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Breathe Easy Air Quality and Lung Health

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James O. Gemmer, MD Chairman of the Board

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In California this is an average savings on premiums of 40.4%* for 2011. MIEC has returned dividends to our California policyholders 18 of the last 21 years, resulting in a California dividend which now exceeds $144,000,000.

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Volume 84, Number 4, Breathe Easy: Air Quality and Lung Health FEATURE ARTICLES

10 Lung Transplantation: An Update for the Clinician Jeffrey A. Golden, MD


4 Membership Matters

12 Pulmonary Arterial Hypertension: An Epidemic? Thomas E. Addison, MD

5 Classified Ad

15 Pollution and Inflammation: Polluted Air Leads to Disease by Promoting Widespread Inflammation Emily Caldwell

25 Hospital News

7 President’s Message 14 Teens and Asthma: Improving Health Outcomes Through George Fouras, MD Support and Education from Health Care Providers and School Personnel 9 Editorial Karen Licavoli Farnkopf, MPH Gordon Fung, MD, PhD

17 Breathe Easy Indoors: Improving Indoor Air Quality in the Physician’s Office Deborah Crosby, ASID, LEED AP 18 A Billion Deaths? Progress and Perils in the Ongoing “Tobacco Wars” Steve Heilig, MPH

30 In Memoriam Nancy Thomson, MD Editorial and Advertising Offices: 1003 A O’Reilly Ave., San Francisco, CA 94129 Phone: (415) 561-0850 extension 261 e-mail: Web: Advertising information is available by request.

19 Secondhand Smoke: Protections Expanded in San Francisco Alyonik Hrushow, MPH

20 Cardiology RX for Change: Addressing Tobacco Use and Secondhand Smoke Exposure in Training and Clinical Practice Judith J. Prochaska, PhD, MPH, and William Grossman, MD 21 Air Quality in U.S. Cities by the American Lung Association OF INTEREST

26 CMA Foundation AWARE Project Initiative to Address COPD Crawford Chung, MD 27 Cocooning: A Strategy to Prevent Pertussis in Infants Andrew Resignato, MS 28 SFMS Community Health Agenda and Activities

29 Heath Policy Perspective: A Dog in Peaceful Times Revisiting the “Interesting Times” Curse Steve Heilig, MPH

May 2011 San Francisco Medicine 3

Membership Matters May 2011 A Sampling of Activities and Actions of Interest to SFMS Members

Volume 84, Number 4 Editor Gordon Fung, MD, PhD Managing Editor Amanda Denz, MA Copy Editor Mary VanClay

Editorial Board Editor Gordon Fung, MD, PhD Obituarist Nancy Thomson, MD Stephen Askin, MD

Erica Goode, MD, MPH

Toni Brayer, MD

Shieva Khayam-Bashi, MD

Linda Hawes Clever, MD

Arthur Lyons, MD

Peter J. Curran, MD

Stephen Walsh, MD

SFMS Officers President George A. Fouras, MD President-Elect Peter J. Curran, MD Secretary Lawrence Cheung, MD Treasurer Shannon Udovic-Constant, MD Immediate Past President Michael Rokeach, MD SFMS Executive Staff Executive Director Mary Lou Licwinko, JD, MHSA Assistant Executive Director Steve Heilig, MPH Director of Administration Posi Lyon Director of Communications Amanda Denz, MA Director of Marketing and Membership Jonathan Kyle Board of Directors Term: Jan 2011-Dec 2013

Lily M. Tan, MD

Jennifer H. Do, MD

Shannon Udovic-

Benjamin C.K. Lau, MD

Constant, MD

Man-Kit Leung, MD

Joseph Woo, MD

Keith E. Loring, MD Terri-Diann Pickering, MD

Term: Jan 2009-Dec 2011

Marc D. Rothman, MD

Jeffrey Beane, MD

Rachel H.C. Shu, MD

Andrew F. Calman, MD Lawrence Cheung, MD

Term: Jan 2010-Dec 2012

Roger Eng, MD

Gary L. Chan, MD

Thomas H. Lee, MD

Donald C. Kitt, MD

Richard A. Podolin, MD

Cynthia A. Point, MD

Rodman S. Rogers, MD

Adam Rosenblatt, MD CMA Trustee Robert J. Margolin, MD AMA Representatives H. Hugh Vincent, MD, Delegate Robert J. Margolin, MD, Alternate Delegate

4 San Francisco Medicine May 2011

Young Physicians Mixer Will Take Place June 16! The San Francisco Medical Society’s annual Young Physicians Mixer has been rescheduled and will now be held on June 16, 2011, from 6:30 p.m to 8:00 p.m. This is an excellent opportunity for physicians who are new in their practice, or new to the area, to meet other local physicians and build upon their professional network. The event will be held at the SFMS offices in the Presidio and complimentary refreshments will be provided. Residents and nonmembers are encouraged to attend. To RSVP, please contact Jonathan Kyle at (415) 561-0850 extension 240, or jkyle@

CMA Webinar Calendar

CMA is offering a number of excellent webinars this year that are free to SFMS members. Register at calendar. • June 1: ICD-10 | Practice Management Institute • 12:15 p.m. to 1:15 p.m. • June 15: Best Practices for Accounts Receivables | Mary Jean Sage • 12:15 p.m. to 1:15 p.m. and 6:00 p.m. to 7:00 p.m.

SFMS Webinars

The SFMS will offer the following webinars in partnership with ACCMA. Visit our website,, for full details or to register. Contact Posi Lyon with any questions at or (415) 561-0850 extension 260. • Billing & Coding Bootcamp (a fivepart series) • June 3: Webinar #3: Managing & Preventing Claims Denials | 10:00 a.m. to 12:00 p.m. • June 17: Webinar #4: Understanding Insurance Guidelines and Maximizing Payout | 10:00 a.m. to 12:00 p.m. • June 7: Can You Hear Me Now? Physician-Patient Communication to Promote Outcomes and Reduce Liability |12:30 p.m. to 1:45 p.m.

• June 22: Managing Your Managers (for Physicians) |12:30 p.m. to 1:45 p.m. • July 13: CalOSHA Training for the Medical Practice |12:30 p.m. to 1:45 p.m.

CMA’s 14th Annual California H e a l t h C a r e L e a d e r s h i p Academy

The Next Step: Successfully Negotiating Health Reform. June 3–5, 2011 at the Renaissance Esmeralda Resort and Spa in Indian Wells, CA. Members can save up to $200 per person if registering as part of a group— before May 6. Contact Posi Lyon for details, or (415) 561-0850 extension 260. The landmark federal health reform legislation signed into law last year set in motion what may be the biggest sea change in the practice of medicine since the advent of managed care. Changes in Medicare reimbursement methodologies portend a dramatic transformation of the health care delivery system, affecting not only how providers are paid, but the structural forms of medical practice itself. As provisions of the new law continue to be phased in over the next three years, is your practice prepared to navigate the waves of change? Consonant with the California Health Care Leadership Academy’s mission of informing physicians and medical practice managers about leading-edge trends and developments in the evolving health care marketplace, this year’s conference has been designed to provide both information and tools to help successfully negotiate the challenges—and opportunities—of the new era. Continuing the Academy’s standard of programming excellence, the presentations and workshops will be an invaluable resource in surviving and thriving in the new environment.

SFMS On-Site Seminars • October 14, 2011: Creating a Director of First Impressions—Customer Service, Patient Relations, and Telephone Techniques This half-day practice management seminar provides valuable training for both front and back office staff to handle patients and tasks efficiently and professionally, using superlative customer service skills. This seminar will provide your staff with the tools necessary for positive patient relations. 9:00 a.m. to 12:00 p.m. (8:40 a.m. registration/continental breakfast). $95 for SFMS/CMA members and their staff ($85 each for additional attendees from the same office); $150 each for nonmembers. Contact Posi Lyon, or 415-561-0850 extension 260 for more information.

• October 28, 2011: ‘MBA’ for Physicians and Office Managers This one-day seminar is designed to provide critical business skills in the areas of strategic planning, finance, operations, marketing, and personnel management. This seminar teaches the core business elements of managing a practice which physicians don’t receive in medical school training. 9:00 a.m. to 5:00 p.m. (8:40 a.m. registration/continental breakfast). $225 for SFMS/CMA members and their staff ($200 each for additional attendees from same office); $325 for nonmembers. Contact Posi Lyon at or 415-561-0850 extension 260 for more information.

Classified Ad South San Francisco Medical/ Dental Building Medical suite of 1088 sq. ft. available in central South San Francisco, close to downtown and to BART. Suite includes reception room, administrative/business area, 4 exam rooms, large private office, a lab, bathroom and excellent on-site parking. Contact: Charles Bona, DDS, (650) 342-5001.

San Francisco Health Information Exchange Featured in the Examiner The San Francisco Health Information Exchange, a project of the SFMS, was the subject of the following Op-Ed in the San Francisco Examiner on April 17. A full update on the health information exchange will appear in next month’s issue of San Francisco Medicine.

Op Eds: San Francisco Launching New Health Information Exchange By David Chiu and Arieh Rosenbaum MD

San Francisco is on the cusp of launching a groundbreaking new health care initiative that will transform medical care in our city for the better. The San Francisco Health Information Exchange will allow the city’s health care providers to securely and efficiently exchange patient health information. It will additionally allow patients access to their personal community health record. This program will dramatically improve patient care in San Francisco and save millions of dollars in overall health care costs. Anyone who has moved to a new doctor knows how the process of transferring medical records and personal health information can be slow, frustrating, and bureaucratic. Imagine going through that process during a crisis. Today, exchange of clinical information in San Francisco is highly variable in terms of its timeliness, reliability and effectiveness. Most providers and organizations continue to use telephones, faxes, the U.S. mail and physical messengers for clinical collaboration. New information from outside sources is frequently unavailable to providers at the point of care, and if it is, the information is often incomplete, illegible or both. This process leads to inefficiencies in terms of costs and precious lost time as routine procedures and expensive tests can be duplicated by multiple health care providers. Until recently, the idea of a unified

patient record that aggregates all available clinical data when it is needed had been just a dream. But now, with support from President Barack Obama’s stimulus legislation, which contains funding for health information technology, we can make that dream a reality. On May 28, 2009, a San Francisco town hall addressing the creation of a citywide health information exchange was packed with enthusiastic local stakeholders. Less than one year later, the first meeting of the San Francisco Health Information Exchange Governance Committee included all the major health care organizations in San Francisco at the table. The Governance Committee has since outlined a detailed collective vision for the future health information exchange in San Francisco. Having developed the business and technology plans, the focus is now on pursuing grants and funding. With the pieces fitting together, the exchange should launch in early 2012. The San Francisco Health Information Exchange is groundbreaking work and will bring San Francisco’s health information sector into the 21st century. David Chiu is president of the San Francisco Board of Supervisors. Arieh Rosenbaum, M.D. is chair of the San Francisco Health Information Exchange Governance Committee.

