San Antonio Medicine February 2024

S A N A N TO N I O

SAN ANTONIO

TABLE OF CONTENTS

THE OFFICIAL PUBLICATION OF THE BEXAR COUNTY MEDICAL SOCIETY

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WWW.BCMS.ORG

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ORGAN DONATION The End-of-Year Thoughts of a Kidney Transplant Professional

By Matthias H. Kapturczak, MD, PhD ..............................................12

Innovations in Liver Transplantation

By Fred Poordad, MD, FAASLD, and Corrie Berk, DNP, MBA, APRN 14

Corneal Transplantation

By Natalie A. Johnson, MS1, and Daniel A. Johnson, MD, MBA...18

Pediatric Liver Transplantation: A path to life beyond liver disease

By Danielle Fritze, MD, and Francisco G. Cigarroa, MD ................20

One Organ Donor Could Save up to Eight Lives Through Donation Courtesy of the Texas Organ Sharing Alliance .............................22

A Love Story

By Kristy Y. Kosub, MD ................................................................24

BAMC Nurse Receives Life-Saving Bone Marrow Transplant Interview with Karina Hernandez, coordinated by Robert A. Whetstone, Deputy, Communications Division, Brooke Army Medical Center, and conducted by Monica Jones, BCMS COO, and Trisha Doucette, Editor ..........26 BCMS President’s Message .................................................................................................................................................8 BCMS Alliance Message ....................................................................................................................................................10 San Antonio Physicians: Your Opportunity to Shape Medicine in Texas

By Ezequiel “Zeke” Silva III, MD, President, BCMS ................................................................................................28 You CAN Teach an Old Doc New Tricks By Tim Hlavinka, MD..................................................................................30 Dementia: Incidence, Prevalence, Diagnostic and Treatment Approaches By Antonio Cavazos, MD, and Amber Casarez, AGNP-C, PhD-C ...................................................................................................................................32 2024 BCMS Joint Installation of Officers, Golden Aesculapius and Distinguished Service Awards .....................................34 The 1853 Club Luncheon...................................................................................................................................................38 BCMS Vendor Directory .....................................................................................................................................................40 Auto Review: 2023 Rivian R1S By Stephen Schutz, MD....................................................................................................44 Recommended Auto Dealers .............................................................................................................................................46

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SAN ANTONIO MEDICINE • February 2024

FEBRUARY 2024

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VOLUME 77 NO.2

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. EditoriAl CorrESpondEnCE: Bexar County Medical Society 4334 n loop 1604 W, Ste. 200 San Antonio, tX 78249 Email: editor@bcms.org MAGAZinE AddrESS CHAnGES: Call (210) 301-4391 or Email: membership@bcms.org SuBSCription rAtES: $30 per year or $4 per individual issue AdvErtiSinG CorrESpondEnCE: louis doucette, president traveling Blender, llC. A publication Management Firm 10036 Saxet, Boerne, tX 78006 www.travelingblender.com

For advertising rates and information Call (210) 410-0014 Email: louis@travelingblender.com SAN ANTONIO MEDICINE is published by SmithPrint, Inc. (Publisher) on behalf of the Bexar County Medical Society (BCMS). Reproduction in any manner in whole or part is prohibited without the express written consent of Bexar County Medical Society. Material contained herein does not necessarily reflect the opinion of BCMS, its members, or its staff. SAN ANTONIO MEDICINE the Publisher and BCMS reserves the right to edit all material for clarity and space and assumes no responsibility for accuracy, errors or omissions. San Antonio Medicine does not knowingly accept false or misleading advertisements or editorial nor does the Publisher or BCMS assume responsibility should such advertising or editorial appear.

Articles and photos are welcome and may be submitted to our office to be used subject to the discretion and review of the Publisher and BCMS. All real estate advertising is subject to the Federal Fair Housing Act of 1968, which makes it illegal to advertise “any preference limitation or discrimination based on race, color, religion, sex, handicap, familial status or national orgin, or an intention to make such preference limitation or discrimination.

SmithPrint, Inc. is a family-owned and operated San Antonio-based printing and publishing company that has been in business since 1995. We are specialists in turn-key operations and offer our clients a wide variety of capabilities to ensure their projects are printed and delivered on schedule while consistently exceeding their quality expectations. We bring this work ethic and commitment to customers along with our personal service and attention to our clients’ printing and marketing needs to San Antonio Medicine magazine with each issue.

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BCMS BOARD OF DIRECTORS ELECTED OFFICERS

Ezequiel “Zeke” Silva, iii, Md, President lyssa ochoa, Md, Vice President John Shepherd, Md, President-elect Jennifer r. rushton, Md, Treasurer lubna naeem, Md, Secretary John Joseph nava, Md, Immediate Past President

DIRECTORS

Woodson “Scott” Jones, Md, Member Sumeru “Sam” G. Mehta, Md, Member M. “Hamed” reza Mizani, Md, Member priti Mody-Bailey, Md, Member dan powell, Md, Member Ana rodriguez, Md, Member raul Santoscoy, do, Member lauren tarbox, Md, Member nancy vacca, Md, Member Col. Elisa d. o’Hern, Md, MC, FS, Military Representative Jayesh Shah, Md, tMA Board of Trustees Representative John pham, do, UIW Medical School Representative robert leverence, Md, UT Health Medical School Representative ramon S. Cancino, Md, Medical School Representative lori Kels, Md, Medical School Representative ronald rodriguez, Md, Medical School Representative victoria Kohler-Webb, BCMS Alliance Representative Carolina Arias, Md, Board of Ethics Representative Melody newsom, BCMS CEO/Executive Director George F. “rick” Evans, Jr., General Counsel

BCMS SENIOR STAFF

Melody newsom, CEO/Executive Director Monica Jones, Chief Operating Officer Yvonne nino, Controller Al ortiz, Chief Information Officer Brissa vela, Director of Membership & Corporate Partnerships phil Hornbeak, Auto Program Director Mary E. nava, Chief Governmental Affairs Officer Betty Fernandez, BCVI Director

PUBLICATIONS COMMITTEE

Monica Jacqueline Salas, Md, Co-chair Jennifer C. Seger, Md, Co-chair lokesh Bathla, Md, Member Elizabeth Clanton, Md, Member Erika Gabriela Gonzalez-reyes, Md, Member timothy C. Hlavinka, Md, Member John robert Holcomb, Md, Member Soma S. S. K. Jyothula, Md, Member Kristy Yvonne Kosub, Md, Member Jaime pankowsky, Md, Member George-thomas Martin pugh, Md, Member rajam S. ramamurthy, Md, Member Adam v. ratner, Md, Member John Joseph Seidenfeld, Md, Member Boulos toursarkissian, Md, Member Francis vu tran, Md, Member Faraz Yousefian, do, Member louis doucette, Consultant Brissa vela, Consultant Monica Jones, Staff Liaison trisha doucette, Editor deepthi S. Akella, Student Moses Alfaro, Student victoria Ayodele, Student tue Felix nguyen, Student Andrew ta, Student Alixandria Fiore pfeiffer, do, Resident Elizabeth Allen, Volunteer Adelita G. Cantu, phd, Volunteer rita Espinoza, drpH, Volunteer natalie reyna nyren, pA-C, Volunteer david Schulz, Volunteer 6

SAN ANTONIO MEDICINE • February 2024

PRESIDENT’S MESSAGE

BCMS: Our Most Important Asset: Our Members

By Ezequiel "Zeke" Silva III, President, Bexar County Medical Society (BCMS)

As BCMS President, I am deeply committed to our members, a diverse and dynamic group of physicians and medical students in Bexar and surrounding counties. Our primary mission is understanding and serving their needs, ensuring that we remain a vital part of their professional and personal growth.

Why It Matters: BCMS, an association of physicians and medical students, is fundamentally dependent on its membership and their engagement. The health and well-being of our community are directly linked to our success. We are the backbone of medical advocacy and support in our region, and our strength comes from our members' active participation.

Who We Are: BCMS proudly represents physicians across Bexar and neighboring counties. We are dedicated to addressing the varied needs of our members, which includes a wide range of specialties, practice models and career stages. This diversity makes our task both challenging and rewarding, as we strive to cater to the unique needs of each member.

What We Offer: 1. Services: Our multifunctional building is a central hub for community gatherings, educational events and BCMS-related meetings.

San Antonio Medicine, our monthly publication, features articles from members, providing insights into different specialties and patient care innovation. Our online presence offers resources on vaccines and physician wellness. We focus on professional growth through our Speaker’s Bureau, Medical/Legal Committee, Leadership Course and mentorship programs. Additionally, we offer practice support to physicians' staff, providing resources focused on reimbursement issues and ancillary staffing support.

2. Experiences: We recognize the stressful nature of medicine and focus on building a supportive community. We organize social events like the Holiday Party and Auto Show, fostering networking and relaxation. Leadership opportunities abound in BCMS committees, the Board of Directors and delegations to the TMA and AMA. We celebrate leadership beyond BCMS with events like the Women Leaders in Medicine Awards and the Installation of Officers, and recognize outstanding individual achievement through awards like the Golden Aesculapius and the Dianna Burns-Banks Community Service Award.

3. Representation: Advocacy is a cornerstone of our work. We listen to the local challenges and needs of our members, translating them into actionable solutions. A prime example was our response to the COVID19 vaccine distribution challenge in early 2021, where we facilitated ac8

SAN ANTONIO MEDICINE • February 2024

cess for office-based practices, who lacked access through local healthcare systems. Our advocacy extends to state and national levels, with members serving on delegations to the TMA and AMA, and testifying before legislative and regulatory bodies. These efforts ensure our members' voices are heard and their concerns are addressed beyond San Antonio.

Dig Deeper: BCMS has a 170-year history of representing physicians and medical students. Our calendar is packed with events and activities, which can be found at www.bcms.org/commevents.php. A description of our various committees is available at www.bcms.org/committees.php. We are also fortunate to have a robust BCMS Alliance, fostering partnerships with families supporting their physician family members. More information about this important group is available at www.bcmsalliance.org and www.texmedalliance.org.

Physicians are busy professionals with responsibilities to their practice, family and personal needs. BCMS seeks to complement these responsibilities by providing a venue to translate what we see in our practices into solutions for our community. We strive to do this efficiently and with effective communication and support.

Get Involved: We invite you to engage with us. Use this link to send us your information, and we will tap into your talents: www.bexarcv.com/secure/ bcmsform.php?pdf=committeepreferenceform.pdf.

Conclusion: BCMS is unwavering in its commitment to its members, continually adapting to meet their evolving needs. We understand the importance of member contributions, both in terms of dues and volunteer efforts, to sustain and enrich our community. Our goal is to be the indispensable resource for our physicians, ready to respond to their concerns and aspirations. Through collective efforts, we aim to strengthen the voice of physicians in San Antonio and make significant contributions to patient care and public health.

Ezequiel “Zeke” Silva III, MD, is the 2024 President of the Bexar County Medical Society. Dr. Silva is a radiologist with the South Texas Radiology Group, Adjunct Professor of Radiology at the UT Health, Long School of Medicine, and Vice-Chief of Staff at Methodist Hospital Texsan.

He serves on the TMA Council on Legislation and is a TMA Delegate to the AMA. He chairs the AMA RVS Update Committee (RUC).

Visit us at www.bcms.org

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BCMS ALLIANCE

lect a, President-E Brittany Garci ne Physician, ici ed M ts , Spor Dr. Ramy Noche the Christus of r nio/Directo Ortho San Anto llowship orts Medicine Fe Primar y Care Sp s in Bexar nt de stu ships to Awarding Scholar e the TMA lik and service projects County every fall distribute ers mb me ere m, wh ty, make Bookshare progra ni mu com ildren in the books to young ch .

SA M BC of part me proud to be a

Victoria Kohler-Webb, President Dr. Benjamin Webb, Otolaryngology/Head Neck Surgery, Partner, Alamo ENT Associates To me, BCMSA is the perfect blend of fun, friendship and function. We advocate for physicians and their patients AND we build a strong physician family community!

Julia Halvorsen, VP Community Outreach Dr. Jake Halvorse n, Emerg ency M edicine, Medical Director-B aptist Neighborhoo d Hospital-Kelly I love the Alliance bec ause it has provided me with the opportunity to for m friendships and con nections with people who sha re the goals of fostering community with other physi cian families and im proving healthcare for all Te xans.

Meet Your BCMSA Board!

