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Serving Harris, Galveston, Brazoria and Fort Bend Counties

HOUSTON

August Issue 2017

Inside This Issue

Protecting Your Organization from Ransomware Attacks By Jan Hertzberg, CIPP, CISA

R Memorial Hermann Announces Chuck Stokes as New President and CEO See pg. 11

INDEX Mental Health...................... pg.3 Legal Matters........................ pg.5 Oncology Research......... pg.6 Geriatric Medicine............ pg.8 Healthy Heart..................... pg.10

What’s the difference between Alzheimer’s and Dementia? See pg. 12

ansomware is a form of malware that targets your critical data and systems for the purpose of extortion. On average, more than 4,000 ransomware attacks have occurred daily since January 1, 2016, according to the U.S. Department of Justice (DOJ). That’s a 300 percent increase over the approximately 1,000 attacks per day seen in 2015. The U.S. Computer Emergency Readiness Team stated the latest version of a ransomware variant, known as WannaCry, WCry or Wanna Decryptor, was discovered the morning of May 12, 2017, by an independent security researcher and rapidly spread to more than 99 countries—including the U.S., U.K., Spain, Russia, Taiwan, France and Japan—through a period of several hours. Ransomware often is delivered through spear phishing emails targeting a specific organization or individual. After the user has been locked out of the data or system, the cyber actor demands a ransom payment. After receiving payment, the cyber actor provides further instructions as to how the victim can regain access to the system or data. Health care environments are primary targets for identity theft and ransomware events. This is due to the treasure trove of data available, including personally identifiable information and electronic

protected health information. These data sources often are in great demand by cybercriminals and fetch strong prices from the underground market. From the ransomware perspective, rendering health care systems useless until a ransom is paid raises patient care concerns and often incentivizes payment of the ransom. Compounding the lucrative nature of health care targets, health care entities often are highly complex and dynamic in structure. Such an organization becomes difficult to protect in terms of risk management, information governance and internal controls. This environment creates an ideal situation where cyberthreat actors can operate. The DOJ recommends taking steps now to help prevent the worst effects of a ransomware attack, including: ∙∙ ∙∙

Implement a strong cybersecurity awareness and training program. Put in place effective technical measures to protect computer networks, such as: ∙∙ Enable strong spam filters to prevent phishing emails from reaching the end users and implement technologies to prevent email spoofing. ∙∙ Scan incoming and outgoing emails to detect threats and filter executable files from reaching end users.

∙∙ Configure firewalls to block access to known malicious IP addresses. ∙∙ Patch operating systems, software and firmware on devices. Consider using a centralized patch management system. ∙∙ Set antivirus and antimalware programs to automatically conduct regular scans. ∙∙ Configure access controls— including file, directory and network share permissions with least privilege in mind. ∙∙ Implement effective system logging and monitoring tools. ∙∙ Regularly back up data and verify the integrity of those backups by testing the restoration process to ensure that it’s working. ∙∙ Conduct an annual cybersecurity a s ses sment—wit h net work penetration testing—to identify vulnerabilities. If systems become infected with ransomware, we recommend these actions: ∙∙ Forensically preserve affected systems ∙∙ Collect relevant logs and activity ∙∙ Maintain chain of custody evidence ∙∙ Reconstruct event timeline ∙∙ Identify threat actor tactics ∙∙ Determine if data exfiltration see Ransomware Attacks... page 18

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Mental Health The Benefits of Outpatient Treatment for Addiction & Behavioral Health Recovery By Dr. Frank Chen, M.D

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hile many are aware that addiction and untreated mental health disorders have a devastating impact on overall health and wellness in our community, it’s not easy to navigate all the varying treatment options available when you or a loved one is caught in the throes of addiction or behavioral health crisis. Therefore, it’s important to be aware of the various levels of care that fall on the continuum of mental health and substance use treatment. The traditional model of substance use disorder and behavioral health treatment often begins at the acute level. Inpatient stabilization or detoxification under supervision of medical professionals often occurs in a hospital setting where the process can be closely monitored. However, this 5-10 day span is brief when you consider that recovery from drugs, alcohol or a behavioral health diagnosis is a life-long journey. After inpatient hospitalization, there are several different treatment

paths from which to choose. Residential treatment is one path on the continuum that many people select when pursuing treatment for addiction and co-occurring disorders. There are many reputable programs that span the length of 30, 60 or 90 days of residential treatment both in Texas as well as in other states. Some health insurance plans do cover this level of care, but much of the financial responsibility can fall on the individual. Cost and treatment philosophy will vary and it’s important to call a few different facilities to inquire about their programs before selecting a provider that aligns with your goals for recovery. Another path to treatment is to select a partial hospitalization or intensive outpatient program (PHP and IOP) to assist with recovery. These programs are relevant as either the next step after discharge from inpatient hospitalization or a direct admission if inpatient care is not required. Partial hospitalization programs (PHPs) occur daily and the average length of stay can range from a few weeks to a month depending on the patient’s needs.