May 2011 San Francisco Medicine 5

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President’s Message George Fouras, MD

Why Membership Matters


here was a time, certainly within my lifetime, that almost every physician belonged to his or her county medical society. Perhaps the greatest reason for this was the requirement (or advantage) that membership in the medical society was needed to join a medical staff or obtain hospital privileges. However, over the last several decades things have changed, and that aspect of membership no longer exists. So why do physicians today become members of the medical society? Does it even matter? For me, the answer is, “Yes.” I didn’t always feel this way. When I was a medical student I joined the AMA, largely because membership was free at the time. However, I didn’t join the county medical society, largely because I didn’t identify with its members ideologically. Prior to my first year of medical school, I was returning from a cross-country motorcycle trip on my brand-new Harley-Davidson, complete with long hair and bushy beard, and found that I couldn’t relate well to my fellow students—or, by extension, to what I perceived to be a much older and highly conservative group of physicians. It was only once in residency, where one of my professors took an interest in me and asked me to run for office in my specialty society, that I became active in organized medicine. Currently, the San Francisco Medical Society has roughly 33 percent of eligible physicians as members. Each of these members have different reasons for joining. What I wonder is why the remaining 66 percent don’t become members. The most common reasons for this appear to be that the dues are too expensive or, as I used to believe, that the SFMS/CMA is too conservative/too liberal. What it really boils down to is not so much the accomplishments or goals of our organization but what the perceived value is to the individual. Unfortunately, unlike dinner at a fine restaurant, what we have to offer is, for the most part, intangible. There are three broad values that SFMS has to offer: the “practical”, such as legislative issues; “public health/ community advocacy,” such as local initiatives and programs; and the “social or collegial” function. I think most members tend to feel that the primary goal or advantage that they want from the SFMS/CMA is that of legislative advocacy. I refer you to my last column for review of the accomplishments that the SFMS and CMA have achieved. But even with our recent achievements—the passage of Proposition A to fund a new San Francisco General Hospital;

the CMA lawsuit, which has now reached the U.S. Supreme Court, regarding state-mandated Medi-Cal cuts and protection of the public safety net; the ongoing battle to preserve MICRA, and more—it has been difficult convincing more of our colleagues to join us. Take MICRA, for example. It doesn’t take much to see how someone in private practice would benefit from having MICRA in the state of California, as this one piece of legislation has dramatically decreased medical malpractice insurance premiums. Yet this statute also helps entities that are self-insured, such as Kaiser Permanente and city and county governments, by decreasing their malpractice and litigation expenses. But I suspect that most physicians who practice in these settings are not aware of MICRA, and they would deny that MICRA has any impact on them because they don’t personally have to cope with these expenses. Another example is Proposition A. This directly benefited physicians who work with the San Francisco Department of Public Health and physicians at UCSF. Yet very few physicians who practice in the public sector have chosen to belong to our society. Furthermore, many physicians belong to one or more specialty societies. These societies have their importance. However, they do not wield the strength of numbers that can occur when we all come together. And this, perhaps, is the greatest reason why membership matters. For it is only when we stick together, as the “House of Medicine,” that we are able to accomplish great things. During times of crisis, it’s relatively easy to convince our fellow physicians to become members, because they perceive the danger in not belonging and are able to rally around a cause. But I’m afraid now that the crises are coming so fast and so furious that we have become numb to them. However, this is the time when it is even more urgent that we stick together. If we do not, when a real crisis arises there won’t be enough of us left to advocate for what is right for our patients and our profession. And for those who believe that the SFMS/CMA does not share their ideals, I would say, “It is easier to change an organization from within than from without.”

May 2011 San Francisco Medicine 7

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Editorial Gordon Fung, MD, PhD

Lung Health


ung health is a timely topic during this time of discussions at the federal and state levels regarding environmental pollution and protections from a policy standpoint. The issues are exceedingly complex and have an impact on discussions ranging from global warming to air quality and our health. From anatomical and physiological perspectives, the lungs are the gateway of the interaction of the environment with our bodies. Ideally the air is clean, without pollutants, to minimize the damage to the tissue during the journey in the body to the site of action. But even natural substances like pollen and dust can cause significant problems for the tubular route, preventing air from entering or leaving the lungs. Many times viruses and bacteria and fungi can get into the lungs and cause significant disease. This month’s issue addresses some of the basic problems in lung health and air quality. The initial question to be answered is, “What is good lung health?” And then what can we do to improve, maintain, and even optimize our lung health? It is gratifying to hear that some of the discussions at the Environmental Protection Agency refer to the impact of pollution on human and animal health, and we must be aware of the pertinent issues so we can advocate for our patients’ and our own health. As physicians, we often look at health from the disease standpoint first, as we are trained to make diagnoses and treat disease. From this standpoint, the most common lung diseases are still increasing in frequency. Asthma affects 10 percent of children, and the frequency has increased over the past several decades. Among Americans, 34.1 million have been diagnosed as having asthma by a health care professional. Worldwide, 300 million people suffer from asthma, and annually there are 250,000 deaths attributed to by asthma. The prevalence of asthma has increased by 75 percent from 1980 to 1994, and the asthma rates for children under five years old have increased 160 percent! Workplace conditions, such as exposure to fumes, gases, or dust, are responsible for 11 percent of asthma exacerbations worldwide. Asthma accounts for 500,000 hospitalizations per year. It is estimated that by 2025, 100 million Americans will have asthma. One of the major risk factors for acute and recurrent asthma attacks and other lung health issues is smoking. Smoking and tobacco use was identified as a leading cause of poor lung health, leading to chronic obstructive pulmonary disease (COPD), and

is the leading cause of cancer death in the United States—lung cancer accounting for 90 percent of cancer deaths in men and 80 percent of cancer deaths in women. Smoking cessation has been the focus of the American Heart Association, the American Lung Association, and the American Cancer Society, as well as many other health organizations. In 2009, 20.6 percent of the American population smoked. On September 8, 2010, Thomas Maugh II wrote in the Los Angeles Times, “After forty years of continual declines, the smoking rate in the United States has stabilized for the last five years, with one in every five Americans still lighting up regularly, the Centers for Disease Control and Prevention said Tuesday. Moreover, more than half of all children are exposed to toxic, secondhand smoke and 98 percent of those who live with a smoker have measurable levels of toxic chemicals in their blood stream, setting them up for future harm from cancer, heart disease, and a variety of other ailments.” Several articles in this issue focus on the current state of tobacco cessation attempts with legislation, through the advocacy efforts of many healthrelated organizations, while other articles clarify the ravages and management of chronic lung disease. Other disease can affect the lungs and result in such destruction that it can impact the heart, in a situation called “cor pulmonale.” Although the manifestations of cor pulmonale are progressive shortness of breath with exertion leading to decreased exercise tolerance to the point of dyspnea at rest, many times there is concomitant pulmonary arterial hypertension. Dr. Thomas Addison highlights some of the main causes of this condition and some of the treatments that have been developed over the past fifteen years. One of the most challenging treatment options we have for end-stage pulmonary disease is lung transplant. Like other organ transplants, there is a significant demand that far exceeds the supply of donor organs. Dr. Jeffrey Golden, director of the UCSF lung transplant program, gives us the latest update on where lung transplantation fits in the management of lung disease and some of the challenges to successful outcomes. We hope you enjoy and find useful this mix of clinical, scientific, preventive, and policy-oriented material.

May 2011 San Francisco Medicine 9

Breathe Easy: Air Quality and Lung Health

Lung Transplantation An Update for the Clinician

Jeffrey A. Golden, MD


efore 1981, lung transplantation had been undertaken in thirtyeight patients, and virtually none lived more than two weeks. With the availability of the novel immunosuppressant cyclosporine, lung transplants became more successful in terms of one-year survival rates. In the post-cyclosporine era, the first heart-lung transplant was done at Stanford in 1981 by Bruce Reitz, and the first lung transplant was done in 1983 at the University of Toronto by Joel Cooper. Since this initial success, progressively more patients are receiving lung transplantation; today the annual international volume is 2,700 procedures including 1,700 recipients in the U.S. However, the five-year survival has remained at 50 percent for the past twenty-five years. The two broad categories that need improvement in the field of lung transplantation include this low five-year survival and the limited availability of donor organs.

Outcome of Lung Transplantation

The five-year survival after lung transplantation of only 50 percent is particularly low compared with the fiveyear survival of renal transplantation of 90 percent and that of heart and liver transplantation of over 75 percent each. The fundamental reason for this relatively poor outcome in lung transplantation is chronic airway rejection: bronchiolitis obliterans. This entity is difficult to detect on bronchoscopic transbronchial lung biopsy (TTBx). Therefore, the diagnosis of bronchiolitis obliterans syndrome (BOS) defines chronic airway rejection on the basis of a decreased forced expired volume in one second (FEV1) in the absence of alternative causes such

11 San Francisco Medicine May 2011 10 San Francisco Medicine May 2011

as infection, acute rejection (easy to diagnose by TBBx), and/or the presence of structural airway narrowing. BOS and bronchiectasis are associated with infections including pseudomonas and/ or aspergillus, simulating patients with end-stage cystic fibrosis. Further intersection of BOS, or chronic airway rejection, and infection includes the emerging role of community-acquired viral infections in promoting rejection. In addition to the role of immunosuppression and such infectious complications, atypical mycobacterial infections are frequent among transplant recipients. Similarly, certain malignancies such as lethal skin cancer and post-transplant lymphoproliferative disease (PTLD) clearly relate to the higher levels of immunosuppression applied to lung transplant recipients than to other solid organ transplant patients.

Lung Availability

The major limiting factor to increasing the number of lung transplants performed is donor shortage. In addition to the overall donor shortage, only 15 percent of cadaveric donors provide acceptable lungs for transplantation, compared to the kidney or liver harvest rates of 88 percent. This disparity relates to lung injury among potential donors including aspiration, donor brain deathinduced lung inflammation, and ventilator-associated injury, among other causes that limit lung donation. Investigators at UCSF have shown that 40 percent of donor lungs turned down for transplant can actually be safely placed in recipients. Furthermore, investigators in Toronto are pioneering new methods to rehabilitate imperfect lungs taken from donors. Such

unacceptable ex-vivo lungs are ventilated and perfused (“ex-vivo perfusion”) and treated so that they can ultimately be successfully placed in patients (Cypel M, 2009). Such “ex-vivo lung perfusion” is now being investigated in several centers, including UCSF.

Lung Allocation Score

To ensure equitable distribution of donor lungs and avoid death on the waiting list, the lung allocation score (LAS) was developed by UNOS (United Network of Organ Sharing). UNOS is a private, nonprofit organization that operates the Organ Procurement and Transplantation Network (OPTN) under a contract with the U.S. Department of Health and Human Services. In addition to ensuring efficient and equitable use of organs, UNOS also maintains data pertaining to the waiting list, organ matching, and transplant procedures. All local Organ Procurement Organizations (OPOs) are members of UNOS. The LAS system became operational in 2005. Prior to that time, donated lungs went to candidates for transplant based on length of waiting time. The LAS system prioritizes organ donation to the sickest patients to avoid death on the waiting list. Additionally, by including prediction of survival post-transplant in the score, the system ensures that futile procedures are not undertaken in patients whose impairment is so severe that transplant success is predictably jeopardized. The score is calculated using the patient’s clinical and physiological metrics. The LAS ranges from 0 to 100, with the higher scores reflecting higher urgency and greater transplant benefit so as to avoid death on the waiting list.

Patient Benefit of the Lung Allocation Score

Lung Allocation Score: Additional Clinical Implications

In the years since application of the LAS system, there has been less death on the waiting list as potential recipients with higher LAS are getting organs with a decreased wait time. Thus far, the oneyear survival after transplantation has not declined compared to the pre-LAS system, suggesting transplanting the more ill patients has not hurt outcomes.