By Victoria Kohler-Webb, BBA, MS

Amy Samples, Se cretary Dr. D. Clint Sample s, Cardiothoracic An esthesia I love BCMSA for the opportunity to connec t with others who understa nd the joys and cha llenges of medical life. This yea r, I’m looking forwa rd to opportunities to give bac k and support the com munity while having fun!

Taylor Frantz, VP Social Programs Dr. Garrett Frantz, Emergency Medicine I love the BCMSA because it is a community that understands the uniqueness of being married to medicine!

Thais Reichert, VP Membership Dr. Ryan Reichert – Resident, Anesthesia BCMS A has helped me meet wonderful people who have been and wh o are in the same journe y I am in, and make life long friends. It has als o given me opportunitie s to be more involved with my community and ser ve others.

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SAN ANTONIO MEDICINE • February 2024

tions VP Communica Heather Davila, icine ed M l na ter In DO Dr. Edwin Davila, to give back ause it’s a great way I love BCMSA bec Projects like ch. mu so e lov I t to the community tha McDonald Peace and Ronald Sleep in Heavenly ce that reien centering exper House were such a never take d an ul tef gra be to minds me always involved get to me s It also allow health for granted. ough the thr t th friends I've me in the community wi y. medical communit

Carly Friedman, Treasurer Dr. Duncan Friedman, MD, MPH Ophthalmology, Central Texas Retina Institute I love BCMSA because of the opportunities to connect with other families in the field. It is so rewarding to have a shared purpose with others who know the joys and stresses of working in medicine.

ORGAN DONATION

The End-of-Year Thoughts of a Kidney Transplant Professional

By Matthias H. Kapturczak, MD, PhD

F

ollowing a well-traveled tradition of Dickens’ “A Christmas Carol,” December always awakens in me the need to reflect on the past before I look at my current situation and, finally, gather the courage to ponder on what the future might bring. As most of my time seems to be dedicated to work, a good portion of this reflection pertains to my professional life.

For over 25 years now, kidney transplantation has been my passion.

Although I have missed the true pioneering times, I have been fortunate to be able to witness the miracle of organ transplantation having now followed a few thousand kidney transplant recipients, witnessing their suffering prior to the life-saving surgery, and enjoying their recovery and return to a full life: children given the chance to grow up without being tethered to dialysis machines, men and women returning to work from disability, children being born to transplanted parents, families growing where they once could not.

Without a doubt, I am deeply grateful to have been able to participate in medicine of the 20th and 21st centuries. Enormous technological and pharmaceutical advancements have been made in all areas making organ transplantation possible. The 20th century witnessed ground-braking contributions of intellectual giants making overcoming the immunological barriers possible. The first six of the Nobel prizes were awarded to scientists, who contributed to the areas of immunology and transplantation, and it did not stop there. Organ transplantation became the primary treatment preference for management of end-stage failure of many organs.

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SAN ANTONIO MEDICINE • February 2024

The true miracle of transplantation to me, however, are the organ donors — the families agreeing to donate the organs of their deceased loved ones and, above all, the living donors. This is the part of medicine now all too frequently overlooked — the non-scientific, the un-reimbursed, the “humane” part of our healing endeavors. It is incredibly refreshing to see true selflessness, empathy and love at work. It is not just family members, but friends, co-workers and the non-directed donors who just want to help someone. Even if things do not work as hoped, the donors rarely have second thoughts. I have recently asked a young man who donated a kidney to his father, that passed away two weeks later, if he had any regrets. He replied, “Just seeing the hope in his eyes and joy of being off dialysis was enough for me; I would do it again, without a doubt.” This is the part of medicine that is very humbling to me and makes me want to get up every day. A powerful cure for professional “burnout,” as I have found it.

The year 2024 will mark 70 years since the first successful living donor kidney transplant, which was performed in December of 1954 in Boston between identical twin brothers. Almost two years prior to that, a mother donated a kidney to her teenage son in Paris, France — the kidney lasted only three weeks. The development of effective immunosuppression allowed the process to continue and, since that time, more than 180,000 living donor organ transplants were made possible in the U.S. alone. Living kidney donation affords a superior patient and transplanted organ survival, and allows for higher rates of early and pre-emptive transplants.

ORGAN DONATION

I am grateful to be practicing in San Antonio. Our city has been on the forefront of championing the living donation path in the attempt to improve access to kidney transplantation. For over 13 years now, our city has seen the highest rates in the country of live donor kidney transplants. San Antonio also hosts the largest single-center paired-donor exchange program in the country created to improve access to living donor kidney transplants for patients with non-compatible donors.

Further, our city has seen one of the highest numbers of transplanted ethnic minority patients in the U.S. This is, without a doubt, all amazing news. But why am I not at peace?

Currently in the United States, over 100,000 patients await a lifesaving organ transplant, and around 90,000 of those are hoping for a kidney transplant. Yearly, only about a quarter of that number are transplanted, with about one-tenth of that number either dying while waiting or removed from the list because they are too sick to undergo a kidney transplant surgery. Sadly, the proportion of patients awaiting transplant, who have lost a previous one, is steadily rising. The overall wait times have been increasing. This is troubling knowing that the sooner the transplant can be performed, the better the patient and transplant survival.

End-stage kidney disease (ESKD) affects our state the most — over 10 percent of the U.S. ESKD population are Texans. This is, in no small part, related to staggering rates of diabetes. Over 60 percent of patients listed for kidney transplant in Bexar County have lost their kidney function due to complications of diabetes. This is painfully true especially for our Hispanic patients, who also represent over 60 percent of the kidney transplant wait list. Although numerically superior, our Hispanic community is not immune to known national trends in ethnic healthcare access disparities. Even here, where over 60 percent of the population is Hispanic, Hispanic patients are less likely to get transplanted, which is true for both deceased donor and live donor kidney transplants. They also wait longer on the list. At least a good part of it seems to be related to general healthcare access as well as a variety of societal issues. The encouraging fact is that, among the living donor kidney recipients, these differences appear to significantly dissipate.

Now a quick look into the future. And this gives me a lot of trepidations.

The success of organ transplantation has become its own worst enemy. The ever-growing demand for organs will require other solutions and approaches (induction of tolerance, biocompatible devices, etc.), the development of which is sadly lagging. We will have to work very hard to prolong the function of the “gift of life.” This puts extra

pressure not only on transplant professionals but also the entire medical community and the society at large. The above-mentioned ethnic disparities, for example, do not vanish after transplant. Disease prevention effort alone is still quite underutilized, and it will require an “it takes a village” approach.

Living donors are still the best.

They have contributed more than their fair share — let us work on ours. We are, at the end of the day, all in this together — a fact that both frightens me and gives me hope, all at once.

Matthias H. Kapturczak, MD, is the Medical Director of the Methodist Transplant Institute | Kidney and Pancreas Transplant Program and Transplant Section Chief at the Methodist Hospital | Specialty and Transplant in San Antonio, Texas. He is also a member of the Bexar County Medical Society and serves as the Co-chair of the Physician Health and Rehabilitation Committee of BCMS. A native of Poland and Germany, he obtained his medical degree from the Free University of Berlin, Germany and internal medicine/nephrology training at the University of Florida in Gainesville, FL. Prior to arriving in San Antonio, he was a transplant fellow and faculty member at the University of Alabama at Birmingham, AL. His passion is expanding access to and overcoming barriers to kidney transplantation for everyone in need.

Visit us at www.bcms.org

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ORGAN DONATION

Innovations in Liver Transplantation

By Fred Poordad, MD, FAASLD, and Corrie Berk, DNP, MBA, APRN

F

he first known mention of transplantation, specifically skin grafting for burns, dates to 1550 BC, but the first human-to-human solid organ transplant was not until 1 1933. By the 1950s, kidney transplantation (KT) had become rather well-established, but still plagued with a high rate of rejection.

Inspired by the success of KT, Dr. Thomas Starzl performed the first liver transplant (LT) in 1963 at the University of Colorado before ultimately establishing a program at the University of Pittsburgh in the early 1980s. By the mid-1970s, 35 transplant programs opened around the world.2 As impressive as the surgical component was, the real success story in transplantation was the development of immunosuppressive agents that allowed for long-term graft and patient survival. With the approval of cyclosporine in 1983 and tacrolimus in 1994, excellent survival and manageable rejection rates were realized, compared with predecessor regimens such as 6-mercaptopurine. Since then, dosing optimization aimed at minimizing toxicity, preventing opportunistic infections, and surveilling for malignancy, has led to patient survival >30 years Dr. Fred Poordad with a patient. Photo courtesy of University Health Transplant Institute. and counting after organ transplantation.

Until recently, the most common indication for liver transplantation in the U.S. was chronic hepatitis C infection. Ironically, ex- in addition to bilirubin, creatinine, sodium and INR, incorporates altended donor criteria (EDC) now include the use of hepatitis C bumin and sex to better account for disparities between men and infected organs transplanted into non-infected recipients, with post- women. Nonetheless, nearly 20 percent of patients die or become too transplant eradication of hepatitis C using direct-acting antivirals. The sick waiting for a cadaveric liver transplant.3 Living donor liver transplantation (LDLT), however, is not dependrising obesity epidemic in the U.S. over the past several decades has led to steatotic liver disease (formerly known as fatty liver disease) becom- ent on the MELD score. Recipients and donors can electively schedule ing the leading indication for transplantation along with alcohol liver their respective procedures, allowing for ample timing and preparation. injury. Roughly two-thirds of all transplants are now for these indica- The recipient’s insurance provider covers medical costs for the donor, and most donors are discharged five days post operatively. Paired organ tions. exchanges can be done if a donor and recipient do not match due to Cadaveric Versus Living Donor Transplantation blood type or organ size.

The conventional liver transplant uses donation after brain death The life-years gained with LDLT are similar or greater than any other (DBD) organs. A higher risk comes with donation after circulatory life-saving procedure.4 Accounting for ~6 percent of all liver transdeath (DCD), which is often used in patients who are in more urgent plants, LDLT requires a surgical team with specialized training as well need of an organ. Both use the Model for End Stage Liver Disease as a network of ancillary medical specialists including hepatologists, (MELD) score to rank candidates by priority. The original MELD advanced endoscopists and interventional radiologists familiar with score was replaced by MELD Na, and recently by MELD 3.0, which, the nuances of the procedure and outcomes (Figures 1 and 2).

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SAN ANTONIO MEDICINE • February 2024

ORGAN DONATION

Figure 1: Anastomosis of left and right liver grafts. University Health Transplant Institute generally performs duct-duct anastomosis of bile ducts.

Borhani AA. https://doi.org/10.1148/rg.2021210012

Emerging Areas in Liver Transplantation The Best Treatment for Liver Cancer Surprising to many healthcare providers, liver transplantation is the best therapy for hepatocellular carcinoma (HCC), provided the cancer is confined to the liver and not too large. By removing the diseased liver, which is the “fertile soil” for cancers to grow, it not only cures the cancer, but the underlying disease. Resecting a liver cancer does nothing to change the milieu that allowed it to blossom, which is why most liver cancers recur after surgical resection. Resection and chemotherapy are used for patients when liver transplantation is not an option.

Liver transplantation can also be performed for other cancers such as neuroendocrine tumors, intrahepatic cholangiocarcinoma and nonresectable colorectal metastases.5 As aggressive as this may sound, selected candidates do very well and life can be extended many years.

Acute alcohol-associated liver injury Until recently, a 6-month sobriety rule was enforced prior to transplantation for alcohol-associated liver disease. This was challenged in 2011 since data did not support this arbitrary mandate. Furthermore, requirements for dietary change largely did not apply to obesity and steatotic liver disease, which histologically is very similar to alcohol-associated liver disease. Hence, many U.S. programs are now transplanting select patients with alcohol use disorder if they were unaware of a liver issue, have good insight about alcohol use, are otherwise healthy and have a good support system. The outcomes are excellent and, with appropriate follow-up and care, harmful relapse is rare.6

Liver Transplantation and Gastric Sleeve Resection Since obesity and metabolic-associated steatotic liver disease (MASLD) are the driving forces for most liver transplants in South Texas, a new concept of performing a sleeve gastrectomy along with liver transplantation has emerged. This decreases recurrent steatotic liver disease as well as diabetes and obesity-related complications since lifestyle modifications typically fail, offering a “jump-start” to a healthier post-transplant lifestyle.

Liver Transplantation at the University Health Transplant Institute in San Antonio The liver transplant program at the University Health Transplant Institute was established in 1992, under the leadership of Dr. Glenn Halff, who was later joined by Dr. Francisco Cigarroa. The addition of several outstanding surgeons from around the country, a core of eight hepatologists, two transplant fellows, ten advanced practice providers, an army of nurse coordinators, and a multi-disciplinary team of healthcare professionals has led the program to: • Transplanting ~150 livers per year.

