SAN FRANCISCO MEDICINE J O U R NA L O F T H E S A N F R A N C I S C O M E D I CA L S O C I E T Y
ADVANCES IN CARDIOLOGY Atrial Fibrillation
New Perspectives on Treatment
Are Guidelines Worth the Trouble?
Battles Won, But the Tobacco War Continues The ‘Thin-Fat’ South Asian Phenotype Understanding MASALA
Plus: SFMS Annual Gala Photos
VOL.89 NO.2 February/March 2016
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IN THIS ISSUE
SAN FRANCISCO MEDICINE
February/March 2016 Volume 89, Number 2
Heart Matters: Advances in Cardiology FEATURE ARTICLES
10 Atrial Fibrillation: New Perspectives on Treatment Robert ElDabaje, MD, and Remo L. Morelli, MD, FACC
President’s Message Richard Podolin, MD
11 The ‘Thin-Fat’ South Asian Phenotype: Understanding MASALA Alka Kanaya, MD 12 Diet for Cardiovascular Health: Recommended Changes: Evidence-Based or Not Erica Goode, MD, MPH 15 Battles Won, But the War Continues: Key Tobacco Events Timeline 1964-2015 Stanton Glantz, PhD 19 Congenital Heart Disease: A Coming of Age Ian Harris, MD
20 Hypertension Treatment: Are Guidelines Worth the Trouble? Gordon Fung, MD, PhD 21 The Widowmaker: A Movie Review Michel Accad, MD
23 Valvular Heart Disease: Percutaneous Approaches Mark Villalon, MD, and Vaikom S. Mahadevan, MD 25 Cardiology Fellowship: A Love Story Vishal Patel, MD 26 Cannabis: Clearing Some Smoke? Matthew L. Springer, PhD
Dental Disease: Helping Primary Care Providers Prevent the Most Common Chronic Condition of Childhood Susan Fisher-Owens, MD, MPH; Maryna Spiegel; Cecilia Gonzalez, MD; Irene Hilton, DDS, MPH; Abby Wolf, RN; Margaret Fisher, RDHAP; Lisa Chung, DDS, MPH
27 Dietary Sugars Intake and Cardiovascular Health: A Scientific Statement From the American Heart Association 27 Physician-Assisted Death: How Neutrality in California Was Attained: A Letter Submitted to JAMA John Maa MD, Steve Heilig MPH, Shannon Udovic Constant MD Editorial and Advertising Offices: 1003 A O’Reilly Avenue San Francisco, CA 94129 Phone: (415) 561-0850 Web: www.sfms.org
Editorial Gordon Fung, MD, PhD
32 Medical Community News 34 Upcoming Events
OF INTEREST 28 SFMS Annual Gala Recap and Photos
Welcome New Members! ACTIVE REGULAR MEMBERS Kristina Lyn Casadei, MD | Internal Medicine Ben Tsu-Ping Chung, MD | Internal Medicine Richard Franklin Grossman, MD | Plastic Surgery Marsha Ann Haller, MD | Family Medicine Susan Rose Lessin, MD | Hematology Oncology Robert Edward Mayle, MD | Orthopaedic Surgery Justin Poy Quock, MD | Internal Medicine Jess Andrew Thompson, DO | Pediatrics Amber Lydia Wheeler, MD | Endocrinology, Diabetes and Metabolism Erica Yen, DO | Internal Medicine HOUSE OFFICERS Lydia Hui Ling Chan, MD, MS | Internal Medicine Peter Kitrick Moore, MD | Internal Medicine Aarthi Sabanayagam, MD | Internal Medicine STUDENTS Sarah Koser Prihatha Rengalakshmi Narasimmaraj Dennis Pang Amy Pugh Alexandra Ewa Rojek Angel Rosario, Jr. Manu Vikram Venkat
MEMBERSHIP MATTERS Activities and Actions of Interest to SFMS Members
Medicare Meaningful Use Exemption Application Now Available; Filing Deadline 7/1 Centers for Medicare and Medicaid Services (CMS) has granted a blanket exemption for all eligible physicians from the 2015 meaningful use penalties. Under the new law, physicians are still required to file for a hardship exemption to avoid a payment adjustment for 2015 no later than July 1, 2016. Physicians who wish to apply for an exemption need to do the following: 1. Download an application at https://www.cms.gov/ Regulations-and-Guidance/Legislation/EHRIncentivePrograms/ Downloads/HardshipApplication.pdf. 2. Complete the application and check box 2.2.d in order to avoid a penalty under the meaningful use program. 3. Submit the application via email ehrhardship@providerresources. com or fax (814) 456-7132.
New Physician Resource on California’s End of Life Option Act
The California Medical Association (CMA) has released a new On-Call document to help physicians understand ABX2-15, California’s End of Life Option Act. The guide was developed by CMA’s Center for Legal Affairs to help physicians and patients understand the End of Life Option Act, which will go into effect 90 days after the special session of the California state legislature ends. California became the fifth state in the nation to allow physicians to prescribe terminally ill patients medication to end their lives. ABX2-15, the “End of Life Option Act,” was passed in October 2015 and permits terminally ill adult patients with capacity to make medical decisions to be prescribed an aid-in-dying medication if certain conditions are met. (ABX2-15, Stats. 2015, Ch.1; Health & Safety Code §§443et seq.) The fifteen-page guide offers FAQs and outlines documentation and forms required to adhere to this legislation and can be accessed at http://bit.ly/1navlzN. At the urging of the SFMS, CMA removed its longstanding opposition to physician aid-in-dying in May 2015. SFMS presented both surveys of physician opinion and reassuring evidence from other states to successfully advocate that CMA become neutral on the bill and topic, thus allowing the legislation to reach Governor Brown.
CURES 2.0 Update; Technical Assistance Available to Users
The California Department of Justice (DOJ) implemented an upgrade in early January to the Controlled Substance Utilization Review and Evaluation System (CURES), California’s prescription drug monitoring system. Known as “CURES 2.0,” the system promises a significantly improved user experience and features a number of added functionalities. All users who log into CURES after January 8 will be prompt4
ed to update their security information in order to confirm their account. Those users who meet specific web browser compatibility requirements will be directed to CURES 2.0, while others will be routed to the old CURES 1.0 interface. After following this security step, physicians may experience a 15-20 minute wait before being able to log into the system with their updated credentials. Physicians who encounter technical difficulties—such as logging into their accounts, retrieving their log-in information or verifying their accounts—should contact the DOJ CURES Help Desk at (916) 227-3843 or email@example.com. All individuals practicing in California who possess both a state regulatory board license authorized to prescribe, dispense, furnish or order controlled substances and a Drug Enforcement Administration Controlled Substance Registration Certificate must be registered to use CURES no later than July 1, 2016. To register using the new automated online system, visit http://oag.ca.gov/cures.
3/16: SFMS Member Networking Mixer
Join SFMS for our March Physician Networking Mixer at Pa’ina in Japantown. Connect with your colleagues, meet SFMS leaders, learn about new member benefits, and hear SFMS’ efforts on the tobacco tax and Tobacco 21 initiatives. Visit https:// www.sfms.org/events.aspx for event details and to RSVP.
New Approval Time Frames for Prescription Drug Prior Authorizations
A new law took effect January 1, 2016 that requires health plans and health insurers to respond to prescription drug prior authorization requests within 72 hours for non-urgent requests and 24 hours for urgent requests. SB 282 deems such requests to be granted if the payor fails to respond within these time frames. SB 282 also requires the Department of Managed Health Care and the Department of Insurance to create a standard electronic prior authorization request form no later than January 1, 2017. Prescribers and payors will be required to use and accept this uniform electronic prior authorization form beginning July 1, 2017, or six months after the form is developed, whichever is later. For more information, visit http://bit.ly/1UPEtED.
Flu Update: 2015-2016 Influenza Season
Influenza season is here. The San Francisco Department of Public Health is advising all people age six months and older to get a flu vaccine every year. The SFMS is encouraging physicians to continue recommending influenza vaccination to patients who have not yet received it. Although flu activity remains low across the US, two deaths have been reported in California this season. Please visit http://bit.ly/1jTBQ83 for a list of resources available for San Francisco physicians.
SAN FRANCISCO MEDICINE FEBRUARY/MARCH 2016 WWW.SFMS.ORG
Free Online CME Course to Help Providers Identify Child Abuse The Institute for Medical Quality (IMQ) is offering a free course on child abuse prevention, recognition and reporting. The course is designed for California physicians, nurses, and other health care professionals who regularly or occasionally treat pediatric patients. Physicians and other health care professionals are mandated by law to report suspected child abuse and neglect. This course will help providers understand their reporting obligations and how to recognize the signs and symptoms of child abuse and neglect. It has been approved for 1.25 CME credits and can be accessible at http://bit.ly/1ZnWtJs.
Covered California Update: Patient Eligibility and the 90Day Grace Period
Under the Affordable Care Act, Covered California enrollees who receive federal premium subsidies (approximately 90% of enrollees) to help pay their premiums are entitled to keep their insurance for three months after they have stopped paying their premiums. In the first month of the grace period, federal law and California regulations require plans to pay for services incurred even if the patient fails to pay the premiums due by day 90 (CCR §1300.65.2(b)(1)(A)). But in months two and three of the grace period, plans can “suspend” coverage and pend or deny claims if the patient doesn’t true up on his or her premiums by day 90. In 2014, CMA was successful in advocating that plans be required to clearly communicate to practices through their real-time eligibility and verification systems if an enrollee’s coverage is suspended during the second and third months of the grace period. It is extremely important that practices verify eligibility on all exchange patients, ideally on the date of service, or as near the time of service as possible, and that the practices retain a printout of the eligibility verification and includes it as part of the patient’s chart. If a patient’s eligibility verification comes back indicating his or her coverage is suspended, the practice can treat the situation as it would any other patient who has had a lapse in coverage. For non-emergency services, patients may be given the option to either pay cash at the time of service or reschedule to a later date. For more information, visit http://www.sfms. org/for-physicians/covered-california.aspx.
Cosmetic Surgery Practice for Sale - Fairfield, CA. Long established. Revenue $805,000 ($200k of revenue from Fillers and Botox, $100k of revenue from Obagi) Office Surgical Suite certified by AAAHC and IMQ. 2,000 sq ft with free parking. Photos available. Offered at only $205,000. Real estate also available for purchase. firstname.lastname@example.org. (800) 576-6935. www.PracticeConsultants.com. Law Offices of David Young, Esq. Legal representation before Medical Board of CA; Medical staff privileges issues & peer review investigations, proceedings, and appeals. Harvard/Cornell Law School. (310) 575.0308 email@example.com. Well Established Medical Weight Loss Practice in Marin County. Fall in love with practicing medicine again. Enjoy work-life balance and financial freedom. This all cash practice offers a flexible schedule and provides income streams besides doctor visits. In addition, this practice presents a significant growth opportunity. This is and will continue to be an active ongoing practice. The seller will enable a smooth transition. Email now BariatricPracticeForSale@gmail.com.
Occupational Medicine Practice for sale. East San Francisco Bay, CA. Revenue $663,000 in 5,000 square feet facility near hospital; 6 exam rooms plus procedure and treadmill rooms. Outstanding reputation draws patients and contracts from throughout the San Francisco Bay Area. Existing transferable contracts assure steady revenue stream. Independent appraisal available. Offered for $312,000. Contact: firstname.lastname@example.org (800) 576-6935 www.medicalpracticesusa.com. WWW.SFMS.ORG
February/March 2016 Volume 89, Number 2 Editor Gordon Fung, MD, PhD Managing Editor Steve Heilig, MPH Production Editor Amanda Denz, MA Copy Editor Amy LeBlanc EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Erica Goode, MD, MPH Michel Accad, MD Erica Goode, MD, MPH Stephen Askin, MD Shieva Khayam-Bashi, MD Payal Bhandari, MD Arthur Lyons, MD Toni Brayer, MD John Maa, MD Chunbo Cai, MD David Pating, MD Linda Hawes Clever, MD SFMS OFFICERS President Richard A. Podolin, MD President-Elect Man-Kit Leung, MD Secretary John Maa, MD Treasurer Kimberly L. Newell, MD Immediate Past President Roger S. Eng, MD SFMS STAFF Executive Director and CEO Mary Lou Licwinko, JD, MHSA Associate Executive Director, Public Health and Education Steve Heilig, MPH Associate Executive Director, Membership and Marketing Jessica Kuo, MBA Director of Administration Posi Lyon Membership Coordinator Ariel Young BOARD OF DIRECTORS Term: Jan 2016-Dec 2018 Charles E. Binkley, MD Katherine E. Herz, MD Todd A. LeVine, MD Raymond Liu, MD David R. Pating, MD Monique D. Schaulis, MD Winnie Tong, MD
Term: Jan 2014-Dec 2016 Benjamin L. Franc, MD Benjamin C.K. Lau, MD Ingrid T. Lim, MD Keith E. Loring, MD Ryan Padrez, MD Rachel H.C. Shu, MD Paul J. Turek, MD
Term: Jan 2015-Dec 2017 Steven H. Fugaro, MD Brian Grady, MD Todd A. May, MD Stephanie Oltmann, MD William T. Prey, MD Michael C. Schrader, MD Albert Y. Yu, MD
CMA Trustee Shannon Udovic-Constant, MD AMA Delegate Robert J. Margolin, MD AMA Alternate Gordon L. Fung, MD, PhD
FEBRUARY/MARCH 2016 SAN FRANCISCO MEDICINE
Hilton San Francisco Union Square
May 13 - 15, 2016
San Francisco, CA
Physicians, nurses, medical practice managers and all other health care industry professionals—Join us in the heart of San Francisco to prepare for changes affecting your profession, your practice and your economic future.