With the availability of more organs for sicker patients, double-lung transplantation can be offered for IPF patients rather than the single-organ procedure. Although controversial, double-organ transplant recipients have a better longterm outcome in lung fibrosis relative to single-lung transplantation. In patients with septic lung disease such as cystic fibrosis, and patients with pulmonary artery hypertension such as IPH, doublelung transplant is required and not a matter of debate. Another collateral opportunity afforded by the LAS system is “emergent” transplantation, especially applicable for patients with IPF or other fibrotic diseases. Given the increased availability of lungs for the sickest patients with the highest LAS, transplantation may be a reality for even intubated patients. Further, we have expanding experience in bridging such patients with extracorporeal membrane oxygenation (ECMO) to enable organ transplantation. Such patients are highly selected, and our outcomes have been excellent. It should be stressed that such opportunities for “emergent” transplantation are limited. It is better to refer all potentially eligible newly diagnosed IPF patients to transplant centers independent of their level of impairment. We know that such patients are at risk for acute exacerbation, making it difficult for them to be fully evaluated and placed on a list even in the LAS era. Also, an early referral helps educate the patient and family regarding transplantation and may discover comorbidities that can be modified. Timing of referral for other diagnostic categories is more qualitative. All candidates for transplant must have strong family support, no social or psychiatric issues, and absence of substantial nonpulmonary comorbidities. Regarding specific diagnostic groups, emphysema patients should be referred to a transplant center when their FEV1 is below 700 ml, especially if they suffer from frequent exacerbations. For patients with cystic fibrosis, the timing is based on poor quality of life

Lung Allocation Score and Recipient Diagnostic Categories

In the pre-LAS system, emphysema was diagnosed in more than 50 percent of lung recipients, followed by idiopathic pulmonary fibrosis (IPF, among other fibrosing processes), followed by cystic fibrosis and idiopathic pulmonary hypertension (IPH). However, as patients with IPF are more ill than those in other categories, especially emphysema, IPF is becoming the most-transplanted diagnostic category in the U.S. At UCSF, more than 60 percent of our recipients have IPF or other fibrosing diseases. In the past, because patients with emphysema could survive a long time on the waiting list, they were more likely to obtain organs in the pre-LAS period. In the old system of organ allocation when waiting time was the key determinant, about half of the patients with IPF died on the waiting list. With the present LAS system, IPF patients are dying much less on the list, as there is almost a 50 percent increase in transplantation for this diagnostic group. However, it should be pointed out that although emphysema patients with substantial lung impairment can live longer than other diagnostic categories, their quality of life is poor in the context of this prolonged survival. Also, as a group, lung transplantation does not extend the survival in patients with emphysema. It is key that the lung transplant community is now starting to evaluate quality of life before and after lung transplant so that survival is not the only metric to assess priority of organ allocation.

manifested by frequent hospitalizations for infection with progressive diminishing utility of antimicrobial therapy; such patients generally have an FEV1 of under 30 percent of predicted. Lung transplantation for IPH is becoming more uncommon due to the rapidly increasing pharmacologic agents available. However, patients who have hemodynamic failure despite cotemporaneous application of multiple medications are candidates for transplantation. Additional issues that are precipitated by the LAS, especially regarding the increasing opportunity to transplant patients with IPF, include establishing the precise upper age limit of transplant and associated comorbidities such as coronary artery disease. The International Society of Heart Lung Transplantation (ISHLT) has recommended that sixty-five be the upper age limit for lung transplantation. Given that the average age of patients with IPF is in fact sixty-five, the upper age limit for transplantation is creeping up, with patients now being transplanted in their seventies. Ultimately the LAS is going to need to be adjusted to ensure, for example, that younger potential candidates with cystic fibrosis are not competing with older recipients, which is especially poignant when the donor is young. To make this topic even more complex, patients with IPF have a statistical significant propensity to have coronary artery disease. Because it is not easy to uniformly characterize chronologic age with or without various comorbidities, and given nuances of such issues in specific patients, each candidate must be evaluated as an individual. Finally, certain patient categories, such as scleroderma, are not even considered for lung transplant at most centers but are acceptable candidates at others. More outcome data in such controversial patient categories is needed. Our recent review of our lung transplant experience in patients with scleroderma documents that such patients have equivalent outcome relative to that of other patient categories who have traditionally been offered lung Continued on page 13 . . . May 2011 San Francisco Medicine 11

Breathe Easy: Air Quality and Lung Health

Pulmonary Arterial Hypertension An Epidemic?

Thomas E. Addison, MD


n 1973, a World Health Organization international conference classified pulmonary arterial hypertension as either “primary” or “secondary,” depending on the presence or absence of identifying risk factors. Primary pulmonary hypertension was rare, affecting only 1 in 1,000,000 individuals. In 1991, the results of a four-year study from eight academic medical centers described 194 patients with this rare but morbid disease. The median survival was 2.8 years and there was no effective treatment. If you read any of the popular cardiology, pulmonary, or rheumatology journals today you will find that among the most heavily advertised drugs are those treating this rare disease. What has happened since 1991 has been a tale of successful scientific investigation into the basic mechanisms of disease, a dramatic reclassification and reorganization of diseases associated with pulmonary arterial hypertension, innovative drug development based on suggested disease pathogenesis, and skillful testing and marketing of these new treatments by a handful of academic investigators and drug companies in the United States and Europe.

Scientific Investigation and Drug Development

Early studies demonstrated reduced production of the vasoconstrictor and growth inhibitors PGI2 (prostacyclin) and nitric oxide (NO) and increased production of endothelin, a potent vasoconstrictor and stimulant of endothelial cell growth, making these perturbations attractive targets for drug development. Since 1990, nine new drugs have been introduced to treat this disease. They have

12 San Francisco Medicine May 2011

fallen largely into three categories: prostanoids; endothelin receptor antagonists; and PDE–5 inhibitors, which stimulate synthesis of nitric oxide.

Reorganization and Reclassification of the Disease

Why such interest in treatment of this rare disease? In 1998, pulmonary hypertension experts convened in Evian, France, and dramatically reclassified pulmonary arterial hypertension into five categories. The first category, called Group I, would include idiopathic or “primary” pulmonary hypertension and many other conditions that were associated with pulmonary arterial hypertension, including common conditions like rheumatologic diseases, hemaglobinopathies including sickle cell disease, congenital heart disease, liver disease, and HIV. One of the arguments for including all of these diseases in one group was their similar pathologic findings, including the finding of so-called “plexiform lesions,” thought to be pathognomonic of primary pulmonary hypertension. The Evian group classified other “secondary” causes of pulmonary hypertension into four additional groups: PAH in Group 2, associated with left heart disease; in Group 3 with lung disease; in Group 4 with thromboembolic disease; and in Group 5 with miscellaneous diseases. The primary effect of this reclassification was to put many more individuals into Group 1, a category felt to be similar enough to allow treatment with the burgeoning new types of drugs being developed for the rare disease of idiopathic pulmonary arterial hypertension. In fact, modern drug trials have included all types

of patients in Group 1 pulmonary arterial hypertension, and drugs approved by the FDA are approved for and used for all of the diseases included in Group 1. The problems that arise from this reclassification include the widely different natural histories of untreated PAH associated with congenital heart disease, sickle cell anemia (much longer life expectancy), and other conditions in Group 1 such as scleroderma and pulmonary veno-occlusive disease (shorter life expectancy) from those with idiopathic (“primary”) pulmonary hypertension. A second and perhaps more significant problem is that, absent any survival data, patients in Group 1 who are receiving modern therapies are frequently compared with “historical controls” (the NIH cohort from 1991), which included only patients with idiopathic (“primary”) pulmonary hypertension. This dramatically skews survival benefits to the modern era of drug treatment.

Drug Testing and Marketing

To date, the nine agents approved for treatment of PAH have been approved on the basis of small, controlled clinical trials with outcomes based on improved exercise tolerance (average improvement in six-minute walk distance of 60 to 120 feet), a delay in time to clinical worsening, and improvement in functional class. The studies have all lasted twelve to sixteen weeks, many extended in unblinded fashion up to fifty-two weeks. Metanalysis of these studies have suggested either no effect or a small effect on overall mortality. More than 5,000 patients have participated in these studies, which were done by a handful of investigators in academic

medical centers. Based on these studies, the drugs have been widely prescribed to many patients with all types of pulmonary arterial hypertension, including “off label” use in patients from Groups 2 through 5. Most of the opinion leaders in the field of pulmonary arterial hypertension have been heavily supported by the drug industry, receiving speaking fees, research grants, and salary support as consultants to that industry. The same experts speak at national meetings and drug dinners and serve on advisory panels to the FDA, the Pulmonary Hypertension Association, and international conferences such as Evian in 1998 and Dana Point in 2008, which develop the guidelines for evaluation and treatment of patients with pulmonary arterial hypertension. Since most data is limited to drug company-sponsored trials and registries of patients, many of the guidelines are advanced primarily as “expert opinion.” One such registry, known as REVEAL (Registry to Evaluate Early and Long-Term PAH Disease Management), suggests that many centers are using combination therapy, combining drugs from each of the approved groups, despite a paucity of evidence of benefit. This frequently doubles or triples the cost of therapy. Although all of the expert opinion leaders indicate that the treatment of patients in Groups 2, 3, 4, and 5 should be avoided except in controlled clinical trials, many patients in these groups receive these medications “off-label.” In fact, patients in these groups may be the largest number of patients receiving the oral agents (PDE 5 inhibitors and endothelin antagonists), even though there is little evidence of benefit to patients in those groups.

Bottom Line

There is no doubt that advances in the modern era of pulmonary hypertension have provided benefits to patients with that disease, but it remains a morbid disease, with the majority of patients dying in spite of treatment. The cost of drug treatment is striking, ranging from $40,000 per drug per patient per year, to more than $100,000 per drug per patient

per year, and many patients are receiving more than one drug to treat this disease, with evidence of long-term benefit limited to expert opinion. As a “consumer” of the science guiding management of this morbid disease, one would like to see additional evidence of benefit with some hard outcomes, such as improved mortality in carefully controlled groups. Additionally, it would seem that public understanding of the costs and benefits of such treatment should be part of the debate about health care costs as we move to such expensive therapy. Finally, we must understand the subtle marketing that currently prevails with many new therapeutic agents, where science and profits mingle closely together. Thomas E., Addison, MD, is emeritus professor of medicine, clinical faculty, University of California at San Francisco, and is with the Pulmonary Hypertension Referral Center at Permanente Medical Group, San Francisco.


Lung Transplantation Continued from page 11 . . . transplantation. Lung transplantation is an expensive treatment with only modest improvements in quality-adjusted survival. Emerging quality-of-life investigations reveal that more than 89 percent of recipients report no activity limitations, and the majority of five-year survivors are working. Lowering the morbidity and mortality of BOS would improve the costeffectiveness of lung transplantation. The challenge for investigators is to improve our understanding of the mechanism of BOS so that novel interventions can be undertaken that do not result in further global immunosuppression. In addition to minimizing the occurrence and severity of BOS, leveling the playing field in terms of fairness regarding both use of donated organs and selection of transplant recipient candidates will be challenging in this frontier of lung transplantation. Jeffrey A. Golden, MD, is a professor of clinical medicine and surgery at UCSF.

Proceedings of the Fourth World Symposium on Pulmonary Hypertension. Journal of the American College of Cardiology. 2009; 54 Supplement S, S1-S117. Note: The opinions expressed in this paper are solely the opinions of this author and do not represent official opinions of TPMG, Kaiser Permanente, or the University of California, San Francisco.

Check out What LA County Is Doing: Cure the Air It is with great pleasure and a “breath” of fresh air that we welcome you to our Cure the Air initiative. Cure the Air is a campaign formed by physicians in Los Angeles County who believe that reducing the dramatic and alarming rates of asthma and air-related illness in our communities requires stepping out of the doctor’s office and into the public policy arena. In short, these doctors realize that curing their patients involves curing the air! Cure the Air is dedicated to using education, engagement, and cooperation with business, government, and the community to reduce the health effects caused by air pollution in Southern California. We can all understand the direct value of cleaner air in the form of reduced hospital visits and medical care costs. Working together, we can pinpoint the largest sources of air pollution in our region and collaborate on solutions that keep both our patients and the economy healthy. May 2011 San Francisco Medicine 13

Breathe Easy: Air Quality and Lung Health

Teens and Asthma Improving Health Outcomes Through Support and Education from Health Care Providers and School Personnel

Karen Licavoli Farnkopf, MPH


ealth care providers and school personnel often overlook the specific issues and needs of teens with asthma. According to the Asthma and Allergy Foundation of America, “among children ages five to seventeen, asthma is the leading cause of school absences from a chronic illness, and it accounts for an annual loss of more than 14 million school days per year (approximately eight days for each student with asthma).” The 2009 Youth Risk Behavior Health Surveillance System indicated that 7.6 percent of San Francisco Unified School District (SFUSD) high school students currently have asthma. This means that in a population of 18,742 SFUSD high school students, it can be assumed that 1,424 teens have asthma. Recently, Breathe California conducted a needs assessment of teens ages thirteen through eighteen in San Francisco to assess how well they understand and get support for their asthma needs. Findings include a lack of knowledge about what caused their asthma; some knowledge of what triggered their asthma, but not knowing what to do about it; unfamiliarity with the names of their medications; unfamiliarity with or absence of an asthma action plan; and confusion regarding the California Schools Asthma Medication Law. The teens had different interpretations of this law, and in the case of this assessment, teens with asthma may have not carried their medications because they were confused about the policy. This finding is particularly alarming in that it could potentially reduce their access to quick-relief prescription medications. Teens also identified the need for teachers to understand the difficulties of having asthma. This shows that teens look to their teachers for support, but they feel