• Growing to the second largest living donor liver program in the U.S. • Establishing a pediatric living donor transplant program.

• Increasing opportunities for transplant as the first program to do paired living donor organ exchanges.

• Being named as the #1 liver transplant program in the U.S. out of 86 programs reviewed. continued on page 16 Visit us at www.bcms.org

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ORGAN DONATION continued from page 15

ical therapies. Until then, liver transplantation remains one of the most effective life-saving therapies for advanced liver disease.

What Healthcare Providers Can Do to Help Patients with Liver Disease Many liver diseases are treatable and even reversible if diagnosed early. The earliest indicators of liver disease are elevated liver enzymes or a platelet count below the lower limit of normal.

All patients with cirrhosis should be referred to hepatologists affiliated with a transplant program as early in the disease course as possible to allow for the best long-term outcomes. This results in treatment, proper cancer surveillance, symptom management, cutting edge research opportunities, and if needed, early evaluation for liver transplantation.

Figure 2: Axial CT image of example of right lobe that would be donated.

Borhani A.A. https://doi. org/10.1148/rg2021210012

References: 1. Paul, CN (2008). "Skin grafting in burns." Wounds 20(7): 199202 2. Sharma, S, et al. (2022). "A brief history of liver transplantation and transplant anesthesia." BMC Anesthesiol 22(1): 363 3. Kwong, AJ, et al. (2021). "Correcting the sex disparity in access to liver transplantation: Lest perfect be the enemy of better." Am J Transplant 21(10): 3217-3218 4. Jackson, WE, et al. (2022). "Survival Benefit of Living-Donor Liver Transplant." JAMA Surg 157(10): 926-932 5. Ros, J, et al. (2023). "Liver transplantation in metastatic colorectal cancer: are we ready for it?" Br J Cancer 128(10): 1797-1806 6. Mathurin, P and MR Lucey (2020). "Liver transplantation in patients with alcohol-related liver disease: current status and future directions." Lancet Gastroenterol Hepatol 5(5): 507-514

Fred Poordad, MD, is Chief of Hepatology for the University Health Transplant Institute located in San Antonio’s University Hospital. He is Vice President of Academic and Clinical Affairs and co-founder of the Texas Liver Institute, and spent 11 years as the Chief of Hepatology at Cedars Sinai Medical Center prior to joining the Liver Institute in 2012. Dr. Poordad sits on many national committees for the American Association for the Study of Liver Diseases and the American College of Gastroenterology. He has authored over 300 papers and book chapters, and is internationally recognized for his work in liver disease research and teaching. Dr. Poordad also serves as a Clinical Professor of Medicine at the University of Texas Health Science Center at San Antonio, and is a member of the Bexar County Medical Society.

Figure 3: University Health Transplant Institute Survival Statistics *Single organ transplants performed between 07/01/2020 and 12/31/2022 **Single organ transplants performed between 01/01/2018 and 03/12/2020 & 06/13/2020 and 06/30/2020 Reference: srtr.org (January 9, 2024)

In addition to having a unique single-day multi-disciplinary liver cancer evaluation, University Health Transplant Institute is performing combined transplant-bariatric procedures and transplanting select colorectal metastases and acute alcohol-associated liver injury cases. To expand the cadaveric donor pool, DCD donors are being utilized with great success using ex vivo perfusion therapy technology.

The Future Innovations have not stopped in the field of liver disease and transplantation. With direct-acting antiviral (DAA) therapies for hepatitis C, allowing clearance of viral infection before and after transplantation, research is now focusing on eradication of chronic hepatitis B, effective treatments for steatotic liver disease and antifibrotics. This will help reserve transplant for those who cannot be successfully treated with med16

SAN ANTONIO MEDICINE • February 2024

Corrie Berk is a board-certified Family Nurse Practitioner and serves as the Director of Hepatology & Transplant Outreach Programs at the Texas Liver Institute. Clinically, she practices with the Austin team and at outreach clinics.

Visit us at www.bcms.org

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ORGAN DONATION

Corneal Transplantation

By Natalie A. Johnson, MS1, and Daniel A. Johnson, MD, MBA

C

orneal transplantation involves exchanging normal corneal tissue for that which is diseased or damaged. The 500–600micron thick cornea is the most anterior extension of the globe and is divided into five layers: epithelium, Bowman layer, stroma, Descemet membrane and endothelium. The cornea is responsible for nearly 75 percent of the eye’s ability to focus light clearly on the retina and is composed predominantly of Type 4 collagen fibers uniformly arranged to maintain optical clarity. The cornea receives its oxygen supply from the tear film, and its nutrients and macromolecules from the aqueous humor. Cells of the endothelial layer pump fluid from the cornea into the anterior chamber to maintain deturgescence.

In states of disease in which infection or trauma create scars that alter the orderly arrangement of collagen fibers in the corneal stroma, the image reaching the retina degrades. Fluid may also collect within the corneal stroma as a result of endothelial cell loss from age, surgery or trauma. This resulting edema can alter the orderly arrangement of fibers and similarly degrade optical quality.

When corneal clarity, either from edema or scarring, declines below a level required by the patient for adequate functioning, corneal transplantation may be considered. Although concepts of corneal surgery can be dated to Galen (130-200 AD), it was not until 1837 when Samuel Bigger reported a successful gazelle-to-gazelle corneal transplant. Subsequent xenografts to humans failed, as expected. In 1905, the first successful human-to-human corneal transplant was performed

by Edward Zirm. In this procedure, the enucleated eye of an 11-yearold who suffered a penetrating scleral wound was used as the donor for a 45-year-old with bilateral alkali burns. Since then, numerous advances have paved the way for modern corneal surgery, including the understanding of sterile technique and the refinement of anesthesia. The development of specialized instruments, surgical microscopes, inert suture material, corticosteroids, eye banks and donor storage medium that can maintain endothelial function for approximately two weeks have further contributed to this field.

Full-thickness transplantation (Figure 1) was previously required in the event of loss of corneal clarity, but evolving techniques have allowed selective replacements for either superficial, deep or full-thickness pathology. In fact, in 2010, Ljubis Nikolic and colleagues reported the use of one donor cornea for two different patients. The superficial half of the donor cornea was transplanted into a 60-year-old with a necrotic corneal melt to Descemet membrane from herpes simplex keratitis as a Deep Anterior Lamellar Keratoplasty (DALK). The remaining posterior layers of the donor cornea, including the posterior corneal 18

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stroma, Descemet membrane and endothelium, were then transplanted into a 76-year-old with endothelial dysfunction following cataract surgery as a Descemet Stripping Endothelial Keratoplasty (DSEK).

Due to advancements in the techniques for corneal transplantation, the frequency of these procedures has drastically increased. In 2022 alone, approximately 72,000 transplants were performed worldwide, with nearly 50,000 of them having taken place within the United States.

Within the United States for this year, the leading indication for keratoplasty was due to endothelial disease. Since 2012, for endothelial diseases such as Fuchs corneal dystrophy, the number of endothelial keratoplasties (Figure 2) has surpassed that of full-thickness corneal transplants. According to the Eye Bank Association of America, in 2022, there were 15,835 full-thickness, 30,812 endothelial and 476 anterior lamellar keratoplasties performed nationwide.

The sheer number of types of keratoplasty procedures has led to the development of a proverbial “alphabet soup” of abbreviations to include ALK (Anterior Lamellar Keratoplasty), ALTK (Anterior Lamellar Therapeutic Keratoplasty), DALK (Deep Anterior Lamellar Keratoplasty), dDALK (Descemetic Deep Anterior Lamellar Keratoplasty), pdDALK (pre-Descemet Deep Anterior Lamellar Keratoplasty), DMEK (Descemet Membrane Endothelial Keratoplasty), DSEK (Descemet Stripping Endothelial Keratoplasty), DSAEK (Descemet Stripping Automated Endothelial Keratoplasty), DSO/DWEK (Descemet Stripping Only/Descemet Without Endothelial Keratoplasty), EK (Endothelial Keratoplasty), FLAK (Femtosecond Laser-Assisted Keratoplasty), FLEK (Femtosecond Laser-Enabled Keratoplasty) and PKP/PK (Penetrating Keratoplasty). The selection of the appropriate technique depends upon the depth of the corneal pathology. For fullthickness disease, such as a corneal scar from a contact lens-related infection, transplantation of all layers of the cornea is typically required.

For diseases of the corneal endothelium, such as Fuchs endothelial dystrophy, the most common procedures include partial-thickness keratoplasties, such as DMEK or DSEK. Partial-thickness, or lamellar surgery, has advantages over full-thickness procedures in terms of globe stability, less risk of suture-related erosion and infection, and lower incidence of allograft rejection (Figure 3). In 2022, the most common indication for full-thickness transplantation was corneal ectasia. However, the frequency of these grafts has decreased, mostly attributed to the development of corneal cross-linking, specialty contact lenses and scleral lenses.

The risk of transplant rejection is low for eyes without significant comorbidities, such as corneal neovascularization, uveitis, prior corneal

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Figure 1: Full-thickness corneal transplant in a child with Herpes Simplex Keratitis at 4-year follow-up.

Figure 2: Endothelial keratoplasty in a patient with pseudophakic bullous keratopathy at 1-month follow up.

Figure 3: Full-thickness corneal transplant with endothelial deposits indicating allograft rejection.

temic corticosteroids and immunomodulatory therapy may be required to resolve the rejection. In a large series of penetrating keratoplasties (n=4499), Kaplan-Meier survival curves showed survivals of 97 percent, 79 percent, 72 percent and 69 percent at one, three, five and seven years, respectively. The predominant reasons for graft failure included rejection (34 percent), infections (18 percent), glaucoma (9 percent), primary failure (6 percent), trauma (4 percent) and other causes. Given that transplant rejection is a significant cause of graft loss, it is important that patients monitor for symptoms of photophobia, pain, redness and decreased vision, and know to seek ophthalmologic care immediately for evaluation and management in the event of these changes.

Future goals for corneal transplantation include the development of bioengineered corneal tissue, which will prevent allograft rejection and provide a solution to a corneal donor shortage. In addition, the development of an ex-vivo expanded endothelial cell culture that can be injected into the eye and directed to the Descemet membrane would revolutionize the management of endothelial disease.

References: American Academy of Ophthalmology Basic Science and Clinical Series, Section 2, Fundamentals and Principles of Ophthalmology and Section 8, Cornea and External Disease. 2023-2024. San Francisco, CA, EPub Crawford AZ, Patel DV, McGhee CNJ. A brief history of corneal transplantation: From ancient to modern. Oman J Ophthlamol 2013 Sep-Dec; 6 (suppl 1): S12-17 2022 Eye Banking Statistical Report. Eye Bank Association of America. Copyright 2023 EBAA Nikolic L, Javanovic V, Jamkov II. One cornea for two patients: case report. Arq Bras Optalmol 2010;73(3):291-293 Williams KA, Muehlberg SM, Lewis RF, Coster DJ. How successful is corneal transplantation? A report from the Australian Corneal Graft Register. Eye 1995, 9:219-227 American Academy of Ophthalmology Preferred Practice Pattern: Corneal Edema and Opacification. American Academy of Ophthalmology, 2018. San Francisco, CA. www.aao.org/ppp Natalie Johnson is a graduate of the Texas A&M University College of Biomedical Sciences and is now a first-year medical student at the Long School of Medicine in the combined MD/MPH pathway. She is considering a career in Ophthalmology.

transplants, prior rejection and glaucoma. In the event of transplant rejection, topical steroids alone are often used as treatment due to their excellent penetration through the corneal graft. For complex cases, sys-

Daniel A. Johnson, MD, MBA, is the Herbert F. Mueller Chair, Department of Ophthalmology at UT Health San Antonio. He specializes in the management of uveitis/ocular inflammatory disease and cornea and external diseases. Dr. Johnson is a member of the Bexar County Medical Society.