Health care power players will share strategies and resources for accelerating the shift to a more integrated, high performing and sustainable health care system. Speakers include Dr. Atul Gawande, distinguished surgeon, teacher and writer – named one of TIME magazine’s 100 most influential thinkers; Karl Rove, former Deputy Chief of Staff and Senior Advisor to President George W. Bush; and Donna Brazile, Al Gore campaign manager and Democratic National Committee Vice Chair.
PRESIDENT’S MESSAGE Richard Podolin, MD
Advances in Cardiology I was fortunate to enter the field of interventional cardiology near its inception. When I started my interventional fellowship in 1982, the balloons, which had a few inches of wire fixed to their tips for guidance, were so bulky that it was not possible to inject contrast around them. The operator visualized the stenosis in two projections before inserting the balloon, and then blindly tried to steer the balloon into the same location. After removing the balloon, you would inject contrast again to visualize your results. Sometimes the lesion would be absolutely unchanged and you knew you had inflated the balloon in the wrong location, perhaps even the wrong vessel. Other times the lesion was worse, with a fresh dissection and diminished or even occluded distal flow, and the patient would be rushed to the operating room for emergency bypass. In those days the surgeons, anesthesiologist, perfusionist and nurses were all sitting in the OR waiting for the call. But sometimes the lesion was improved and the patient’s symptoms alleviated without the risks and discomfort of surgery. Over the ensuing years there has been a steady parade of improvements. Over-the-wire balloons permitted accurate localization. Perfusion balloons allowed us to treat some dissections without the need for surgery. Stents were developed, initially bulky and prone to become dislodged, but gradually more flexible, with improved profile and better adherence to the balloon. Thienopyridines reduced both the thrombosis and bleeding risks of earlier regimens. Drug-eluting stents were developed, nearly eliminating re-stenosis. And now we have expanded the technology to the treatment of chronically occluded vessels and the catheter insertion of heart valves. Along the way, some technologies were tried and abandoned, but after thirty years, interventional cardiology has become a safe, routine, and highly effective treatment that can often be performed on an outpatient basis. It’s tempting to see this history as an unequivocal victory of physician ingenuity and medical science over an epidemic disease and the major cause of death in our nation. But the truth is more complex, and reveals a fundamental vulnerability in the forces driving medical discovery. Interventional cardiology became a lucrative field—for the physicians who practiced it certainly, but especially for the innovators and companies that advanced the technology. There’s nothing wrong with that; it led to the rapid development of the field, to the benefit of millions of patients. But coronary atherosclerosis is not fundamentally a plumbing problem to be treated with balloons and stents, it’s a metabolic and inflammatory problem. The real success would be in its prevention, not its treatment. WWW.SFMS.ORG
What if the real problem is, as some investigators have proposed, an insulin induced inflammatory process fueled by excessive carbohydrate consumption? I hasten to add that this is a hypothetical—it has never been proven—but it is useful as a thought experiment. The explosive development of interventional cardiology was largely spurred by private investment from companies that stood to make enormous profits if their technology was adopted. Who will fund the difficult, long term studies necessary to prove or disprove the carbohydrate hypothesis even if the potential benefits of that research far exceed the societal impact of interventional cardiology? And if this hypothesis were confirmed, do we have the infrastructure in our medical practices to promote a change in patients’ dietary habits with the same enthusiasm and vigor that we promoted coronary intervention, or even pharmacologic advancements like the statins? In this issue of San Francisco Medicine, we rightfully celebrate the achievements of one of the most technologically progressive branches of medicine. These advances have saved countless lives, and their impact is certain to grow. But it is also possible that we may be entering an era when public health interventions, such as the promotion of evidence-based changes in dietary habits, could have even greater impact on population health. While we can advise our patients about food choices, bringing the potentially powerful but low-tech science of nutrition to our patients as effectively as we deployed high-tech and expensive treatments will require engagement in the public sphere, driving change in food policy. Individually, we can have little impact, but by working together in our medical societies our influence is magnified. It’s our professional responsibility as stewards of our community’s health. Dr. Podolin is a cardiologist at St. Mary’s Medical Center where he has been chief of the medical staff and currently serves as vice-chair of the Community Board. He graduated from Stanford University School of Medicine, did his residency in internal medicine at the University of Chicago, and his cardiology fellowship at UCSF. Connect with Dr. Podolin via the SFMS LinkedIn Group or send him an email at email@example.com.
FEBRUARY/MARCH 2016 SAN FRANCISCO MEDICINE
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EDITORIAL Gordon Fung, MD, PhD
Focusing on the Heart Heart disease has long been one of the two leading causes of death in the United States, along with cancer. However, there have been many advances in all areas of cardiovascular disease. Over the past century two major health organizations developed in response to this major killer with a focus on emergency management and treatment to early detection to prevention. The education of the public to respond to cardiac emergencies with CPR and calling EMS as well as teaching the warning signs and symptoms of a “heart attack” begins in schools and is wide spread in community settings with public awareness campaigns. This month in honor of our incoming president, we are dedicating this issue to cardiology. One of the major cardiac arrhythmias that is present in up to 14% of the elderly population > seventy-five years of age is atrial fibrillation. This challenging problem has many causes but the most significant risk factor is age, so that it is a problem of the elderly with significant morbidity—usually stroke—and mortality. Drs. ElDabage and Morelli update the latest management of this disorder. The main challenge is the varied presentations from completely asymptomatic to very symptomatic with palpitations to dizziness to decreased exercise tolerance. One of the main focuses of cardiac disease management is identifying the patient at high risk and managing the risk factors. Dr. Alka Kanaya, discusses a study that she is spear heading on trying to understand the elevated risk of CVD in the South Asian population. In the U.S., South Asian men in the ages of thirty-five to fifty are the only demographic where cardiovascular disease is the leading cause of death. Dr. Goode discusses the issue of diet for cardiovascular health as one of the most modifiable risk factors. Dr. Glantz presents a timeline of the prolonged fight against tobacco from 1964 acknowledging that the fight is not over. Another major risk factor is hypertension control that I share the latest guidelines from the JNC VIII. Dr. Michel Accad reviews a movie, The Widowmaker, the nickname for the acute proximal left anterior descending coronary artery occlusion. Over the past several decades, previously a small population of patients with congenital heart disease began to survive major open-heart surgical repair of their defects and live to adulthood. These patients previously had a lifespan expectation that was measured in a few years but never expected to live beyond their teenage years. As more survived the initial surgeries to adulthood and were cared for by pediatric cardiologists it was obvious that they needed to be followed by adult cardiologists and adult physicians. Currently, the number of adults with congenital heart disease outnumbers the WWW.SFMS.ORG
patients born with CHD. Dr. Ian Harris tells his story of how he became interested and a national expert in this field. As technology has advanced in catheter-based therapies, the field of valvular heart disease is no longer a disease that is exclusively in the hands of surgeons. Over the past decade, many advances have exploded the field of interventional cardiology. Drs. Mark Villalon and Vaikom Mahadevan of UCSF describe the latest in this subspecialty of cardiology. With all the advances of cardiology, the training of the cardiovascular specialists has been prolonged and somewhat protracted. The training includes four years of medical school, two to four years of internal medicine residency, three years of general clinical cardiology and additional one to three years for non-invasive imaging specialty, two to three years of interventional training, three years for adult congenital heart disease, and two years for advanced heart failure specialty. Dr. Vishal Patel having just completed this journey relays his story of his cardiology training. Two very important issues related to cardiac disease is hidden usually in other “health” journals and are not usually discussed in cardiology journals. The first is dental disease and how dental caries is a contributing factor to the chronic inflammation in the body that increases the risk of cardiovascular disease. Drs. Fisher-Owens, Spiegel, Gonzalez, Hilton, and Abby Wolf, Margaret Fisher, and Dr. Lisa Chung discuss this. Finally, a scientific statement from the American Heart Association on dietary sugars intake and cardiovascular health. The evidence is very compelling that good dental health and diet are keys to good cardiac health. Editor and cardiologist Dr. Fung is clinical professor of medicine at UCSF with a practice in consultative general clinical cardiology, and is medical director of the Electrocardiography Lab at Moffit/Long Hospitals and of the nation’s first UCSF Asian Heart & Vascular Center located on the Mount Zion Campus. He is a former SFMS President.
FEBRUARY/MARCH 2016 SAN FRANCISCO MEDICINE
Heart Matters: Advances in Cardiology
ATRIAL FIBRILLATION New Perspectives on Treatment Robert ElDabaje, MD, and Remo L. Morelli, MD, FACC Atrial fibrillation (AF) is the most common serious arrhythmia in the US, accounting for 750,000 hospital ad-
missions yearly. It affects 2-3% of the population, but 14% of those over the age of eighty. It contributes to 130,000 deaths and 15-25% of all ischemic strokes, with an economic cost of six billion dollars annually. While the incidence of AF increases yearly, associated mortality and morbidity has been declining over the last decade largely as a result of new medical and nonmedical developments. Despite these advances, the treatment of AF continues to be a challenge. The goal of therapy is to prevent hemodynamic instability and strokes. To this end, two approaches are equally effective: rate and rhythm control. Rate control effectively reduces or eliminates presenting symptoms as well as achieves hemodynamic stability. Alternatively, rhythm control achieved either pharmacologically or by electrical cardioversion can be used. Often, adjunctive pharmacologic therapy is needed after conversion to maintain sinus rhythm. While both rhythm and rate control can achieve hemodynamic stability, only rhythm control can reduce the risk of stroke. However, this is only if sinus rhythm can be sustained, something not possible given the available resources and limited efficacy of available antiarrhythmics. For many years, reasonable long-term protection against strokes, the most devastating potential complication of AF, was only possible with warfarin. Managing patients on warfarin has its own challenges, as most physicians can attest. Advances in pharmacology have made anticoagulation both easier, and safer, with the recent introduction of novel oral anticoagulants (NOACs) such as dabigatran (direct thrombin inhibitor) or rivaroxaban, apixaban or edoxaban (factor Xa inhibitors). While historically warfarin is the best-studied anti-coagulant, NOACs have been shown to be non-inferior or even superior to warfarin for stroke prevention in non-valvular AF, with no increase in the overall risk of bleeding. The NOACs are rapidly gaining popularity due to their ease of use. While reversal agents are available for warfarin, only dabigatran has a recently approved reversal agent, Idarucizumab. There are currently no FDA approved reversal agents for the factor Xa inhibitors beyond clotting factor repletion. The lack of reversal agents, the fact that NOACs are not yet approved for AF due to valvular heart disease, and their cost have limited the wider use of the NOACs. However, considering the cost and difficulty of monitoring warfarin use, frequent blood draws, difficulty in maintaining patients within the therapeutic INR, and dealing with the bleeding complications related to warfarin, the NOACs will likely prove to be cost effective long term. Furthermore, their effectiveness and rapid onset of action has virtually 10
made bridging with parenteral agents in the acute stage unnecessary, thus reducing hospital stay. Yet, despite these advantages, the risk of stroke is not totally reduced while the potential for bleeding remains. The last seventeen years have also brought about advances in non-pharmacologic interventions to prevent thromboemboli in patients with AF by restoring normal rhythm. Pulmonary Vein Isolation and Radiofrequency Ablation (RFA), in its many forms, is rapidly gaining in popularity. The technique of RFA continues to evolve, showing promise of even greater efficacy and ease of use in the future. Maintaining normal rhythm may be the most effective guard against the continued risk of stroke. Recognizing that the left atrial (LA) appendage was the source of thromboemboli in non-valvular AF, surgical amputation or ligation of this structure was first used in the 1940s. The need for sternotomy, however, limited its acceptance, but is again now recommended for those patients at risk of AF who are otherwise in need of open-heart surgery. It is often accompanied by the Maze or modified-Maze procedure for the prevention of AF. Percutaneous methods to exclude the LA appendage from systemic circulation have recently been introduced. The WATCHMAN™ device, which is placed within the LA appendage, or the LARIAT®, which delivers a suture around the LA appendage via a pericardial approach, are in current use in the US. Both procedures are presently still performed only in select centers. Currently, they are reserved for individuals with AF at significant risk of stroke, but who are at even greater risk from anticoagulation. Successful closure of the LA appendage has been shown to reduce thromboembolic events in patients with nonvalvular AF while remaining off of anticoagulants. With further refinements of these techniques there is the potential to expand their use beyond the high-risk patient. Despite such advances in the treatment, AF continues to be a challenge. New developments no doubt will continue to make further advances, and lead to better and more effective treatment of AF. Robert Eldabage, MD, is chief resident at St. Mary’s Hospital and Medical Center. Remo L. Morelli, MD, FACC, is director of the Cardiac Catheter Laboratory at St. Mary’s Hospital and Medical Center.