14 San Francisco Medicine May 2011

that in the case of an asthma episode, their teachers wouldn’t know how to respond. Although the CDC promotes the use of asthma action plans for all people with asthma, fewer than half of the teens surveyed reported any knowledge of having an action plan. These asthma action plans are an integral part of asthma management that teens are capable of following, if they have one. If there are asthma issues with a student, the school site needs to be informed and have a plan on file in the case of an emergency. For this age group, quality of life is dependent on how well each teen adapts to his or her chronic condition across a range of social, emotional, and physical issues. For example, as important as it is for teens with asthma to know what triggers their asthma symptoms, it is also critical for them to understand how succumbing to social pressures, such as using drugs or smoking, also exacerbates their asthma condition. Another factor is that teens may be seeing their physician without their parents and may not be asking the follow-up or clarifying questions essential for the self-management of their asthma. At a time in their lives when being “cool” and “fitting in” may mean, for some teens, ignoring their asthma symptoms, not using their medication when needed or smoking, asthma is an issue that health care providers and school personnel need to address more directly. CDC best practices recommend that schools address asthma in the following ways: (1) Have students’ asthma action plans on file. (2) Permit students with asthma to carry and self-administer quickrelief prescription inhalers. (3) Provide staff development on identification or

school-based management of asthma. (4) Provide case management for students with asthma. (5) Supply peak flow meters, nebulizers, and albuterol inhalers for use by students who may need this equipment. (6) Provide a full-time school nurse. Any intervention that is developed based on the best practice recommendations would need to include training teachers and coaches on asthma as a chronic illness, asthma triggers, and management; making sure school administrators clearly understand the protocols of the state schools asthma medication law that allows students to keep their prescription medications with them; having health care providers proactively provide asthma action plans to schools; and training for health care providers on enhancing communication skills with teens, including teaching them how to follow their asthma action plans, avoid triggers, and resist the social pressures of engaging in activities that can exacerbate asthma symptoms, as well as giving them information on the California Schools Asthma Medication Law. These interventions will positively impact the communication between teens and teachers and the communication between teens and their health care providers, and most importantly, these actions will empower teens to effectively manage their own asthma. For more information on asthma, visit Breathe California’s Asthma Resource Center for Health Care Providers at www. Karen Licavoli Farnkopf, MPH, is vice president of Program Development and director of Tobacco Control Programs for Breathe California, a Golden Gate Public Health Partnership.

Breathe Easy: Air Quality and Lung Health

Pollution and Inflammation Polluted Air Leads to Disease by Promoting Widespread Inflammation

Emily Caldwell


hronic inhalation of polluted air appears to activate a protein that triggers the release of white blood cells, setting off events that lead to widespread inflammation, according to new research in an animal model. This finding narrows the gap in researchers’ understanding of how prolonged exposure to pollution can increase the risk for cardiovascular problems and other diseases. The research group, led by Ohio State University scientists, has described studies in mice suggesting that chronic exposure to very fine particulate matter triggers events that allow white blood cells to escape from bone marrow and work their way into the bloodstream. Their presence in and around blood vessels alters the integrity of vessel walls. They also collect in fat tissue, where they release chemicals that cause inflammation. The cellular activity resembles an immune response that has spiraled out of control. A normal immune response to a pathogen or other foreign body requires some inflammation, but when inflammation is excessive and has no protective or healing role, the condition can lead to an increased risk for cardiovascular diseases, diabetes, obesity, and other disorders. Though many questions about the beginning of this process remain unanswered, the scientists predict that the damage may originate in fluid that lines the lung. Tiny molecules in this fluid change structure after being exposed to polluted air, and that change appears to set off this cascade of damaging white blood cell behavior by activating a receptor called toll-like receptor 4. The job of toll-like receptor 4, or TLR4, is to recognize specific characteristics of

pathogens and then send out signals to activate other players in the immune system. Mice that lack this molecule don’t produce as much inflammation after exposure to pollution as do normal mice, suggesting that TLR4 has a prominent role in the body’s response to chronic exposure to particulate matter. “Our main hypothesis is that particulate matter stimulates inflammation in the lung, and products of that inflammation spill over into the body’s circulation, traveling to fat tissue to promote inflammation and causing vascular dysfunction,” said Sanjay Rajagopalan, professor of cardiovascular medicine at Ohio State and senior author of the study. “We haven’t identified the entire mechanism, but we have evidence now that activation of TLR4 influences this response.” The results of the study have been published in a recent issue of the journal Circulation Research. Many of these researchers already have documented the link between chronic exposure to polluted air and high blood pressure, diabetes, and obesity. They now aim to pinpoint how and where the earliest damage occurs. For this study, the scientists exposed different groups of mice to filtered air or to air containing between eight and ten times more fine particulates than the ambient air in an urban environment—an average of approximately 111 micrograms per cubic meter. The mice were exposed for six hours per day for five days per week for at least twenty weeks. The polluted air contained fine particulates that are so tiny—2.5 micrometers or smaller in diameter, or about 1/30th of the average width of a human hair—that they can reach deep areas of

the lungs and other organs in the body. For most of the experiments, the effects of exposure to pollution were compared in normal mice and mice deficient in TLR4. After exposure to polluted air, the normal mice showed higher levels of white blood cells known as inflammatory monocytes in their spleens and circulating in their bloodstream than did mice breathing filtered air. Deficiency of TLR4 diminished this effect in mice breathing dirty air. That suggested that if the receptor is not active, the monocytes will not be released. Other findings implicated yet another potential compound involved in the damage. The increase in monocytes was accompanied by an increase in superoxides in the blood vessels. These compounds are designed to kill pathogens, but they are toxic if they have no bug to fight. They are produced by an enzyme called NADPH oxidase, which is found inside monocytes. In an experiment comparing normal mice and mice lacking a component of the NADPH oxidase enzyme, the mice without the enzyme produced fewer oxygen free radicals in response to polluted air than did normal mice. “The free radicals can have a high impact on vascular function,” explained Thomas Kampfrath, a postdoctoral researcher in Ohio State’s Davis Heart and Lung Research Institute and first author of the study. Indeed, an examination of the aortas of these mice showed that vessels in animals exposed to polluted air exhibited exaggerated responsiveness to stressors— a sign of incipient hypertension, or high blood pressure, Kampfrath said. Yet another model of mice genetically altered so their monocytes express Continued on the following page . . . May 2011 San Francisco Medicine 15

Pollution and Inflammation Continued from page 15 . . . yellow fluorescent protein allowed the researchers to observe exactly where the monocytes traveled in segments of mouse muscles and fat tissue. In mice breathing polluted air, the monocytes began to stick to blood vessel walls and fat cells. “This is a sign that the monocytes are responding to inflammatory stimuli—which in our case is particulate matter—and then in turn they can cause more inflammation because they release inflammatory factors,” said Rajagopalan, who is also the associate director for vascular research at the Davis Heart and Lung Research Institute. Those factors include what are called proinflammatory cytokines, including TNFa (tumor necrosis factor alpha), MCP-1 (monocyte chemoattractant protein), and IL-12 (interleukin-12). These are chemical messengers that cause inflammation, most often to fight infection or repair injury. When they circulate without an infection to fight, the body experiences excess inflammation. Mice breathing polluted air showed higher levels of these cytokines in their blood than did mice breathing filtered air. And the mice deficient in the TLR4 receptor showed dramatically lower levels of the cytokines. “Most of our experiments initially assessed global inflammation. The monocytes are virtually everywhere in the body,” Rajagopalan said. “And then we asked, ‘How does it happen, and where does it come from?’” Kampfrath in particular is focused on the lung’s role in this process. Those same cytokines were also significantly elevated in the lungs of mice that had experienced prolonged exposure to polluted air, and the lack of TLR4 activation lowered this effect. Protective fluid in the lung contains molecules called phospholipids, and this research showed that those molecules become oxidized—meaning a chemical reaction changes their shape and function— after they are exposed to polluted air. And a series of experiments in different types of white blood cells demonstrated that when the cells are treated with oxidized

16 San Francisco Medicine May 2011

phospholipids, they will release those proinflammatory cytokines. The lack of TLR4 in those cells diminishes these effects. The experiments confirmed that these activities in the lung could trigger inflammation seen throughout the rest of the body in mice exposed to polluted air. The question that remains unanswered, however, is the process by which phospholipids become oxidized after chronic lung exposure to dirty air, Kampfrath said. “After exposure, there is an increase in oxidized phospholipids in the lung fluid. We know it happens, but we don’t know how. What we do know is that the increase in oxidized phospholipids in turn promotes inflammation.” In an editorial in the same issue of Circulation Research, Daniel Conklin of the University of Louisville wrote, “Is the mystery solved regarding the mechanism of how inhaled [fine particulate matter] exposure stimulates vascular inflammation and injury? Well, probably not completely, but the present scenario laid out . . . connects findings from their study with many disparate human and animal epidemiological/exposure studies into a plausible story.” This research was supported by grants from the National Institutes of Health and DFG (German Research Foundation). Coauthors include Andrei Maiseyeu, Zhekang Ying, Zubair Shah, Jeffrey Deiuliis, Nisharahmed Kherada, Sampath Parthasarathy, Susan Moffatt-Bruce, and Qinghua Sun of the Davis Heart and Lung Research Institute; Xiaohua Xu of the Division of Environmental Health Sciences; Kongara Reddy and Nitin Padture of the Department of Materials Science and Engineering at Ohio State; Robert Brook of the University of Michigan; Lung Chi Chen of New York University; and Henning Morawietz of the University of Technology in Dresden, Germany. This article was reprinted from a report that appeared online on April 14, 2011.

Air Pollution May Hurt School Kids’ Lungs Allergy season is known to aggravate kids’ asthma attacks, but other types of fineparticle pollution in the air throughout the year also measurably affect children’s lung function, sometimes dramatically, according to a study by Taiwanese researchers. On the day following a rise in one of the air pollutants studied, the researchers found, schoolchildren had a smaller lung capacity—presumably due to inflammation that made their airways shrink up. It’s well established that poor air quality can worsen symptoms in people with asthma or other lung disease, and some studies have linked it to heart disease, too. But few studies have followed the health effects over time. In the current study, Bing-Yu Chen, of National Taiwan University, and colleagues followed 100 school-aged children—some with asthma or hay fever and some without allergic diseases. Children are thought to be particularly susceptible to the ill effects of air pollutants because their airways are smaller and their immune systems less developed. The researchers tested the youngsters’ lungs once a month over a school year and collected data on several air pollutants, including fungal spores, ozone, and fine particles less than 2.5 microns (millionths of a meter) in size, which are often byproducts of burning fossil fuels. A ten-year-old’s lung capacity is typically between two and three liters, but even a modest increase in fine particles in the air was tied in the study to a 0.16-liter decrease in the amount of air kids could take in. A similar effect was seen for fungal spores, even after taking into account levels of other air pollutants such as sulfur dioxide. Ozone also affected the airways, but the researchers didn’t find any increases in the number of asthma attacks linked to ozone. Nonetheless, the researchers write in the journal Pediatrics, the findings suggest that even without producing observable changes in asthma attacks or the children’s medication use, exposure to pollutants and spores could harm their lung function. SOURCE: Pediatrics, online February 21, 2011

Breathe Easy: Air Quality and Lung Health

Breathe Easy Indoors Improving Indoor Air Quality in the Physician’s Office

Deborah Crosby, ASID


e spend about 90 percent of our time indoors. Today’s buildings are airtight and seal in harmful toxins, which affects indoor air quality. The tighter your building is, the less the opportunity for gases released from everyday products (such as many cleaning agents, carpet, paint, or formaldehyde used in cabinets and other products) to escape. In a very well-insulated office, these gases will simply recirculate and build in concentration. Your patients and employees will appreciate your ongoing commitment to their well-being while working or visiting your office. So here are some suggestions to detox your office:

paint (exterior and interior) has been recommended by doctors for people with chemical sensitivities and allergies. I like Green Planet Paints, which have no toxic petro-chemicals and are a clay paint. Plaster walls have a beautiful texture and improve air quality, since they absorb C02 while curing. Two companies I like are Tobias limestone plaster and American Clay plaster. My favorite decorative wall covering is by Jacobsen & Balla; it is 100 percent postconsumer-waste recycled paper, is handpainted, is manufactured in the San Francisco Bay Area, and has a class A fire rating. It is also moisture resistant and washable.