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ORGAN DONATION

Pediatric Liver Transplantation:

A path to life beyond liver disease

By Danielle Fritze, MD, and Francisco G. Cigarroa, MD

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hile end stage liver disease prompting transplantation is most common later in life, infants, children and adolescents are also impacted. Each year in the U.S., around 500 children receive a new liver, yet more than 1,000 remain on the waitlist.1 Unfortunately, waitlist mortality remains a significant problem, and the youngest patients are at the greatest risk.1 Living donor liver transplant (LDLT) is an important means of access to transplantation that is not dependent upon a child’s priority on the waitlist. While pediatric liver recipients may be extremely ill from their liver disease prior to transplant, outcomes remain excellent with 1-, 5- and 10-year post-transplant survival of 94 percent, 90 percent and 88 percent, respectively.1 The indications for liver transplant in children represent a broad array of conditions, with approximately half involving cirrhosis. Biliary atresia is the most common indication, comprising 40 percent of pediatric liver transplants.1 Auto-immune hepatitis, Primary Sclerosing Cholangitis, Progressive Familial Intrahepatic Cholestasis, and severe Cholestasis related to Total Parenteral Nutrition are other causes of cirrhosis and transplantation in children. Unlike in adults, nearly half of pediatric liver transplants are performed in children who do not have cirrhosis. Several primary hepatic neoplasms, most notably unresectable hepatoblastoma (without evident extrahepatic disease), have high cure rates with liver transplantation. A number of metabolic disorders can also be effectively treated with liver transplantation. In ornithine transcarbamylase deficiency and maple syrup urine disease, for example, liver transplantation effectively functions as a form of gene therapy — the missing enzyme is produced by the healthy transplanted liver to restore the affected metabolic pathway. Finally, acute liver failure accounts for approximately 10 percent of pediatric liver transplants.1 Many of these cases are triggered by a non-hepatitis viral illness such as adenovirus or enterovirus in a child with a previously healthy liver. Hepatitis B, toxic ingestions including acetaminophen, autoimmune and metabolic conditions can also lead to acute liver failure. While the immediate mortality of fulminant hepatic failure is high, children who receive a timely liver transplant have an excellent prognosis. Prompt referral to a pediatric liver transplant center is thus crucial.

A child’s candidacy for liver transplantation is determined by a multidisciplinary team who comprehensively reviews each child’s individual case — primary disease process, comorbidities, hepatic anatomy and social support. Few contraindications are absolute; barriers are identified and addressed prior to transplant to pave the way for the child to 20

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thrive after transplant. Most children will benefit from appropriate vaccination and younger children with chronic liver disease often require intensive nutritional interventions to promote growth while awaiting a new liver. The timing of transplant evaluation is determined by the severity and trajectory of a child’s liver disease, but early referral is beneficial. For children with acute liver failure, who are at risk for immediate progression to cerebral edema and death, full evaluation and listing can occur in a matter of hours.

In the United States, the allocation of deceased donor livers for transplant is determined primarily by acuity, secondarily factoring in a recipient’s waiting time and the distance between the organ and recipient.

Livers are thus allocated first to those with the highest risk of mortality, typically patients in fulminant hepatic failure, and then to those who are more critically ill with chronic liver disease. There is not a separate waitlist for children, but children do receive priority for livers from pediatric and adolescent donors.

On a population scale, this liver allocation system is designed to save lives and avoid waitlist mortality by directing livers first to patients in the most urgent need. For an individual patient, the unfortunate reality of this system is that the child may become critically ill before they rise high enough on the waitlist to receive a liver transplant. In 2021, 5.4 percent of children on the waitlist either died waiting for a transplant, or were removed from the list when they became too sick to undergo liver transplantation.1 Waitlist mortality is highest in children less than a year old.1 This cohort of the youngest liver patients has particularly limited access to transplantation due to their small abdominal domain (limiting the size of the liver that may be transplanted), and the paucity of pediatric donors. For many children, the answer is transplantation with a portion of a larger liver, termed a split liver graft, from either a deceased or living donor. In the past decade, living donor liver transplantation has been established as the modality of choice for most children, with fewer graft losses and improved overall survival compared to deceased donor liver transplant (5-year survival: 91 percent vs. 85 percent).1 In our practice, outstanding access to living donor liver transplantation has been transformational. Overall transplant rates have increased, currently more than twice the expected rate and more than five times the national rate.2 Median wait time is significantly shorter for those children receiving a living donor liver transplant, but graft and patient survival have remained excellent for both living and deceased donor

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liver recipients. Critically, the availability of a suitable living donor allows a child to receive a liver transplant in the timeframe that is most optimal for their health, often before they become critically ill. For children in fulminant hepatic failure who may not receive a suitable deceased donor liver offer in time, living donor liver transplant may literally be the difference between life and death. For families, the experience of living donor liver transplant has many advantages. Rather than receiving an unexpected phone call and having to rush to the hospital when a donor liver becomes available, families now have the opportunity to mark the date of their child’s transplant on the calendar weeks in advance. This allows time to make preparations for additional support, and arrangements for work absences, childcare, etc. Donors report that the ability to intervene definitively to save the life of a child is extremely rewarding.

Our extraordinary Champion for Life program, recipient of the 2023 Pinnacle Award from Donate Life America, helps each family to identify an individual who can help to spread the word about the child’s need for a living donor, termed a “Living Donor Champion.” The Champion for Life program then educates the donor champion about liver disease, transplantation and living donation, and equips the donor champion to effectively share the patient’s story. Donors may be related, unrelated or even anonymous. In the past three years, altruistic nondirected donors — individuals who volunteered to donate part of their liver to anyone in need — have saved the lives of seven children through living donor liver transplantation at our transplant center.

For those children fortunate enough to receive a transplant, the outlook is bright. Survival curves flatten after the first-year posttransplant,1 with improved quality of life compared to chronic liver

disease. For young adults >20 years post-transplant, healthrelated quality of life is similar to the general population of young adults in the U.S. across most domains.3 Outcomes also continue to improve with time, with patient and graft survival for pediatric liver recipients on an upward trend in the U.S. since 2010.1 Pediatric liver transplantation is a technically complex operation, and the care of pediatric liver candidates and liver recipients requires a highly specialized and dedicated team of transplant professionals. Living donor liver transplant is a key means of access to timely transplantation, particularly for infants and children, and a pathway to life beyond liver disease.

Additional information about pediatric liver transplantation and living liver donation can be found at our website: https://www.universityhealth.com/services/transplant-care.

References: 1. Scientific Registry of Transplant Recipients Annual Report 2021 2. https://www.srtr.org/transplant-centers/interactive-report?center=TXUC&type=TX1&organ=li 3. Mohammad S., et al. Health status in young adults 2 decades after pediatric liver transplantation. AJT 2012 Jun; 12(6): 1486-1495.

Danielle Fritze, MD, completed her medical degree and subsequent surgical training at the University of Michigan. Following general surgery residency, she pursued additional fellowship training in transplantation and hepatobiliary surgery before joining the faculty at UT Health San Antonio. Dr. Fritze specializes in liver and kidney transplantation as well as surgery of the liver, bile duct and pancreas. She has a particular interest in pediatric transplantation and was named the McCombs Director of Pediatric Transplantation. Dr. Fritze is a member of the Bexar County Medical Society.

Francisco G. Cigarroa, MD, is the Director of the Malu’ and Carlos Alvarez Center for Transplantation, Hepatobiliary Surgery and Innovation. He specializes in pediatric and adult kidney and liver transplantation. He holds the Alvarez Distinguished University Chair and the Ashbel Smith Professorship in Surgery.

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21

ORGAN DONATION

One Organ Donor Could Save up to Eight Lives Through Donation Courtesy of the Texas Organ Sharing Alliance

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n the United States, there are 56 organ procurement organizations (OPOs) dedicated to this objective. Texas Organ Sharing Alliance (TOSA) is one of three in Texas. TOSA headquarters are in San Antonio, Texas, with additional offices in Austin and McAllen. The organization serves 56 counties across the state, accounting for 7 million Texans.

Since being established in 1975, TOSA has had a mission of saving lives through the power of organ donation and has focused on two major initiatives: increasing the number of registered donors and facilitating the donation process. To accomplish this, TOSA works with over 140 hospital partners, community leaders and volunteers dedicated to organ donation and its life-saving possibilities. In 2022, within TOSA’s service region, there were 280 organ donors who gave the precious gift of life resulting in 829 organs transplanted.

TOSA has committed to serving their donor families and the selfless generosity of their donor heroes by creating two specialized facilities in collaboration with a coalition of donor recovery agencies: The Center for Life in San Antonio and The Center for Hope in Austin, Texas. These first-of-their-kind recovery centers save additional lives and increase organ donation by expediting the recovery of organs, allowing families to begin grieving and arranging memorial services in a timely manner.

TOSA works closely with Donate Life Texas (DLT), the official tissue, eye and organ donor registry in the state, to promote the registry and increase the number of registered donors across their region. Joint campaigns, events and community education opportunities combat misconceptions and misinformation while reinforcing the importance of signing up as an organ donor. Once an individual makes the decision to sign up and save lives, they are encouraged to share their decision with loved ones so families will be aware of their wish to become a 22

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donor hero.

From the moment organ donation becomes an option, TOSA’s teams of caring professionals begin to coordinate and facilitate the donation process and work with families through the journey. That process begins after a patient is legally declared brain dead (BD) or deceased after circulatory death (DCD). The hospital staff refers the patient to TOSA’s 24x7 call center to evaluate the patient, their medical history and verify if they meet donation criteria. TOSA staff will also confirm if the patient is registered as a donor.

Of the 2.2 million people who die each year, only approximately two percent will qualify to be organ donors. If the patient is a candidate for donation and did not register their decision, TOSA’s trained professionals have a conversation with the patient’s next-of-kin to get consent for organ donation. If the patient has given first-person authorization (FPA) by registering to be an organ donor, TOSA staff will inform the family of the decision their loved one made. Texas law dictates firstperson authorization of a donor is legally binding and cannot be revoked, regardless of the mechanism of death.

The recovery of organs takes place at either the patient’s current hospital or one of TOSA’s centers. Organs recovered are transported to a transplant center for the recipient to undergo surgery.

After the donation is made, TOSA provides donor families with support in their grieving process and connects them with a community of other donor families. To honor donors, TOSA unveiled The Wall of Heroes at their San Antonio Headquarters in 2020. The centerpiece pays tribute to organ donors from TOSA's service area. The Wall of Heroes will eventually display over 6,000 donor medals engraved with the donor's first name, last name, initial and date of donation.

TOSA’s collaborative efforts aim to create a positive culture for organ donation in multicultural communities to make a difference in the lives

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of those waiting for a transplant. There are over 100,000 people currently on the national transplant waiting list with over 10,000 of them in Texas. Today, 40 percent of the patients on the waiting list in Texas are Hispanic while 25 percent are Black.

The need for organ donation and transplantation is more pronounced in minority communities where disproportionately higher rates of diabetes, high blood pressure and heart disease contribute to organ failure. Although transplants can be successful regardless of the race or ethnicity of the donor and recipient, the chance of longer-term survival may be greater if the donor and recipient share a similar genetic background.

Therefore, TOSA’s education and recovery efforts are essential for successful organ transplants.

“Over the past 48 years, TOSA has worked tirelessly with compassion, dignity and respect to stay true to our mission of saving lives through the power of organ donation,” said TOSA President and CEO Joseph Nespral. “We strive to continue growing and innovating and expanding our reach to keep going strong for years to come.”

TOSA is now looking to the future and exploring possibilities of incorporating technology that could facilitate vital healthcare services. In 2022, TOSA and the Matador Consortium began a collaboration and discussion on the possibility of using uncrewed aerial systems (UAS) to help transport organs and tissue to and from rural areas, potentially improving healthcare access for the 60+ million people living in rural communities across Texas and the United States.

These types of innovations, alongside other plans for the future of Texas Organ Sharing Alliance, keep the non-profit on pace to grow and expand services. The achievements in the past years have leveraged teamwork, knowledge and dedication, which helped to shape a donation culture that inspires and educates Central and South Texas communities and keeps focus on their vision of an organ for every person on the waiting list.

For more information, visit www.tosa1.org and www.donatelifetexas.org/tosa1, and contact TOSA at communications@TOSA1.org and 210-614-7030.

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ORGAN DONATION

A Love Story

By Kristy Y. Kosub, MD

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ifteen years ago, Dr. Kanapa (Kana) Kornsawad received a special gift for which she is forever grateful and has inspired her work in medicine. Her story begins in Bangkok, Thailand, where she was born. Kana’s parents struggled economically but were committed to their children having an education, even borrowing money to pay tuition at private schools to ensure Kana could go to university. Kana first expressed her dream to be a doctor at four years of age. She remembers her father going to the hospital with asthma exacerbations because he could not afford regular primary care. Seeing the inner workings of the hospital over time inspired Kana to care for others in the same way.

