatitis C is defined as a “sustained virologic response” – no detectable virus in the bloodstream of the patient – three to six months post treatment. Unlike HIV or hepatitis B, which can become part of our genome and hence “non curable,” we know hepatitis C cannot sustain itself unless it constantly replicates.

Benefits of higher cure rates There are many direct and indirect benefits to these new cure rates of hepatitis C. There will be less cirrhosis, which means there will be less liver cancer and lower mortality. Fewer cancers means there is a potential increase in organ availability for people who need transplants for other reasons. This all contributes to a tremendous societal benefit that not only will reduce the financial burden in Texas and other areas, but also significantly improves the lives of all involved in the equation. The patient benefits, of course, but the large circle

of caregivers – especially family members who must spend a significant amount of time and money caring for and dealing with these patients – are now relieved of that burden. It all adds up to a very positive effect on the lives and economies of people on a micro scale as well as on a greater scale for the entire country.

With these excellent cure rates, Dr. Poordad and other researchers have shifted their focus to the five to seven percent of patients whose virus resists the treatment. Dr. Poordad is also turning his attention back to FLD, which is becoming more pressing thanks to the cure rate for hepatitis C. Fatty liver disease is not just an obesity problem.

Fat metabolism in the liver is very complex, with many metabolic transporters and enzymes that are genetically determined and are problematic for many patients who suffer with FLD. Non-alcoholic steatohepatitis (NASH) is liver inflammation and damage caused by a buildup of fat in the liver. It is part of a group of conditions called non-alcoholic fatty liver disease. We see hepatitislike damage from the inflammation but it does not manifest in every patient as FLD. As well, some patients progress to cirrhosis and cancer and some do not. There is a great deal to be discovered, especially in the Hispanic population which is more prone to NASH and FLD. Dr. Poordad served as the co-director of liver transplantation at Johns Hopkins and chief of hepatology and liver transplantation at Cedars-Sinai Medical Center in Los Angeles prior to his arrival here.

Dr. Lawitz was a specialist in gastroenterology and hepatology at Brooke Army Medical Center and founded the very successful Alamo Medical Research Center before both joined forces to form the TLI. Besides working at the TLI, Dr. Poordad teaches medical students, residents and fellows and rotates on the liver transplant team at University Hospital System. Along with Dr. Lawitz and others within the School of Medicine, they are part of a team that is not just working on the issues that affect Central and South Texas, but is making unprecedented progress in the fight against these and other diseases.

All the best, Francisco González-Scarano, MD Dean, School of Medicine Vice President for Medical Affairs Professor of Neurology John P. Howe, III, MD, Distinguished Chair in Health Policy The University of Texas Health Science Center at San Antonio scarano@uthscsa.edu visit us at www.bcms.org

31

LEGAL EASE

Who’s responsible when a crime happens?

Think twice

By George F. “Rick” Evans Jr. BCMS General Counsel, Evans, Rowe & Holbrook

So, you’re thinking one of two things. This is one of those “Duh” questions as in “it’s obvious who’s responsible for a crime.

The criminal, right?” Or, you’re thinking “this is one of those trick questions lawyers use.” Well, it’s a little bit of both but the answer has relevance to you which is why it’s the subject of this month’s article.

Yes, it goes without saying that the person who commits a criminal act is accountable for it. That’s a given. The more complicated question is “who else?” And here are some examples of why you might just want to know the answer to that question.

Suppose you park your car at a local restaurant and come back after dinner to find it’s stolen. Or you leave some packages in your car while shopping at the mall and, when you come back after more shopping, discover your car has been broken into and robbed. Or maybe your daughter is assaulted while walking back to her apartment building. Can you make the restaurant pay for your car? Or is the apartment manager responsible for your daughter’s injuries or stolen purse?

Let’s look at it from a practice management standpoint. Suppose one of your patients is mugged while walking from your office to the parking lot. Or suppose a patient or one of your staff members steals your prescription pad, uses it to get drugs, and then causes some injury while high on them? Or suppose one of your employees sexually abuses a patient? Are you on the hook?

Texas law has evolved now to make people other than the criminal liable for their crimes. So, under the right circumstances, if it’s your car that was stolen, or broken into, or your daughter who was assaulted, the mall owner or apartment manager may be accountable. Just as you might be held accountable for an assault 32 San Antonio Medicine • December 2015

on your patient or the misuse of your prescription pad.

Liability is far from automatic. There are some legal obstacles before a person can be held accountable for somebody’s crimes.

For example, if a crime occurs on a property (i.e. parking lot, apartment complex, etc.), the person responsible for that property is liable for it provided the following conditions exist.

•

There have been other, reasonably similar, crimes committed on or immediately near the property in question.

•

These other crimes occurred recently and with some degree of frequency.

•

Some degree of publicity or notice should have made the property owner aware of the history of these crimes.

LEGAL EASE

Reading between the lines, the point of these three factors all relate to the issue of foreseeability. A property owner or manager who should be aware that crimes are occurring at or near his property has a duty to take steps to protect people from them. Cars are frequently broken into at the mall so they have a duty to protect you from those criminals when you go shopping. That’s why they have roving golf cart security, lighting, cameras and patrolmen.

Just as you would have an obligation to take reasonable measures to protect your patients if you knew your parking lot had a history of frequent and recent assaults. Just as you could be liable for misuse of your prescription pad if you had reason to believe it was being misappropriated. Just as you could be liable for your employee if he had a recent, serious, prior sexual offense history and you didn’t bother to do a background check.