Open your windows, get some good ventilation, and consider using PVC-free window coverings. Polyvinyl chloride (PVC) is a major domestic and global pollutant, since dioxin, one of the most toxic chemicals ever synthesized, is a by-product of both its manufacture and disposal. PVC also needs phthalates to make it functional. They are known to leach out of plastic products into the air and dust. I recommend solar shades, like EcoVeil by Mecho, which can be reclaimed and recycled. This product reduces heat gain (which saves on utility bills) and has different options of visibility. Another choice would be Conrad window shades, which use beautiful natural fibers for a softer look.

Consider using natural products that come from sustainable sources such as wood, bamboo, cork, and linoleum, which are preferable to man-made products that are generally derived from oil. When the products are natural, they are usually biodegradable. Carpet is one of the worse offenders in a landfill. Today there are many locations to drop off old carpet to be recycled. Carpet is horrible for allergies and other respiratory problems because it contributes to particulate allergens and it off-gasses VOCs. If you must have carpet, look for low-VOC types that have the Green Label Plus certification, and carpet that may have recycled content and is recyclable. Consider doormats for your entry to catch allergens and dirt before they are tracked inside.



Use only natural or no-VOC paint inside the office. Paints and finishes can release VOC emissions for years after application. AFM’s SafeCoat


no recognized safe level of exposure. Choose composites and plywoods that do not have added urea-formaldehyde. You can get exotic FSC (Forest Stewardship Council)-certified or salvaged veneers that achieve a high-end look. Today, there are many options for furniture and natural fiber fabrics with natural dyes and finishes. Your choices are not limited.

Office Equipment

Most offices have plenty of computers, copiers, printers, and medical equipment that are packed with toxic synthetic chemicals. These release more gaseous pollutants into the air, and the longer the appliances are on, the hotter they get. Turn off when not in use, and buy from manufacturers committed to reducing toxic chemical content. For example, Dell has phased out brominated flame retardants and PVC; and Nokia, Samsung, and Sony are following suit.

Cleaning Products

After installing beautiful, safe, and healthy interior finishes, the last thing you want to have happen is to spoil things with toxic cleaning solutions, used by an unaware cleaning crew. There are safe and effective cleaning agents available, and it is important to have them handy and to instruct the cleaning crew on how to safely clean your newly “greened-up” office.

Cabinets and Furniture

Particleboard, often used in cabinets, has urea-formaldehyde resins that release formaldehyde, a known carcinogen with

May 2011 San Francisco Medicine 17

Breathe Easy: Air Quality and Lung Health

A Billion Deaths? Progress and Perils in the Ongoing “Tobacco Wars”

Steve Heilig, MPH


obacco abuse is projected to cause a billion premature deaths in this century. To put it another way, until and unless we have a nuclear war, the tobacco industry will continue killing more people than any other man-made cause. This true in just about any region, but here in California, there are nearly four million smokers, and as the American Lung Association reminds us, “Tobacco-related illness remains the number-one preventable cause of death in the state, responsible for more than 36,000 deaths each year—that’s more people lost to tobacco than to alcohol, HIV/AIDS, car crashes, illegal drugs, murders, and suicides combined.” The national toll is about 438,000 deaths per year. In any event, the annual UCSF Center for Tobacco Control Research and Education symposium again keyed off on the “billion lives” estimate and showcased ongoing efforts to apply research toward decreasing that daunting figure. This year, American Cancer Society CEO John Seffrin, PhD, said that the twelve million cigarettes smoked each minute meant an ever-increasing morbidity and mortality, despite whatever progress, with a tripling of disease and death in the developing world—“a tsunami of tumors” and other disease. The majority of smokers start while young—and, not coincidentally, that is where marketing of tobacco is concentrated. An illuminating talk on “The Mind of the Adolescent Smoker” by Bonnie HalpernFelsher PhD, UCSF professor of pediatrics, highlighted the prevalence of denial, social norms and peer pressure, and the tobacco industry’s ongoing efforts to promote so-called “light” cigarettes and “chew” to kids—with an imperative not to try to scare young people but to show them they can’t

18 San Francisco Medicine May 2011

trust the manipulative marking approaches. Other talks regarding tobacco treatment in addiction treatment and the race-based targeted marketing and risks of menthol in tobacco were reminders of how tricky the industry can be—a timely talk, as the FDA is being urged to ban menthol altogether. For all the good science produced, the war remains profoundly political as well. This is a battle with many fronts, and the American Lung Association issues progress reports with grades. Seffrin noted that California was once a pioneer in tobacco control but has slipped in some respects. Most recently, California earned an A for smokefree air policies but an F in funding tobacco control, including a D for a low cigarette tax—we rank thirty-third of states in that regard. More locally, San Francisco earned an overall B, an improvement over a previous D due mostly to our comprehensive environmental tobacco smoke ordinance. The most recent (December 2010) U.S. Surgeon General’s report on tobacco is titled “How Tobacco Smoke Causes Disease,” with six primary conclusions—which are worth relaying to patients: 1. There is no safe level of exposure to tobacco smoke. 2. Damage from tobacco smoke is immediate. 3. Smoking longer means more damage. 4. Cigarettes are designed for addiction. 5. There is no safe cigarette. 6. The only proven strategy for reducing the risk of tobacco-related disease and death is to never smoke, and if you do smoke, to quit. So, what else to do? As many physicians know too well, clinically, the tough job is to encourage and help patients quit. A new tool for that purpose, premiered at the UCSF conference, is presented on page 20 of this issue by Drs. Prochaska and Grossman; the link

for more information is also included here. On a public health/policy front, the SFMS has endorsed the California Cancer Research Act (CRCA) (http://www., which would increase cigarette taxes by a dollar per pack, with the funds going for tobacco cessation, research, and control. As the previous five-cent tax hike instituted in 1988 is only worth two cents now, this would go a long way toward restoring our state’s status as a leader in tobacco control. There is room for evidence-based optimism regarding tobacco use. At the UCSF seminar, the ACS’s Seffrin also said we are saving 350 more lives daily than twenty years ago. California’s smoking rate is about 12 percent, as compared to a national rate of 21 percent. Many of those are “light smokers” more amenable to stopping. As UCSF’s longtime leading foe of the tobacco industry professor Stanton Glantz, PhD, noted, it is possible that if California again pushed hard, as before, smoking could be virtually eliminated in this decade. And that’s not necessarily a pipe dream.


• Rx for change: Clinician-assisted tobacco cessation program. http:// • For more on UCSF’s Center for Tobacco Control Research and Education, go to • The SFMS is part of the San Francisco Tobacco Free Project: http://sftfc.globalink. org/about.html • 2010 Report of the Surgeon General: How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking: tobaccosmoke/index.html

Breathe Easy: Air Quality and Lung Health

Secondhand Smoke Protections Expanded in San Francisco

Alyonik Hrushow, MPH


n April 24, 2010, a new ordinance (San Francisco Health Code Article 19F) that expanded protection from secondhand smoke in indoor and outdoor settings went into effect, while the outdoor dining provision took effect on October 24. In addition to outdoor dining areas of restaurants, the new areas include outdoor waiting lines, building entrances, and farmers markets, as well as indoor areas such as hotel lobbies, common areas of apartments and condos, tobacco shops, owner-operated bars, and charity bingo establishments. The ordinance was sponsored by Supervisors Mar and Avalos and received strong support from the San Francisco Medical Society, whose former President Steve Fugaro testified on behalf of the expanded protections at several Board of Supervisors committee hearings. Supervisor Mar worked closely with the San Francisco Tobacco Free Coalition on this policy, as well as several stakeholder groups. The final ordinance was the result of a consultative process with stakeholders. The Tobacco Free Coalition, which advocated for this new public health measure for more than three years, worked hard to balance the concerns of tenants’ rights advocates on the multiunit housing and private enforcement provisions as well the concerns of the Small Business Commission with the need to protect public health. Secondhand smoke, which is the third-leading cause of preventable death, was declared a toxic air contaminant by the California Air Resources Board in 2006. The 2006 Surgeon General’s report on secondhand smoke also found there is no safe level of exposure. Additionally,

researchers at Stanford University found that exposure in outdoor settings, such as outdoor dining areas, can be significant, depending on proximity to smokers, the number of smokers, and wind conditions. San Francisco’s ordinance, which banned smoking in enclosed worksites, including restaurants, was adopted in 1994 while the California Smoke-Free Workplace Law was adopted in 1995, with the ban on smoking in bars taking effect in 1998. While San Francisco had adopted bans on smoking in parks in 2005 and at bus stops in 2006, protection from exposure in outdoor areas where people congregate or where secondhand smoke easily drifts into buildings had not been addressed until 2010. San Francisco has joined the dozens of other cities and municipalities that have enacted increased protections for their residents and visitors. While in 2009, San Francisco received a C from the American Lung Association’s annual report card on local tobacco control laws, in 2010 it received a B due to its new secondhand smoke ordinance, with its outdoor provisions and housing provision that banned smoking in enclosed common areas. The multiunit housing setting is currently the one that poses the greatest risk for exposure to secondhand smoke in San Francisco. Secondhand smoke is a mixture of many toxic chemicals and includes both gases and microscopic particles. Secondhand smoke seeps into and out of apartments through shared ventilation systems, open windows and doors, ceiling crawl spaces, and gaps around electrical wiring, light fixtures, plumbing, ductwork, and even baseboards. As much as 30 percent to 50 percent of air in multiunit buildings

comes from other apartments. Many property owners are under the impression that they cannot prohibit smoking inside multiunit dwellings. While the Federal Fair Housing Act prohibits discrimination in the rental of dwelling units because of race, color, religion, sex, familial status, or national origin, there is no constitutional right to smoke, as smoking is not protected under the Civil Rights Act of 1964 nor any other Housing and Urban Developmentenforced civil rights authorities. While a nonsmoking policy can be adopted when a lease is renewed for apartments that do not fall under rent control, adopting a new nonsmoking policy in a rent-controlled apartment would require that the tenant agree with such a change and could not be evicted for refusing to do so. However, a nonsmoking policy may be required by a property owner of a rent-controlled building to all new tenants. The Department of Public Health’s initial focus was on educating business owners, apartment building owners, and the public through educational mailings to business owners and a media campaign that was kicked off June 4, 2010. Enforcement followed the educational awareness campaign and complainants are encouraged to call 311, San Francisco’s customer service hotline, to report violations or obtain information. A website was set up to provide information regarding the new ordinance at Alyonik Hrushow, MPH, has been the project director since 1990 for the San Francisco Department of Public Health’s Tobacco Free Project, which is a comprehensive tobacco-control program with a focus on changing social norms and advocacy for tobacco-control policies. May 2011 San Francisco Medicine 19

Breathe Easy: Air Quality and Lung Health

Cardiology RX for Change Addressing Tobacco Use and Secondhand Smoke Exposure in Training and Clinical Practice

Judith J. Prochaska, PhD, MPH, and William Grossman, MD


eart disease is the leading cause of tobacco-related death in smokers and of deaths due to secondhand smoke (SHS) exposure in nonsmokers. Tobacco use and SHS exposure cause immediate adverse effects on the cardiovascular system and increase the risk for heart disease. Much of the acute cardiovascular risk of smoking and SHS exposure is due to activation of platelets and impairment of endothelial function, impairing vasodilation and vascular thrombosis, resulting in reduced coronary or cerebral blood flow. Reducing tobacco use and SHS exposure among patients with documented cardiovascular disease can yield critical health benefits. Quitting smoking reduces the recurrence risk of coronary events to that of a nonsmoker within three years and reduces mortality following a heart attack by up to 50 percent over three to five years. Clinician advice doubles the likelihood that smokers will quit, and clinical practice guidelines recommend that clinicians ask all patients about tobacco use; for those who smoke, advise cessation, assess readiness to quit, assist with treatment, and arrange follow-up (the five A’s of tobacco treatment). Yet rates of clinician assistance and follow-up with treating tobacco dependence are generally low, and SHS exposure is rarely addressed clinically in adults. Tobacco treatment training increases health care professionals’ attention to patients’ tobacco use. With the aim of improving attention to tobacco use and SHS exposure in cardiology training and clinical practice, Drs. Judith Prochaska, William Grossman, and colleagues at the