Kana was an excellent student. She entered Pharmacy School at the age of 16 and after graduating, worked for two years as a pharmacist before being accepted into medical school at Faculty of Medicine, Chulalongkorn University in Bangkok. Life was beautiful. She was on her path to be a doctor and fell in love with Daniel (Danny) Ranch, a fellow student. In 1999, during her third year of medical school, Kana developed an upper respiratory infection followed by abdominal pain. She was discovered to have microscopic hematuria and ultimately received a diagnosis of IgA nephropathy, the most common form of primary glomerulonephritis and a major cause of chronic kidney disease and kidney failure. Kana was treated with medications, graduated from medical school, and began her post-graduate year of service working 24

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in an underserved Thai community. Her disease worsened, however, and she decided to put residency training on hold temporarily. Kana and Danny returned to the United States. Danny completed his Pediatrics residency in Nevada, followed by a move to San Francisco for a nephrology fellowship, while Kana worked as a research coordinator.

Unfortunately, Kana’s kidney function continued to decline and she was faced with having to start dialysis. She experienced constant muscle cramps, insomnia and fatigue. As she expressed her fears to Danny, he did not hesitate, replying, “You don’t need dialysis. You’re going to get my kidney.” And on April 29, 2009, Kana received her husband’s left kidney. She recalled the tremendous anxiety of the experience, sharing, “I remember the anesthesiologist telling me, ‘Take a good nap and we’ll see you on the other side.’ After I woke up from surgery, I felt tremendous pain and the first thing I said was, ‘Where’s Danny?’” Danny recuperated well and was discharged from the hospital two days later.

Kana was released in three days.

The early years, post-transplant, were filled with regular clinic visits, blood draws, strict diet and exercise, and up to 20 pills daily of immunosuppressant medications to prevent rejection. Kana says that her experience allowed her to learn the other side of medicine — the patient’s perspective. She understands the uncertainty and fear that patients feel during illness. When asked what helped her cope with physical and

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emotional difficulties of her illness, Kana said, “The mind is so powerful over the body. Using meditation and breathing exercises helped me.”

She was excited to complete her training, and Danny encouraged her to apply to residency programs, telling her, “My kidney will serve so many lives through you.” In 2010, Kana began Internal Medicine residency at UT Health San Antonio (UTHSA). Danny joined the university as an Assistant Professor in the Department of Pediatrics.

April will be a special month for Kana and Danny. It will be 15 years since he donated his kidney to his wife. April is also National Donate Life Month. Donate Life America, a national non-profit organization, focuses attention on the public to become organ, eye and tissue donors, and honors those who have saved lives through donation (https://donatelife.net/celebrations-and-observances/april-is-national-donate-life-month/). Living donor kidney transplants increase the number of organs available for individuals on the waitlist. While living kidney donors can potentially face medical and emotional risks, they also experience the immense reward of positively impacting someone’s life. Advantages of a living donor kidney include less time on dialysis, less time to transplantation, a healthier organ, and improved health outcomes for the recipient. As of July 2023, 8,289 individuals were on the kidney transplant waiting list in Texas — the second highest in the nation.

The love story continues. Kana and Danny are still at UTHSA. Danny is an Associate Professor and Director of the Pediatric Kidney Transplant Program, continuing to be inspired by his wife and helping save lives of children and adolescents with chronic kidney disease. Kana described her joy in life, “I am amazed I have come this far. I have a passion for medicine.” Kana’s passion is evident in her work, teaching residents and medical students and caring for patients as an Associate Professor and hospitalist at University Hospital. She recently became a certified Professional Life Coach to help others going through personal and professional issues. Kana said, “I have cared for thousands of patients, and if I can teach one learner, then they will go and help thousands more.” She added, as she laid her hand on her abdomen, “And I always have Danny with me.”

Kristy Y. Kosub, MD, is a Faculty Associate at the Charles E. Cheever Jr. Center for Medical Humanities & Ethics, a member of the Bexar County Medical Society and serves on the BCMS Publications Committee.

Opposite page: Danny Ranch and Kana Kornsawad with their precious Camille.

Visit us at www.bcms.org

25

ORGAN DONATION

BAMC Nurse Receives Life-Saving Bone Marrow Transplant Interview with Karina Hernandez, coordinated by Robert A. Whetstone, Deputy, Communications Division, Brooke Army Medical Center, and conducted by Monica Jones, BCMS COO, and Trisha Doucette, Editor

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n July of 2017, Karina and Jesse Hernandez were excited to grow their young family. However, Karina had recently miscarried a baby, and began experiencing severe upper left quadrant pains. Initial tests revealed an enlarged spleen and a diagnosis of myelofibrosis, a rare bone marrow cancer that predominately effects patients 65 years and older.

They also revealed she was pregnant again.

“I was at the military hospital at the time, and they were really concerned with the thought that I had myelofibrosis to begin with, but that I was pregnant as well. Many tests were done. I had to get a bone marrow biopsy while I was pregnant, and other different tests. They said it was chronic; it was progressive. And we would watch and wait to see how quickly it progresses,” explained Karina, who said a second opinion at MD Anderson in Houston confirmed her diagnosis. She received several blood transfusions and hospital stays during her high-risk pregnancy, but in the spring of 2018, Karina delivered a healthy baby boy named Josiah, who is now 6 years old now.

Following her pregnancy, Karina underwent three types of chemotherapy treatments within the six years of living with myelofibrosis, that were only stabilizing the progression. Karina said, “So, in the summer of 2022, I got really sick. I had gastric varices; my body was just 26

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building a lot of collaterals to aid with circulation. I was on my third oral chemo that would eventually stop working. I also now had a new cancer mutation. And they said it's time, you need to have a bone marrow transplant.” Unfortunately, Karina had to leave her PACU BAMC nurse position to prepare for her fight against cancer.

The odds were not in her favor. According to the National Marrow Donor Program (NMDP), formerly called Be The Match, a perfect match is difficult to find — the chances of a Caucasian patient finding a match is 79 percent, Hispanics are a 48 percent chance and African Americans are only a 29 percent chance. Even siblings have a one-infour chance of matching. With approximately 41 million people worldwide registered as donors, the list is still not large enough to guarantee perfect matches every time. NMDP states that matching unrelated donors and recipients is based on eight genetic markers of human leukocyte antigens (or HLAs). This eight-of-eight match has long been the standard, because it reduces the threat of graft-versus-host disease, which occurs when donor cells don't recognize the recipient's cells and attack them. However, studies in non-perfect, unrelated donor and recipient matches have provided alternatives.

Karina started with her siblings, who were not a match. “Honestly, it

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was just shocking when I found out how difficult it was to find a donor.

And then the story changed. Then it became greater than me. It was like, oh my gosh, here I am. I have a little bit of time to still find my donor, when there are people that are sick that need a donor, too. And there's just such little education on how to be a donor. That's when it became so important for us, me and my husband, to begin to share awareness on how simple it was to just swab and say ‘yes’ to becoming a donor.

And so we began that journey,” Karina shared.

Karina’s first bone marrow drive was at her family’s church, St. Anthony Mary Claret, followed by a drive at Fort Sam Houston through the Salute to Life program. There was another drive in El Paso through Plant a Seed, coordinated by Leticia Mondragon, Account Manager for NMDP for South and Central Texas, El Paso and Nebraska. “We also organized a couple of other registry drives in San Antonio and shared her story at many of our registry drives,” said Leticia. Their efforts resulted in approximately 3,000 volunteers swabbed in total.

In the end, it was Karina and Jesse’s 16-year-old son David (DJ) that provided her life-saving bone marrow as a half-donor with some of the genetic markers needed to fight Karina’s cancer.

Karina said, “My son got tested at 16 years old. I needed to explain to him the challenges in case this didn’t work. I told him there was only a 50 percent chance this will work, and if it doesn’t work, I want you to know how heroic you are to do this. He said, ‘I got this.’ As a mother, you give them life and here my son is giving me life.”

Karina spent four months at MD Anderson undergoing multiple rounds of aggressive chemo treatments prior to receiving her son’s stem cells. “I almost died twice. Two days after my transplant, I woke up with an intensive GI bleed, and had emergency interventive radiology surgery

with general anesthesia where they went in through my wrist to remove part of my spleen. A week later, it happened again. This time they removed another section of my spleen. My husband was calling on our prayer warriors; we are very devout.”

Leticia said that to date no other matches have resulted from Karina’s drives but the names will be left in the registry until they are 61 years of age. In June of 2023, 702 patients were matched nationally in one month — a record for the organization. To register with NMDP, you must be 18-40 years of age. If you are the best match for a patient, NMDP pays for all travel costs to donate to a patient.

Leticia added, “Seventy percent of all patients who have been diagnosed with a blood cancer or blood disorder need to find a best match outside of their family. Only 30 percent of patients have a match in their family. Karina was very blessed to find her best match within her family.

We encourage everyone to become a part of someone's cure for blood cancer. Many do not register until it hits home and someone in their family needs their help. When we go looking for a best match for a patient, it all has to do with a person's genetic background. This is why it's so important to diversify our registry to ensure that we have a match for patients in need.”

What’s also amazing is that Karina earned her LVN, RN, then BSN and is now looking forward to completing the FNP program she had begun prior to receiving her transplant. She said, “Here I am on day 168 post-transplant. I have a spirit that has never changed since day one. I always told myself there is purpose beyond pain. I feel like I am here for a reason.”

For more information, please visit www.NMDP.org.

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27

TMA DELEGATE

San Antonio Physicians:

Your Opportunity to Shape Medicine in Texas

By Ezequiel “Zeke” Silva III, MD, President, Bexar County Medical Society

THE ROLE: BCMS Delegate to the Texas Medical Association (TMA) WHAT'S AT STAKE: • Advocating for San Antonio physicians.

• Enhancing medical practice across Texas.

• Fostering connections with doctors statewide.

OUR TEAM: • Strength in Numbers: Our delegation is 42 strong and comprises elected delegates, TMA leaders and past TMA Presidents from Bexar County.

• Diversity: We represent various specialties, practice models and career stages across Bexar and surrounding counties.

• Our Platform: We voice BCMS interests at the TMA House of Delegates (HOD), convening each spring at TexMed. OUR IMPACT: • Resolutions: We drive change through resolutions heard by the HOD. • Policy Influence: Successful resolutions shape TMA policy.

• Dual Roles: We present BCMS-focused resolutions and evaluate proposals from other HOD members, aligning with BCMS policies and local physician needs.

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SAN ANTONIO MEDICINE • February 2024

RECENT WINS: • AI in Medicine: A BCMS resolution led to TMA's inaugural policy on artificial intelligence in 2020. Resolution 201 (2020) – a Resolution that 1.) the TMA Council on Socioeconomics, TMA Committee on Health Information Technology, and TMA Council on Medical Education collaboratively study the effects of augmented intelligence (AI) on healthcare in Texas; and 2.) TMA ensures this effort includes guidance on how physicians may be affected and how physicians may prepare for the challenges and the opportunities AI creates. Initially tabled to 2021, Resolution 421 (2021) went on to be adopted as amended to collaboratively develop augmented intelligence (AI) policy.

• Obesity Treatment Access: Our advocacy now reflects in TMA policy.

WANNA DIG DEEPER INTO THE PROCESS?: At the House of Delegates (HOD), resolutions serve as the primary vehicle for action.

These proposals cover a wide range of interests pertinent to physicians, including public health, advocacy, education and medical practice. The process involves presenting, debating and voting on these resolutions at the HOD meetings. Once a resolution is accepted, it be-

comes a policy of the TMA. In certain cases, the HOD may refer a resolution for further study or action. This involves the TMA Board of Trustees or one of the TMA Councils examining the issue and reporting back to the HOD. If their report and associated policy recommendations are approved, these too become TMA policy.

Our delegation presents resolutions that reflect the needs and policies of our Bexar County Medical Society (BCMS) members.

We also review resolutions from other HOD members and delegations. Our support for resolutions from other HOD members is contingent on their alignment with BCMS policy and the specific needs of our local physicians.

The discussions within the HOD are structured around parliamentary procedure. This framework is essential to maintain orderly conduct and ensure that every participant can

TMA DELEGATE

contribute effectively. While parliamentary procedure may initially seem formal or complex, it is integral to the efficient and fair progression of meetings. New delegates often find that, with a bit of experience, they quickly adapt to this structure. Moreover, our more seasoned delegates play a crucial role in mentoring newcomers, helping them navigate and understand the intricacies of the process.

IN CONCLUSION: • The TMA HOD empowers members to voice ideas and concerns in a forum that respects every member’s ability to be heard.

• BCMS has a long history of contributing effectively at the HOD, but it requires the dedication of our physician members.

• Interested in shaping healthcare in San Antonio and in our state? Join us as an alternate delegate. Elections are held each fall.