A PHP can help patients to make a successful transition to outpatient and community based services for their behavioral health or substance use disorder. Patients return to their home environment at the end of the day, often to the stressful or dysfunctional environment that contributed to their initial crisis. PHP allows for patients to come in every day and process in the treatment environment the events of the previous evening; there by learning new ways to cope through their situational real-life experiences. One of the additional benefits of partial hospitalization is that patients are seen by the program psychiatrist twice weekly. Intensive outpatient programs (IOPs) occur three to five days per week for a few hours at a time depending on

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the needs and goals of the individual. IOP programs are most effective when an individual has established recovery but needs additional treatment and support. They can be a great option when barriers to residential treatment exist such as: distance to program, financial considerations and family or work obligations. Many programs are in-network with insurance providers and fit within busy schedules. While peer support in community based 12 step programs may be invaluable during recovery, Chemical Dependency Intensive Outpatient Programs offer a level of structure as the sessions are led by a Licensed C/D Counselor. CD IOPs tend to have more educational components as compared to AA or other programs and allow patients in early see Mental Health page 18

August 2017


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Heroes in Health Hosts Chillin’ and Grillin’ with Memorial Hermann Life Flight®

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emorial Hermann Heroes in Health members, physicians, and the Memorial Hermann Life Flight® crew celebrated summer at a recent gathering at Holler Brewery. More than 100 guests enjoyed smoked brisket, chicken and ribs cooked by Life Flight’s Smokin’ Choppers on their very own pit, and light bites by TacoDeli Houston. The family event featured a face painter, balloon artist, Kona shaved ice truck, and a large inflatable Life Flight helicopter for photo opportunities. The affair was the perfect way for Heroes in Health members and guests to learn more about Memorial Hermann’s trauma prevention program and enjoy the summer evening. “As Steering Committee members, we’re proud to help educate the community about the amazing work performed every day at Memorial Hermann. We’re so grateful for the Life Flight crew, and we’re honored to call them a part of the Memorial Hermann Health System,” said event

co-chairs Ben and Bethany Buchanan and Judy and Jacob Roberts. Both the Buchanans and Roberts serve on the Heroes in Health Steering Committee and have been members for many years. Following welcoming remarks, 2017 Heroes in Health Sporting Clay Shoot Chairs Whitney and Leigh Martin presented Life Flight crew members and Dr. Lillian Kao, Director of the Division of Acute Care Surgery at Memorial Hermann-Texas Medical Center, with a $150,000 check from the clay shoot proceeds. Founded in 1976 by Dr. Red Duke, Life Flight is on-call for Harris and surrounding counties 24 hours a day, 365 days a year. With more than 150,000 missions flown, Life Flight is one of the most successful air-ambulance programs in the country and has faithfully served the Greater Houston area for over 40 years. Heroes in Health brings together professionals of all occupational backgrounds and stages of life to learn more about the changing landscape

Call 713-600-9500 for a free assessment, 24/7.

Heroes in Health Chair Will Hedges and his wife Casey, Vice Chair Mari Treviño and Bryan Glass, Stacy and Jason Johnson, Elizabeth and Alexander Dwyer, Elizabeth and Mark Lester, Melissa and Dan Sugulas, Anat and Jay Zeidman, Leslie and James Selmser, Savanna and David Bowman, and Liz and Stephen Bender.

of healthcare and the medical strides Memorial Hermann’s affiliated physicians are performing on a daily basis. Events hosted by Heroes in Health are attended by Houstonians who are passionate about health care and will advocate and raise funds for Memorial Hermann’s many facilities,

affiliated physicians and research projects. Events include educational opportunities, volunteerism and social gatherings. To become a member of Heroes in Health and learn more about Memorial Hermann, visit heroesinhealth.org.

Your provider of choice

Behavioral health and substance use treatment We offer: • Services for Adolescents, Adults and Seniors • Exclusively women program • Detoxification • Outpatient services for adults - Intensive Outpatient Program - Partial Hospitalization Program

Physicians are on the medical staff of Behavioral Hospital of Bellaire but, with limited exceptions, are independent practitioners who are not employees or agents of Behavioral Hospital of Bellaire. The facility shall not be liable for actions or treatments provided by physicians. Model representations of real patients are shown. Actual patients cannot be divulged due to HIPAA regulations. 162038 6/16

August 2017

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Legal Matters Congressional Task Force Issues Report on Cybersecurity in the Health Care Industry By Zuzana S. Ikels, J.D. Polsinelli

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ecently, the Health Care Industry Cybersecurity Task Force (the “Task Force”) issued its Report on Improving Cybersecurity in the Health Care Industry (the “Report”). The Task Force, which was created by Congress as part of the Cybersecurity Act of 2015, is comprised of subject matter experts from the public and private sector who evaluated the cybersecurity threats to health care industry, the current state of the IT systems for health care industry stakeholders, and the related health care laws and regulations. The Task Force observed that the health care sector has only invested in cybersecurity in the last five years, while rapidly expanding the use of the Internet of Things (internet-connected, medical devices) and the transition to EHR data, the combination of which

magnifies the risk of breaches and data theft. The Report discusses the acute threat of cyber-incidents related to the rise and sophistication of ransomware attacks that hold data hostage involving critical patient information and monitoring devices. The Report offers a laundry list of recommendations, guidelines and practices aimed to streamline the compliance process and reduce risk, while encouraging technological innovation, research and development, and sharing information. Highlights of the Task Force’s observations and recommendations include: • There should be a national, uniform set of standards, which follow the National Institute of Standards and Technology (NIST) Cybersecurity Framework, but customized to reflect the complexity of patient and health care data. • A single cybersecurity leader should be appointed to govern the privacy concerns for medical information