20 San Francisco Medicine May 2011

University of California, San Francisco (UCSF), developed the one-hour Cardiology Rx for Change curriculum. The investigators evaluated the Cardiology Rx for Change curriculum with twenty-two cardiology fellows and seventy-seven medical residents at the UCSF School of Medicine. Fellows’ and residents’ tobacco treatment knowledge increased significantly and perceived barriers to treating tobacco use decreased significantly from pre- to post-training. The changes, however, were not sustained at three months’ follow-up, suggesting the need for booster training efforts. Significant post-training gains in clinician confidence for treating tobacco dependence were sustained at three months’ follow-up, and from pre-training to three months’ follow-up, the curriculum was associated with improvements in clinician’s assessing patients’ readiness to quit smoking and providing assistance. Training effects were consistent for both cardiology fellows and medical residents, and all trainees (100 percent) recommended dissemination of the Cardiology Rx for Change curriculum to medical providers. Tobacco and SHS exposure are leading risk factors for morbidity and mortality in cardiology. The Cardiology Rx for Change curriculum has demonstrated lasting impacts on clinicians’ confidence in treating tobacco dependence and the tailoring of assistance to patients’ readiness to quit. Available online via http:// at no charge for use and dissemination, Cardiology Rx for Change offers a packaged training tool for improving clinical performance related to this critical health issue. To access the Cardiology Rx for

Change curriculum materials, go to, complete the brief registration, and then click on Cardiology Care Providers. The one-hour slide presentation and accompanying handouts are available at no charge for use and dissemination. The Rx for Change website also includes curriculum materials for addressing tobacco use in general medicine, anesthesiology, oncology, and psychiatry. Judith J. Prochaska, PhD, MPH, is an associate professor in the Department of Psychiatry at the University of California, San Francisco (UCSF), and a member of the UCSF Center for Tobacco Control, Research, and Education. William Grossman, MD, chief of cardiology at UCSF from 1977 to 2007, directs the Center for Prevention of Heart and Vascular Disease at UCSF and is the Charles and Helen Schwab Endowed Chair in preventive cardiology and professor of medicine at UCSF. Development of the Cardiology Rx for Change curriculum was informed by expert advice and feedback from Drs. Neal Benowitz, Stanton Glantz, and Karen Hudmon and supported with funding from a William Cahan Distinguished Professor Award from the Flight Attendant Medical Research Institute (FAMRI) to Dr. Grossman.

Breathe Easy: Air Quality and Lung Health

Air Quality in U.S. Cities American Lung Association Rates Air Quality of U.S. Cities


zone and particle pollution are the most widespread air pollutants—and among the most dangerous. Recent research has revealed new insights into how they can harm the body—including taking the lives of infants and altering the lungs of children. All in all, the evidence shows that the risks are greater than we once thought. Recent findings provide more evidence about the health impacts of these pollutants: • Ozone pollution can shorten life, a conclusion confirmed by a 2008 scientific review by the National Research Council. Evidence warns that some segments of the population may face higher risks from dying prematurely because of ozone pollution, including communities with high unemployment or high public transit use and large Black/African-American populations. • Good news: Reducing air pollution has extended life expectancy. Thanks to a drop in particle pollution between 1980 and 2000, life expectancy in 51 U.S. cities increased by 5 months on average, according to a 2009 analysis. • Growing evidence shows that diabetics face a greater risk from air pollution than once believed. Several studies found increased risk of several factors associated with cardiovascular risks in people with diabetes. Some new research with animals indicates that fine particle pollution may impact insulin resistance and other factors. • Lower levels of ozone and particle pollution pose bigger threat than previously thought. A Canadian study showed that levels well below those considered safe for these pollutants triggered asthma attacks and increased the risk of emergency room visits and hospital admissions

for children with asthma. Another study found that low levels of these pollutants increased the risk of hospital treatment for pneumonia and chronic obstructive pulmonary disease (COPD). • Busy highways are high risk zones. Not only may they worsen diseases, but some evidence warns that years of breathing the pollution near busy roads may increase the risk of developing chronic diseases. • A growing body of evidence suggests breathing pollution from heavy traffic may cause new cases of asthma in children. • Some emerging research has found particle pollution associated with increasing the risk of new cases of three chronic diseases in adults: adult-onset asthma,9 diabetes,10 and COPD, especially in people who already have asthma or diabetes. • Research had already connected pollution from heavy highway traffic to higher risks for heart attack, allergies, premature births and the death of infants around the time they are born. Evidence of the impact of traffic pollution, even in a city with generally “cleaner” air, expanded the concern over the health effects of chronic exposure to exhaust from heavy traffic. Two types of air pollution dominate the problem in the U.S.: ozone and particle pollution. They aren’t the only serious air pollutants: others include carbon monoxide, lead, nitrogen dioxide, and sulfur dioxide, as well as scores of toxins such as mercury, arsenic, benzene, formaldehyde, and acid gases. However, ozone and particle pollution are the most widespread pollutants. Look up your city here: http://www.

Breast Cancer and Air Pollution A New Study Shows Link Exposure to air pollution early in life and when a woman gives birth to her first child may alter her DNA and may be associated with premenopausal breast cancer later in life, researchers at the University at Buffalo have shown. The findings indicated that higher air pollution exposure at birth may alter DNA methylation, which may increase levels of E-cadherin, a protein important to the adhesion of cells, a function that plays an essential role in maintaining a stable cellular environment and assuring healthy tissues. Methylation is a chemical process that has been implicated in determining which genes in a cell are active, a process essential to normal cellular function. Women with breast cancer who lived in a region with more air pollution were more likely to have the alteration in the DNA in their tumor than those who lived in a less-polluted region, results showed. Higher air pollution concentration at the time of first child birth also was associated with changes in p16, a gene involved in tumor suppression, according to findings. Results of the research were presented April 6 at the 2011 American Association for Cancer Research meeting in Orlando, Fla. Jo L. Freudenheim, PhD; Menghua Tao, MD, PhD; Jing Nie, PhD; and Matthew Bonner, PhD, all from UB, contributed to the study, as well as researchers from Lombardi Comprehensive Cancer Center, Georgetown University, Washington D.C.; Roswell Park Cancer Institute, Buffalo, N.Y.; Potomac Hospital, Woodbridge, Va.; and University of Nevada Health Sciences System, Las Vegas, Nev. The study was funded by the National Cancer Institute.

May 2011 San Francisco Medicine 21

Dr. David Young, MD reconstructive plastic surgeon

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23 San Francisco Medicine May 2011

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May 2011 San Francisco Medicine 23 4/15/2011 8:23:26 AM

Hospital News Kaiser

Robert Mithun, MD

In the United States, the prevalence of obesity has doubled in adults and approximately tripled in children and adolescents since 1980. Today, two-thirds of U.S. adults and one in six children and adolescents are overweight or obese. Evidence indicates that the prevalence of asthma has increased significantly in the same general time period. Obesity may directly cause or worsen asthma through its effects on the mechanics of breathing, systemic and airway inflammation, and/or other biophysiological mechanisms. While asthma is often mistakenly viewed as a disease that only originates in childhood, when compared with normal-weight adults, the incidence of a first-time diagnosis of asthma increases by an average of 38 percent in overweight and 92 percent in obese adults. And it is well known that weight loss reduces the risk of several other major illnesses that are associated with obesity, such as diabetes and hypertension. Researchers and clinicians at Kaiser Permanente in Northern California and the Palo Alto Medical Foundation Research Institute are collaborating in the conduct of a randomized clinical trial, BE WELL (Breathe Easier through Weight Loss Lifestyle Intervention). The primary objective of the trial is to determine whether weight loss, in addition to improving overall health, reduces asthma symptoms and improves lung function. The study is supported by a grant from the National Heart, Lung, and Blood Institute of the U.S. National Institutes of Health and involves collaborators at the Stanford University School of Medicine, Harvard Medical School, and Oregon Health and Science University. The trial began enrollment of patients in September 2010; results are expected to be available early in 2014.

24 San Francisco Medicine May 2011


David Eisele, MD

“May you live in interesting times.” This Chinese curse can certainly apply today to the treatment of obstructive sleep apnea and snoring, although ongoing developments in the field make it anything but cursed. The first-line treatment for obstructive sleep apnea remains positive airway pressure therapy. The UCSF Sleep Disorders Center offers a comprehensive range of services and treatments for sleep disorders, including recent innovations that can enhance tolerance in patients who experience difficulty with positive airway pressure. Research into novel techniques and technologies reveals important advances for those who consider alternative treatments, whether for obstructive sleep apnea or snoring. No single treatment works well for all patients, making an individualized evaluation critical to developing a targeted, effective treatment plan. This may be particularly true for surgery. The Division of Sleep Surgery in the UCSF Department of Otolaryngology—Head and Neck Surgery, directed by Eric Kezirian, MD, MPH, incorporates its work in NIH-funded research concerning patient evaluation, surgical techniques, and outcomes of different procedures in the clinical care of snoring and obstructive sleep apnea. The division works extensively with established and start-up companies in the development and refinement of new technologies. For example, UCSF is the lead United States site for trials of a novel device using hypoglossal nerve stimulation to treat obstructive sleep apnea. The eighteenth annual Advances in Diagnosis and Treatment of Sleep Apnea course will encompass medical, surgical, and dental treatment of these disorders; it will be held in San Francisco on President’s Day weekend, February 17-18, 2012. For more information about the work of the Division of Sleep Surgery, visit For more information about the UCSF Sleep Disorders Center, visit ucsfhealth. org/sleepdisorderscenter.

Saint Francis

Patricia Galamba, MD

As the only hospital in San Francisco with a pulmonary rehabilitation program, we are improving the lives of COPD patients daily. An American Lung Association survey revealed that half of all COPD patients (51 percent) say their condition limits their ability to work. It also limits them during normal physical exertion (70 percent), household chores (56 percent), social activities (53 percent), sleeping (50 percent), and family activities (46 percent). Saint Francis reported excellent patient outcomes for 2010. Program participants, on average, added 52 meters to their post-program six-minute walk test distances, improved their perceived rate of breathlessness (via BORG scale) by 25 percent, and showed a 26 percent improvement in their QOL questionnaires. One hundred percent of participants self-reported greater strength, endurance, and energy; 81 percent believed their pulmonary health has improved; and 77 percent reported less coughing, wheezing, and congestion. Research has demonstrated that pulmonary rehabilitation decreases shortness of breath and improves function and quality of life scores. Emerging research also shows that pulmonary rehabilitation may reduce hospitalizations and health care costs. Pulmonary rehabilitation is an individually designed program of care for patients with COPD. Our program is open five days a week from 9:00 a.m. to 5:00 p.m.. Face-to-face interpreter services are available in Cantonese, Mandarin, and Spanish. Medical direction is provided by Dr. Fred Hom, specializing in pulmonary and critical care medicine. Pulmonary rehabilitation is a covered Medicare benefit for patients with GOLD Stage II, III, and IV COPD. Medicare and commercial insurers also cover many other pulmonary diagnoses that limit the individual’s ADLs, including pulmonary fibrosis, cystic fibrosis, sarcoidosis, and bronchiectasis. For more information regarding pulmonary rehabilitation or to refer a patient, call (415) 353-6960.