• Required: Attendance at TMA's Annual Meeting, TexMed. Contact: For more information, reach out to Mary Nava at mary.nava@bcms.org.

Ezequiel “Zeke” Silva III, MD, is the 2024 President of the Bexar County Medical Society. Dr. Silva is a radiologist with the South Texas Radiology Group, Adjunct Professor of Radiology at the UT Health, Long School of Medicine, and Vice-Chief of Staff at Methodist Hospital Texsan. He serves on the TMA Council on Legislation and is a TMA Delegate to the AMA. He chairs the AMA RVS Update Committee (RUC).

Visit us at www.bcms.org

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SAN ANTONIO MEDICINE

You CAN Teach an Old Doc

New Tricks

By Tim Hlavinka, MD

I recently saw an advertisement from BCMS announcing a CME webinar featuring Dr. Nora Vasquez entitled, "Reimagining Life in Medicine: Coaching, Renewal and Infinite Possibilities." I signed up as I had attended a couple of her previous webinars and they were amazing. I digress, but this entire article should be about Dr. Vasquez and what she has done for our medical community. Devoting oneself to the cause of promoting the wellbeing of fellow physicians is a laudable one.

But with this session, I was reluctant to sign up. What could eight young women physicians teach me, Boomer Geezer, MD, anything about life in medicine? At age 68, I hardly have any time left for renewal and infinite possibilities. Nonetheless, I signed up and attended.

The webinar was among the best two hours I have ever spent in medicine. The energy and enthusiasm of the team was over the top. The effort and intensity necessary for these young women to overcome barriers and break ceilings in medicine were truly inspirational. That they had gone beyond surmounting those obstacles to create a superlative life and life in medicine is extraordinary. I thought back to what sort of role model I had been to younger physicians, and wondered if I had had any impact on their lives, professionally and personally, like these young women were affecting the lives of their peers. One of the participants had a motivational poster on the wall behind her, such that, every time I read a phrase from it, I immediately felt more encouraged.

Some highlights (yes, I took notes!): "Burnout is a spectrum, not an on/off switch" "Know your why" "Stop trying to mind read and learn to communicate" "We forgot why we were dreaming"

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SAN ANTONIO MEDICINE • February 2024

Then I remembered my own experience with burnout and how I first started to pull myself out of it. I read a story in a throwaway journal in the "Doctor's Lifestyle" section. It was written by a young woman, Ob/Gyn thirdyear resident, who was trying to explain her own emergence from burnout. She had three children and was about to quit medicine because of the toll it had taken on her, her family and her patients. She decided to try a simple method to make each day better; each encounter with a colleague better; each opportunity to connect with staff and patients more enriching. What was her magic secret? She said hello and good morning to everyone she saw and addressed them by name. In a crowded elevator, busy hospital hallways, parking lots, doctors' lounges ... she never missed a chance to say hello. Eventually she came to know most of her colleagues' stories. By sharing their passion and reason for choosing medicine with her, she was able to find the courage to pursue her dream with reinvigorated fervor. My thought was, "If a busy Ob/Gyn resident with three kids can do all that, I have no excuse for not making the effort to pull myself out of my funk." It was remarkable. Within months, I had regained faith in myself and the worthiness of the practice of medicine.

My research identified the commonality of the Imposter Syndrome as a major contributing factor in the development of burnout. It seems that what we have here is a case of Imposter Syndrome gone amuck. Information comes at us at dizzying speeds and we have to balance the needs of patients and our personal lives with the requirement to be on top of our game professionally. Indeed, managing the knowledge base we need to maintain the level of authority we all feel we must possess to have credibility is crushingly burdensome. Let me give you a universal pass on that one. You cannot do it. If your journal and medical news review is more than a week prior, you are behind. This is not to induce ill feelings, but to suggest that the way around it is to create a

SAN ANTONIO MEDICINE

team. I invite Dr. Google into the exam room.

We search together, so that I can guide the search. Enlisting staff and ancillary services where necessary is another way. Patients want an advocate. Most of them no longer expect us to be the final authority. Dr. Google has seen to that. The power of admitting that you do not know it all and that you are fallible is essential in gaining our patients' trust. Take it from an old doc who has had to do both more often than I care to admit!

The concept of a Moral Injury is also one prevalent in burnout literature. Different than burnout, it involves the devolution of the human psyche when there is a disconnect between our calling and the reality of our daily work. This is what we are experiencing — detailing the somber statistics on burnout serves no purpose when we live it on a daily basis. I took a TMA CME webinar on childhood and sexual abuse, and I was struck by the irony that the language and experiences cited in that literature were eerily similar to the relationship we physicians have with those that control our healthcare systems.

The core principles behind what we have achieved as individuals in medicine are empowerment, agency and transparency. We all go through the rigors of the guild-like residency system with gradually acquired skills, experience and responsibility. Anyone who has been the "Guest of Dishonor" at an M&M presentation knows exactly how the three interact to promote professional growth. These tenets must be the core principles for solving problems and creating meaningful change in healthcare, regardless of the scope of the problems or the depth of brokenness of the institutions themselves. Capacity is the overarching theme.

We can discuss these issues to our heart's content but if we keep going back to an unhealthy work environment that produces unhealthy colleagues, we are more than just wasting our time. We are perpetuating a problem. This is the source of the eye rolls and ennui-laced shoulder shrugs when we are

shown the latest plan by management to "deal with burnout." To give healthcare workers hope for a better work environment that is not substantiated by actions at the highest levels of system control is an egregious breach of authenticity about self-determination. Once again, they are using our best professional qualities and character against us. Think about this: We feel the need to present mountains of evidence to substantiate our obviously meritorious position on this issue when the C-suite can take it all away with the stroke of a budgetary pen.

Agency, transparency and empowerment that create a healthy environment to practice meaningful clinical care is the solution to burnout. The power structure of the healthcare system that has evolved has decided that we as physicians cannot have both financial success and provide meaningful clinical care.

We must choose between or become part of management and ownership.

I have an alternative. It is said that laughter is medicine, faith is medicine and music is medicine. Let me add one. Collegiality is medicine. Let us be healers to each other and follow the life of that young Ob/Gyn resident

who turned despair into renewed hopes and dreams. Let us follow the path of the young women physician coaches who are eminently wise beyond their years.

I have always wanted to create a meme where a doc is taking hold of their laptop and throwing it to the floor, smashing it to pieces. The next scene is that same doc emphatically placing a stethoscope around their shoulders, walking into a patient's room and sitting down on the patient's bed, eyes connected with the patient's eyes. What I am suggesting is not a revolution, but an evolution. Sometimes they look the same. To change, there must be a need, a want and action. Thank you, Dr. Vasquez, for showing us a way. Thank you for starting me, Boomer Geezer, MD, dreaming again.

Tim Hlavinka, MD, is the Medical Director of Vidamor Medical and has been a member of the Bexar County Medical Society for three decades. The father of five and grandfather of four, he firmly believes that the mutual power of collegiality among physicians has great potential to bring us lasting and effective changes in healthcare. Dr. Tim is anxious to hear your stories.

Visit us at www.bcms.org

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SAN ANTONIO MEDICINE

Dementia:

Incidence, Prevalence, Diagnostic and Treatment Approaches

By Antonio Cavazos MD, and Amber Casarez AGNP-C, PhD-C

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SAN ANTONIO MEDICINE • February 2024

Dementia is a global health disparity in aging, affecting an estimated 55 million older adults worldwide.1 Over time, the number of adults aged 65 and older is expected to rise to 78 million by 2030 and to 139 million by 2050.2 Currently, there is an estimated 6.7 million older adults diagnosed with Alzheimer's Disease (AD) as of 2023. As such, if medical advances are not achieved to prevent, slow progression or treat AD, this figure is predicted to increase to 13.8 million by 2060. The increasing burden of AD is demonstrated by the rise in recorded deaths from the condition, which increased by more than 145 percent between 2000 and 2019.3 This surge has shed light on the aging boomer population and the increase in the diagnosis of various types of Dementia. Previously, epidemiological studies were few and frequently had a narrow focus in the early stages of official Dementia research. As a result, the actual effect and scope of Dementia in populations were significantly underestimated. Reports of Dementia cases rose along with knowledge of the condition, especially in the latter half of the 20th century. A portion of this growth can be ascribed to enhanced diagnostic standards and heightened awareness of the illness among the public and medical community.

The current paradigm for diagnosing Dementia uses biological markers like blood testing, neuroimaging and cognitive examinations to highlight the significance of early identification. Current cost-effective, approved clinical pathophysiological testing for Dementia includes objective findings in memory, language, executive function and visuospatial abilities, as well as a decline in functional dependence. Advancements in testing include biological markers in AD, including CSF analysis and MRI for amyloid and tau proteins, which are currently undergoing FDA approval, with neurotracers (Amyvid, Tauvid) being the gold standard. Despite these advancements, logistical challenges to these methods exist for clinicians and patients alike.

SAN ANTONIO MEDICINE

Although blood-based biomarkers are FDAapproved, they are not yet independently diagnostic and remain uncovered by Medicare.

Lumbar punctures are both FDA and Medicare-approved, however, there remains limited utilization due to potential cost and patient risk.

Current literature cites similar treatments among Dementia types. Cholinesterase inhibitors (donepezil, rivastigmine, galantamine) and NMDA Receptor Agonists (Memantine) remain the most common treatment modalities in Lewy Body Dementia, AD, and Behavioral and Psychological Symptoms in Dementia. Although these treatment options are thought to reduce neuron death and improve cholinergic pathways, they fail to prevent or slow infiltrative plaque and disease progression. Recent advancements in Alzheimer's treatments show promise. In 2023, the U.S. Food and Drug Administration approved lecanemab (Leqembi) for people with mild AD and mild cognitive impairment due to Alzheimer's.4 Lecanemab is a monoclonal antibody that prevents beta-amyloid from clumping into plaques and assists the body in clearing them from the brain.5 Another promising medicine, donanemab, targets and reduces amyloid plaques and tau proteins and has been found to slow declines in thinking and functioning in people with early AD. Aducanumab (Aduhelm), while approved for the treatment of Alzheimer's, has shown mixed results in studies regarding its effectiveness in slowing cognitive decline and has limited insurance coverage.5 There is a growing consensus that multi-drug trials targeting different aspects of the disease process, including metabolic dysfunction and inflammation, will be crucial for effective treatment in the future.

Understanding Dementia's evolving trajectory is vital for healthcare planning and resource allocation. Continued research and innovation in diagnosis and treatment are imperative to address this growing challenge

effectively to improve the trajectory of disease burden on patient and community outcomes. Projections indicate that increased life expectancy will correlate with higher Dementia prevalence. This expected rise necessitates a corresponding enhancement in healthcare infrastructure, including more robust caregiver support systems and improved public health strategies to manage the increasing burden of Dementia. One such improved public health strategy includes employing home-based primary care services such as Doctor at Your Service, which provides comprehensive primary care to rural, homebound and in-clinic patients. Likewise, improvements in caregiver support systems, such as the involvement of Dementia Care Specialists, Gerontologic Specialists and allocation of community resources, assists in applying the evolving research leading to early detection and diagnosis, treatment, enhanced disease management and advanced care planning to improve outcome for patients, families and communities.

References: 1. World Health Organization. (2023). Dementia. https://www.who.int/newsroom/fact-sheets/detail/dementia 2. Alzheimer's Disease International. (2021).

World Alzheimer Report 2021. https://www.alzint.org/resource/worldalzheimer-report-2021/ 3. Rajan, KB, Weuve, J, Barnes, LL, McAninch, EA, Wilson, RS, and Evans, DA. (2021). Population estimate of people with clinical Alzheimer's disease and mild cognitive impairment in the United States (2020–2060). Alzheimer's & dementia, 17(12), 1966-1975 4. Kurkinen, M. (2023). Lecanemab (Leqembi) is not the right drug for patients with Alzheimer’s disease. Advances in Clinical and Experimental Medicine, 32(9), 943-947 5. Cummings, J. (2023). Anti-Amyloid

Monoclonal Antibodies are Transformative Treatments that Redefine Alzheimer's Disease Therapeutics. Drugs, 1-8 Aguree, S, Zolnoori, M, Atwood, TP, and Owora, A. (2023). Association between Choline Supplementation and Alzheimer's Disease Risk: A Systematic Review Protocol. Frontiers in Aging Neuroscience, 15, 1242853 Miziak, B, Błaszczyk, B, and Czuczwar, SJ. (2021). Some candidate drugs for pharmacotherapy of Alzheimer’s disease. Pharmaceuticals, 14(5), 458 Tucker-Drob, EM. (2019). Cognitive aging and dementia: a life-span perspective. Annual review of developmental psychology, 1, 177-196 Antonio Cavazos, Jr., MD, is the founder of Doctor At Your Service PLLC, and a Past President of Bexar County Medical Society.