within HHS. The Report criticizes the dizzying number of federal agencies, noting that the Federal Trade Commission (FTC) regulates some aspects, coupled with six, different agencies within the HHS jockeying for control: the Office for Civil Rights (OCR), CMS, the Food and Drug Administration (FDA), the Office of the National Coordinator (ONC), and the Office of the Assistant Secretary for Preparedness and Response (ASPR). • The need for a federal, uniform standard is evident by the burden on healthcare entities to comply with the panoply of state laws that vary in definitions, scope,

standards, and expectations. The Report highlighted the variation in state laws governing: (1) Unauthorized access, malware, and viruses (all 50 states), (2) Denial of service attack laws (25 states); (3) ansomware laws in two states, with another four states currently under consideration; (4) Spyware laws (20 states); and (5) Phishing laws (in 23 states). • Implement scalable best practices that impose different expectations, obligations and standards depending on the size of the health care entity. • Congress should create an see Legal Matters page 18

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Oncology Research CAR-T Cells: Pursuing and Hunting Cancer Cells By Jorge Augusto Borin Scutti, PhD Houston Medical Times

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he Oncologic Drugs Advisory Committee (ODAC) responsible for reviewing and evaluating data concerning the safety and effectiveness of human drugs products for use in the treatment of cancer patients has been recommended, unanimously for approval by FDA, the investigational CAR T cell therapy (CTL019 or CART19) sponsored by Novartis® to treat pediatric and young adult relapsed or refractory patients with B-cell acute lymphoblastic leukemia (ALL). B- cell acute lymphoblastic leukemia or also called B-ALL is a fast-growing cancer comprising approximately 25% of cancer diagnoses in children under 15 years in which bone marrow makes a plenty of B immature lymphocyte cells (a type of white blood cells). In physiologic patterns normal B-lymphocytes helps our body to fight against infections by

August 2017

destroying infected cells or producing antibodies in which stimulate the immune system to enhance the cellular (T cells) response against cancer cells. In B-cell ALL context the lymphocytes don’t fight infections because they are so immature to realize their functions - they are considered cancerous cells (leukemic blasts). The cause of ALL is unknown but the following factors may play a role in the development of ALL such genetic translocations (in which some genes on a chromosome may be shuffled or swapped between a pair of chromosomes). The most common genetic translocation in ALL is called Philadelphia (Ph) chromosome, where the nucleotides are swapped between chromosomes 9 and 22. Another common translocation in ALL is referred to TEL-AML1 occurring in about 20% of patients with ALL. Past treatment with chemotherapy drugs, receiving a bone marrow transplant, exposure to radiation, including X-rays before birth, some viral infections and toxins such benzene may contribute for the development of ALL. Thus, these cells grow quickly and crowd out the bone marrow preventing it from making the normal red blood cells, white blood

cells, and platelets that our body needs. Classically, there are 3 strategies used for ALL treatment: Chemotherapy, radiation (not usually) and bone marrow transplant. Extensive progress has been made in the treatment of acute lymphoblastic leukemia, but recurrent disease remains a leading cause of death in children. T cells (most involved against cancer immune response) can be genetically engineered to create customized receptors on their surfaces – called as Chimeric Antigen Receptors (CARs), a personalized treatment that involves genetically modifying T cells to make them target. CAR-T differs from those biologic therapies such monoclonal antibodies or targeted therapy using small molecules because it is produced for each individual (personalized treatment). The T cells are selected from patient’s blood and reprogrammed in laboratory to create T cells that are genetically programmed to express a chimeric antigen receptor to recognize and fight against cancer cells expressing that particular antigen. In this case, CTL019 is driven against the expression of CD19 in bone marrow or peripheral blood, the major antigen expressed by B cells in B-ALL. The

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NCT 02435849 “Determine Efficacy and Safety of CTL019 in Pediatric Patients with Relapsed and Refractory B-cell ALL (ELIANA)” conducted by Novartis® is the first pediatric global CAR-T cell therapy registration trial. “The panel’s unanimous recommendation in favor of CTL019 moves us closer to potentially delivering the first-ever commercially approved CAR-T cell therapy to patients in need. We’re very proud to be expanding new frontiers in cancer treatment by advancing immunocellular therapy for children and young adults with r/r B-cell ALL and other critically ill patients who have limited options. We look forward to working with the FDA as they complete their review” said Bruno Strigini, CEO, Novartis Oncology. Despite several encouraging results it is time to balance the risks and prizes regarding CART-T cells therapy.


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We pledge to help build your practice.