It all goes to the issue of foreseeability. The bottom line is that if a person has reason to anticipate that somebody else will commit a criminal act, that person may be liable for the act if he’s in a position to reduce the chance of it happening. The duty to take reasonable steps to protect from a crime isn’t owed to the public at

large. But it does apply to those with whom a relationship exists (i.e. a business owner has a duty to his patrons just as a physician has a duty to his patients). So, next time you’re the victim of a crime, you may have recourse beyond the person who did it. Conversely, you may have responsibility for the criminal acts of others for the same reason.

Gone are the days when only the criminal was on the hook. Remember, liability is not automatic. It requires proof that this crime was something you should have known was likely to happen. And, beyond that, it requires proof that you were in a position to do something about it. And, beyond that, it requires proof that you took no preventative measures whatsoever, or that the ones you took weren’t reasonable.

George F. “Rick” Evans Jr., is the founding partner of Evans, Rowe & Holbrook. A graduate of Marshall College of Law, his practice for 36 years has been exclusively dedicated to the representation of physicians and other healthcare providers. Mr. Evans is the BCMS general counsel.

visit us at www.bcms.org

33

BUSINESS OF MEDICINE

Electronic Health Records (EHRs) and Interoperability in Healthcare Today

By Joseph (Joe) P. Gonzales, MHA, FACHE In a recent article on EHRs it sites a Government Accountability Office (GAO) report, released September 16, 2015, that highlighted some of the barriers to interoperability of EHRs. An “interoperable” EHR system is one that shares health information with other systems and processes that information without much effort by the user.

would develop a rating system for health IT products to measure interoperability, security, and usability. The goal of the legislation is to improve health IT transparency and interoperability. So with that as a background, I will share some perspectives that would seem to ask “…can we really wait until 2024 to make this happen?”

Various Perspectives Identified Challenges to Interoperability The GAO interviewed 18 non-federal organizations to describe some of the main challenges that many organizations face in achieving greater interoperability. They identified five predominant challenges:

Challenge

Details

During the week of Oct. 4, 2015 the Office of the National Coordinator for Health Information Technology (ONC) released its final version of the health information technology (IT) roadmap.

This roadmap aims to coordinate efforts across the country to improve health IT interoperability. This plan lays out a number of goals through 2024 to improve interoperability and achieve better quality and outcomes. In addition, Congress is introducing legislation aimed at improving EHR interoperability. The legislation 34 San Antonio Medicine • December 2015

EHR’s Design In a June 26, 2014 article by Marla Hirsch in FierceEMR, entitled “It’s time to redesign EHRs to improve patient safety”, she describes that providers have been “…lashing out against subpar electronic record design for years.” Some of the reasons she explains is that the EHRs are poorly designed since they impede workflow and cost too much, and they tend to create new patient safety problems, and contrary to the promise – they don’t share data with other systems in order to help coordinate care. She further points out that there were studies in 2014 that would support the premise that EHRs, as currently designed, adversely impact patient safety. One study, by the Veterans Affairs Department (VA), shows that 75 percent of 100 EHR-patient safety issues studied related to design issues. Moreover, a huge 94 percent of the safety concerns were traced back to just four problems, all of them design flaws, including: • Unmet data display needs, such as small print or a “poor fit” between information needs and the clinician’s task at hand • Problems with software upgrades and modifications, which created configuration errors • System-to-system interface problems • “Hidden dependencies” within the EHR, such as use of matching algorithms that created errors and delays.

BUSINESS OF MEDICINE

In a related blog post by the U.S. Food and Drug Administration (FDA), Janet Woodcock, director of the FDA’s Center for Drug Evaluation and Research, lamented that the EHRs’ lack of interoperability is a fundamental design defect, implying that it has negative impact on the FDA’s work to monitor the safety of FDA-regulated medical products, in order to improve public health.

Ms. Woodcock called for further standardization of data and the way it is exchanged, and she called for the use of standard terms for “adverse events” or “treatments” so that EHRs can communicate with each other. If patient safety is front and center, then the industry should make fixing these design flaws a top priority.

workarounds, and processes that will not get the country to true interoperability. Among the issues the report points out is the expense of the interfaces that hospitals use to connect disparate systems, such as lab, pharmacy, and imaging. A single hospital with a fully integrated EHR might have dozens, while a large health system with multiple sites might have hundreds or thousands. One example listed was Truman Medical Centers in Kansas City, Mo., that has more than 55 connections to external organizations. Truman estimates the average cost of an interface is $10,000 to $20,000, yet that doesn’t include the cost of IT staff to implement and maintain these connections and systems.

AMA Town Hall In a recent (July, 2015) American Medical Association (AMA) town hall meeting in Atlanta, physicians expressed widespread discontent with EHRs and the federal government’s Meaningful Use program. AMA’s President, Steven J. Stack, M.D., stated that more than 80 percent of U.S. physicians use EHRs, yet something is not right when too often these tools “blunt their efficiency, diminish their effectiveness, and get between them and their patients.” In addition, Stack made the case that EHRs today are not interoperable and “don’t talk to each other,” creating digital silos.

He emphasized that the AMA’s goal is to promote EHR interoperability, improve usability, and increase patient engagement.

Stack further criticized the Meaningful Use program for proposing new requirements and new stages “without making good use of our current knowledge about what works and what doesn’t.” U.S. Rep. Tom Price (R-Ga.), M.D. told the attendees that “Meaningful Use sounds wonderful. The problem is that it oftentimes is inconsistent with the product and the work that’s required. And, in this instance, I believe we’re on the path to an un-meaningful and oftentimes useless product.” He further argued that one of the major problems with EHRs is that they are “removing the science from medicine” by asking doctors to “check certain boxes” and to perform tasks designed by those without the medical experience or firsthand knowledge of the physician-patient relationship “that is the key to quality healthcare in our country.”