SAN FRANCISCO MEDICINE FEBRUARY/MARCH 2016 WWW.SFMS.ORG
Heart Matters: Advances in Cardiology
THE ‘THIN-FAT’ SOUTH ASIAN PHENOTYPE Understanding MASALA Alka Kanaya, MD As an immigrant from India with a large extended family spread around the world, I witnessed many rela-
tives develop early diabetes and heart disease unexpectedly with no warning signs. As a third year medical student, I spent six months working in primary care and specialty clinic settings in different regions of India and Nepal and was struck by the pervasiveness of diabetes and cardiovascular disease in mostly thin individuals. This pattern did not resemble the patients I would see in my primary care medicine residency in San Francisco, where the norm was obesity as the trigger for both diabetes and heart disease. In my general medicine/clinical epidemiology fellowship, I researched the relative associations of body mass index (BMI) and waist circumference with cardiovascular disease (CVD) and saw a clear pattern emerge. It was all about the waist size–higher waist circumference was strongly and linearly associated with higher CVD risk while BMI was not. Moreover, a higher BMI was protective against CVD and mortality. This observation, coupled with my own ancestral history of early cardiometabolic disease, motivated me to dig deeper into understanding why relatively thin South Asians have such high rates of diabetes and heart disease. Statistics from the World Health Organization proclaimed that 60% of the world’s cardiac patients are South Asian. Researchers in the U.K. and Singapore had found strikingly higher rates of type 2 diabetes in South Asians compared to Europeans and other ethnic groups. While attending the American Heart Association meeting in San Francisco, I heard about a new National Institutes of Health-funded study called the Multi-Ethnic Study of Atherosclerosis (MESA) that included whites, African American, Latinos and Chinese Americans to chart the natural history of atherosclerosis. That was the moment of inspiration. I began networking with the MESA investigators to propose my idea of creating a cohort of South Asians which would be parallel to MESA so that we could compare the prevalence of risk factors and disease progression across five ethnic groups. In 2006, we established a pilot study called the Metabolic syndrome and Atherosclerosis in South Asians Living in America (MASALA) which enrolled 150 Asian Indians who were randomly sampled from the SF Bay Area. MASALA was created with similar methods and measures to MESA and showed a clear signal that South Asians had lower BMI, higher rates of diabetes, high blood pressure and atherosclerosis than most of the MESA groups. This compelling data led to an expansion of the MASALA study (renamed to Mediators of Atherosclerosis in South Asians Living in America) that included over 900 South Asians who were sampled from both the SF Bay Area and the greater Chicago area. We have followed this larger MASALA cohort for the past WWW.SFMS.ORG
three years and have made some interesting observations. The early findings from the pilot study still ring true in the larger sample–South Asians do have a modest BMI, lower tobacco use, lower levels of exercise, and a much higher prevalence of diabetes, hypertension, and the metabolic syndrome than the four MESA ethnic groups. Coronary artery calcium in South Asian men is higher than other ethnic minority groups in MESA and as high as the white men. South Asians in MASALA consume one of three major dietary patterns—a fresh fruits/vegetables/nuts/ legumes vegetarian diet; a fried snacks/sweets/high-fat dairy vegetarian diet; or an animal protein diet. Both the animal protein and the fried snacks/sweets/high-fat dairy diets are associated with higher metabolic risk factors, while the fresh fruits/ veggies/nuts/legumes diet consumers have lower hypertension and metabolic syndrome. Traditional cultural beliefs may influence CVD risk–those with very strong and very weak traditional South Asian cultural beliefs have higher carotid intima media thickness (cIMT, a subclinical atherosclerosis measure linked to risk of stroke), while those with moderate traditional beliefs have the lowest cIMT, independent of all other CVD risk factors. Can having a “bicultural” affiliation by adopting some Western beliefs in the U.S. but retaining some traditional South Asian beliefs be protective for cardiovascular disease? Indeed biculturalism has been associated with lower rates of obesity in Latinos and Asian Americans. With CT scans of the abdomen, liver, and heart we have found that South Asians have significantly larger deposits of fat in the liver, abdomen and in muscles than the four MESA groups. It’s all about where the fat is, not what the weighing scale reads, which may unlock the puzzle of this ‘thin-fat’ ethnic phenotype and high rates of diabetes and heart disease. For now, when you see a South Asian patient, remember that his/her low-normal BMI is deceptive. Check their fasting blood glucose and blood pressure, and delve a little deeper into their dietary habits and exercise. Remember that CVD prevention begins with risk assessment, but because current CVD risk prediction calculators do not incorporate data on South Asians, the accuracy of risk prediction scores in South Asians is uncertain. As MASALA matures into a long-term study, we will be able to analyze which sociocultural, behavioral, biologic and genomic factors are most predictive of diabetes and cardiovascular disease. Alka Kanaya is Professor of Medicine, Epidemiology & Biostatistics at UCSF. She is a practicing physician and clinical investigator. She completed medical school, residency, and fellowship at UCSF and has been on faculty since 2001. She is principal investigator of the MASALA study and also conducts behavioral trials for diabetes prevention.
FEBRUARY/MARCH 2016 SAN FRANCISCO MEDICINE
Heart Matters: Advances in Cardiology
DIET FOR CARDIOVASCULAR HEALTH Recommended Changes—Evidence-Based or Not Erica Goode, MD, MPH The newest iteration of Dietary Guidelines (DG’s), which are revised every five years as “new information
becomes available”1 are, on the surface, generally moving toward a healthier pattern. But with any scrutiny of the details, there are major problems, even though the 2015 DG’s are better in terms of Cardiovascular and overall health than their predecessors. Markedly lower sodium levels as part of the total daily intake is one example. But bowing to pressure from Congress and the food industry giants, many omissions in specific “best practices” food choices for all individuals is still a problem. In her very pointed summary of the problems in the previous DG’s, as an example, Marion Nestle, PhD, has clarified many of these issues in her book, Food Politics, UC Press, 2002. Further, nutrition experts have begun a groundswell of mutinous comments regarding the latest DG’s.2 I have thought, taught, and written about these issues for years. I hold nutrition undergraduate and MPH degrees from UC Berkeley; I co-taught an elective course in nutrition in medical school, and have developed and lead nutrition programs on obesity, and later on a wide range of nutrition topics for medical residents, for the past forty years. However, the 2015 DG’s are moving in the right direction, despite obfuscation of many known details, and sensible, useful recommendations. But these guidelines are capable of providing better facts than previously, for the purpose of providing guidance to pregnant moms, children, people in the workplace, institutional food programs, restaurants, and fast food chains. In scrutinizing any broad set of recommendations for the U.S. population—be it objections to prior, more nonspecific DG’s (Basic Four Food Groups, The USDA Pyramid, My Plate to a lesser extent), and those recommended now—researchers, clinicians, and professors of nutrition have their biases based upon the care with which they scrutinize the data and design flaws in their own or others’ work, and upon the industrial lens with which they view the recommended changes. With skewed financial distribution of wealth in America, less government funding toward basic research in universities is available . . . and the money, when it comes, is often from tainted sources. Remember: the Gold Standard is a cohort study, such as the Framingham Study; where truths are only revealed over decades. Such studies are rare because of the cost, commitment, and near impossibility in increasingly mobile, shifting human populations.4 After all of this, I agree most closely with David Katz, MD, MPH, that the politics behind the food industry are largely responsible for many distorted or unmentioned truths.5 As I see it, U.S. red meat consumption in significant amounts IS a problem, largely because of the way it is raised or cooked.6,7 Fish needs to come from sustainable sources, free of pollutants.8 Trans fats should be shunned.9 Pesticide and herbicide residues derived from petroleum products should be discussed.10 Food preservatives, emulsifiers, engineered flavoring and aroma enhancers, excess sugar, and gluten (which 12
can alter gut integrity at tight junctions, in many people allowing foreign protein and other atypical molecules past our IgA barriers) should be eliminated from foods.11 All of these issues bear on cardiovascular health, directly or indirectly. Each revision of the DG’s attempts to provide recommendations based upon the needs of an entire population. Yet substantive changes in our understanding of food science are ignored. (For example: regarding hydrogenated trans fats, we are told to “limit” these and saturated fats.12 How about “avoiding” trans fats? This is a critical problem, not only for those with cardiovascular problems, but to all of us, since trans fats alter cell membrane receptors.) Even the recommended breakfast in the DG’s, “whole wheat bagel with peanut butter”, makes no mention of the need that it be unhydrogenated peanut butter. Epigenetic issues should be mentioned, even though this is an evolving topic. There is no mention in the DG’s about the gathering science around the micro biome and its importance in how well our gut function translates into overall health. The DG’s, by oversimplification, discount circumstances of such groups as those performing unusually hard physical work, those operating in extreme heat or cold, the need to avoid certain foods in early infancy, mention of increased fluid and salt needs for the ill, or altered needs in people with genetic abnormalities. The Global Dietary Guidelines are good and better than those in prior DG’s. But the devilish details are insufficiently clarified, and thus often misleading. For example:
1. Follow a healthy eating pattern across the lifespan.
How many of us know what we were fed before age one? Would our mothers remember? But it is important—for decades, researchers conducting generational studies on rats have learned that many factors in the grandmother rat’s diet are played out in the nutritional status of the second generation. Does this translate to humans? Women in prenatal clinics and pediatric offices, and fathers of those children, need to be reminded that processed cheese, burgers and fries should be rare treats, if ever, foods.
2. Focus on variety, nutrient density, and amount. People need to be told what variety means, and how to make changes. Example: having different types of greens—spinach, kale, beet greens, dark green lettuces—in salads. Nutrient density (discussed in the new DG’s) is a terrific teaching tool if it is clarified for people: ND = overall nutritional quality / Calories spent. Hence a handful of mixed, roasted, salt-free nuts vs. sugar glazed salted nuts. Popcorn with some butter, lightly salted, for a snack at the State Fair, vs. a haze of cotton candy or fried Twinkies. 3. Limit Calories from added sugars and saturated fats and reduce sodium intake. The sugar recommendation is
SAN FRANCISCO MEDICINE FEBRUARY/MARCH 2016 WWW.SFMS.ORG
good. As for clarification of fat intake, there are problems. While bar graph diagrams are shown regarding fats, both solid and liquid, with % of saturated, mono-unsaturated, and omega 3 (linoleic acid) fats, no distinction is made regarding best choices in oil if omega 3’s were the goal. The widely understood Mediterranean diet emphasizes olive oil, cold pressed if possible.13 For omega 3 content, canola (rapeseed) oil is a better choice. Meanwhile, ALL saturated fats have less onerous consequences than trans fats, yet food labels are still allowed to state “0 trans fat” when they in fact are allowed to contain a certain amount of “partially hydrogenated” oil, until June, 2018.
4. Shift to healthier food and beverage choices. This sounds wonderful, but it assumes that most American adults come from childhoods where meals, at regular times, are the norm, and that children learned sensible cooking skills at some point before adulthood. This is absolutely not the case. Of individuals or groups with weight issues, it is only those who know how to prepare healthy meals and snacks—paired with exercise and some knowledge of food groups and nutrient density, phytochemicals, fiber, and appropriate liquid intake who also honor the need to eat regularly—who succeed.
5. Support healthy eating patterns for all. Nice idea. Much of this is covered in the film, Supersize Me (2004). School lunches in California are moving toward better food patterns, but many hospitals continue to contract with outside Food Service Meal Delivery Programs to arrive from off-site sources. This limits flexibility for those providing meals to patients, and unless food is well handled, color, texture, and variety of foods suffer. Everyone knows the woes of trying to eat healthily at fast-food restaurants, and for many of the poor this is often their only option. There are a few programs for gleaning in California, where farm workers can remove fresh produce that is imperfect, but we as a nation waste 40% of fresh fruit/ vegetables as much of it “looks funny”. A few grocers are beginning to offer “ugly foods”, such as double carrots and foods with minor blemishes, at lower prices. This is an excellent option.