2015

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Geriatric Medicine Stress and Coping Techniques By Deborah Y. Liggan, MD

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tress and the Aging Brain. Stress is no respecter of age, but as the brain ages it becomes more vulnerable to the effects of stress. Cortisol works together with excitatory neurotransmitters, chiefly glutamate, to produce stress related learning and memory as well as damage, but there is another consequence. The implications for the elderly are uncertain, but if cortisol enhances the effects of glutamate to produce free radical damage, this may be one way stress exerts its effects. Stress Response. The stress response is also known as the fight-or flight response. The stress response helps us react to an emergency and cope with change. To do so, it musters the brain, glands, hormones, immune system, heart, blood, and lungs. You can feel your body responding to stress: your pulse races, your blood pressure rises, and you feel a massive release of energy. That’s the famous hormone adrenaline at work. Psychosocial Stressors. The measurement of stress responses and the assessment of psychosocial

variables such as hostility, depression, anxiety, and social isolation fall within the purview of health psychology. If the stressor persists, the person achieves a new level of adaption to the stress. How well an individual person deals with stress is probably influenced by a number of factors, including prior experience. Other studies have assessed individual differences in transactional variables such as coping strategies, whereas others have focused on mood or personality factors. Cardiovascular Stress. Stress can hurt more than our brains. In the short term, acute stress can boost cardiovascular performance. Over the long term, however, too much adrenaline stops regulating surges in your blood pressure. Not surprisingly, people who experience chronic stress have an elevated risk of heart attack and strokes. Stress hormones can do some truly nasty things to your brain if boatloads of the stuff are given free access to your central nervous system. That’s what is going on when you experience chronic stress; the increase cortisol damages the cells of the hippocampus, crippling your ability to

learn and remember. Immunity. The immune system plays and important role in helping us deal with stress. Acute stress can enhance the response of the immune system, sending white blood cells to their battle stations. Ongoing stress, on the other hand, has a tendency to suppress the immune system, thus setting the stage for infection. Diabetic Control. Stress may interfere with diabetes self-management by distracting the patient from careful monitoring and proactive self-care. Stress increases secretion of counter regulatory hormones that block insulin action or transform stored glycogen into glucose for release into the bloodstream. Does stress make you hungry? Stress also affects the gastrointestinal tract with increased gastric secretions, and colonic contractions that lead to spasms in the intestine? Too much fat around the midriff (the so-called spare tire) is a risk factor for both diabetes and heart disease. The problem with stressful times is that many of us turn to food for comfort and solace. Unfortunately, this is case where our solutions can be even worse than our

problems. People often over eat out of a sense of emotional despair trying to stimulate pleasing senses in the brain, which creates a vicious cycle. We cannot eat our way out of stress, but we can eat our way to health. The good news is that we have choice. The linked chains between stress and disease hampers our efforts to prevent harmful stress responses and you don’t realize how much stress you are carrying. Try taking time to relax or meditate, breathing slowly and letting go. All have been shown to be helpful in reducing stress, alleviating depression, lowering blood pressure, improving immune function, and increasing independence.

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Healthy Heart Back to School, Back to Good Health By Suzie Flores American Heart Association

Dear Doctors and Staff, Let us take the guesswork out of fracture referrals.

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ith summer drawing to a close, back-to-school season not only is a time to stock up on supplies, it’s also an opportunity to encourage kids to eat healthy and be active. Physical inactivity is a major risk factor for developing coronary artery disease. It also increases the risk of stroke and such other major cardiovascular risk factors as obesity, high blood pressure, low HDL (“good”) cholesterol and diabetes. The American Heart Association recommends that children and adolescents participate in at least 60 minutes of moderate to vigorous physical activity every day. Inactive children are likely to become inactive adults.

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Why is exercise or physical activity important for my child? Just like in adults, increased physical activity has been associated with an increased life expectancy and decreased risk of cardiovascular disease. Physical activity produces overall physical, psychological and social benefits. Physical activity helps with: • • • •

controlling weight reducing blood pressure raising HDL (“good”) cholesterol reducing the risk of diabetes and some kinds of cancer • improved psychological well-being, including gaining more self-confidence and higher self-esteem How do I promote physical activity in my child? • Physical activity should be increased by reducing sedentary time (e.g., watching television,

August 2017

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playing computer video games or talking on the phone). Here’s a great tip: Give children toys that encourage physical activity, such as balls, kites, skateboards and jump ropes. • Physical activity should be fun for children and adolescents so get creative! Join a sports team, hike a trail, ride a bike path, plant a garden, or have them chip in with chores around the house. • Parents should try to be role models for active lifestyles and provide children with opportunities for increased physical activity. As you juggle work and family, be mindful that research shows active parents raise active children. Fitness should always be a priority in a family’s daily schedule. Looking for more ways to get active as a family? The American Heart Association is hosting five Heart Walks in the Houston area this fall, including the Houston Heart Walk on Nov. 4 in the Texas Medical Center. The free, family-friendly event promotes physical activity and heart-healthy living while raising funds critical to cardiovascular research and education programs. To find a walk near you, visit www.heart. org/hgcevents. Heart Walk is the signature fundraising event of the American Heart Association’s Healthy For Good campaign. Healthy For Good is designed to inspire all Americans to live healthier lives and create lasting change. It focuses on the simple idea that making small, simple changes today can create a difference for generations to come. The approach is simple: Eat smart. Add color. Move more. Be well. For tips, tools and hacks you can actually use to get Healthy For Good, visit www.heart.org/movemore. Join the movement!