Conclusions

AHA Perspective According to a report from the American Hospital Association, hospitals are sharing more data than ever, due to EHRs, but limitations exist as well as barriers due to high costs. The authors of the report state that hospitals have tried to overcome interoperability barriers through the use of interfaces and health information exchanges (HIEs) but they admit that at best, these are costly

The United States has expended extraordinary efforts and money towards the digitization of its healthcare system, and policymakers look to HIT as a means of making healthcare systems safer, more affordable, and more accessible, but there remain significant barriers to achieving these goals. I realize this article raises many questions about the appropriate role of federal government, healthcare stakeholders, and vendors in creating workable standards to improve EHR interoperability. One aspect of this problem seems to be the answer to this simple question “Who’s in charge?” and “Who should be in charge?” Robert Wergin, M.D., board chair of the American Academy of Family Physicians (AAFP), in responding to the ONC for HIT’s interoperability roadmap indicated that “It’s time for action on interoperability.”

He also stated that AAFP members “…do not sense the necessary level of urgency to achieve this important goal (interoperability) and call on ONC to further accelerate this work.” The argument is that vendors have reaped huge profits from the HITECH Act while not being held responsible for poor design and lack of interoperability, and that physicians and their patients shouldn’t have to wait until 2024 for improved interoperability. I would agree with this assessment, and in my opinion it will only succeed if the provider leads the charge, and continues to be an active participant in the move towards interoperability.

Joseph P. (Joe) Gonzales is a “Specialist Master” with Deloitte Consulting, LLP. An Adjunct Faculty with UTSA, he has taught in the MBA Program, Business of Healthcare Track. Joe is a Fellow in the American College of Healthcare Executives, and has years of experience in healthcare as a hospital administrator in the Army, as CEO of a county hospital in rural Florida, and as a consultant with DoD and commercial healthcare projects. visit us at www.bcms.org

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36 San Antonio Medicine â&#x20AC;˘ December 2015

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Please support our sponsors with your patronage; our sponsors support us.

ACCOUNTING FIRMS Padgett Stratemann & Co., LLP (HH Silver Sponsor) Padgett Stratemann is one of Texas’ largest, locally owned CPA firms, providing sophisticated accounting, audit, tax and business consulting services.

Vicky Martin, CPA 210-828-6281 Vicky.Martin@Padgett-CPA.com www.Padgett-CPA.com “Offering service more than expected — on every engagement.”

Sol Schwartz & Associates P.C. (HH Silver Sponsor) We specialize in areas that are most critical to a company’s fiscal well-being in today’s competitive markets.

Jim Rice, CPA 210-384-8000, ext. 112 jprice@ssacpa.com www.ssacpa.com “Dedicated to working with physicians and physician groups.”

BANKING

BBVA Compass (HHHH 10K Platinum Sponsor) Our healthcare financial team provides customized solutions for you, your business and employees.

Commercial Relationship Manager Zaida Saliba 210-370-6012 Zaida.Saliba@BBVACompass.com Global Wealth Management Mary Mahlie 210-370-6029 mary.mahlie@bbvacompass.com Medical Branch Manager Vicki Watkins 210-592-5755 vicki.watkins@bbva.com Business Banking Officer Jamie Gutierrez 210-284-2815 jamie.gutierrez@bbva.com www.bbvacompass.com “Working for a better future.”

Amegy Bank of Texas (HHH Gold Sponsor) We believe that any great rela-

tionship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability. We work hard and together with our clients to accomplish great things.

Jeanne Bennett 210- 343-4556 jeanne.bennett@amegybank.com Karen Leckie 210-343-4558 karen.leckie@amegybank.com www.amegybank.com “Community banking partnership.”

BB&T (HHH Gold Sponsor) Checking, savings, investments, insurance — BB&T offers banking services to help you reach your financial goals and plan for a sound financial future.

Chris Sherman 210-247-2978 csherman@bbandt.com Ben Pressentin 210-762-3175 bpressentin@bbandt.com www.bbt.com

Broadway Bank (HHH Gold Sponsor) Healthcare banking experts with a private banking team committed to supporting the medical community.

Ken Herring 210-283-4026 kherring@broadwaybank.com www.broadwaybank.com “We’re here for good.”

Frost (HHH Gold Sponsor) As one of the largest Texas-based banks, Frost has helped Texans with their financial needs since 1868, offering award-winning customer service and a range of banking, investment and insurance services to individuals and businesses.

Lewis Thorne 210-220-6513 lthorne@frostbank.com www.frostbank.com “Frost@Work provides your employees with free personalized banking services.”

IBC Bank (HHH Gold Sponsor) IBC Bank is a $12.4 billion multibank financial company, with over 212 facilities and more than 325 ATMs serving 90 communities in Texas and Oklahoma. IBC BankSan Antonio has been serving the Alamo City community since 1986 and has a retail branch network of 30 locations throughout the area.

Markham Benn 210-354-6921 MarkhamBenn@ibc.com www.ibc.com “Leader in commercial lending.”

Ozona Bank (HHH Gold Sponsor) Ozona National Bank is a full-service commercial bank specializing in commercial real estate, construction (owner and non-owner occupied), business lines of credit and equipment loans.

Lydia Gonzales 210-319-3501 lydiag@ozonabank.com www.ozonabank.com

The Bank of San Antonio (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians.

Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community.

Brandi Vitier 210-807-5581 brandi.vitier@ thebankofsa.com www.thebankofsa.com

SSFCU (HHH Gold Sponsor) Founded in 1956, Security Service provides medical professionals with exceptional service and competitive rates on a line of mortgage products including one-time close construction, unimproved lots/land, jumbo and specialized adjustable-rate mortgage loans.