In summary, a good Cardiovascular Diet is a good General Diet. The emphasis is on all of the above principles. To give good hints to patients, I do the following:
1. Posters in the exam rooms. Online sources are available
for the Harvard Pyramid, developed by two Harvard Physicians who reviewed the literature and published their findings to support the Pyramid, also published in Scientific American as the lead article.14
2. Colorful posters of the rainbow of fruits and vegetables: green, blue purple, red, yellow, orange, with healthy representatives of each color.
3. A few handouts for Cardiovascular issues, emphasizing potassium and magnesium rich foods; healthy meat,
fish, and lower fat cheeses; best fat choices; the benefits of whole grains and seeds; the need to engage in healthy levels of exercise.
4. A few handy recipes: make-ahead items like ratatouille, soups, bean dishes, tabouli; use of hummus; healthy ways to have WWW.SFMS.ORG
dessert (fresh fruit compote, cut in advance, with an oatmeal cookie) unhydrogenated peanut butter snacks for kids.
5. I provide a sheet called the “15-minute dinner”. Sim-
ple, healthy, very little cleanup.
6. If overweight or pre-diabetes is at issue, ask the person to make a contract to lose 25 lbs. that year, with a
copy to someone who will hold them to it. Or to agree to this with you alone if that seems more appealing. Urge this patient not to lose more than 2 lbs/week. If the individual is over age fifty, be especially clear about the need for adequate protein and physical exercise, since both are required to maintain adequate muscle mass and energy. Ask the patient to see a nutritionist for a few sessions if the weight loss process is not going well. Have him/her compete with someone else. Urge use of a Fitbit or other app to measure actual exercise. Individuals need choices: perhaps have a handout of options, some of which will work for that person. And remind them to take a few slow breaths before each meal, to eat slowly enough to really enjoy each bite. By all means, see a trained and credentialed nutritionist or dietitian, individually or in a well-regarded program. Finally, sustained changes in habits are hard for all of us. My favorite resources for coaching patients are included in the references, which are available on the SFMS Website, www.sfms.org. Erica Goode, MD, MPH, practices general medicine with an emphasis on nutrition. Dr. Goode maintains an Associate Clinical Professorship at UCSF. She is a longtime member of the SFMS and of the San Francisco Medicine editorial board.
The Dietary Pyramid and Healthy Nutrition From a recent letter in The Wall Street Journal No randomized, controlled trials (RCTs) have shown a high saturated-fat/red-meat diet to be beneficial. On the contrary, there is consistent RCT and observational evidence to support the benefits of a diet high in fruits, vegetables, whole grains, nuts, legumes and healthy oils, and lower in saturated fat, red meat and sugars. A five-year RCT of 7,447 patients found that a Mediterranean diet recommended by the DGAs reduced cardiovascular disease (CVD) risk by 30%, strong evidence ignored by the commentary. These meta-analyses merely showed that if saturated fat is replaced by refined carbohydrates, heartdisease risk doesn’t change because both are equally deleterious. However, replacing saturated fat with healthy fats from plant sources and seafood significantly reduces heart-disease risk. A recent meta-analysis of 15 RCTs with 59,000 participants showed the significant benefits of replacing saturated fat with healthy fats on LDL-cholesterol levels and CVD (by 27%). The DGAs must be based on the best available science, not biased views of the evidence. The 2015 dietary guideline scientific review conducted by 14 leading experts was rigorous, transparent and of the highest standard. However, its translation to the policy document was subject to undue political pressures from lobbyists, industry and special-interest groups. It is critical for the National Academy of Medicine to address political influences and maintain the scientific integrity of the process. —Frank Hu, MD, PhD, and Walter Willett, MD. Har-
vard University. Dr. Hu is a member of the 2015 Dietary Guidelines Advisory Committee. FEBRUARY/MARCH 2016 SAN FRANCISCO MEDICINE
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Heart Matters: Advances in Cardiology
BATTLES WON, BUT THE WAR CONTINUES Key Tobacco Events Timeline 1964-2015 Stanton Glantz, PhD California, San Francisco, and University of California San Francisco (UCSF) have been at the center of the global tobacco wars for decades. What follows
here is an edited version of a full timeline on permanent public exhibit outside the UCSF Center for Tobacco Control Research and Education in UCSF’s Library at Parnassus Heights. It summarizes this history, with particular emphasis on local events. The big tobacco control issues in California today include closing loopholes in and adding e-cigarettes to California’s clean indoor air law, raising the age to buy tobacco products to 21, increasing the tobacco tax, and reinvigorating the state’s tobacco control program, which has lost half its purchasing power since voters created it when they passed Proposition 99 in 1988. While local progress continues, the tobacco industry is resurgent in the state legislature and Jerry Brown is the first California governor to take money from tobacco companies in decades.
While there is a lot of progress, the fight continues.
1964 • “Smoking and Health: Report of the Advisory Committee to the Surgeon General,” the first major U.S. report on smoking and health, is published. The report concluded that cigarette smoking is a cause of lung cancer in men and a suspected cause in women. Identifies many other causal relationships and smoking-disease association. The report called for “appropriate remedial action.” 1970 • Congress enacts the Public Health Cigarette Smoking
Act of 1969, banning cigarette advertising on television and radio and requiring a stronger health warning on cigarette packages: “Warning: The Surgeon General Has Determined that Cigarette Smoking is Dangerous to Your Health.”
1972 • First Report of the Surgeon General to identify involuntary smoking (also called passive smoking) as a health risk.
1973 • Civil Aeronautics Board requires no-smoking sections on all commercial airline flights.
1983 • San Francisco passes workplace smoking restrictions. The tobacco industry attacks with Proposition P. Health groups defeat it, the first such defeat for the tobacco industry.
1986 • Surgeon General’s report focuses on the health consequences of involuntary smoking, finds that it causes lung cancer problems in kids, and that simple separation of smokers may reduce, but does not eliminate, the risks. National Academy of WWW.SFMS.ORG
Sciences issues similar report.
1988 • Proposition 99 passes to increase tobacco tax and set
up large control program. First plaintiff wins a jury verdict in a smoking and disease case.
1994 • FDA Commissioner David Kessler announces plans to consider regulation of tobacco as a drug. Seven leading tobacco executives testify in Congressional hearings that they believe “Nicotine is not addictive”; Justice department holds hearings regarding possible perjury. California passes AB13 mandating 100% smoke-free workplaces. Prof. Glantz of UCSF places internal tobacco industry documents in UCSF library for public viewing; Brown and Williamson sues for return of documents. 1995 • FDA declares nicotine a drug. B&W’s suit to retain documents from UCSF is denied. Analysis of documents by Glantz and colleagues appears in JAMA; Glantz’s book Cigarette Papers published next year. FDA proposes limiting access and advertising of tobacco to minors; tobacco industry sues FDA. 1997 • FTC accuses Joe Camel ad campaign of illegally targeting
underage youth. Tobacco companies and state attorneys general announce $368.5 billion settlement agreement, with much controversy. Tobacco industry again sues Glantz re use of tobacco documents, but suit is dismissed.
1998 • California bars become smoke-free.
2003 • Philip Morris Companies renames itself Altria Group to
deflect attention from its tobacco business. R.J. Reynolds and Lorillard Tobacco Companies sue California Director of Health Services for using Proposition 99 tobacco taxes to create ads that stigmatize the tobacco industry; suit later dismissed. In Lancet, Dalton and colleagues show exposure to smoking in movies triples likelihood that adolescents will start smoking.
2005 • World Health Organization (WHO) Framework Convention on Tobacco Control goes into effect after 40 countries –not including the United States –ratify it. In American Journal of Public Health, Farrelley and colleagues report that anti-smoking campaigns by public health agencies work. Philip Morris pays Patricia Henley $17 million in compensatory and punitive damages. The case is the first in California in which a smoker recovers a verdict against a cigarette manufacturer. UCSF researchers Barnoya and Glantz publish “Cardiovascular Effects of Secondhand Smoke: Nearly as Large as Smoking” in Circulation. The Continued on the following page . . .
FEBRUARY/MARCH 2016 SAN FRANCISCO MEDICINE
Tobacco Continued from previous page . . .
ity of measures that protect the public.”
study shows that despite the much lower “dose”, secondhand smoke affects blood and blood vessels in ways that increase the risk of heart disease and attacks. California Environmental Protection Agency concludes that secondhand smoke causes breast cancer in younger women.
ports that e-cigarette use among middle and high school students doubled between 2010 and 2011. All major U.S. cigarette companies are selling e-cigarettes. At WHO’s request, UCSF researchers Grana, Benowitz, and Glantz prepare Background Paper on E-Cigarettes (Electronic Nicotine Delivery Systems), which recommends e-cigarettes be subject to the same rules as cigarettes. New York City becomes the first major municipality to raise age for sales of all nicotine and tobacco products to 21. UCSF becomes a tobacco-free campus.
2006 • California Air Resources Board identifies secondhand smoke as a “Toxic Air Contaminant.” U.S. Surgeon General issues “The Health Consequences of Involuntary Exposure to Tobacco Smoke,” which concludes that even brief secondhand smoke exposure can cause immediate harm, and that the only way to protect nonsmokers from the dangerous chemicals in secondhand smoke is to eliminate smoking indoors. 2008 • San Francisco becomes first place in the U.S. to end sale of tobacco in pharmacies. Michael Bloomberg and Gates Foundation commit $500 million to combatting the global tobacco epidemic and call on governments to act to reduce tobacco use.
2009 • Federal cigarette tax increased by 69 cents, bringing the federal tax to $1.01. San Francisco enacts 20-cent fee per pack of cigarettes sold to recover the cost of cleaning up cigarette butts. President Obama signs Family Smoking Prevention and Tobacco Control Act, giving Food and Drug Administration regulatory authority over tobacco products. U.S. Federal Court blocks FDA regulation of e-cigarettes as drug delivery devices, fueling marketing of e-cigarettes. U.S. Court of Appeals affirms Judge Gladys Kessler’s 2006 ruling that the major cigarette companies constructed an illegal “racketeering enterprise” to defraud the American people by covering up the health risks associated with smoking and marketing their products to children.
2010 • Belmont, CA becomes the first local government to prohibit smoking in all market rate multiunit housing. World Health Organization calls for enforceable policies to end on-screen smoking in films rated for youth. San Francisco extends ban on tobacco sales in pharmacies to grocery and big-box stores with pharmacies. President Obama signs the Patient Protection and Affordable Care Act into law, requiring insurance companies and employers to cover tobacco cessation treatment. 2011 • FDA issues regulation requiring larger, graphic warning labels illustrating the negative health consequences of smoking. Cigarette companies sue FDA and block graphic warning labels.
2012 • Lorillard Tobacco becomes first cigarette company to
enter e-cigarette business when it buys Blu eCigs. Cigarette companies spend $46 million to defeat California Proposition 29, a $1 cigarette tax increase to fund medical research and reinvigorate the state tobacco control program. U.S. Surgeon General concludes that exposure to on-screen smoking causes young people to smoke. WHO Director General Margaret Chan delivers landmark speech at the World Conference on Tobacco or Health, calling multinational tobacco companies “bullies” who “[Pay] people to use a country’s judicial system to challenge the legal16
2013 • U.S. Centers for Disease Control and Prevention re-
2014 • European Union’s new Tobacco Products Directive requires large pictorial warnings on cigarette packs in 2016, a traceability system in 2019, a ban on menthol in 2020, and a regulatory framework for e-cigarettes. New York, Chicago, Los Angeles, Chicago and San Francisco include e-cigarettes in their smokefree laws; 164 cities take such action in 2014. U.S. Surgeon General report concludes that cigarettes are even more deadly than 50 years earlier and cigarette companies have been responsible for 20 million premature deaths since 1964. U.S. Surgeon General reports that R-rating future movies with smoking will avert a million U.S. tobacco deaths. NIH and FDA select UCSF as one of 14 Tobacco Centers for Regulatory Science. CVS Pharmacy stops selling tobacco products nationwide; other major pharmacies Wal-Mart, Walgreen and Rite Aid refuse to follow CVS lead. Entire University of California becomes 100% smoke-free and tobacco-free. 2015 • UCSF launches third generation of tobacco documents library, renamed Truth Tobacco Documents Library, with 88 million pages in 15 million documents as part of online UCSF Industry Documents Library. San Francisco caps number of tobacco retailers at 45 per supervisorial district. San Francisco becomes the first city to prohibit the use of smokeless tobacco at all sport and playing fields; California follows with statewide legislation. U.S. Centers for Disease Control and Prevention reports that exposure to secondhand smoke has been cut in half since 2000, from 53% in 2000 to 25% in 2012, leaving 58 million people still exposed, mostly African-Americans, children, and the poor. CVS pulls out of U.S. Chamber of Commerce after New York Times exposes the Chamber’s work on behalf to undermine tobacco laws globally. Berkeley passes California’s first ordinance prohibit the sale of menthol and other flavored tobacco products within 600 feet of schools and playgrounds. Hawaii raises the age for sales of all nicotine and tobacco products to 21. Tobacco incidents in top grossing U.S.-produced films fall to historic low.