Houston Medical Times

Memorial Hermann Health System is pleased to announce the appointment of longtime and highly accomplished System Chief Operating Officer (COO) Charles “Chuck” D. Stokes to President and CEO of Memorial Hermann, effective immediately. In addition to his role as Executive Vice President and COO, Stokes had been serving as interim President and CEO following the departure of Benjamin K. Chu, M.D., who left the organization in June to pursue his passion in public and health policy.

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tokes, who began his career as a registered nurse, is a well-respected industry veteran with nearly four decades of leadership experience and demonstrated success in fostering a culture of innovation and exceptional patient care experiences, with an emphasis on superior quality, safety and stellar operations. “Chuck has proven himself to be an outstanding leader during the course of his remarkable career with our organization, working tirelessly to guide Memorial Hermann on its journey toward becoming a high-reliability organization with a strong focus on innovation and transformation,” said Memorial Hermann Board Chair Deborah M. Cannon. “He has an unwavering commitment to our patients, medical staff and to Memorial Hermann, the latter of which has been instrumental in helping us transform our operational structure in order to meet the challenges and demands of a rapidly changing healthcare landscape.” As COO, Stokes was responsible for overseeing operations for the System, which has 17 hospitals, more than 200 outpatient clinics, 25,000 employees and 5,500 affiliated physicians. He has a proven track record of achieving success in service line leadership, employee engagement, physician collaboration, and leadership development. “I am honored and humbled to work alongside our exceptional employees and talented medical staff as we fulfill our mission to advance the health of all Houstonians,” Stokes said. “In its 110 years of faithfully serving this community, Memorial Hermann has grown to become a nationally recognized organization

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By Mike Williams Rice University

NO5 M HO W O D M ES O E CO P LS M EN IN G ! S

Memorial Hermann Announces Chuck Stokes as New President and CEO

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Charles D. Stokes

with an unrelenting focus on providing enhanced access to the safest, highest-quality care, all at an affordable cost.” Most recently, Stokes’ leadership was instrumental in helping Memorial Hermann Sugar Land Hospital become the first organization and hospital in the Houston area to receive the Malcolm Baldrige National Quality Award, the nation’s highest presidential honor for performance excellence. During his tenure, Memorial Hermann also has been perennially recognized as the country’s most successful Accountable Care Organization, underscoring the emphasis on innovative, evidence-based medicine designed to improve overall population health. Stokes was recently named among the Top 25 COOs in healthcare by Modern Healthcare, a list that recognizes high-achieving leaders across the industry and the increasingly demanding roles they play. He also serves as the Chairman of the Board of Governors for the American College of Healthcare Executives (ACHE), an organization of more than 48,000 healthcare executives working together to improve care delivery and the education of healthcare leaders. Prior to his appointment as Chairman, Stokes served as ACHE faculty for 10 years. “At a time when our industry is facing unprecedented challenges with declining reimbursements and escalating costs, I have every confidence that Chuck has the experience and visionary leadership necessary to navigate our organization through this period of change and uncertainty,” Cannon said.  

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What’s the Difference Between Alzheimer’s and Dementia? By Dominic Hernandez

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ot all dementia is Alzheimer’s— but it can be just as devastating when it affects loved ones While often used interchangeably, dementia and Alzheimer’s disease are not the same. Dementia is a general term for a decline in mental ability severe enough to interfere with daily life. Alzheimer’s disease is a specific type of dementia that causes memory loss and impairment of other important mental functions. An expert from the Texas A&M School of Public Health describes how these conditions can impact the lives of both patients and those around them, and provides insights into ways of minimizing risks.

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Dementia (and Alzheimer’s) “Dementia is an umbrella term for a serious decline in mental ability that impacts one’s overall health and functioning,” said Marcia Ory, PhD, MPH, head of the Center for Population Health and Aging and Regents and Distinguished Professor at the Texas A&M School of Public Health. “There are different types of dementia, and the most common type of dementia is Alzheimer’s.” Alzheimer’s disease makes up between 60 to 80 percent of dementia cases. It is a progressive disease, which means that the symptoms gradually worsen over a number of years. Alzheimer’s is also the sixth-leading cause of death in the United States, and those with Alzheimer’s live an average of eight years after their symptoms became noticeable to others. Other specific types of dementia include vascular dementia and mixed dementia. Vascular dementia is considered the second-most common form of dementia after Alzheimer’s disease and is usually the result from injuries to the vessels supplying blood to the brain—often after a stroke or

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series of strokes. Other less-common types of dementia come from frontotemporal disorders and Lewy body dementia. Frontotemporal disorders are a form of dementia caused by a family of brain diseases known as frontotemporal lobar degeneration (FTLD), and Lewy body dementia is caused by abnormal deposits of a protein—called alpha-synuclein—in the brain. Mixed dementia is a term that describes having multiple types of dementia, such as both Alzheimer’s disease and vascular dementia. In a person with mixed dementia, it may not be clear which symptoms are attributed to one type of dementia over the other. Researchers are still working to understand how the disease processes influence one another in mixed dementia patients. In some cases, it’s not known what type of dementia someone has or if it’s not a specific, named type at all. The causes of dementia are not always known, and some older people may develop age-associated memory impairment—which is different than dementia and Alzheimer’s disease. Risk factors for dementia Two of the most common risk factors for Alzheimer’s and dementia are age and genetics. Most individuals with Alzheimer’s are 65 or older, and those who have a parent or sibling with Alzheimer’s are more likely to develop the disease. However, there is evidence to suggest that there are other factors that people can influence. According to research from the University of Cambridge, one-third of Alzheimer’s disease cases were attributed to preventable risk factors. The seven main risk factors for Alzheimer’s disease are diabetes, see Alzheimer’s and Dementia page 16