Hospital News St. Mary’s

Francis Charlton, MD

The CHW Cancer Center at St. Mary’s is fully up and running. The Grand Opening was held on March 26, 2011, and we celebrated with physicians, staff, donors, patients, and community supporters. The Archbishop of San Francisco, the Most Reverend George H. Niederauer, blessed the Center and spoke eloquently, along with Lloyd Dean, CEO of Catholic Healthcare West; Barbara Garcia, Executive Director of the San Francisco Department of Health; Anna Cheung, CEO of St. Mary’s; Sister Ellene Egan, Community Board Chair; and Chuck Higueras, Foundation Vice-Chair. Mistress of Ceremonies Renel Brooks-Moon, the familiar voice of our World Champion San Francisco Giants, brightened the day for all. The a cappella University of San Francisco Voices livened the air and entertained all present, including San Francisco Supervisors Ross Mirkarimi , Scott Weiner, and Eric Mar. The new Center is located on the St. Mary’s campus at 2250 Hayes Street, providing easy access for our patients. The Center was designed as a patient-centric facility to provide a continuum of comprehensive cancer care, from diagnosis to education to treatment and recovery, all in one location. We now have a state-of-the-art radiation therapy unit with the most advanced linear accelerator available. The adjacent Outpatient Infusion Center and a dedicated van service to get patients to and from their appointments promises to meet our patients’ needs further still. I would like to welcome back our own Dr. Sara M. Huang as the director of radiation oncology. Dr. Huang trained at St. Mary’s prior to working as a radiation oncologist at Saint Francis Memorial. We extend our thanks to the St. Mary’s Foundation, which led the way in fund-raising for the 14,200 square-foot Cancer Center. The new Center is expected to treat 400 infusion and 200 radiation therapy patients annually.


Diana Nicoll, MD, PhD, MPA

On April 6, 2011, Michael W. Weiner, MD, director of the San Francisco VA Medical Center’s Center for Imaging of Neurodegenerative Diseases and principal investigator of the Alzheimer’s Disease Neuroimaging Initiative (ADNI), accepted the 2011 Ronald and Nancy Reagan Research Award from the Alzheimer’s Association. The Association is presenting the award to ADNI “for its collaborative and innovative approaches to furthering Alzheimer’s treatment, prevention, and care.” It cites Dr. Weiner for his “extraordinary leadership, [which] has helped make ADNI the largest public-private Alzheimer’s disease research partnership in our country.” ADNI is a $140 million multiyear clinical trial involving more than 1,000 patients at fiftyfive centers in the United States and Canada. Its mission is to establish biomarkers for the progression of Alzheimer’s disease based on markers in the brain, spinal fluid, and blood. “I am incredibly moved by this,” said Dr. Weiner. “Of course, none of this would be possible without the huge support that our research group and I have received during the past decades from the leadership of the VA, NCIRE, and UCSF.” “This award is wonderful recognition of the great contribution to Alzheimer’s disease neuroimaging research made by Dr. Weiner and his group,” said Judy Yee, MD, chief of radiology at SFVAMC. “We are very proud of Dr. Weiner’s achievements. The dedication and hard work of the excellent investigators of ADNI are also to be commended.” The award, presented by Virginia Governor Bob McDonnell at the National Alzheimer’s Gala in Washington, DC, pays tribute to President and Mrs. Nancy Reagan for their courage and leadership in the fight against Alzheimer’s and honors researchers who are leading the way in promising and innovative approaches to Alzheimer’s treatment, prevention, and care.

CMA Supports San Francisco’s Ban of Tobacco Sales in Stores with Pharmacies The California Medical Association (CMA) filed a brief last week in U.S. District Court supporting the City and County of San Francisco’s ban on the sale of tobacco products in retail stores with pharmacies. “Unlike other retail outlets that sell cigarettes, stores that provide pharmacy services pose a unique problem if they also sell tobacco products,” CMA’s brief states. “Stores such as Safeway that contain a pharmacy are an integral part of the health care delivery system. “Selling tobacco products in such institutions creates a conflict of interest and sends a mixed message that can undermine the campaign against smoking,” the CMA brief asserts. “Furthermore, as a practical matter, making cigarettes available where patients go to fill prescriptions can frustrate the treatment protocols of physicians.” Safeway, Inc., argues that the ordinance distinguishes between retail stores that contain pharmacies and those that don’t, thus violating equal protection provisions of the U.S. Constitution. San Francisco City Attorney Dennis Herrera attacked Safeway’s argument: “It strains credibility to argue that the City’s ban on cigarette sales in stores with pharmacies is ‘arbitrary’ when leading health organizations like the California Medical Association and the San Francisco Medical Society have worked tirelessly for its enactment,” Herrera said. “We are truly grateful for their leadership on this issue and for their brilliant courtroom advocacy on our behalf.” CMA has been a tireless advocate for stronger restrictions on the tobacco industry for decades. In 1970, 1978 and 1980, CMA supported ballot initiatives that would have banned smoking in many public places. In 1987, CMA took on its biggest tobacco-related challenge and won, with the passage of Proposition 99, which established a 25-cents-perpack tax on cigarettes and a tax hike for other tobacco-related products.

May 2011 San Francisco Medicine 25

Update from the CMA Foundation Crawford Chung, MD

CMA Foundation AWARE Project Initiative to Address COPD


OPD is a preventable and treatable disease and is currently the fourth leading cause of death in the U.S. and California. Unlike other leading causes of death, COPD continues to rise and is predicted to be the third leading cause of death by 2020.1 About 24 million Americans have COPD, and it is projected that fewer than half know they have the disease. COPD results in more than 125,000 deaths in the U.S. each year.2 The highest COPD death rates for persons aged 45 and older are found for whites at 138.4 per 100,000, with the next-highest COPD death rates found in blacks or African Americans with 107.5 per 100,000. The most common cause of COPD is smoking, responsible for 80 percent to 90 percent of California’s COPD cases.3 Smoking is also responsible for roughly 75 percent of COPD deaths. Smoking cessation programs are critical in COPD prevention efforts. High levels of exposure to air pollution and secondhand smoke can also lead to COPD, along with increased risk in a number of industries, including construction, food products manufacturing, and agriculture.4 Comorbidities of COPD include heart disease, osteoporosis, and musculoskeletal disorders. Dexter Louie, MD, chair of the CMA Foundation Board of Directors, said that in order to support efforts to prevent and manage COPD, the CMA Foundation’s Alliance Working for Antibiotic Resistance Education (AWARE) began its COPD Initiative in 2010. The Initiative contains a number of resources for physicians and their patients.

What can physicians do to reduce the risk associated with COPD? Encourage your patients to quit smoking and provide cessation materials. Use the “My Quitting Smoking Diary” found in AWARE’s COPD patient education materials. Talk with your patients about their COPD. Questions to discuss with your patients include: What signs of a flare-up should I watch out for? What should I do if I have a flare-up? Should I make any changes in the medicines I take? What else can I do to reduce my COPD symptoms? Encourage your patients to bring a list of questions with them to each visit, to ensure that COPD is always part of the discussion. For patient and physician resources addressing COPD, visit the AWARE website at or contact Sara Cook, MPH, at


1. Cruz A et al. Global surveillance, prevention, and control of chronic respiratory diseases: A comprehensive approach. World Health Organization, 2007; 27. 2. Strategic plan to address COPD in California. November 2010. 3. American Lung Association of California. COPD Educator Institute. 2009. 4. CDC Data and Statistics. COPD prevalence in the United State s. September 2010.

Help Foster Kids Go to Summer Camp! Join the Department of Public Health for the DPH Got Talent! Show on May 26, 2011. In collaboration with SF Public Health Foundation, join emcee Christie James from 98.1 KISS FM for a night of entertainment and fundraising for the Worker’s Children’s Fund to pay for foster kids to go to summer camps 7 p.m. St. Mary’s Event Center 1111 Gough Street. For tickets or to make a donation call (415) 554-2600.

27 San Francisco Medicine May 26 San Francisco Medicine May 26 San Francisco Medicine May2011 2011

Public Health Report Andrew Resignato, MS

Cocooning: A Strategy to Prevent Pertussis in Infants


n 2010, California experienced a serious pertussis (whooping cough) epidemic that took the lives of ten infants and hospitalized more than 475. Preventing deaths and hospitalization in infants from pertussis is a critical public health issue. Cocooning is a term that describes the process of immunizing all contacts of newborns with pertussis-containing vaccine (either DTaP for children less than seven years old or Tdap for those over seven) to form a protective ring of immunity from this disease for infants. Contacts can include mothers, fathers, grandparents, siblings, nannies, and babysitters. Health care providers are also part of the cocoon, as they may have regular contact with a newborn. Studies have shown that caregivers transmit pertussis to infants.1 Pertussis is extremely contagious, with a high attack rate or basic reproduction number (Ro). The Ro for pertussis is estimated at 12-17, which is similar to measles and in contrast with influenza, which has an Ro of 1-2. Ninety percent of susceptible household contacts become infected with pertussis when a household member contracts the disease.2 In 2005, a San Francisco mother contracted pertussis while in the hospital and spread the disease to her newborn. The infant was hospitalized and eventually died from the complications of the disease. Although it may be higher in California, national data indicate that the Tdap immunization rate for family members of newborns is well below 10 percent and only 17 percent for health care workers.3 For these two groups, there is real room for improvement. Hospitals have an important role in facilitating the cocooning process. All birthing hospitals in San Francisco are immunizing pregnant or postpartum women with Tdap. Two San Francisco birthing hospitals have gone further. The University of California San Francisco and San Francisco General have set up programs to immunize family contacts of newborns, even those who are not their patients. This model of prevention and good public health should be carried out by all birthing hospitals across California. Health care providers outside of the hospital setting can also play a role in the cocooning process. First, they themselves should be vaccinated, a fact that can be forgotten by providers.4

Second, providers can remind patients with infants that they and their family members should all be vaccinated to protect the infant. Every office visit is an opportunity to vaccinate and create a cocoon of immunization protection around a newborn. In addition to on-time immunization of infants, reducing susceptible people around a newborn by cocooning offers the best way to decrease the spread of pertussis to the population that bears the highest burden of the disease. Efforts in this direction represent a high standard of health care and an intervention that will improve the health of all Californians. Andrew Resignato, MS, is director of the San Francisco Immunization Coalition (of which the SFMS is a member organization). The San Francisco Immunization Coalition has educational materials (posters and DVDs) for providers about pertussis and cocooning. For more information, go to www.

References 1. Transmission of Bordetella pertussis to young infants. Pediatr Infect Dis J. 2007; 26: 293-299. 2. California Department of Public Health Report. August 2010. 3. National Health Interview Survey. MMWR 2010; 59:1302-6. 4. ACIP provisional recommendations for health care personnel on use of tetanus toxoid, reduced diphtheria toxoid and accellular pertussis vaccine (Tdap) and use of postexposure antimicrobial prophylaxis. Centers for Disease Control. April 2011.

May 2011 San Francisco Medicine 27

SFMS Community Health Agenda and Activities San Francisco Medical Society

An Advocate for Physicians and their Patients

The San Francisco Medical Society has been involved in many community health issues since the 1800s. As the only medical association in San Francisco representing the full range of medical specialties and interests, SFMS health advocacy has been broad. Via our policymaking efforts with state and national medical and political leaders and our award-winning journal, we have often been influential far beyond San Francisco as well. Our agenda and activities continue to focus on the community and the following areas of involvement:


• Forming the San Francisco health information exchange to electronically link health records within the San Francisco medical community to improve patient care and reduce costs. • Preserving the healthcare safety net and public health programs in times of severe budget cuts, including advocacy for Medi-Cal reimbursement. • Supporting anti-tobacco legislation and San Francisco’s law banning the sale of tobacco in pharmacies. • Supporting the Healthy San Francisco program and participating in legal defenses to preserve the program. • Providing physicians for medical consultation for SF schools. • Working on legislation to allow minors to receive vaccines to prevent STIs without parental consent. • Co-Sponsorship of Hep B Free program in San Francisco. • Advocacy for improving end-of-life care in Bay Area, via use of new advance directives (POLST) and educational outreach.