Stanton Glantz, PhD, is Professor of Medicine in the Cardiology Division and director of the UCSF Center for Tobacco Control Research and Education. He conducts research on the health effects of secondhand smoke, the health and economic effects of tobacco control policymaking, and the policymaking process. The tobacco industry has unsuccessfully sued UCSF twice to block his work.
SAN FRANCISCO MEDICINE FEBRUARY/MARCH 2016 WWW.SFMS.ORG
Tobacco 21 Moves Forward in San Francisco Legislation that would increase the legal age to buy tobacco in San Francisco from 18 to 21 was unanimously approved by the Board of Supervisors on March 1. Authored by Supervisor Scott Weiner, the Tobacco 21 ordinance was endorsed by the San Francisco Medical Society, and SFMS members provided testimony in strong support of the legislation at February’s public comment session to ensure bill passage. Long experience and much research indicates that perhaps the most important preventive goal with regard to decreasing tobacco use is to delay the onset of use as long as possible. 90% of tobacco users start before 21 and that if such use can be prevented, the young adults are unlikely to start. San Francisco joins New York City and Boston to raise the minimum age to purchase cigarettes and other tobacco products, including c-cigarettes. The ordinance will go into effect on June 1. SFMS would like to applaud Supervisors Scott Weiner, Eric Mar, Malia Cohen, and Mark Farrell for their leadership in championing sound public health policies for the health of all San Franciscans.
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Heart Matters: Advances in Cardiology
CONGENITAL HEART DISEASE A Coming of Age Ian Harris, MD Like many internists and adult cardiologists, I became
aware of congenital heart defects during medical school as bits of interesting esoterica, but did not spend much time at that point learning the details, secure in the belief that I would never encounter these patients in my practice. As it turns out, all of my early impressions and assumptions about congenital heart disease were wrong. First, these defects are not the esoteric rarities I had initially imagined: taken together, they are the most common birth defects in humans. Second, the care of these patients has become the primary focus of my practice in the new field of Adult Congenital Cardiology. Just this week, I did four inpatient consults on patients with complex congenital defects and saw an additional seventeen congenital patients in clinic, six of them new referrals! The field of congenital heart disease has seen a dramatic epidemiologic shift in the last twenty years. Breakthroughs in surgical technique, developments in interventional therapy, and advances in medical care over the last few decades have transformed congenital heart disease from a problem of infancy and childhood to a disease of adulthood. As a result of these advances, most patients born with a congenital heart defect that once meant certain death in childhood can now expect to reach adulthood and to live relatively normal lives. As of 2006, adults with congenital heart disease outnumbered children with these defects in the United States.1 A population-based study in Canada in 2014 revealed even more dramatic findings: fully two-thirds of all congenital heart patients identified were adults.2 With these facts in hand, it is clear that we need to revise our concepts of congenital heart defects and prepare to take care of this growing population. This preparation will entail multiple challenges. First, physicians taking care of these patients will need to develop a more sophisticated understanding of the defects themselves and of the details of the post-palliation anatomy and physiology. Second, we will need to be aware of the potential impact of acquired conditions such as hypertension, diabetes, atherosclerotic cardiovascular disease, obesity, smoking-related lung disease, and pregnancy on the unique physiology of these patients. This challenge requires significant further research, aided by a funding initiative at the American Heart Association to support basic and clinical investigation related to congenital heart defects. Finally, systems of care and specialty programs will need to be created to provide coordinated services to these patients. The medical community is rising to these challenges. In 2012, in recognition of the changing demographics of the congenital heart disease population, the American Board of Medical Specialties granted official recognition to Adult Congenital Heart Disease (ACHD) as an independent specialty. The ACGME followed suit, and under the guidance of working groups from the American College of Cardiology and the American Heart Association, announced the creation of an ACHD committee and defined criteria for accreditation WWW.SFMS.ORG
of advanced fellowships in ACHD. In 2015, the American Board of Internal Medicine administered the first sitting of the advanced certification examination in ACHD. Finally, the Adult Congenital Heart Association, the leading U.S. organization supporting adult patients with congenital heart defects, has published criteria for accreditation of specialty referral programs in ACHD. Together, these initiatives have created a roadmap for the advanced training of physicians in ACHD and the building of centers of excellence designed to provide comprehensive care to this unique population of patients. The Bay Area is home to a long tradition of excellence in congenital heart care. The UCSF ACHD program is one of the oldest and largest ACHD programs on the west coast. In light of the recent changes in field of ACHD care, we have reorganized and developed our program to meet modern clinical demands. Today, the program is composed of four ACHD cardiologists, three ACHD interventionalists, four ACHD electrophysiologists, three congenital cardiac surgeons, a medical geneticist and a genetic counselor. In addition, we operate a joint program with high-risk obstetrics/perinatology and a joint clinic with pediatric hepatology focusing on the care of adults with single ventricle physiology. Our educational mission has expanded as well. We offer a two-year advanced fellowship in ACHD open to physicians who have completed clinical training in either adult or pediatric cardiology. We have ongoing collaborations with the ACHD programs at Kaiser, CPMC, and Stanford, and together, we are poised to make the Bay Area a national leader in ACHD care, research, and clinical training. The population of patients with congenital heart disease is very different today from what it was twenty years ago. Once confined to pediatric practices, most of these patients are now adults, and many are seeking care in adult practices. It is therefore incumbent upon internists and adult specialists to be aware of them. The ACC/AHA guidelines suggest that all of these patients be seen at least once in an ACHD center.3 For the care of the more complex ACHD patients, primary care physicians should partner with their regional ACHD center to coordinate ongoing care. In the modern era, the great majority of ACHD patients should expect to be able to live complete and normal lives, and together as practitioners, our goal should be to ensure that this becomes our reality. Ian Harris, MD, is a cardiologist specializing in Adult Congenital Cardiology, the management of heart disease in pregnancy, and genetic cardiovascular diseases. He directs the Adult Congenital Cardiology Program and is the Cardiology consultant to the Cardiovascular Genetics/Marfan Syndrome, lysosomal storage diseases, and Ras/MAPK pathway clinics. Dr. Harris joined the UCSF cardiology team in 2007. Â
1. Huehnergarth, KV et al. Heart 94 (2008): 1663-1669. 2. Marelli AJ, et al. Circulation 130 (2014): 749-756. 3. Warnes C, et al. Circulation 118 (2008): e714-e833.
FEBRUARY/MARCH 2016 SAN FRANCISCO MEDICINE
Heart Matters: Advances in Cardiology
HYPERTENSION TREATMENT Are Guidelines Worth the Trouble? Gordon Fung, MD, PhD On February 5, 2014, the report of the Joint National Commission 8 (JNC 8) on the management of hypertension
(HTN) was published in JAMA.1 This was significantly delayed from the JNC 7 and was nicknamed “JNC late”. The ten-year gap belies the significant changes in process of development of the report. Immediately after the report of nine recommendations, there were multiple editorials commenting on every aspect of the report from the difference in process, the focus on specific questions, the use of limited data on only randomized clinical trials, the absence of the National Heart, Lung, and Blood Institute (NHLBI) as one of the sponsoring agencies, and the recommendations themselves. Also, shortly afterward, the American College of Cardiology, in collaboration with the American Heart Association and the American Society of Hypertension, published their own recommendations in March 2015, “Treatment of Hypertension in Patients with Coronary Artery Disease”.2 These recommendations were listed as an update to the JNC 8 but were actually clarifications of how to manage elevated blood pressure (BP) in patients with Coronary Artery Disease (CAD) that was not specifically mentioned in the original report.
The JNC 8 made nine specific recommendations:
1. For patients < 60 yo, start treating HTN for diastolic blood pressure (DBP) > 90 mmHg with a goal < 90 mmHg.
2. For patients < 60 yo, start treating HTN for systolic blood pressure (SBP) > 140 mmHg with goal < 140 mmHg.
3. In adults < 60 yo with hypertension, there are no random-
ized controlled trials (RCTs) of good or fair quality to determine whether initiating treatment with antihypertensive medication to lower BP at any systolic BP threshold improves cardiovascular outcomes, cerebrovascular outcomes, or mortality. The major benefits of treatment of morbidity in hypertension was from treating diastolic hypertension with DBP averaging 90-114 mmHg in death, stroke, coronary events, fatal coronary events, CHF and renal damage.
4. In patients with Chronic Kidney Disease (CKD) or Diabetes Mellitus (DM), start treating BP > 140/90 with goal < 140/90 mmHg.
5. There was no benefit to treating DM patients with HTN to SBP < 120 mmHg.
6. For non-black population, recommend thiazide-type diuretic, Calcium Channel Blocker (CCB), angiotensin-converting enzyme (ACE)-I, and Angiotensin Receptor Blocker (ACB). 20
7. For black population, recommend begin with thiazide-type diuretic or CCB.
8. For CKD patients, recommend ACE-I /or ARB.
9. For all patients, if BP goal is not reached within a month, in-
crease the dose or add a drug from one of the classes (Thiazidetype diuretic, CCB, ACE-I, or ARB); Do not combine ACE-I with ARB; If goal BP still not reached, use drugs from other classes; Referral to a specialist may be indicated. In one sense the JNC 8 report was a significantly different report than its predecessors. In this committee, rather than having the guidelines reviewed and approved by the NHLBI and 39 other professional societies, the committee was composed of expert reviewers without official sponsorship by any organization. The committee restricted its focus on answering three specific questions: 1. Does starting drugs at specific BP thresholds improve outcomes? 2. Does titrating drugs to a specific BP goal improve outcome? and 3. Do various BP drugs or drug classes differ in benefits and harms on specific outcome? They also did not address other issues of HTN like diagnosis, measuring BP, resistant HTN, secondary HTN, or compliance. The JNC 8 also graded the strength of their recommendations and reported that only two were grade A (Strong Recommendation – high certainty that benefit is substantial); two were B (Moderate recommendation—moderate certainty benefit is moderate to substantial or there is high certainty that benefit is moderate); one was C (Weak Recommendation—moderate certainly that there is a small benefit); and four were E (Expert opinion). With these differences, the JNC 8 was not considered to be the source document on the latest summary of diagnosis and treatment of hypertension with a broad scan of the field of hypertension. As there was no discussion on the other forms of hypertension—such as white coat hypertension, masked hypertension, nocturnal hypertension, or secondary or refractory hypertension—the clinician is forced to seek other resources for specific guidelines for special patient populations. As a result, the compliance with these guidelines is probably less than desired. I think one of the best recommendations is the timeline of medication titration to reevaluate any intervention in one month. This will help to minimize compliance issues, add to the urgency of the controlling BP with monthly visits until controlled, and hopefully decrease clinical inertia. The added recommendation of seeking consultation from a hypertensive specialist also adds resources to already overwhelmed primary care physicians to manage complex or difficult to control hypertensive patients.