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Page 14

Heroin-Assisted Treatment Programs Can Help in Fight Against Opioid Deaths By Jeff Faulk

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stablishing heroin-assisted treatment programs, which provide severely addicted individuals with controlled access to pharmaceutical-grade heroin, could make a significant dent in the number of U.S. deaths from opioid use, according to an expert at Rice University’s Baker Institute for Public Policy. Katharine Neill Harris, the Alfred C. Glassell III Fellow in Drug Policy, outlined her insights and recommendations in a new Baker Institute blog, “Want Fewer People To Die From an Opioid Overdose? Give Them Heroin (Assisted Treatment).” She is available to discuss the issue with media. Of the 52,404 drug overdose deaths in the U.S. in 2015, roughly 63 percent involved an opioid, according to the Centers for Disease Control and Prevention (CDC). Prescription painkillers, the most widely used opioids, still accounted for the largest share of

opioid overdose deaths – nearly half – in 2015. But over the last few years, the rise in overdose deaths has been driven primarily by a spike in deaths related to heroin and synthetic opioids. From 2014 to 2015, there was a 20.6 percent increase in deaths involving heroin and a 72.2 percent increase in deaths from synthetic opioids other than methadone, particularly fentanyl and its analogues, according to the CDC. “If current trends continue, we will see an increase in the share of the heroin supply that is not heroin at all but much more powerful opioids like fentanyl,” Neill Harris wrote. “This poses a life-threatening risk to users who, unable to determine the content of drugs they purchase off the street or the internet, are more likely to consume a lethal dose, incorrectly assuming that they are taking an appropriate amount.” Neill Harris said heroin-assisted treatment, or HAT, is a well-established treatment method that was available in the U.S. until the early 1920s and

is currently used in several countries. HAT programs provide severely addicted individuals with access to pharmaceutical-grade heroin (diacetylmorphine) on the grounds that doing so will decrease demand for illicit heroin, reduce criminal activity associated with obtaining heroin, improve patients’ lives, reduce the spread of communicable diseases and reduce overdose deaths by providing unadulterated heroin in a supervised setting. Germany, Belgium, Denmark, the Netherlands and the United Kingdom all have HAT programs. The most well-known is the Swiss model, which began in 1994 in response to a persistent open-air heroin market and the spread of HIV through needle sharing, Neill Harris said. The Swiss program has demonstrated success in several areas, she said. Criminal activity and new incidences of hepatitis C and HIV among HAT patients have declined significantly. No patient has died of an overdose from heroin

received through HAT; this is because of the high quality of the heroin administered and because patients use the drug under supervision, which ensures that someone is available to revive them if they do have an adverse reaction. Switzerland’s HAT did not encourage heroin use, as evidenced by the fact that after its implementation, the heroin-dependent population declined from approximately 30,000 in 1992 to 26,000 in 2002. If the federal government would allow states and localities to operate HAT programs, it would be an opportunity to see how HAT works in see Treatment Programs page 18

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Music Therapy: Can It Help? Music has a number of benefits, but does it have a place in health care? By Dominic Hernandez

T

here is not enough time in a day to talk about all of the goodness that music can bring. In fact, Ludwig van Beethoven may have said it best when he wrote, “Music is indeed the mediator between the spiritual and sensual life.” However, what many people consider a hobby or an art may be going further, and is now also being used in a medical setting. An expert from the Texas A&M College of Medicine explains why music is part of delivering the best care. Health benefits of music Music has a universal range and is one of the rare things that makes people feel good AND has a beneficial effect on the body—unlike sugary desserts or salty snacks. Music has been linked to reducing stress and anxiety—especially before stressful situations. In fact, one study done by researchers at the Texas A&M College of Nursing showed that students who listened to music before patient care simulations had higher self-efficacy and lower anxiety. “Music has a lot of beneficial effects in day-to-day life,” said Laurel Kilpatrick, MD, clinical assistant professor of medicine at the Texas A&M College of Medicine. “It can trigger comforting memories or just have a natural calming effect that relieves some of the stresses or anxieties that are happening.” Also, music has been linked to decreasing pain. A 2013 study investigated the effects of music on pain and depression for people with fibromyalgia, a chronic pain syndrome. The treatment group reported a significant reduction in pain and depression compared to the control group, who reported no differences in pain. Another study showed that

music can benefit even the smallest patients. A study in 2016 showed that babies born prematurely gained more weight listening to music therapists sing “Twinkle, Twinkle” than their own mothers singing the song. In that same study, the babies would begin quietly sleeping by the song’s end with the music therapist, but not with their moms’ singing. Music therapy can benefit people of all ages, for a wide range of conditions—such as Alzheimer’s disease and chronic pain—and has even found its place in palliative care. Music and palliative care “We use music and music therapy in palliative care,” said Kilpatrick, who is also an expert in palliative and hospice care. “Music can affect your mood, and that’s part of the caregiving experience in palliative care.” It’s hard to measure the quantitative effects that music has in health care, but there is qualitative evidence to support the practice, at least in hospice and palliative care. “We look at the patient reports and testimonials from the families,” Kilpatrick said. “Music interventions have shown to decrease pain and anxiety and improve quality of life. Some studies looking at the use of music therapy in hospice and palliative care have use standardized scales for quality of life assessment and demonstrated benefit.” However, music intervention is so much more than just popping in any old CD and expecting benefits. For the best results, working in conjunction with a licensed music therapist (with hundreds of hours of training) can help tailor-make an approach for the patient. In palliative care, music