Amber Casarez, AGNP-C, PhD-C, is a Dementia-Certified Specialist and Gerontologist.

Visit us at www.bcms.org

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2024 BCMS INSTALLATION OF OFFICERS

2024 BCMS Joint Installation of Officers And Golden Aesculapius Awards BCMS BOARD OF DIRECTORS WITH TMA LEADERSHIP Standing L-R: Rick W. Snyder II, MD, TMA President; Michael Darrouzet, TMA Executive Vice President; John Pham, DO, UIW Medical School Representative; John Shepherd, MD, President-Elect; Ezequiel “Zeke” Silva III, MD, President; John Nava, MD, Immediate Past President Seated L-R: Melody Newsom, BCMS CEO/Executive Director; Jennifer Rushton, MD, Treasurer; Lubna Naeem, MD, Secretary; Lyssa Ochoa, MD, Vice President

BCMS ALLIANCE LEADERSHIP Jenny Shepherd, Presidential Advisor and Incoming TMAA President Amy Samples, Secretary Taylor Frantz, VP Social Programs Julia Halvorsen, VP Community Outreach Victoria Kohler-Webb, President Heather Davila, VP Communications Carly Friedman, Treasurer Thais Reichert, VP Membership Jenny Case, Immediate Past President

Dr. Snyder swearing in the 2024 BCMS Officers

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SAN ANTONIO MEDICINE • February 2024

2024 BCMS INSTALLATION OF OFFICERS

Left: Dr. Silva and Victoria Kohler-Webb Right: Dr Silva, Dr. Nava and Melody Newsom

BCMS PAST PRESIDENTS Standing L-R: Gerald “Gerry” Greenfield, MD, 2020; Sheldon Gross, MD, 2018; J. Marvin Smith III, MD, 1998; Gerardo Ortega, MD, 2001; Rodolfo “Rudy” Molina, MD, 2021; Jayesh “Jay” Shah, MD, 2016; John R. Holcomb, MD, 1993 Seated L-R: John Nava, MD, 2023; Leah Jacobson, MD, 2017; Ezequiel “Zeke” Silva III, MD, 2024; Dianna Burns-Banks, MD, 2006; Rajam Ramamurthy, MD, 2004

BCMS PAST PRESIDENTS L-R: Rajam Ramamurthy, MD; Somayaji Ramamurthy, MD; Gigi Gross, Sheldon Gross, MD; Gerardo Ortega, MD; Delbert Chumley, MD; Louise Chumley; Catherine Ortega

Visit us at www.bcms.org

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2024 BCMS INSTALLATION OF OFFICERS

BCMS ALLIANCE PRESIDENTS L-R: Taylor Frantz, 2022; Victoria Kohler-Webb, 2024; Jenny Case, 2023; Jenny Shepherd, 2018

Above left: Dr. Silva and family Above right: Dr. Silva and Victoria Kohler-Webb with guest emcee Marvin Hurst Left: Dianna Burns-Banks, MD and family.

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SAN ANTONIO MEDICINE • February 2024

2024 BCMS INSTALLATION OF OFFICERS

GOLDEN AESCULAPIUS AWARD HONOREES

Dr. Silva and Dianna Burns-Banks, MD

Dr. Silva and John R. Holcomb, MD

Dr. Silva and Rodolfo “Rudy” Molina, MD

DISTINGUISHED SERVICE AWARD HONOREE

Dr. Silva and Mary Wearden, MD

Rodolfo “Rudy” Molina, MD; Mary Wearden, MD; Dianna Burns-Banks, MD; John R. Holcomb, MD

Thank you to this years’ event sponsors: Dr. Dianna Burns-Banks UT Health SA - Office of the President UT Health SA - Long School of Medicine

UIW School of Osteopathic Medicine Mission Oncology Partners Texas Indo Physicians - Southwest Chapter (TIPSW) Visit us at www.bcms.org

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1853 CLUB

The 1853 Club Luncheon The 1853 Club met on January 9, 2024 at the BCMS headquarters. Guest speaker, Brent Fessler, Ed.D., of Kinected Coworking, presented the characteristics, utilization, pros and cons of Artificial Intelligence (AI) in daily life.

The next luncheon for the 1853 Club will take place on April 2, 2024, at 11:30 a.m. at the BCMS headquarters. Spouses or guests are welcome to join us.

If you are interested in receiving information about this and other 1853 Club events, please contact the BCMS Membership Department at 210-301-4371 or membership@bcms.org.

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SAN ANTONIO MEDICINE • February 2024

Visit us at www.bcms.org

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Shop Businesses Who Support BCMS BCMS Business Directory We encourage you to use our friends of medicine businesses whenever you or your practice need supplies or services.

ACCOUNTING FIRMS

Sol Schwartz & Associates P.C. (HHH Gold Sponsor) Sol Schwartz & Associates is the premier accounting firm for San Antonio-area medical practices and specializes in helping physicians and their management teams maximize their financial effectiveness.

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

ASSET WEALTH MANAGEMENT

Aspect Wealth Management (★★★ 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.

Michael Clark, President 210-268-1520 mclark@aspectwealth.com www.aspectwealth.com “Your wealth. . .All aspects”

BANKING

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

Thomas M. Duran SVP, Private Banking Team Lead 210-283-6640 TDuran@Broadway.Bank www.broadwaybank.com “We’re here for good.”

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

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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 Amegy Bank of Texas (HH Silver Sponsor) We believe that any great relationship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability. We work hard and together with our clients to accomplish great things.

Robert Lindley SVP | Private Banking Team Lead 210-343-4526 Robert.Lindley@amegybank.com Denise Smith Vice President | Private Banking 210-343-4502 Denise.C.Smith@amegybank.com Scott Gonzales Assistant Vice President | Private Banking 210-343-4494 Scott.Gonzales@amegybank.com www.amegybank.com “Community banking partnership” Synergy Federal Credit Union (HH Silver Sponsor) Looking for low loan rates for mortgages and vehicles? We've got them for you. We provide a full suite of digital and traditional financial products, designed to help Physicians get the banking services they need.

Synergy FCU Member Services 210-750-8333 info@synergyfcu.org www.synergyfcu.org “Once a member, always a member. Join today!”

CLINICAL DIAGNOSTICS

Kevin Setanyan Managing Partner 210-503-0003 kevin@genicslabs.com Artyom Vardapetyan Managing Partner 210-503-0003 www.genicslabs.com “Accurate results in record time.”

Livingston Med Lab (HH Silver Sponsor) High Complexity Clia/Cola accredited Laboratory providing White Glove Customer Service. We offer a Full Diagnostic Test Menu in the fields of Hematology, Chemistry, Endocrinology, Toxicology, Infectious Disease, & Genetics.

Robert Castaneda, CEO 210-316-1792 Robert@livingstonmedlab.com www.livingstonmedlab.com/home “Trusted Innovative, Accurate, and STAT Medical Diagnostics”

CREDENTIALS VERIFICATION ORGANIZATION

Bexar Credentials Verification, Inc. (HHHH 10K Platinum Sponsor) Bexar Credentials Verification Inc. provides primary source verification of credentials data that meets The Joint Commission (TJC) and the National Committee for Quality Assurance (NCQA) standards for health care entities.

Betty Fernandez Director of Operations 210-582-6355 Betty.Fernandez@bexarcv.com www.BexarCV.com “Proudly serving the medical community since 1998”

FINANCIAL ADVISORS Genics Laboratories (HHH Gold Sponsor) Genics Laboratories offers accurate, comprehensive and reliable results to our partners and patients. Genics Laboratories is committed to continuous research, ensuring our protocols are always at the peak of current technology.

Yulia Leontieva Managing Partner, Physician Liaison 210-503-0003 yulia@genicslabs.com

SAN ANTONIO MEDICINE • February 2024

Oakwell Private Wealth Management (HHH Gold Sponsor) Oakwell Private Wealth Management is an independent financial advisory firm with a proven track record of providing tailored financial planning and wealth management services to those within the medical community.

Brian T. Boswell, CFP®, QKA Senior Private Wealth Advisor 512-649-8113 SERVICE@OAKWELLPWM.COM

www.oakwellpwm.com “More Than Just Your Advisor, We're Your Wealth Management Partner” Elizabeth Olney with Edward Jones (HH Silver Sponsor) We learn your individual needs so we can develop a strategy to help you achieve your financial goals.

Join the nearly 7 million investors who know. Contact me to develop an investment strategy that makes sense for you.

Elizabeth Olney Financial Advisor 210-858-5880 Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabeth-olney "Making Sense of Investing"

FINANCIAL SERVICES

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.

Michael Clark, President 210-268-1520 mclark@aspectwealth.com www.aspectwealth.com “Your wealth. . .All aspects”

Hancock Whitney (HHH Gold Sponsor) www.hancockwhitney.com Since the late 1800s, Hancock Whitney has embodied core values of Honor & Integrity, Strength & Stability, Commitment to Service, Teamwork, and Personal Responsibility. Hancock Whitney offices and financial centers in Mississippi, Alabama, Florida, Louisiana, and Texas offer comprehensive financial products and services, including traditional and online banking; commercial, treasury management, and small business banking; private banking; trust; healthcare banking; and mortgage services.

John Riquelme San Antonio Market President 210-273-0989 John.Riquelme@hancockwhitney.com

Larry Anthis Corporate Banking, Relationship Manager 210-507-9646 Larry.Anthis@hancockwhitney.com Serina Perez San Antonio Business Banking 210-507-9636 Serina.Perez@hancockwhitney.com Erik Carrington Texas Regional Wealth Management Manager 713-543-4517 Erik.Carrington@hancockwhitney.com

GERIATRICS/PRIMARY CARE

Conviva Care Center (HHH Gold Sponsor) Conviva’s value-based care model allows physicians to deliver high quality, personalized care and achieve better outcomes, while feeling free to focus on health equity and patient outcomes.

Kim Gary Senior Physician Recruiter 812-272-9838 KGary4@humana.com www.ConvivaCareers.com “Fuel Your Passion & Find Your Purpose”

HOSPITALS/ HEALTHCARE FACILITIES

UT Health San Antonio MD Anderson Cancer Center (HHH Gold Sponsor) UT Health provides our region with the most comprehensive care through expert, compassionate providers treating patients in more than 140 medical specialties at locations throughout San Antonio and the Hill Country.

UT Health San Antonio Physicians Regina Delgado Business Development Manager 210-450-3713 delgador4@uthscsa.edu UT Health San Antonio MD Anderson Mays Cancer Center Laura Kouba Business Development Manager 210-265-7662 norriskouba@uthscsa.edu https://uthscsa.edu/ Appointments: 210-450-1000 UT Health San Antonio 7979 Wurzbach Road San Antonio, TX 78229

HOSPITALS/ HEALTHCARE SERVICES

INSURANCE/MEDICAL MALPRACTICE

Equality Health (HHH Gold Sponsor) Equality Health deploys a wholeperson care model that helps independent practices adopt and deliver value-based care for diverse communities. Our model offers technology, care coordination, and hands-on support to optimize practice performance for Medicaid patients in Texas.

Cristian Leos Network Development Manager 210-608-4205 cleos@equalityhealth.com www.equalityhealth.com “Reimagining the New Frontier of Value-Based Care.”

Texas Medical Liability Trust (HHHH 10K Platinum Sponsor) With more than 20,000 healthcare professionals in its care, Texas Medical Liability Trust (TMLT) provides malpractice insurance and related products to physicians.

Our purpose is to make a positive impact on the quality of healthcare for patients by educating, protecting, and defending physicians.

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

HR HUMAN RESOURCES Insperity (★★Silver Sponsor) Insperity’s HR solutions offer premium service and technology to facilitate growth by streamlining processes related to payroll, benefits, talent management and HR compliance. We provide the tools to help you lighten your administrative load, maximize productivity and manage risks – so you can focus on growth.

Cynthia Marshall Business Performance Advisor 210-558-2520 cynthia.marshall@insperity.com Dayton Parker Business Performance Advisor 210-558-2517 dayton.parker@insperity.com www.insperity.com “Insperity’s mission is to help businesses succeed so communities prosper”

INSURANCE

TMA Insurance Trust (HHHH 10K Platinum Sponsor) TMA Insurance Trust is a full-service insurance agency offering a full line of products – some with exclusive member discounts and staffed by professional advisors with years of experience. Call today for a complimentary insurance review. It will be our privilege to serve you.