Commercial Services Luis Rosales 210-476-4426 lrosales@ssfcu.org Investment Services John Dallahan 210-476-4410 jdallahan@ssfcu.org Mortgage Services Glynis Miller 210-476-4833 gmiller@ssfcu.org Bank of America (HH Silver Sponsor) Bank of America provides people, companies and institutional investors the financial products and services they need to help achieve their goals at every stage of their financial lives.

Jennifer Dooling 210-270-5226 jennifer.dooling@baml.com Courtney Martinez 210-419-2643 courtney.martinez@baml.com http://about.bankofamerica.com/ en-us/index.html Making financial lives better — one connection at a time Firstmark Credit Union (HH Silver Sponsor) Address your office needs: Upgrading your equipment or technology • Expanding your office space • We offer loans to meet your business or personal needs.

Competitive rates, favorable terms and local decisions.

Gregg Thorne SVP Lending 210-308-7819 greggt@firstmarkcu.org www.firstmarkcu.org Generations Federal Credit Union (HH Silver Sponsor) Generations provides a wide array of innovative products including

Continued on page 38 visit us at www.bcms.org

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Continued from page 37 loan, deposit and investment solutions for personal and commercial banking needs.

Yvonne "Bonnie" M. Aguilar 210-229-1800 bonnie.aguilar@ mygenfcu.org www.mygenfcu.org “For this generation and the next.”

RBFCU (HH Silver Sponsor) 210-945-3800 businesslending@rbfcu.org www.rbfcu.org St. Joseph's Credit Union (HH Silver Sponsor) A credit union providing savings, checking, IRA, club and CD accounts, plus auto, signature, lines of credit, MasterCard and real estate loans.

Armando Rodriguez 210-225-6126 arodriguez@sjcusatx.net www.sjcusatx.com “Better rates on auto loans, signature loans and Platinum MasterCard.”

BIOMEDICAL WASTE DISPOSAL

BioMedical Waste Solutions, LLC (HHH Gold Sponsor) Save costs on your medical waste disposal! BioMedical Waste Solutions provides a compliant, reliable and low-cost service.

Wes Sonnier 1-877-974-1300 Wes@BioMed-Disposal.com Joe Loyacano 1-877-974-1300 Joe@BioMed-Disposal.com www.BioMedicalWasteSolutions.com “BCMS members save 10 percent off or one free month! Request a free quote in 10 seconds at www.BioMedicalWasteSolutions.com.”

CONTRACTORS/BUILDERS/ COMMERCIAL

Huffman Developments (HHH Gold Sponsor) Premier medical and professional office condominium developer.

Our model allows you to own your own office space as opposed to leasing.

38 San Antonio Medicine • December 2015

Steve Huffman 210-979-2500 Shawn Huffman 210-979-2500 www.huffmandev.com

RC Page Construction, LLC (HHH Gold Sponsor) Commercial general contractor specializing in ground-up and interior finish-out projects. Services include conceptual and final pricing, design-build and construction management. Single-source management from concept to completion ensures continuity through all phases of the project.

Clay Page 210-375-9150 clay@rcpageconstruction.com

ELECTRONIC DOCUMENTATION AND TRANSCRIPTION SERVICES

Med MT, Inc. (HHH Gold Sponsor) Narrative transcription is physicians’ preferred way to create patient documents and populate electronic medical records.

Ray Branson 512-331-4669 branson@medmt.com www.medmt.com “The Med MT solution allows physicians to keep practicing just the way they like.”

ELECTRONIC MEDICAL RECORDS

Greenway Health (HHH Gold Sponsor) Greenway Health offers a fully integrated electronic health record (EHR/EMR), practice management (PM) and interoperability solution that helps healthcare providers improve care coordination, quality and satisfaction while functioning at their highest level of efficiency.

Stacy Berry 830-832-0949 Stacy.berry@greenwayhealth.com www.greenwayhealth.com

FINANCIAL SERVICES

Northwestern Mutual Wealth Management (HHHH 10K Platinum Sponsor) Comprehensive financial planning, insurance and investment planning, estate planning and trust services.

Eric Kala, CFP, CLU, ChFC Wealth Management Advisor 210-446-5752 eric.kala@nm.com www.erickala.com

Aspect Wealth Management (HHH Gold Sponsor) We believe wealth is more than money, which is why we improve and simplify the lives of our clients, granting them greater satisfaction, confidence and freedom to achieve more in life.

Jeffrey Allison 210-268-1530 jallison@ aspectwealth.com www.aspectwealth.com “Get what you deserve … maximize your Social Security benefit!”

Frost Leasing (HHH Gold Sponsor) As one of the largest Texas-based banks, Frost has helped Texans with their financial needs since 1868, offering award-winning customer service and a range of banking, investment and insurance services to individuals and businesses.

Laura Elrod Eckhardt 210-220-4135 laura.eckhardt@frostbank.com www.frostbank.com “Commercial leasing for a doctor’s business equipment and vehicle.”

Bob Davidson New York Life (HH Silver Sponsor) Dedicated agent at New York Life helping physicians and medical professionals achieve their financial dreams.

Bob Davidson 210-321 1445 rdavidson02@ft.newyorklife.com www.linkedin.com/in/bobdavidsonnyl “Taking care of those who take care of us.”

Retirement Solutions (HH Silver Sponsor) Committed to providing comprehensive, reliable consultation to help you navigate the complex world of retirement planning.

Robert C. Cadena 210-342-2900 robert@retirementsolutions.ws www.retirementsolutions.ws

HIPAA COMPLIANCE SERVICES Cyber Risk Associates (HH Silver Sponsor) Cyber Risk Associates provides HIPAA compliance services designed for small practices, offering enterprise-quality privacy and security programs, customized to your needs.