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Page 16

The Doctor is IN….the Custom Homebuilding Business. By Tim Moloney

A

s a student at Rice University and Baylor College of Medicine, Dr. Arpan Gupta was doing a different kind of homework: remodels, repairs and fixer-uppers on local properties. It had been an interest for much of his life, always enmeshed in his medical pursuits. In fact, in the summer of 1994, he went on a three-week trip to study the health care system in the UK, the NHS, to further his immersion into medicine, and ended up gaining an appreciation for the architectural differences between the UK and the United States. And, in particular, English architecture.

Arpan Gupta, M.D.    

“I was always very interested in business, and while in school, I was doing one or two big remodels a year. Around 2009, I had to make a choice: was I going to stick with medicine or follow my entrepreneurial path?” he explains. He chose to become a custom homebuilder and started a company – Carnegie Homes. The name was inspired by Andrew Carnegie, and his commitment to service, quality, luxury and philanthropy. “Don’t get me wrong; I loved the camaraderie of the medical center and the interactions among students, residents, fellows, attending physicians and especially my patients,” he says. “But my interest in medicine was shifting, and if were to set up a practice, it probably would have been in the suburbs, with none of those interactions and friendships I had grown to enjoy. So, I made a calculated risk – and began with two luxury homes in the Galleria area. I’m sure my family thought I was crazy, but they kept it to themselves,” he laughs. Fast forward to 2017: Carnegie is building about 40 new homes a year now. The company specializes in all styles of construction; two of their recent projects include Masterson Oaks at Westmoreland – a community of 15 Victorian-inspired homes built around a 300-year-old tree in the shadow of downtown Houston, and Kensington at

River Oaks – an exclusive townhouse development which includes the tallest townhouse in Houston. It’s five stories and at a height of nearly 70 feet, with refined amenities that reflect its vertical mansion status. Carnegie Homes command a premium over similar comps in their neighborhoods. Why? The fine materials, thoughtful finishes, high-end appliances, energy-saving and green features, and smart home technology. “You might say we build homes with medical precision,” Gupta says. “I am obsessive down to the last detail. For me, getting the floorplans, elevations and interior design perfect is the most-time-consuming facet of the home-building process. Actually building a quality home is a lot easier with the processes I’ve put in place.” As the business has grown, so has the mix of product. The first two homes

were built on spec; today, Carnegie Homes builds 70% spec and 30% custom work. “We’ve been fortunate to have a healthy mix of custom homes and a higher-income clientele, he explains, “including a lot of physicians. An inveterate traveler, Gupta finds inspiration for the details of new projects in buildings old and new. Recent trips this summer yielded many discoveries– in particular, to explore the famed Gilded Age Newport mansions for upcoming River Oaks projects, as well as architecture in Nantucket and Chatham that yielded concepts for Westmoreland. “I take thousands of photos when I travel, because its fascinating to experience how different materials and finishes or architectural ideas are employed. I draw inspiration from all,” he says. Sounds like he’s on the right journey after all.

care provider about your concerns can be very beneficial. They can provide you with information and resources to help ease your concerns or improve your quality of life if you have any of these conditions. “There are simple screening tests that health care professionals can perform during routine medical visits,” Ory said. “Knowing the signs and symptomatology of dementia is important as there are medications that can reduce your symptomatology, and, along with being more active and engaging in other healthy lifestyles, can improve your quality of life.” Although there are no medications or treatment that can cure dementia or Alzheimer’s, medications and a healthy lifestyle will help you process your condition as well as possible. Ask your physician about safety and limitations. There is nothing

shameful about having dementia. “Before people talked about dementia in medical terms, they’d say that the patient was ‘crazy’ or ‘senile,’” Ory said. “People don’t use those terms now because they recognize it’s a medical condition and not about personality or willpower. Alzheimer’s and dementia are far too common and are not something we can ignore.” Ory also recommended that caregivers of someone with dementia look into programs or support groups. “Don’t ignore your own care when you are caring for someone with dementia,” she said. “It takes a group effort sometimes, and joining a program or being able to discuss the difficulties with others or experts, can help immensely.”