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SAN FRANCISCO MEDICINE FEBRUARY/MARCH 2016 WWW.SFMS.ORG
Heart Matters: Advances in Cardiology
THE WIDOWMAKER A Movie Review Michel Accad, MD An award-winning documentary entitled The Widowmaker was released on Netflix a few months ago. It shouldn’t leave viewers indifferent, and doctors in particular are likely to be thoroughly captivated. Cardiologists can identify the title as the nickname commonly given to a threatening plaque near the origin of the left anterior descending artery, the major of the coronary arteries of the heart. A clot forming at that site is frequently fatal. Since middle-aged men are more prone to heart attacks than middleaged women, such a clot often leaves behind a widow and fatherless children, hence the name for the plaque. Cardiologists who watch this movie will also recognize some familiar figures: Drs. Steve Nissen, Matthew Budoff, Bruce Brundage, Martin Leon, Arthur Agaston, Shamin Sharma, Joseph Loscalzo, Julio Palmaz, Douglas Boyd, Harvey Hecht, and many other high profile clinicians, innovators, and academics are featured in a suspenseful tale of heroes and villains. The common thread? The history of the non-contrast cardiac CT scan, the only non-invasive test capable of reliably detecting coronary calcium, and therefore plaque, in a matter of a few minutes and at a reasonably affordable cost. The movie shows how political shenanigans and power-plays have delayed—and perhaps derailed—the wider adoption of the scan as a clinical tool otherwise well suited for the prevention of coronary heart disease . . . and of widows. The documentary takes the viewer from the San Francisco Bay Area, where the scan was invented, to Cleveland, Houston, Miami, New York City, and Boston, retracing the ups and downs in the development of this technology, and showing how it found itself pitted in a battle of influence over who controls medical opinion and who can sway the behavior of practicing physicians and patients. Interviews of famous doctors are intertwined with poignant stories of ordinary folks (mostly wives, but also some husbands), celebrities, astronauts, and politicians, who relate their dreadful experience with heart disease and sudden coronary death. The youngest victim remembered in the movie was thirty-five years old and died suddenly of unsuspected multivessel coronary artery disease. While clearly building the case for the heart scan, the movie gives all key figures a fair chance to defend their position. There are juicy quips and spats. Steve Nissen, former president of the American College of Cardiology, gives a memorable one-liner. Nissen, who opposed the heart scan, confidently tells the interviewer “I don’t like medical cults,” and proceeds to crack his knuckles, seemingly doing his best to impersonate Austin Powers’ Dr. Evil. We also hear Joe Loscalzo, editor-in-chief of the prestigious WWW.SFMS.ORG
cardiology journal Circulation, waxing poetic about how an elite medical journal “creates a path to enlightenment,” only to admit moments later that, in regards to the heart scan, he took the unilateral decision to block the release of an American Heart Association document endorsing its use. His decision seemed to be based on a petty squabble over publishing rights and authority. The movie pits the “Calcium Club,” early adopters of the heart scan, against the “Stent Cowboys,” interventional cardiologists who have benefited from the financial advantage that acute care holds against preventive care. This antagonism makes for a great script, although the storyline gets over-simplistic at times. The personal tragedies told by victims or by surviving relatives are also very well delivered, always touching, and at times funny. Radio and television celebrity Larry King relates his brush with cardiac death in his usual colorful manner, but many of the ordinary folks also give powerful testimonies. I was deeply moved on several occasions. The movie instructively reports how NASA came to its own decision on how to use the technology for the sake of its pilots and the outer space program. The film also relates the successful efforts by the Texas legislature to compel statewide insurance reimbursement for the heart scan (a misguided move, in my opinion). There is a surprising revelation about why insurance companies have refused to pay for heart scans, despite their compelling value in preventing costly cardiac complications. The documentary is engrossing. The viewer gets a behindthe-scenes look at how political the science of clinical care can be. Although the attitude or behavior of some individual characters in the movie seems objectionable, the real villain in the story is the health care system itself, with its increasingly centralized process of decision-making that precisely enables the kind of shortsighted conduct depicted in the documentary. The story behind the movie is also worth knowing. One might be tempted to think that such an expensive production was funded by CT scan manufacturers, but the movie was actually conceived through the philanthropic efforts of a patient, David Bobbett, a highly successful Irish entrepreneur who owns a multinational manufacturing enterprise. At age fifty, Bobbett underwent a heart scan and was stunned to discover that he had “the arteries of an eighty-year-old man.” His entrepreneurial mind got him to wonder why this test was not more widely available, when it was so obviously valuable to him. Bobbett inquired, discovered the unsavory reality, and decided to do something about it. He founded Irish Heart Disease Awareness, a grassroots organization promoting cardiac screening, and funded the production of The Widowmaker, for which he hired Patrick Forbes, an award-winning filmmaker.
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FEBRUARY/MARCH 2016 SAN FRANCISCO MEDICINE
Concussions Continued from the previous page . . . At the end of the movie, Matthew Budoff, a prominent member of the Calcium Club, says that the saga of the heart scan illustrates the old saying about the three stages of truth: first, it is ignored, next it is ridiculed, and finally it is accepted as selfevident. Let’s hope that the foolishness of mindlessly entrusting patient decisions to clinical guidelines designed by unaccountable technocrats will also be accepted as self-evident. Michel Acaad, MD, is a cardiologist in San Francisco. He is an SFMS member and serves on the editorial board for San Francisco Medicine.
Hypertension Treatment Continued from page 20 . . . Another twist in the management of hypertension came in November 2015 with the presentation of the SPRINT trial at the American Heart Association – Late Breaking Trials and joint publishing in the New England Journal of Medicine.3 This study was funded by the NHLBI and terminated by the Data Safety and Monitoring Board earlier than scheduled due to the significant benefit derived from the intensive treatment of BP with a target < 120 mmHg in non-diabetic but high risk for Cardiovascular Disease (CVD) patients > 50 years of age. There were statistically significant differences noted in the composite endpoints of death, CVD events, stroke and heart failure. Should that be our new target BP? So where do we go from here? I believe that the JNC will need to review its process as well as collaborators to come up with a set of recommendations that has broad base of support. There needs to be significant transparency in the process and data. There needs to be inclusion of more data and updates in changes of diagnosis, or measuring of BP and the utility of home based devices. There needs to be a broader discussion on pertinent issues in hypertension like secondary hypertension, obstructive sleep apnea and hypertension, and coronary heart disease and hypertension. It remains to be seen if there will be a JNC 9 in the future.
Gordon Fung, MD, PHD, is Editor of San Francisco Medicine and past president of the SFMS. Dr. Fung is also a clinical professor of medicine in the Division of Cardiology, a Certified Specialist in Clinical Hypertension, and a Fellow of the American Society of Hypertension, the ACC, and the AHA.
References 1. James, PA et al. “2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults”, JAMA 311 (5) (2014): 507-20. 2. Rosendorff, C et al. “Treatment of Hypertension in Patients with Coronary Artery Disease”, HTN 65 (2015): 001-036. 3. The SPRINT Research Group. “A Randomized Trial of Intensive versus Standard Blood Pressure Control”, NEJM 373 (2015):2103-2116. 22
Transformative Discussions Shaping the Next Decade in Healthcare RegisteR tODAY fOR sAvings!
iHT2 HEALTH IT SUMMIT
SAN FrANcISco, cA AprIL 5-6, 2016
THE pArk cENTrAL SAN FrANcISco
Join your colleagues for a transnational discussion on health IT Through collaborative efforts, the Institute provides programs that drive innovation, educate, and provide a critical understanding of how technology applications, solutions, and devices can improve the quality, safety, and efficiency of healthcare. Participating Industry Leaders Include:
Sophia Chang, MD, MPH, Vice President of Programs, California Healthcare Foundation
Mark Hagland, Editor-in-Chief Healthcare Informatics
Ida Sim, MD, PhD, Professor of Medicine, University of California, San Francisco
The San Francisco Health IT Summit’s Numerous Panel Discussions Include... • A Vision for the Future: How Technology Supports a Complete Health System Overhaul • Interoperability: How Close are We? • Using Predictive Analytics to Understand Patient Experience
NEW THIS YEAR! T 2 Talks Ida Sim, MD, PhD, Professor of Medicine, University of California, San Francisco T2 Talks feature engaging, passionate speakers whose talks expose new ideas in healthcare that are supported by concrete evidence and are relevant to current and future industry trends. Presentations will explore novel and counterintuitive approaches to solving the many complex problems facing our health system.
View Complete Agenda: www.iHealthTran.com/SanFran
SAN FRANCISCO MEDICINE FEBRUARY/MARCH 2016 WWW.SFMS.ORG
Heart Matters: Advances in Cardiology
VALVULAR HEART DISEASE Percutaneous Approaches Mark Villalon, MD, and Vaikom S. Mahadevan, MD Percutaneous treatments for valvular heart disease as alternatives to cardiothoracic surgeries began more than thirty years ago when the first pulmonic balloon valvulo-
plasty was reported in 1982. While percutaneous balloon valvuloplasty is still performed today in the management of other valvular processes, newer catheter-based techniques have been developed to manage valvular diseases that were once limited to the arrested heart with full surgical exposure of the valvular anatomy for repair and replacement. The subsequent development of the vascular metal stent revolutionized cardiovascular medicine and developers soon realized the potential to utilize the stent as a percutaneous mode of delivery of a new valve. In 1992, the first report of an artificial aortic valve implanted into a closed-chest pig by a percutaneous catheter technique was published. In 2002, after subsequent reports of successful percutaneous pulmonic valve implantations, Alain Cribier, MD and colleagues from France described their experience with implantation of a stent-mounted bovine pericardium prosthetic heart valve in the aortic position in an inoperable patient with critical aortic stenosis. The field of interventional cardiology and percutaneous approaches to the management of valvular heart disease has since witnessed a rapid growth. The following is a brief overview of such percutaneous treatment options.
Aortic Valve Disease
Until recently, the mainstay of treatment of symptomatic severe aortic stenosis (AS) has been surgical aortic valve replacement (SAVR). While SAVR improves symptoms and alters life expectancy in select patients, it is not without risk, especially in an increasingly elderly population with multiple co-morbidities. Transcatheter aortic valve replacement (TAVR) has been developed for the management of patients with severe symptomatic AS with unacceptably high surgical risk or in patients with whom SAVR is deemed inappropriate given other technical issues such as a porcelain aorta. Current guidelines for valvular heart disease recommend aortic valve replacement (AVR) in symptomatic patients with severe AS, defined by echocardiography as a mean trans aortic gradient of > 40 mmHg and aortic valve area of less than 1.0 cm^2. TAVR is indicated in patients with severe native AS or treatment of a failing bioprosthetic aortic valve (using the “valve-in-valve” strategy). At present, TAVR is not indicated in predominant native aortic valve regurgitation. The decision between SAVR or TAVR is made by an interdisciplinary “heart team” that consists of various health professionals including, but not limited to, interventional cardiologists, cardiac surgeons, and imaging specialists who weigh the risks and benefits of the procedure. This “heart team” must specifically decide if the patient is at high risk, deemed to be inoperable for open surgery based on a Society of Thoracic Surgeons (STS) operative risk score > 8%, or judged by the “heart team” to be at a WWW.SFMS.ORG
greater than 15% risk of post-operative mortality at thirty days. There are two approved types of TAVR valves currently available in the USA: The Edwards Lifesciences balloon-expandable valve (BEV) and the Medtronic self-expandable valve (SEV). The Edwards valve is made of bovine pericardium and mounted in a short cylindrical stent. The Medtronic valve is made of porcine pericardium and mounted in a taller nitinol stent. The evidence favoring TAVR in the high risk and inoperable groups of severe AS is significant. For patients with inoperable severe symptomatic AS, the benefits of TAVR over standard therapy (which includes BAV) are significant and evidenced by the Placement of Aortic Transcatheter Valves (PARTNER) multicenter trial (cohort B). Investigators in this trial randomly assigned 358 patients with severe inoperable AS to either balloon-expandable TAVR or standard therapy and demonstrated a decrease in mortality and improvement in functional status among the survivors. For patients with severe symptomatic AS deemed to be at high surgical risk, randomized trials have demonstrated similar mortality rates following balloon-expandable TAVR versus SAVR, and mortality rates were lower following self-expanding TAVR versus SAVR. Recent trials have shown benefit in intermediate risk patients. The S3i registry evaluated over 1,000 patients deemed to be intermediate-risk (average STS score of 5%) who received a Sapien 3 valve (Edwards Lifesciences). The thirty-day outcomes were favorable and revealed an all-cause mortality of 1.1%, all-stroke rate of 2.6%, pacemaker rate of 10.1%, and the rate of no/mild aortic insufficiency of 96.3%. The Nordic Aortic Valve Intervention (NOTION) trial randomized 280 severe AS patients of low-intermediate surgical risk to TAVR using the self-expanding bioprosthesis CoreValve (Medtronic) versus SAVR. The primary outcome of stroke, myocardial infarction, and all-cause mortality at one year was 13.1% for TAVR and 16.3% for SAVR (P = 0.43). TAVR is mostly performed in a hybrid operating room, which is equipped with high-resolution fluoroscopy and hemodynamic monitoring in addition to the infrastructure of an operating room complete with the ability to perform cardiopulmonary bypass and mechanical ventilation. The default mode of delivery of either of the above two valves is via transfemoral access (nearly 90% in a recent series were suitable for this approach), which includes a primary femoral arteriotomy for which vascular hemostasis can later be achieved with the percutaneous deployment of a suture-mediated closure device or vascular surgical cutdown with repair. If the iliofemoral anatomy is unsatisfactory for the delivery of the valves, then transaortic and transapical access routes are employed. The procedural success rates across large multicenter registries and randomized controlled trials ranges from 77.5%-98.4%. The short- and medium-term mortality is significantly reduced by TAVR among patients with severe AS. The major causes of morbidity follow-
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FEBRUARY/MARCH 2016 SAN FRANCISCO MEDICINE
Valvular Heart Disease Continued from the previous page . . . ing TAVR include paravalvular regurgitation, stroke, conduction disturbances, and vascular complications. The major causes of morbidity following TAVR include paravalvular regurgitation, stroke, vascular complications, and conduction disturbances. In a recent meta-analysis of the predictors of TAVR-related conduction disturbances resulting in pacemaker dependency in over 11,000 TAVR patients, 17% of all patients required pacemaker implantation after TAVR. While the rate of pacemaker insertion ranged from 2% to 51% in individual studies (mean of 28% for Medtronic CoreValve and 6% for Edwards SAPIEN valve), the most significant predictors of pacemaker insertion after TAVR included male sex, baseline conduction disturbances (e.g. 1st degree AV block, left anterior hemiblock, right bundle branch block), and intraprocedural AV block. While TAVR has witnessed tremendous growth in the last several years, its technology is constantly evolving to minimize accessrelated complications, paravalvular regurgitation, and shrinking the size of the delivery system. The Food and Drug Administration (FDA) has recently granted approval for an investigational device exemption (IDE) trial of TAVR in low risk patients with severe aortic stenosis.