David Schulz 210-281-8151 DAS@CyberRiskAssociates.com www.CyberRiskAssociates.com

HIPAA/MANAGED IT/ VOIP/SECURITY

Hill Country Tech Guys (HHH Gold Sponsor) Provides complete technology services to many different industries, specializing in the needs of the financial and medical industries. Since 2006, our goal has always been to deliver relationship-based technology services that exceed expectations.

Whit Ehrich, CEO 830-386-4234 whit@hctechguys.com http://hctechguys.com/ “IT problems? Yeah… we can fix that!”

HOSPITALS/ HEALTHCARE SERVICES

Southwest General Hospital (HHH Gold Sponsor) Southwest General is a full-service hospital, accredited by DNV, serving San Antonio for over 30 years. Quality awards include accredited centers in: Chest Pain, Primary Stroke, Wound Care, and Bariatric Surgery.

Business Development Director Blake Pollock

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY 210-243-9151 bpollock@iasishealthcare.com www.swgeneralhospital.com "Quality healthcare with you in mind."

Warm Springs •Medical Center •Thousand Oaks •Westover Hills (HHH Gold Sponsor) Our mission is to serve people with disabilities by providing compassionate, expert care during the rehabilitation process, and support recovery through education and research.

Central referral line 210-592-5350 “Joint Commission COE.” Elite Care Emergency (HH Silver Sponsor) 24/7 full-service, no-wait, freestanding ER with board-certified physicians and RNs offering Elite Care advantage for patients.

Marketing Liaison Dlorah Martin 509-592-7998 dmartin@elitecareemergency.com Marketing liaison Kylyn Stark 210-978-4110 kstark@elitecareemergency.com www.elitecareemergency.com “When seconds count, Elite Care can make ALL the difference.”

Methodist Healthcare System (HH Silver Sponsor) Palmira Arellano 210-575-0172 palmira.arellano@mhshealth.com http://sahealth.com/ Select Rehabilitation of San Antonio (HH Silver Sponsor) We provide specialized rehabilitation programs and services for individuals with medical, physical and functional challenges.

Miranda Peck 210-482-3000 mipeck@selectmedical.com http://sanantonio-rehab.com “The highest degree of excellence in medical rehabilitation.”

HUMAN RESOURCES

Employer Flexible (HHH Gold Sponsor) Employer Flexible doesn’t simply

lessen the burden of HR administration. We provide HR solutions to help you sleep at night and get everyone in the practice on the same page.

John Seybold 210-447-6518 jseybold@employerflexible.com www.employerflexible.com “BCMS members get a free HR assessment valued at $2,500.”

INSURANCE

Frost Insurance (HHH Gold Sponsor) As one of the largest Texas-based banks, Frost has helped Texans with their financial needs since 1868, offering award-winning customer service and a range of banking, investment and insurance services to individuals and businesses.

Bob Farish 210-220-6412 bob.farish@frostbank.com www.frostbank.com “Business and personal insurance tailored to meet your unique needs.”

Humana (HHH Gold Sponsor) Humana is a leading health and well-being company focused on making it easy for people to achieve their best health with clinical excellence through coordinated care.

Jon Buss: 512-338-6167 Jbuss1@humana.com Shamayne Kotfas: 512-338-6103 skotfas@humana.com www.humana.com

SWBC (HHH Gold Sponsor) SWBC is a financial services company offering a wide range of insurance, mortgage, PEO, Ad Valorem and investment services. We focus dedicated attention on our clients to ensure their lasting satisfaction and long-term relationships.

VP Community Relations Deborah Gray Marino 210-525-1241 DMarino@swbc.com Wealth Advisor Gil Castillo, CRPC® 210-321-7258 Gcastillo@swbc.com Professional Employer Organization Bryce Fegley

830-980-1200 BFegley@swbc.com Ad Valorem Tax Advisor Nikki McNish 210.376.2316 nmcnish@swbc.com www.swbc.com Mortgages, investments, personal and commercial insurance, benefits, PEO, ad valorem tax services

Texas Medical Association Insurance Trust (HHH Gold Sponsor) Created and endorsed by the Texas Medical Association (TMA), the TMA Insurance Trust helps physicians, their families and their employees get the insurance coverage they need.

Wendell England 512-370-1746 wengland@tmait.org James Prescott 512-370-1776 jprescott@tmait.org John Isgitt 512-370-1776 www.tmait.org “We offer BCMS members a free insurance portfolio review.”

Catto & Catto (HH Silver Sponsor) Providing insurance, employee benefits and risk-management products and services to thousands of businesses and individuals in Texas and the United States.

Crystal Metzger James L. Hayne Jr. 210-222-2161 www.catto.com Joel Gonzales Agency Nationwide (HH Silver Sponsor) Joel Gonzales 210-275-3595 www.nationwide.com/jgonzales

INSURANCE/MEDICAL MALPRACTICE

Texas Medical Liability Trust (HHHH 10K Platinum Sponsor) Texas Medical Liability Trust is a not-for-profit health care liability claim trust providing malpractice insurance products to the physicians of Texas. Currently, we protect more than 18,000 physicians in all specialties who practice in all areas of the state. TMLT is a recommended partner of the Bexar County Medical Society and is en-

dorsed by the Texas Medical Association, the Texas Academy of Family Physicians, and the Dallas, Harris, Tarrant and Travis county medical societies.

Patty Spann 512-425-5932 patty-spann@tmlt.org www.tmlt.org “Recommended partner of the Bexar County Medical Society.”

MedPro Group (HHH Gold Sponsor) Medical Protective is the nation's oldest and only AAA-rated provider of healthcare malpractice insurance.

Thomas Mohler, 512-213-7714 thomas.mohler@medpro.com www.medpro.com

The Bank of San Antonio Insurance Group, Inc. (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians.

Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community.

Katy Brooks, CIC, 210-807-5593 katy.brooks@bosainsurance.com www.thebankofsa.com “Serving the medical community.”