SAN FRANCISCO HEALTH INFORMATION EXCHANGE: Working under the auspices of the San Francisco Medical Society Community Service Foundation and guided by a diverse board of San Francisco healthcare industry professionals, the San Francisco Health Information Exchange will provide the infrastructure for a unified electronic health record system for San Francisco. This service will allow providers to have access to secure community-wide patient data when and where they need it. It will also permit patients to gain a complete view of their medical record, irrespective of where individual records may reside. UNIVERSAL ACCESS TO CARE: SFMS leaders have long advocated that every San Franciscan should have access to quality medical care, and most recently our representatives served on the Mayoral Task Force which designed the Healthy San Francisco program. SFMS joined in the lawsuits to preserve that program as well. SFMS advocates advocated for, and even created, community clinics dating back to the original Haight-Ashbury Free Clinics in the 1960s. ANTI-TOBACCO ADVOCACY: SFMS advocates were in leadership roles in the banning of tobacco smoking in San Francisco restaurants, ahead of the rest of the state and nation; we advocate for ever-stronger protections from secondhand smoke, for removal of tobacco products from pharmacy settings, for higher taxes on tobacco products, and

29 San Francisco Medicine May 28 San Francisco Medicine May 28 San Francisco Medicine May2011 2011

more. SFMS recently signed onto an amicus brief in support of upholding San Francisco’s law banning sale of tobacco in pharmacies. REBUILDING AND PRESERVING SAN FRANCISCO GENERAL HOSPITAL: SFMS spokespersons took a lead in both advocacy for full funding of the necessary seismically-sound rebuild, and on the Mayoral committee to advise where and how that would occur. Many of our members and leaders trained and have practiced at SFGH. HIV PREVENTION AND TREATMENT: The SFMS was at the center of medical advocacy for solid responses to the AIDS epidemic, being among the first to push for legalized syringe exchange programs, appropriate tracking and reporting, optimal funding, and more. SCHOOL AND TEEN HEALTH: SFMS helped establish and staff a citywide school health education and condom program, removed questionable drug education efforts from high schools, worked on improving school nutritional standards, and provides medical consultation to the SFUSD school health service. In addition, SFMS has authored a resolution allowing minors to receive vaccines to prevent STIs without parental consent. ENVIRONMENTAL HEALTH: SFMS established a nationwide educational network on scientific approaches to environmental factors in human health, has advocated on reducing mercury, lead, and air pollution exposures, and much more. REPRODUCTIVE HEALTH AND RIGHTS: SFMS has been a state and national leader in advocating for women¹s reproductive health and choice, including access to all medical-indicated services. BLOOD SUPPLY: SFMS has long been a partner and sponsor of the local blood bank, now called Blood Canters of the Pacific, and continually seeks to help increase donations there. ORGAN DONATION: SFMS has been a leader in seeking improved donation of organs to decrease waiting lists and deaths due to the shortage of organs, via both education and proposing new polices regarding consent and incentives for organ donation. OPERATION ACCESS: SFMS is a founding sponsor of this local organization providing free surgical services to the uninsured, and has provided office space, volunteers, and funds. DRUG POLICY: SFMS has been a leader in exploring and advocating new and sound approaches to drug abuse, including some of the first policies regarding syringe exchange, medical cannabis, “treatment on demand”, and treatment instead of incarceration. MEDICAL ETHICS: SFMS has developed and promulgated forward-looking policies and approaches regarding end-of-life care, patient directives, physician-assisted dying, and other topics of interest to patients, physicians, policymakers, and the general public. “I was an SFMS member for almost 50 years until I retired, and always saw them as an important and often progressive voice in organized medicine on many crucial issues.” —Philip R. Lee, MD, UCSF Chancellor Emeritus

Health Policy Perspective Steve Heilig, MPH

A Dog in Peaceful Times Reviving the “Interesting Times” Curse


ay you live in interesting times” was purportedly an old Chinese curse, quoted ad nauseam a decade back by pundits commenting on just about anything. Recent times have brought the curse back to mind. Consider April- “the cruelest month” according to T.S. Eliot.

Federal Reform

The first birthday of The Patient Protection and Affordable Care Act (ACA) sparked a flurry of assessments. Those who were unable to abort the ACO were still working hard on infanticide, but polls tended to show both public and physicians fairly split in favor/against. Nonpartisan evaluations showed the slow rollout of patient protections popular, but the “affordable” part was still much in question. Opinions were strong but rarely evidence-based, with a majority of Americans both cautiously optimistic and confused. Meanwhile a Federal government budget battle shutdown was narrowly averted, with family planning and reproductive rights emerging once again as a sticking point with some legislators willing to bargain that away. Republicans offered a new Medicare policy, focused on privatization and market reform, with tax cuts for the affluent underlying the cost savings. Democrats then offered their own version, which was seen by many as not nearly forceful enough in terms of cutting costs in the long run. But as legendary economist John Maynard Keynes quipped, “In the long run, we’re all dead.”

State Issues

A proposed cut to Medi-Cal rates was postponed by a judge pending further study. But a $26 Billion deficit remained, only half dealt with when the CMA hosted its annual ‘Legislative Day” in Sacramento. A cadre of SFMS representatives attended. Governor Jerry Brown spoke in a somewhat comedic fashion, telling us “We do have a little problem with about $13.5 billion. And this whole water thing, how we’re going to get water to Los Angeles. But other than that, I think it’s clear sailing.” He advised “Don’t worry about the government. I’ve got it under control. You take care of your patients, and I’ll take care of the body politic.” Which was a nice ideal, but struck some as a bit flippant. Lt. Governor Gavin Newsom was less sanguine, noting that he was open to any ideas regarding the budget, which struck him as “impossible and I’ve only been up here a few weeks.” CMA CEO Dustin Corcoran pointed out that “It’s not a question of how are we going to save everything in health care. It’s a question

of how much are we going to be able to mitigate the damage.” Later that day, in our meetings with San Francisco representatives, Senator Mark Leno lamented “Some folks up here seem to have given up on responsible government.”

Local Scene

Still in recovery mode from the Sacramento visit, SFMS leaders ventured downtown to the annual San Francisco Business Times’ “Future Healthcare Leadership Summit.” Panelists from CPMC, UCSF, Blue Shield, Hill Physicians, and the Pacific Business Group on Health seemed to agree that ‘We have an absolute crisis of affordability’ but that somehow we’d figure out a way to afford it. With sub-crises looming in primary care training, (“If you give six million more people Medi-Cal but there are no doctors to care for them, that’s faux-reform”), seismic standards, and more, one panelist still saw “the real danger is that the competitive juices unleashed will lead to self-destructive changes, as there are a lot of people still making a lot of money from the status quo.” SFMS President George Fouras MD lobbed a “grenade” question by asking if some form of “socialized medicine” might arise from the ashes of a competitive meltdown; “That’s a great question” said the moderator, to nervous laughter and little constructive response. One irony of the broader health reform struggle was illustrated by a recent nuts-and-bolts presentation by a renowned health strategy consultant. He focused on the new quality and cost rankings that will determine how Medicare pays under health reform. It will make for cutthroat competition – in a supposed “socialistic government takeover” of healthcare. And it dawned on me that perhaps many of the most rabid opponents of reform might have more to fear than they know, but from a wholly different direction. As for the “interesting times” curse, nobody really knows its authenticity, but one theory calls it a loose translation of an authentic ancient proverb: ““It’s better to be a dog in a peaceful time than be a man in a chaotic period.”

Recommended Reading

Catching a Wave—Implementing Health Care Reform in California Andrew B. Bindman, M.D (UCSF)., and Andreas G. Schneider, J.D. NEJM | March 30, 2011 May 2011 San Francisco Medicine 29

In Memoriam Nancy Thomson, MD

Gary G. Kardos, MD Dr. Gary G. Kardos died on April 15, 2011, from lung cancer at the age of 74. He leaves behind his beloved wife of fifty years, Zeeva; his two loving daughters Dr. Leslie Kardos and Kate Kardos-Polevoi; his four granddaughters, Danielle, Lexie, Sofia and Sasha; his two son-in-laws, Dr. Steven K. Polevoi and Mr. Miguel Barron; and his sister Judy Martin of Los Angeles. Born in Budapest, Hungary, Dr. Kardos grew up in Beverly Hills where he attended Beverly Hills High School and later received his BA in zoology and philosophy from UCLA. A resident of San Francisco since 1958, Dr. Kardos attended UCSF Medical School, where he also completed his internship, residency and chief residency. After two years of military duty as a captain in the Vietnam War, he returned to San Francisco in 1968, where he began the practice of internal medicine and nephrology at Franklin Hospital, (now known as the Davies Campus of CPMC) where remained in private practice until December of 2001. During these years, Dr. Kardos worked with Dr. Frank Gotch in the first public dialysis unit at SFGH and the first private Northern California Hemodialysis unit at Franklin Hospital where he was associate director of the Dialysis Unit from 1980 to 1997. Dr. Kardos was active in both local and state medical affairs and served on many medical committees. He was chief of staff at Davies Medical Center from 1986 to 1987 and he chaired many committees including the Institutional Review Board, Accreditation Committee, Credentials Committee, and Utilization Committee. Dr. Kardos was also a member of the San Francisco Medical Society where he was on the Bylaws Committee, Ethics Committee, Board of Directors, and served as Vice-Chairman of the Hospital Medical Staff Section. Dr. Kardos was a member of the Clinical Faculty at UCSF since 1967, where he remained an active teacher to both the house staff and medical students. In 2002, Dr. Kardos became a clinical professor at UCSF where he worked as a part-time nephrology attending in the Division of Nephrology. In 2005 he became a clinical professor, emeritus and continued to work as a part-time Nephrology attending at the VA Hospital where he remained until his diagnosis in December of 2010. Dr. Kardos was most happy teaching the art, craft and science of the clinical practice of Nephrology to his fellows. His love of clinical medicine and unrelenting dedication to each patient and his own ethical standards were well known to those who had the fortune of working with him. Dr. Kardos will forever be remembered as a devoted husband, father, grandfather, father-in-law, and brother. He was a dedicated patron of both the San Francisco Symphony and A.C.T. and loved to travel with his wife. Dr. Kardos was also an avid reader, writer, amateur photographer, computer enthusiast,

30 San Francisco Medicine May 2011

master gourmand, and chef. He especially loved cooking for his family every Sunday night where they came to enjoy wonderful food and lasting memories. Dr. Kardos’ self -published cookbook, Cooking with the Doctor, was his most recent accomplishment. In lieu of flowers, a fund is being set up in honor of Dr. Kardos through the Department of Medicine, Division of Nephrology at UCSF, for the support and teaching of clinical nephrology.

Theodore van Ravenswaay, MD

Theodore van Ravenswaay, MD, was born July 29, 1927, to Dr. Alex van Ravenswaay and Bernice Brumell van Ravenswaay in Boonville, Missouri. He passed away March 8, 2011, age 83. He attended Kemper Military School in Boonville, after which he served as a lieutenant in the U.S. Army in post-World War II Germany. He attended the University of Missouri and received his medical degree from Washington University in 1953. He interned at Barnes Hospital, St. Louis, and served residencies in pathology at Barnes, UCSF, and Massachusetts General Hospital in Boston. He taught pathology at the Free University of Amsterdam on a Fulbright fellowship in 1958–1959. He returned to Missouri and was the pathologist at Ellis Fischel State Cancer Hospital in Columbia before returning to San Francisco as a pathologist at Kaiser Permanente. He became a pathologist at Kaiser, Terra Linda, in 1967. During his years there he was instrumental in establishing the Mohns Clinic for cancer surgery, was an associate clinical professor in dermatology at UCSF, and served as a lieutenant colonel in the U.S. Army Reserve. He was board certified in pathology, dermatology, and dermopathology and retired from Kaiser Permanente as chief of the San Rafael Dermatology Department in 1987. Dr. van Ravenswaay married Nancy Anne Neef, also of Boonville, on August 7, 1950, and their two children were born in St. Louis. He enjoyed sailing and traveling with his wife and family, especially to visit family in the Netherlands. Following a year in London, the family traveled from the Netherlands to the Mediterranean on their sailboat. He was a lifetime member of the Corinthian Yacht Club. He is survived by his wife, Nancy, of Tiburon; son Paul (also a doctor) of Washington, D.C.; daughter Carolyn of Jackson, California; his extended family in the U.S. and the Netherlands; and many lifelong friends.

A former employee sued me for wrongful termination.

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We Celebrate Excellence – Calvin Lee, MD CAP Member, Internationally Renowned Violinist, and Dedicated Philanthropist


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May 2011  

San Francisco Medicine, May 2011 issue. Breathe Easy: Air Quality and Lung Health.