Alzheimer’s and Dementia Continued from page 12 hypertension, obesity, physical inactivity, depression, smoking and low educational attainment. “Minimizing the risk of these factors can potentially minimize the onset of dementia, but to an unknown degree,” Ory said. “We know that physical activity, a healthy diet and healthy lifestyle can help reduce the symptomology of many major diseases, and similarly these can affect the onset and progression of dementia symptomatology.” If you’re looking for a start to reducing the risk for dementia or Alzheimer’s, a healthy diet and getting enough exercise is a good start. Exercise has been shown to increase blood flow and help connections between neurons, which is important with cognitive functioning. “Systematic review of all the studies of physical activity conclude August 2017

that it’s a modifiable risk factor,” Ory said. “We don’t know what type, how much or how often we should exercise. Further, the newest frontier is to go beyond a single risk factor approach and identify all the good behaviors— such as diet, exercise and cognitive exercises—and examine how the combination can lower the risk or symptomology of dementia.” Overall, because there are multiple risk factors, the solutions should be multi-pronged intervention programs. “Similar to how there are a lot of risk factors for falls, there are a lot of risk factors that increase likelihood of dementia,” Ory said. “It’s complicated to minimize the risk, but you’ll do best with multi-dimensional approach.” Talking with your health care provider Aging is a difficult process for many people, and talking to your health

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Mental Health

Continued from page 3 recovery to resume life activities while still connected to a caring treatment team specializing in addiction. When selecting a PHP/IOP program for yourself or a loved one, it’s important to call and speak to the program facilitator to get a sense of their group goals and how this will integrate with your overall wellness goals. One important factor when selection an IOP program is family involvement. Individuals in long-term recovery are often more successful when those in their sphere of support are active

Houston Medical Times

participants in their treatment. “The Behavioral Hospital of Bellaire believes strongly in providing a full continuum of care for patients and their families to access the care they need. That’s why we deliver evidence-based PHP and IOP programs for our patients to transition back to their home communities. We’ve recently added evening chemical dependency intensive outpatient and more outpatient psychiatry appointment availability at our Bellaire campus because we know that there is a shortage of psychiatry appointments in Houston. We’re always striving to prevent barriers to good quality care.” says Coleby Wright, CEO.

Music Therapy

Continued from page 15 therapists work with patients and their families to help find particular genres or styles that can help reduce stress and anxiety, which can help improve their health. “It’s not a one-size-fits-all approach,” Kilpatrick said. “What is comforting and relaxing to one patient may not be

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occurred and, if so, quantify extent of exfiltration ∙∙ Determine incident lessons learned and conduct a post-breach cybersecurity assessment to identify the presence of other, possible vulnerabilities bkd.com/cybersecurity

Legal Matters

Continued from page 3 exception, under the Stark Law and Anti-Kickback Statutes, to encourage hospitals to share resources and provide financial assistance to doctors and clinics related to cybersecurity systems. • Health care entities should focus on increasing the security of medical devices, health IT, and legacy EHR systems. The Task Force suggests either imposing requirements or financial incentives to share software and systems to ensure a more robust and secure system August 2017

as beneficial to another. It’s really about working with the patient to develop a structured therapeutic approach.” Music therapy going forward While music therapy may sound like some new age sugar pill to medical traditionalists, the use of it in conjunction with traditional medicine

Upon successful completion of an outpatient program, continued regular check-ins with a therapist and/ or outpatient psychiatrist can help individuals to maintain their sobriety and mental wellness. The ultimate goal of all substance use and psychiatric treatment providers is to help patients achieve recovery and wellness within the community. Just like any other medical condition, it is important to get periodic check-ups with a mental health professional to avoid complications and assist with new tools and lifestyle modifications to prevent relapse and maintain coping skills for life’s stressors.

is being researched. “There is ongoing investigation into using music therapy approaches to reduce anxiety or pain in addition to traditional medicine,” Kilpatrick said. “This can be beneficial because there is the potential to reduce the medication burden for some patients.”.” Music likely won’t ever replace the benefits of traditional medicine or cure your illnesses, but when it comes to improving quality of life—it has found its rhythm.

Treatment Programs Continued from page 14 the U.S. on a small scale, Neill Harris said. HAT could initially be made available to people in communities suffering from the highest rates of heroin overdose, she said. However, political barriers to the adoption of HAT programs are high. “Despite growing understanding of the opioid epidemic, heroin remains one of the most heavily stigmatized drugs in our culture,” Neill Harris wrote.

“Such negative perceptions make the suggestion of providing heroin to users seem contradictory to the very idea of drug treatment. But scientific evidence should drive policy decisions, not misguided perceptions. And the evidence available clearly indicates that HAT programs could make a significant dent in deaths from opioid use. This possibility alone should be enough motivation for the U.S. to experiment with HAT programs.”

overall for safe transmissions of patient data. • Implement a multi-step authentication process and training requirements for clinicians accessing the systems. • The Report also discusses a series of specific recommendations regarding appointing a lead IT representative, conducting annual audits and sharing information related to better security measures, Big Data Analytics, and research and development.

enhanced responsibility to secure their systems, IoT medical devices, and patient data. Stakeholders are advised to reduce the use of less defensible legacy and unsupported products and focus on reducing risk through robust development and support strategies. The Report is a sincere and ambitious offering of practical and clear solutions that balance the tension between cybersecurity threats, patient privacy concerns, and technological innovation. The more difficult question is whether Congress will consider the The Report makes clear report and pass federal legislation in that now more than ever, health response.  care delivery organizations have an medicaltimesnews.com

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