NORCAL Mutual Insurance Co. (HH Silver Sponsor) Since 1975, NORCAL Mutual has offered medical professional liability coverage to physicians and is “A” (Excellent) rated by A.M. Best.

Patrick Flanagan 844-4-NORCAL pflanagan@norcal-group.com www.norcalmutual.com ProAssurance (HH Silver Sponsor) ProAssurance helps you control your professional risk and navigate today’s changing medical environment with greater ease — that’s only fair.

Keith Askew, 512-314-4368 Kaskew@proassurance.com Mark Keeney 512-314-4347, ext. 7347 Mkeeney@api-proassurance.com www.proassurance.com “A.M. Best-rated A+ (Superior), ProAssurance treats you fairly.”

Continued on page 40 visit us at www.bcms.org 39

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Continued from page 39 INTERNET/ TELECOMMUNICATIONS

Time Warner Cable Business Class (HHH Gold Sponsor) When you partner with Time Warner Cable Business Class, you get the advantage of enterpriseclass technology and communications that are highly reliable, flexible and priced specifically for the medical community.

Rick Garza 210-582-9597 Rick.garza@twcable.com “Time Warner Cable Business Class offers custom pricing for BCMS Members.”

IT SUPPORT/VOIP/ CLOUD SERVICES

ICS (HHH Gold Sponsor) ICS® is a Texas-based provider of business technology integration solutions, including managed IT support, business telephones, VoIP communications, video conferencing systems, surveillance cameras, and voice/data cabling.

Family owned since 1981.

Daniel Simons 210-581-9020 daniel.simons@ics-com.net Robert Foehrkolb 210-225-5427 rfoehrkolb@ics-com.net www.ics-com.net “Providing IT, voice and video solutions for business.”

LABORATORY SERVICES

PGX TESTING (HHH Gold Sponsor) PGX Testing is a multi-faceted diagnostics company currently offering pharmacogenomics, urine toxicology, women's health testing, cancer screening, and wellness testing to the medical profession.

Charlie Rodkey Sr. charlie@pgxt.com 210-218-8610 Ryan Rodkey ryan@pgxt.com 210-323-7717

40 San Antonio Medicine • December 2015

Ron Inselmann ron@pgxt.com 210-382-7761 www.PGXT.com Clinical Pathology Laboratories (HH Silver Sponsor) Mitchell Kern 210-229-2513 mkern@cpllabs.com www.cpllabs.com

MARKETING SERVICES Digital Marketing Sapiens (HH Silver Sponsor) Healthcare marketing professionals with proven experience and solid understanding of compliance issues. We deliver innovative marketing solutions that drive results.

Irma Woodruff 210-410-1214 irma@dmsapiens.com Ajay Tejwani 210- 913-9233 ajay@dmsapiens.com www.DMSapiens.com Know Your Doctor SA (HH Silver Sponsor) Increase your practice’s unique marketing/communications program. Connect with SA community through video, advertising, PR and medical opinion e-news.

Limited to 300 physicians.

Lorraine Williams 210-884-7505 LWilliams@KnowYourDoctorSA.com www.knowyourdoctorsa.com

MEDICAL BILLING AND COLLECTIONS SERVICES

DataMED (HHH Gold Sponsor) Providing your practice with the latest compliance solutions, concentrating on healthcare regulations affecting medical billing and coding changes, allowing you and your staff to continue delivering excellent patient care.

Betty Aguilar 210-892-2331 baguilar@datastreamllc.net www.datamedbpo.com “BCMS members receive a discounted rate for our billing services.”

Commercial & Medical Credit Services (HH Silver Sponsor) A bonded and fully insured San Antonio-based collection agency.

Henry Miranda 210-340-9515

hcmiranda@sbcglobal.net www.cmcs-sa.com “Make us the solution for your account receivables.”

Mary Beth Fisk 210-616-0885, ext. 215 mbfisk@ecrh.org www.ecrh.org

MEDICAL SUPPLIES AND EQUIPMENT

MERCHANT PAYMENT SYSTEMS/CARD PROCESSING

Henry Schein Medical (HHHH 10K Platinum Sponsor) From alcohol pads and bandages to EKGs and ultrasounds, we are the largest worldwide distributor of medical supplies, equipment, vaccines and pharmaceuticals serving office-based practitioners in 20 countries. Recognized as one of the world’s most ethical companies by Ethisphere.

Tom Rosol 210-413-8079 tom.rosol@henryschein.com www.henryschein.com “BCMS members receive GPO discounts of 15 percent to 50 percent.”

MEDICAL TRAINING/ HANDS ON

LINRON® Bioskills Training Institute (HHH Gold Sponsor) LINRON® is dedicated to providing hands-on medical training to healthcare professionals who want to improve their clinical skills and offer their patients the latest in treatment modalities while using state-of-the-art medical equipment and technology.

Yolanda S. Garza, RN 210-572-2434 yolanda.garza@linrontraining.com www.linrontraining.com

MENTAL HEALTH EDUCATION AND CONSULTING

The Ecumenical Center (HHH Gold Sponsor) The Ecumenical Center provides faith-based counseling and education for healing, growth and wellness. The center is a catalyst, bringing together community leaders in research, education, ethics, medical and mental health professions.

Heartland Payment Systems (HH Silver Sponsor) Heartland Payments is a true cost payment processor exclusively endorsed by over 250 business associations.

Tanner Wollard 979-219-9636 tanner.wollard@e-hps.com www.heartlandpaymentsystems.com “Lowered cost for American Express; next day funding.”

MORTGAGE

SWBC Mortgage at La Cantera (HHH Gold Sponsor) In a complex lending environment we are committed to providing realistic expectations, simple solutions, and a stress-free buying experience.