Mitral Valve Disease
Transcatheter mitral valve repair (TMVR) is indicated for patients with severe, symptomatic primary (degenerative) mitral regurgitation (MR) with favorable anatomy for the procedure and who are of prohibitive surgical risk. Although there are a number of products for management of mitral valve disease in development, the MitraClip, which is an edge-to-edge leaflet repair device, is the only one that is FDA-approved for TMVR. The device consists of a metallic clip with two foldable arms that are designed to grasp the mitral leaflets. Patient suitability is pre-determined with echocardiography. The primary vascular access site used is a femoral vein, through which vascular access is gained into the right atrium, and from where access to the mitral valvular apparatus is achieved with a trans-septal puncture. The only multicenter randomized controlled trial that divided patients with severe symptomatic MR to TMVR versus surgical mitral valve repair was known as EVEREST II. This trial demonstrated non-inferiority but superior safety of this percutaneous TMVR technique when compared with surgery. Given the elevated risk for redo surgery for degenerated mitral bioprostheses or failing surgical mitral rings, an alternative approach is one where a balloon-expandable valve is percutaneously (via trans-septal puncture or trans-apical access) inserted into the failing bioprosthetic valve or ring, known as “valve-in-valve.” Initial experience with such a technique has shown its feasibility. The Edwards TAVR valve has been used “off-label” as valve-in-valve therapy in the mitral and also in the native mitral position in cases with significant annular calcium. There are various mitral valve technologies in progress including the Tiara, Tendyne, Twelve, CardiAQ and various other systems. Of these, the Tiara is currently in early clinical trial in the US. The vast majority of such devices are delivered using a transapical approach.
Tricuspid Valve Disease
Percutaneous management options for tricuspid valvular disease, such as tricuspid regurgitation (TR), are few and the data 24
sparse. Off-label insertion of TAVR devices for management of severe TR or failed bioprosthetic tricuspid valves have been previously described. These procedures have entailed the delivery of a balloonexpandable valve, accessed via the inferior vena cava, to the tricuspid position. The Mitralign™ system, which was originally developed for use in the mitral position, is undergoing a clinical trial in the US for treatment of tricuspid regurgitation using a percutaneously delived suture to the tricuspid annulus. There is also an FDA IDE trial planned in the near future for treatment of tricuspid regurgitation in patients who are not suitable for surgery using an Edwards TAVR valve implantated in the inferior vena cava.
Pulmonary Valve Disease
Percutaneous procedures for management of diseases of the pulmonary valve are usually limited to adult patients born with complex congenital heart disease. The most common examples of such patients include those adults born with anomalies of the pulmonary valve or right ventricular outflow tract (RVOT), such as tetralogy of Fallot, truncus arteriosus, or pulmonary atresia. Early surgical strategies for RVOT reconstruction (e.g. within the first few months of life) is lifesaving and includes insertion of bioprosthetic valves, valve conduits, and patch augmentation. There is great variability of the long-term durability of such surgeries and these patients not uncommonly develop progressive dysfunction of the RVOT. These patients therefore require repeat interventions and recurrent surgeries are associated with significant morbidity. As a minimally invasive alternative to repeat surgery, percutaneous pulmonary valve implantation (PPVI) is an effective therapeutic option for selected patients with stenosis or regurgitation of the right ventricular outflow tract (RVOT) conduit (or native RVOT). The only commercially available and FDA approved valve for PPVI is the Medtronic Melody Transcatheter Pulmonary Valve. The Melody Valve consists of a 34mm-long Cheatham platinum stent into which a Medtronic Contegra bovine jugular venous valve is hand-sewn. There are three sizes (18, 20, and 22mm) that utilize the Ensemble delivery system. In addition, the Edwards SAPIEN Pulmonic Transcatheter Heart Valve has been used in patients with a large annulus as “off-label” use. In closing, techniques in the percutaneous management of heart disease are quickly accelerating as the technology to deliver devices through smaller and smaller percutaneous access sites becomes a reality. Further major technologies in this arena are likely to develop over the next decade, and transcatheter therapies may well become the treatment of choice in select valvular conditions. Vaikom Mahadevan, MD, joined UCSF in July 2014 from the Central Manchester University Hospitals, UK, where he was on staff since 2005 as the Director of the ACHD program and Director of the transcatheter valves and ACHD Interventional program. He is the Director of Structural and Adult Congenital Intervention and the William W. Parmley Endowed Chair in Cardiology. Dr. Mahadevan has extensive experience in performing adult congenital and transcatheter valvar interventions. Mark Villalon, MD, is an interventional cardiology fellow at UCSF. His clinical interests are in interventional cardiology, including percutaneous coronary intervention and structural heart disease. He is a member of Alpha Omega Alpha Honor Medical Society and is board certified in Internal Medicine and Cardiology.
SAN FRANCISCO MEDICINE FEBRUARY/MARCH 2016 WWW.SFMS.ORG
Heart Matters: Advances in Cardiology
CARDIOLOGY FELLOWSHIP A Love Story Vishal Patel, MD Kimberly and I met over lunch during the first day of orientation for our Internal Medicine residency at UCSF. We had done little more than remark on the fact that
we were both vegetarian (“you got the mushroom sandwich too!”) when the Program Director silenced the room for some introductory remarks. Shortly thereafter, we studiously avoided eye contact with each other as he, apparently as some manner of ice breaker, had all of the single interns stand up and suggested that, if history taught him anything, some of us would end up married to each other. In spite of that awkward beginning (or perhaps as a result of the inexorable power of history to repeat itself), we moved to Dallas together for a Cardiology fellowship in 2010, and married during my interventional year (and her post-doc) in 2013. Training with your significant other was—as one might expect—something of a mixed bag. At least in our experience, there were certainly challenges. Some of the hurdles were those likely shared by all two physician couples—for instance conflicting call schedules limiting quality time, sapped energy leading to short tempers, and the intermittent fear that our world was contracting to the point where it revolved solely around the hospital. There were other challenges that were tied to the fact that we shared a specialty—heated disputes about the best management strategy, petty competition for the fastest vascular access in the cath lab, and the occasional disgruntled accusations of one-upmanship if the other answered too quickly during report or morning teaching rounds. And there were bigger problems as well: when we met we both thought we would be happiest in a procedural subspecialty, but could there possibly be room for two interventionalists in one relationship? In the end, for us, the benefits of working together were far more substantial. Starting fellowship was frightening—in many ways, more so than residency. There was more responsibility coupled with greater independence—exhilarating, yes, but also terrifying. So it was an incredible relief to have a second set of eyes on electrocardiograms (EKGs) with questionable ST elevations, when the decision whether to activate the cath lab (and thus pull your attending and the cath lab staff out of bed) rested squarely on our shoulders. There was a second set of ears you could bend to talk through challenging cases—did I miss anything in my differential? Do you think I need to do a transesophageal echo to rule out dissection? And there was a particularly sympathetic eye roll when you recounted how that attending took the wire from you—again!—when you were just starting to make progress on the case. In the end, medical training is a grueling affair, and having a partner who could fully commiserate was incredibly therapeutic. Outside of the clinical setting, collaborating on research with a partner who values your success WWW.SFMS.ORG
as much as her own was an incredibly productive strategy for us. We would brainstorm research ideas together—for instance, on a road trip to the Napa Valley we came up with the idea of performing a meta-analysis evaluating the safety of same-day discharge after percutaneous coronary intervention. We would often alternate as the lead author, making sure to include the other whenever possible in the publication process. Life after fellowship has presented some new and different challenges. Negotiating the fellowship match process was harrowing, but paled in comparison to the difficulties we faced in finding cardiology positions that suited both of us in the Bay Area. We decided that our family, at least, was better off with only one interventionalist, but worried nonetheless about navigating the call schedules of two cardiologists with a growing family. Balancing the demands of being available for patients and colleagues with being available to each other and our child continues to be a work in progress. If our personal history has taught us anything, though, it’s that the same attributes of our relationship that got us through residency and fellowship—shared passions, effective communication, mutual respect, and recognition of each others’ strengths and weaknesses—will continue to provide the foundation for success in our family and careers. Vishal Patel, MD, is an interventional cardiologist practicing in Santa Rosa with Northern California Medical Associates. Kimberly Patel, MD, is a cardiologist practicing in Santa Rosa with Northern California Medical Associates.
Exciting News About Blood Centers of the Pacific Blood Centers of the Pacific will join with BloodSource, a leading non-profit community blood provider based in Sacramento, to serve northern California and the Central Valley. The merger is expected to take place early in 2016. At the same time, the newly combined organization will be part of Blood Systems (based in Scottsdale, Arizona), one of the nation’s oldest and largest nonprofit transfusion medicine organizations. Blood Centers of the Pacific is a long-time affiliate of both BloodSource and Blood Systems. What will change? For dedicated blood donors, nothing will change. Blood Centers of the Pacific will continue to operate with the same name, same friendly staff, same sign-up process, same snacks and Hero Rewards. For hospitals and patients in this community, Blood Centers of the Pacific’s relationship with BloodSource will provide enhanced capabilities for advancing transfusion medicine while also maintaining efficiencies. For more information, visit https://www.bloodheroes. com. —Nora Hirschler, MD, BCP President & CEO FEBRUARY/MARCH 2016 SAN FRANCISCO MEDICINE
Clearing Some Smoke? Matthew L. Springer, PhD The San Francisco Medical Society has been involved in efforts by the California Medical Association to determine how best to regulate non-medicinal mari-
juana if voters pass the “Control, Regulate and Tax Adult Use of Marijuana Act.” Most of the dialogue surrounding this and similar measures elsewhere has focused on the psychoactive and pain management effects of cannabis, and on the political and economic complexities of regulation. A point that risks getting lost in the dialogue is that smoked marijuana is not only a source of drugs, it is a source of smoke. The concerns surrounding inhalation of smoke from burning marijuana should be familiar to the public health community, but tend to get upstaged by the drug considerations. Even exposure of bystanders to secondhand smoke from marijuana has been viewed mostly as an issue of involuntary exposure to THC. The occasional reference to any potential adverse health effects of the smoke itself, such as those resulting from secondhand tobacco smoke exposure, are usually framed with qualifiers (e.g., “there’s no evidence that secondhand marijuana smoke is harmful”). However, marijuana smoke contains almost all of the thousands of chemicals found in tobacco smoke. It would be surprising if inhalation of marijuana smoke did not cause at least some of the problems associated with inhalation of biomass combustion products in general. We reported at the 2014 American Heart Association Scientific Sessions that a single, brief exposure to smoke from the burning tip of marijuana cigarettes impairs vascular endothelial function (arterial flow-mediated dilation) in rats.1 This adverse cardiovascular effect has also been observed after comparable exposures to secondhand tobacco smoke in humans and rats, but the marijuana smoke impaired vascular function to a substantially greater extent than tobacco smoke, and the effect lasted for a considerably longer time. This is especially significant given that the majority of deaths attributed to secondhand tobacco smoke are from cardiovascular complications. As medicinal and recreational marijuana use become more prevalent in society, we need to make it clear to the public and policy makers that “smoke-free” policies should include smoked marijuana. Matthew L. Springer, PhD, is a Professor of Medicine in the UCSF Division of Cardiology and the UCSF Cardiovascular Research Institute, and is faculty in the UCSF Center for Tobacco Control Research and Education.