Wendell England Director of Member Benefits 512-370-1776 wendell.england@tmait.org 800-880-8181 www.tmait.org “We offer BCMS members a free insurance portfolio review.”

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.”

MedPro Group (HH Silver Sponsor) Rated A++ by A.M. Best, MedPro Group has been offering customized insurance, claims and risk solutions to the healthcare community since 1899. Visit MedPro to learn more.

Kirsten Baze, RPLU, ARM AVP Market Manager, SW Division 512-658-0262 Fax: 844-293-6355 Kirsten.Baze@medpro.com www.medpro.com

new development acquisitions and sales, lease representation and financial (RE)-structuring for existing investments.

Jon Wiegand, Principal 210-241-2036 jw@alamocapitaladvisors.com www.alamocapitaladvisors.com

MEDICAL SUPPLIES AND EQUIPMENT Henry Schein Medical (HH Silver 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 to 50 percent.”

PHYSICIAL SUPPORT SERVICES

Provider's Choice Scribe Services (★★★ Gold Sponsor) Our accurate and complete documentation helps our customers focus on what’s most important, their patients. Let us take on the task of documenting your patient encounters, it’s what we do.

Yoceline Aguilar COO 915-691-9178 yaguilar@pcscribes.com Luis Chapa MD/CEO 210-796-4547 lchapa@pcscribes.com www.providerschoicess.com/ “An Unparalleled Scribe Experience”

INVESTMENT ADVISORY REAL ESTATE

Alamo Capital Advisors LLC (★★★★ 10K Platinum Sponsor) Alamo Capital Advisors is focused on Sourcing, Capitalizing, and Executing investment and development opportunities for our investment partners and providing thoughtful solutions to our advisory clients. Current and representation projects include

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BCMS Business Directory PRACTICE MANAGEMENT

Equality Health (★★★ Gold Sponsor) Equality Health deploys a wholeperson care model that helps independent practices adopt and deliver value-based care for diverse communities. Our model offers technology, care coordination, and hands-on support to optimize practice performance for Medicaid patients in Texas.

Cristian Leos Network Development Manager 210-608-4205 cleos@equalityhealth.com www.equalityhealth.com “Reimagining the New Frontier of Value-Based Care.”

PROFESSIONAL ORGANIZATIONS Healthcare Leaders of San Antonio (HH Silver Sponsor) We are dedicated to nurturing business connections and professional relationships, exchanging knowledge to enhance leadership, and creating career opportunities for healthcare and other industry leaders in a supportive community.

David Neathery President 210-797-8412 healthcareleaderssa@gmail.com Gary Meyn, LFACHE Vice President 210-912-0120 gmeyn@vestedbb.com https://healthcareleaderssa.com/ “Come, Learn, Connect!”

The Health Cell (HH Silver Sponsor) “Our Focus is People” Our mission is to support the people who propel the healthcare and bioscience industry in San Antonio.

Industry, academia, military, nonprofit, R&D, healthcare delivery, professional services and more!

Kevin Barber President 210-308-7907 (Direct) kbarber@bdo.com Valerie Rogler Program Coordinator 210-904-5404 Valerie@thehealthcell.org www.thehealthcell.org “Where San Antonio’s Healthcare Leaders Meet”

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San Antonio Medical Group Management Association (SAMGMA) (HH Silver Sponsor) SAMGMA is a professional nonprofit association with a mission to provide educational programs and networking opportunities to medical practice managers and support charitable fundraising.

Jeannine Ruffner President info4@samgma.org www.samgma.org

REAL ESTATE SERVICES COMMERCIAL

Alamo Capital Advisors LLC (★★★★ 10K Platinum Sponsor) Alamo Capital Advisors is focused on Sourcing, Capitalizing, and Executing investment and development opportunities for our investment partners and providing thoughtful solutions to our advisory clients. Current and representation projects include new development acquisitions and sales, lease representation and financial (RE)-structuring for existing investments.

Jon Wiegand Principal 210-241-2036 jw@alamocapitaladvisors.com www.alamocapitaladvisors.com

RETIREMENT PLANNING

Oakwell Private Wealth Management (★★★ Gold Sponsor) Oakwell Private Wealth Management is an independent financial advisory firm with a proven track record of providing tailored financial planning and wealth management services to those within the medical community.

Brian T. Boswell, CFP®, QKA Senior Private Wealth Advisor 512-649-8113 SERVICE@OAKWELLPWM.COM www.oakwellpwm.com “More Than Just Your Advisor, We're Your Wealth Management Partner”

SAN ANTONIO MEDICINE • February 2024

continued from page 41

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.

Mike DeQuattro Director of Operations - Texas & New Mexico 210-918-8737 Mike.DeQuattro@ favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.”

Eleos Virtual Healthcare Solutions (HH Silver Sponsor) Empowering physicians for a Balanced Future. Our virtual health associates alleviate administrative burdens in the evolving healthcare landscape, combatting burnout. Join us in transforming healthcare delivery, prioritizing your wellbeing and patient care.

Pedro Caretto, VP of Business Development 786-437-4009 pcaretto@eleosvhs.com www.eleosvhs.com

TRANSCRIPTION SERVICES

Provider's Choice Scribe Services (★★★ Gold Sponsor) Our accurate and complete documentation helps our customers focus on what’s most important, their patients. Let us take on the task of documenting your patient encounters, it’s what we do.

Yoceline Aguilar COO yaguilar@pcscribes.com 915-691-9178 Luis Chapa MD/CEO 210-796-4547 lchapa@pcscribes.com www.providerschoicess.com/ “An Unparalleled Scribe Experience”

Visit us at www.bcms.org

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AUTO REVIEW

2023 Rivian R1S

By Stephen Schutz, MD

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SAN ANTONIO MEDICINE • February 2024

AUTO REVIEW As regular readers know, I am an internal combustion engine (ICE) enthusiast and battery electric vehicle (BEV) skeptic. Nevertheless, since I can imagine a happy future with BEVs everywhere and no more new ICE cars for sale, I’d rather be known as a BEV “waiter” rather than skeptic.

As we continue into the electric era, Rivian has emerged as an important contender with its groundbreaking R1T pickup truck and R1S large luxury SUV as their first products.

The Rivian R1S SUV’s design is both uninteresting and interesting at the same time. It’s a classic two box design from the side, which means that the R1S looks kind of like the box it came in, and yet it adds a very distinctive front end with unique lighting that blends that boxiness with other contemporary design elements. The rear light bar that spans the width of the back end is also sleek and modern. Compared with competitors like the Mercedes GLS, Cadillac Escalade, BMW X7 and Lexus LX 600, I’d say the Rivian wins just because it looks upscale and different.

The interior of the Rivian R1S is spacious and luxurious. Premium leather upholstery, decent plastics, attractive wood accents and a modern infotainment system let you know that this is a legitimate alternative to the usual luxury alternatives. Seating for seven passengers is standard in all R1Ss. Surprisingly, neither Apple CarPlay nor Android Auto connectivity are available in the R1S. For many buyers, this will be a problem.

The R1S conspicuously incorporates recycled and eco-friendly materials throughout the cabin, reminding environmentally conscious owners that buying or leasing a Rivian provides sustainability bonafides.

As is the case with most BEVs, one of the standout features of the Rivian R1S is its exceptional acceleration. The quad-motor setup in particular delivers the ability to accelerate from 0 to 60 mph in just 3.1 seconds, which is high-performance sports car territory. Obviously, its 6986lbs curb weight means that this large SUV can’t handle anything like a sports car, but you already knew that.

The dual-motor powertrain, like the one in my test vehicle, provides 600HP, which I think is plenty. For those who want more than plenty, the quad-motor R1S pumps out 835HP. Standard all-wheel-drive ensures good traction, while 15 inches of ground clearance make this luxury SUV suitable for traversing a wide

array of terrains in virtually any weather conditions.

You can’t say BEV without thinking range anxiety, and the Rivian R1S does better than any other direct competitor that doesn’t rhyme with Lesla. The base model can go 260mi on a charge, while adding the $6000 Large Battery bumps that up to 352. The largest battery pack called “Max” gets you 400mi of range on a charge, but that costs $16,000.

My usual caveats about all-electric vehicles in 2024 apply to the Rivian as much as they do for every other BEV. Range figures are for ideal conditions only, so cold or hot days will decrease how far you can go, as will adding passengers and/or gear, driving fast or putting the AC on max. In addition, finding charging stations that work, are conveniently located and aren’t being used can be difficult when you’re traveling. For now, I tell people who ask me — and I get asked this a lot — that they will love their BEV most if they charge at home exclusively, use it locally and keep an Escalade or Suburban for road trips.

And given the rapid technology advancements, leasing probably makes more sense than buying.

No review of the R1S would be complete without a mention of its groundbreaking "Tank Turn" feature. By independently controlling the power to each wheel, the vehicle can execute a full rotation in place. I guess if you’re parallel parked between two cars and can’t get out, this might be useful — I’m 60 and this has never happened to me — but otherwise it’s good for cocktail conversation only.

The R1S is equipped with all of the driver-assistance and safety features that you’d expect in the large luxury SUV market segment, including adaptive cruise control, lane-keeping assist and automatic emergency braking.

It also costs as much as vehicles in that segment with a starting price of just under $86,000, which can balloon up to over $100,000 if you get too excited with the configurator.

Driving the R1S reminded me most of the Mercedes GLS (in fact, I suspect Rivian benchmarked that vehicle during the R1S’s development). Steering is light but reassuring, and a relatively soft suspension system keeps road feel at arm’s length. Having said that, there’s more wind noise at highway speeds than there is in the GLS. Rivian’s first SUV is proving to be quite popular, particularly with physicians, and now that I’ve experienced one, I can see why. If you’re interested, call Phil Hornbeak and keep my caveats above in mind.

As always, call Phil Hornbeak, the Auto Program Manager at BCMS (210-301-4367) for your best deal on any new car or truck brand. Phil can also connect you to preferred financing and lease rates.

Stephen 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 magazine since 1995.

Visit us at www.bcms.org

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Kahlig Auto Group

11911 IH 10 West San Antonio, TX 78230

Audi Dominion 21105 West IH 10 San Antonio, TX 78257

Northside Chevrolet 9400 San Pedro Ave. San Antonio, TX 78216

Coby Allen 210-696-2232

Anthony Garcia 210-681-3399

Domingo Saenz 210-341-3311

Chuck Nash Chevrolet Buick GMC 3209 North Interstate 35 San Marcos, TX

Bluebonnet Chrysler Dodge Ram 547 S. Seguin Ave. New Braunfels, TX 78130

William Boyd 210-859-2719

Matthew C. Fraser 830-606-3463 Kahlig Auto Group

Northside Ford 12300 San Pedro San Antonio, TX

Northside Honda 9100 San Pedro Ave. San Antonio, TX 78216

14610 IH 10 West San Antonio, TX 78249

Land Rover San Antonio 13660 IH 10 West San Antonio, TX

North Park Lexus 611 Lockhill Selma San Antonio, TX

Marty Martinez 210-477-3472

Jaime Anteola 210-744-6198

Tim Rivers 832-428-9507

Cameron Tang 210-561-4900

Jose Contreras 320-308-8900

Kahlig Auto Group

Kahlig Auto Group

North Park Lexus at Dominion 25131 IH 10 W Dominion San Antonio, TX

North Park Lincoln 9207 San Pedro San Antonio, TX

Mercedes Benz of Boerne 31445 IH 10 West Boerne, TX

Mercedes Benz of San Antonio 9600 San Pedro San Antonio, TX

9455 IH 10 West San Antonio, TX 78230

James Cole 210-816-6000

Sandy Small 210-341-8841

James Godkin 830-981-6000

Chris Martinez 210-366-9600

Kahlig Auto Group

Kahlig Auto Group

North Park Subaru 9807 San Pedro San Antonio, TX 78216

North Park Subaru at Dominion 21415 IH 10 West San Antonio, TX 78257

Cavender Toyota 5730 NW Loop 410 San Antonio, TX

North Park Toyota 10703 Southwest Loop 410 San Antonio, TX 78211

Raymond Rangel 210-308-0200

Phil Larson 877-356-0476

Spencer Herrera 210-581-0474

Justin Boone 210-635-5000

Kahlig Auto Group

As of November 1, 2023, our loan rate will be

5.5% for 60 months with approved credit.

Call Phil Hornbeak 210-301-4367 or email phil@bcms.org

Jordan Trevino 210-764-6945