Exceeding customer expectations is our highest priority Sr. Loan Officer #212945 Jon M. Tober 210-317-7431 jtober@swbc.com

OFFICE EQUIPMENT/ TECHNOLOGIES Dahill (HH Silver Sponsor) Dahill offers comprehensive document workflow solutions to help healthcare providers apply, manage and use technology that simplifies caregiver workloads. The results: Improved access to patient data, tighter regulatory compliance, operational efficiencies, reduced administrative costs and better health outcomes.

Ronel Uys 210-805-8200, ext. 10105 ruys@dahill.com www.dahill.com

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY REAL ESTATE/ COMMERCIAL

Joe.Salinas@SothebysRealty.com JoeSalinas.com “Embrace your new life ...

I'll help you become a connoisseur.”

Robbie Casey Commercial Realty ( Gold Sponsor ) Robbie Casey Commercial Realty was founded on the principles of providing thorough market strategies, innovative advertising, superior service, and uncompromising integrity. Robbie is dedicated to each of her clients. She brings enthusiasm and creativity to each project and knows how to get the job done.

Robbie Casey 210-872-8453 robbie@robbiecaseyrealty.com http://robbiecaseyrealty.com

SENIOR LIVING

Endura Advisory Group (HH Silver Sponsor) Endura Advisory Group specializes in representing physicians and clients in the purchase, lease, sale, management or sublease of commercial real estate.

Vicki Cade, CCIM 210-366-2222 Mobile 210-827-7640 vcade@endurasa.com Teresa Corbin 210-366-2222 tcorbin@endurasa.com www.endurasa.com

REAL ESTATE/ RESIDENTIAL

Robbie Casey Realty ( Gold Sponsor ) My extensive experience and expertise in the San Antonio, Alamo Heights and Terrell Hills real estate market will benefit you whether you are looking to buy or sell a home in the area.

Realtor, ABS, ILHM, ALMS Roslyn Casey 210-710-3024 Roslyn@roslyncasey.com http://roslyncasey.kwrealty.com “Communication is key” Kuper Sotheby's International Realty (HH Silver Sponsor) My hometown roots are based in Fredericksburg while my home away from home is San Antonio. Local knowledge — exceptional results.

Joe Salinas III 830-456-2233

Legacy at Forest Ridge (HH Silver Sponsor) Legacy at Forest Ridge provides residents with toptier care while maintaining their privacy and independence, in a luxurious resort-quality environment.

Shane Brown Executive Director 210-305-5713 hello@ legacyatforestridge.com www.LegacyAtForestRidge.com “Assisted living like you’ve never seen before.”

STAFFING SERVICES

Favorite Healthcare Staffing (HHHH 10K Platinum Sponsor) Serving the Texas healthcare community since 1981, Favorite Healthcare Staffing is proud to be the exclusive provider of staffing services for the BCMS. In addition to traditional staffing solutions, Favorite offers a comprehensive range of staffing services to help members improve cost control, increase efficiency and protect their revenue cycle.

Brody Whitley Branch Director 210-301-4362 bwhitley@ favoritestaffing.com www.favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.”

TRAVEL CONSULTANTS Alamo Travel Group (HH Silver Sponsor) Locally owned travel agency for over 30 years, offering personalized travel services for your next family vacation, business travel needs or group travel. American Express Travel Network representative.

Mary Jo Salas, 210-593-5500 msalas@alamotravel.com www.amazingjourneysbyalamo.com “See what a difference we can make for you!”

As of November 17, 2015 To join the Circle of Friends program or for more information, call 210-301-4366, email August.Trevino@bcms.org, or visit www.bcms.org/COf.html.

THANK YOU

to the large group practices with 100% MEMBERSHIP in BCMS and TMA ABCD Pediatrics, PA Clinical Pathology Associates Dermatology Associates of San Antonio, PA Diabetes & Glandular Disease Clinic, PA ENT Clinics of San Antonio, PA Gastroenterology Consultants of San Antonio General Surgical Associates Greater San Antonio Emergency Physicians, PA Institute for Women's Health Lone Star OB-GYN Associates, PA M & S Radiology Associates, PA MacGregor Medical Center San Antonio MEDNAX Peripheral Vascular Associates, PA Renal Associates of San Antonio, PA San Antonio Gastroenterology Associates, PA San Antonio Kidney Disease Center San Antonio Pediatric Surgery Associates, PA Sound Physicians South Alamo Medical Group South Texas Radiology Group, PA Tejas Anesthesia, PA Texas Partners in Acute Care The San Antonio Orthopaedic Group Urology San Antonio, PA Village Oaks Pathology Services/Precision Pathology WellMed Medical Management Inc. Contact BCMS today to join the 100% Membership Program! *100% member practice participation as of October 15, 2015.

visit us at www.bcms.org

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42 San Antonio Medicine â&#x20AC;˘ December 2015

North Park Mazda 9333 San Pedro Ave. Ancira Chrysler 10807 IH-10 West Gunn Acura 11911 IH-10 West

* Gunn Infiniti 12150 IH-10 West

Cavender Toyota 5730 NW Loop 410

Ingram Park Auto Center 7000 NW Loop 410 Mercedes-Benz of Boerne 31445 IH-10 W, Boerne Ancira Dodge 10807 IH-10 West

Cavender Audi 15447 IH-10 West

Cavender Buick 17811 San Pedro Ave. (281 N @ Loop 1604)

Ingram Park Auto Center 7000 NW Loop 410

Northside Ford 12300 San Pedro Ave.

Ancira Jeep 10807 IH-10 West Ingram Park Auto Center 7000 NW Loop 410

* North Park Lexus 611 Lockhill Selma

Tom Benson Chevrolet 9400 San Pedro Ave. Gunn Chevrolet 12602 IH-35 North

Ancira Nissan 10835 IH-10 West

* Ancira Volkswagen 5125 Bandera Rd. North Park VW at Dominion 21315 IH-10 West

Ingram Park Nissan 7000 NW Loop 410

North Park Lexus Dominion 21531 IH-10 West Frontage Road Cavender GMC 17811 San Pedro Ave.

Batchelor Cadillac 11001 IH-10 at Huebner

Mercedes-Benz of San Antonio 9600 San Pedro Ave.

North Park Toyota 10703 Southwest Loop 410

Gunn GMC 16440 IH-35 North

Ancira Ram 10807 IH-10 West * North Park Lincoln/ Mercury 9207 San Pedro Ave.

* Fernandez Honda 8015 IH-35 South Gunn Honda 14610 IH-10 West (@ Loop 1604)

Ingram Park Auto Center 7000 NW Loop 410

North Park Subaru 9807 San Pedro Ave. Ingram Park Auto Center 7000 NW Loop 410

North Park Subaru at Dominion 21415 IH-10 West

visit us at www.bcms.org

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AUTO REVIEW

2015 BMW 740d

By Steve Schutz, MD

I love Diesel engines. Regular readers know this, but it’s worth repeating because the recent Volkswagen TDI controversy has, to put it mildly, blunted the momentum of Diesel power plants in the U.S. For the record, I get it. Diesels are not the future. If the experts are to be believed, the future of mobility will inevitably involve self-driving electric drone pods that we won't even own. (Put me down as unenthusiastic and deeply skep44 San Antonio Medicine • December 2015

tical.) But even if they're not the future, Diesel-powered vehicles are really good right now and are worth a look in any German luxury vehicle, which is just about the only non-pickup truck place you can get them.

So, why is a Diesel VW Golf an emissions scofflaw while a BMW, Mercedes, or Audi with a Diesel isn’t? Because of urea traps. Using urea traps to catch NOx pollutants, which Diesel engines produce

more of than gasoline engines, enables Diesels to conform with current emissions rules. If your Diesel vehicle has a urea trap, you probably don’t have to worry that it’s polluting too much. None of the Volkswagen engines implicated in what’s being called Diesel-gate had urea traps.

Having said all that, it is doubtful that any Diesel engines, including those with urea traps, will be able to meet ever-tightening emissions regulations after five

AUTO REVIEW

more years or so. Which means that these wonderfully torquey and character-filled engines will go away, replaced by some type of hybrid contraption that numbercrunchers will love but enthusiasts like me will probably hate. So get ‘em while you can.

The most recent Diesel I tested was the 2015 BMW 740d, the Diesel version of the full size 7-series sedan. Powered by a 255 HP twin-turbo 3.0 liter V6, the 740d is surprisingly quick, zipping from zero to 60 MPH in less than six seconds. In fact, it feels even faster because of its mighty 413 ft-lbs of torque, which gives the big BMW terrific oomph off the line.

Before the Germans began bringing Diesels back to the U.S. about eight years ago, I read an article in Car magazine from the U.K. where the author wrote that he didn't understand why anybody would buy a Mercedes S-class that wasn't Diesel powered. Now that I've driven the Diesel S-class, Porsche Cayenne Diesel, and 740d I agree with him. Diesels’ great everyday performance combined with remarkable fuel efficiency and range are impressive to experience.

Since I tested the 740d, an all-new 7series has launched, so I won't waste your time discussing the old model and will briefly preview the new “7” instead. (I

haven't had the chance to drive it yet but will as soon as I can.)

Looking a lot like the model it replaces, the new BMW flagship is arguably the most technologically advanced car on the road today. Naturally, many cool features like air suspension and in-car wifi come standard, but there's much more including Perfume diffusers, a wireless phone charger, and Surround View camera-driven parking assist system that apparently blows away current “bird’s eye” systems.

Inside the cabin, the coolest new tech thing is gesture control for the audio system and climate control. Thankfully, all maneuvers you can accomplish with gesture control can also be done in the usual way, because, while again, I haven't driven the new 7 yet, I can't imagine using gestures to control anything when I'm by by myself, let alone when somebody else is in the car to ridicule me.

Ironically, the Diesel version of the new 7-series is not available now but is expected sometime in 2016, as is the 12 cylinder top-of-the-line 760i and even a plug-in hybrid which couples an electric motor with a four cylinder gasoline engine.

Two carryover engines are currently offered in the 7, which launched in October: the 320 HP 3.0 liter twin turbo V6 which powers the 740i, and the 445 HP 4.0 liter

twin turbo V8 that sits in the 750i. Rear wheel drive is standard in both the 740i and 750i, and awd--“X-drive” in BMW speak--is an option on the V8 car. Previously, both short- and long-wheelbase 7series sedans were offered, but that's no longer the case and only the bigger cars are available now. Despite that reality, 2016 models are about 200 lbs lighter than last generation cars thanks to the extensive use of aluminum and carbon fiber.

Diesel engines are wonderful things, in my humble opinion, but they are probably not long for this world as passenger car powerplants. If you're curious, ask Phil Hornbeak to arrange a test drive in a car or SUV that has a Diesel. I'll bet you love it. And if you're in the market for a full-size luxury sedan, don't overlook the all new BMW 7-Series.

If you’re in the market for this kind of vehicle, call Phil Hornbeak at 210-3014367 and take a look at the Subaru Legacy.

Steve Schutz, MD, is a board-certified gastroenterologist who lived in San Antonio in the 1990s when he was stationed here in the U.S. Air Force. He has been writing auto reviews for San Antonio Medicine since 1995. visit us at www.bcms.org

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46 San Antonio Medicine â&#x20AC;˘ December 2015