Reference 1. (Wang et al. Circulation 130 (2014): A19538). 26
Helping Primary Care Providers Prevent the Most Common Chronic Condition of Childhood Susan Fisher-Owens, MD, MPH; Maryna Spiegel; Cecilia Gonzalez, MD; Irene Hilton, DDS, MPH; Abby Wolf, RN; Margaret Fisher, RDHAP; Lisa Chung, DDS, MPH
Most providers are not aware that dental disease (especially caries, or dental cavities) is the most common chronic disease of childhood, and the greatest unmet health need for children, with significant racial/ethnic and socioeconomic disparities. Many may also be surprised to learn about the severe impact children’s oral health problems have on adult life, including lower educational attainment and employability, greater likelihood of cardiovascular and other disease, and exacerbation of diabetes. San Francisco’s population is affected by this epidemic, but a dedicated group of health and children’s professionals and advocates have been working together to support the San Francisco Children’s Oral Health (SF COH) Initiative since Fall 2013. (The Plan will be discussed in more detail in the April edition of SFM.) While there has been improvement in SF’s children’s oral health status over the past ten years (i.e. decreased rates of untreated dental problems, as well as caries experience), the rates are still too high: in 2013, >28% of kindergarteners have untreated dental caries. Furthermore, the gap between higher caries rates in children of color children versus Caucasian children has persisted. The great news is that dental caries are highly preventable. Integration of basic oral health screenings, fluoride varnish application (a quick and easy procedure), oral health education, and referral to a dental home into all well-child visits for low income children can make a sizable impact on children’s dental health and the associated health disparities. These efforts are in line with guidelines set by the American Academy of Pediatrics, American Academy of Family Physicians, and other professional bodies. This year, the United States Preventive Services Task Force (USPSTF) added to their recommendations that fluoride varnish should be applied to young children’s teeth in the primary care setting. San Francisco General Hospital and Kaiser Permanente, who have become leaders in the SF COH integration efforts, have already found ways to seamlessly integrate this cost-effective prevention into routine well-child care visits with minimal disruption to the families and clinics. The San Francisco Health Plan (SFHP) is also committed to improving children’s oral health and will soon announce plans to encourage in-network PCPs to offer fluoride varnish to eligible pediatric members. In summary, fluoride varnish and oral health education CAN and SHOULD be done in your practices! February is the 75th anniversary of Children’s Oral Health Month. Start talking to your families about their oral health and look forward to more information in the April edition of San Francisco Medicine! If interested in implementing fluoride varnish in your practice in the meantime, please contact CHDP Oral Health Consultant, Margaret Fisher, RDHAP, at 415-575-5719.
SAN FRANCISCO MEDICINE FEBRUARY/MARCH 2016 WWW.SFMS.ORG
DIETARY SUGARS INTAKE AND CARDIOVASCULAR HEALTH
A Scientific Statement From the American Heart Association High intakes of dietary sugars in the setting of a worldwide pandemic of obesity and cardiovascular disease have heightened concerns about the adverse effects
of excessive consumption of sugars. In 2001 to 2004, the usual intake of added sugars for Americans was 22.2 teaspoons per day (355 calories per day). Between 1970 and 2005, the average annual availability of sugars/added sugars increased by 19%, which added 76 calories to Americans’ average daily energy intake. Soft drinks and other sugar-sweetened beverages are the primary source of added sugars in Americans’ diets. Excessive consumption of sugars has been linked with several metabolic abnormalities and adverse health conditions, as well as shortfalls of essential nutrients. Although trial data are limited, evidence from observational studies indicates that a
higher intake of soft drinks is associated with greater energy intake, higher body weight, and lower intake of essential nutrients. National survey data also indicate that excessive consumption of added sugars is contributing to overconsumption of discretionary calories by Americans. On the basis of the 2005 US Dietary Guidelines, intake of added sugars greatly exceeds discretionary calorie allowances, regardless of energy needs. In view of these considerations, the American Heart Association recommends reductions in the intake of added sugars. A prudent upper limit of intake is half of the discretionary calorie allowance, which for most American women is no more than 100 calories per day and for most American men is no more than 150 calories per day from added sugars. Source: (Circulation 120 (2009): 1011-1020).
PHYSICIAN-ASSISTED DEATH How Neutrality in California Was Attained: A Letter Submitted to JAMA John Maa MD, Steve Heilig MPH, Shannon Udovic Constant MD Thank you to the Editors of JAMA for featuring the January 19th issue on “Death, Dying, and End of Life,” and inviting a series of Viewpoints on the controversial topic of Physician-Assisted Death (PAD). Both Quill et al1, and Yang and Curlin2 make important points in support and opposition to PAD, but there is also a third organizational position to consider—that of “neutrality.” As leaders in the San Francisco Medical Society (SFMS), we wish to share some history from the debate in California, which has recently become the largest state in America to legalize PAD. For years, the California Medical Association’s (CMA) “oppose” position to PAD had been debated, but never modified. In 2015, prompted by the SFMS and survey evidence that physicians were of strongly divided opinion on this topic3,4, and that in states where PAD had been legalized, end-of-life care had actually improved5, the CMA Board of Directors began a discussion of a shift to a neutral position. At both an extended meeting of CMA leadership and in an online poll, it became clear that a plurality, if not a majority, of CMA physicians supported a legal PAD option. A small number of specialty organizations within the CMA did continue to oppose a move to a “support” position. Thus when the California “End of Life Option Act” was proposed, the CMA moved to neutrality and neither actively advocated for the Act’s passage nor for its defeat after securing numerous amendments to make the law protective of both patients and physicians. WWW.SFMS.ORG
We note that the Canadian Medical Association took a similar approach when courts there legalized PAD, and believe that understanding this position of neutrality may be helpful to physician organizations in other states that are considering opening a discussion into this important topic. Gathering further information in the upcoming years from the four states that have now legalized PAD may be of particular help to the American Medical Association as it contemplates whether to adopt a new public policy position in the future. John Maa, MD, is Secretary of the SFMS and part of the division of General and Trauma Surgery at Marin General Hospital. Steve Heilig, MPH, is Director of Public Health and Education at the SFMS. Shannon Udovic-Constant, MD, is past-president of the SFMS and is in the department of pediatrics at Kaiser Permanente San Francisco.
1. Quill TE, Back AL, Block SD. Responding to patients requesting physician-assisted death – physician involvement at the very end of life. JAMA 2016; 315(3): 245-246. 2. Yang YTCurlin FA. Why physicians should oppose assisted suicide. JAMA 2016; 315(3): 247-248. 3. NBC News. Most US doctors now support aid in dying: survey. Available at http:// www.nbcnews.com/health/health-news/most-u-s-doctors-now-support-aid-dyingsurvey-n269691. Accessed February 13, 2016. 4. Medscape Ethics Report 2014, Part 1: Life, Death, and Pain http://www.medscape.com/features/slideshow/public/ethics2014-part1#2 5. Steinbrook, R: Physician-Assisted Death—From Oregon to Washington State. N Engl J Med 2008; 359:2513-2515. http://www.nejm.org/doi/full/10.1056/NEJMp0809394
FEBRUARY/MARCH 2016 SAN FRANCISCO MEDICINE
Celebrating 148 Years of Physician Advocacy and J oCamaraderie in the
More than 200 physicians and influential stake-
S aholders n Fra c imedical sco M e d i c ajoined l S o in c ion e tthe y in nthe community
29,d 2016. a sSFMS w eAnnual g r aGala t e f festivities u l l y a conk January nowle ge
Held at the iconic Legion of Honor, the event marked h e syear u pasp the o r tonly o fphysician t h e s eassociation SFMS’ t148th that advocates d e d i cfora physicians t e d p aacross r t n eall r s specialties and their patients in San Francisco. Attendees were able to network with colleagues, meet SFMS leaders, and enjoy a private viewing of the Legion of Honor’s collections including the famed Rodin Gallery. A special jazz concert by the Madeline Eastman Jazztet was performed to celebrate the installation of Richard Podolin, MD, as the 2016 SFMS President. SFMS would like to thank our members, sponsors, and special guests Senator Mark Leno, Assemblymember David Chiu, Assemblymember Phil Ting, and Supervisor Scott Wiener for their support of the event and SFMS. All photos courtesy of the Legion of Honor of San Francisco and Ginger Tree Photography. All rights reserved.
Left: 2016 SFMS Officers—Man-Kit Leung, President-Elect; John Maa, Secretary; Richard Podolin, President; Kimberly Newell, Treasurer; Roger Eng, Immediate Past President.
Assemblymember David Chiu acknowledging SFMS and our members for strong advocacy on public health initiatives.
Senator Mark Leno presents Immediate Past President Roger Eng with a proclamation in recognition for leading SFMS’ efforts to ensure access to care, viability SILVER SPONSORS of our local health care system, Left: San Francisco Medicine Ediand safeguard the integrity of the tor Gordon Fung with Peggy Fung, practice C h i n e s e H o s p i t a l M e d i c a Eric l S tTabas, a f f and • Connie J o h Tabas. n Maa, M . D . of•medicine. Mercer
B28R O Z E S PMEDICINE O N SFEBRUARY/MARCH ORS SANN FRANCISCO 2016 WWW.SFMS.ORG
Hugh Vincent, Joan Watson, Steven Fugaro, and Jill Fugaro.
Ann Myers, John Umekubo, David Pichardo-Gomez.
UCSF residents Michael Lubrano and Arvind Nishtala.
Ingrid Lim, Lesley Aiken, Angela Wong.
Visit https://www.flickr.com/photos/sfmedicalsociety/sets for more Gala photos.
FEBRUARY/MARCH 2016 SAN FRANCISCO MEDICINE
Fifty-year members Lawrence Lurie (left) and Herbert Konkoff (right) with Sally Kaufmann.
Congratulations Fifty-Year Members! Herbert Konkoff, MD | Dr. Herbert J. Konkoff was born and raised in San Francisco, where he dreamed about growing up to be the city’s mayor or the radio announcer for the SF Seals baseball team. Instead, he completed medical school at UCSF and spent a year in surgery at Mt. Zion. He then joined the army and spent two years as a combat tank battalion surgeon. Upon his return to civilian life, he completed his residency at the old Stanford Hospital in San Francisco (rebuilt as Pacific Presbyterian Hospital) and began private practice in 1966. He is still practicing today. Even though San Francisco has changed drastically over the years, Dr. Konkoff still loves his hometown and his patients. Lawrence Lurie, MD |
Dr. Lawrence Lurie earned his medical degree from Tufts University School of Medicine before moving to California to complete an internship at Stanford University and a residency and fellowship in psychiatry at UCSF Langley Porter. He founded the District V Community Mental Health Center and served there for eight years before going into fulltime private practice in 1987, focusing his work primarily on the elderly. Dr. Lurie served on the SFMS Psychiatric Services and Medical Review and Advisory Committees for several decades, as well as in other leadership positions in organized medicine. With the support of SFMS, Dr. Lurie won the Dr. J. Elliott Royer Community Psychiatry Award in 2003. Dr. Lurie retired from practice in 2003 but continues to teach at UCSF as a Clinical Professor of Psychiatry.
Richard Podolin with fifty-year member Herbert Peterson (left) and also with fifty-year member Demetri Polites (right). Herbert Peterson, MD | Dr. Herbert Peterson completed medical school at Creighton University School of Medicine and completed post graduate work at the Mayo Clinic before serving two years as a Naval Flight Surgeon at Moffett Field near Morgan Hill. Dr. Peterson spent forty years dividing his time between private practice in psychiatry and teaching at UCSF Medical School. One of his fondest memories at UCSF is of conducting a special course in interviewing techniques where he provided first-year medical students their first opportunity to interact with patients. A talented musician, Dr. Peterson has kept busy since retirement, mostly playing the piano, as well as some bass and flute. Demetri Polites, MD | Dr. Demetri J. Polites completed medical school at Louisiana State University, New Orleans and residency training in psychiatry at the University of Virginia, before serving for two years at Tripler Army Hospital in Honolulu. He spent several years working in an outpatient psychiatric clinic at San Francisco General Hospital, and later coordinated residency training programs for residents at UCSF, Langley Porter, and Mt. Zion. Dr. Polites not only served on the clinical faculty at UCSF throughout his career, but also served on the SFMS Mental Health and Chronic Illness and Aging Committees. He was an early member of the Bay Area Physicians for Human Rights (BAPHR) —the forerunner of GLMA—and later served on their Board of Directors for four years. Dr. Polites loved his career and the fact that he was able to work with patients from all walks of life. He retired from practice in 1997.
Left: Shannon Udovic-Constant, Pratima Gupta, Dawn Ogawa. Center: UCSF first-year medical students. Right: Health Commissioner Edward Chow with Stephanie Wu and Todd May.
Join the San Francisco Medical Society as we gratefully acknowledge the support of these dedicated partners
SILVER SPONSORS Chinese Hospital Medical Staff • John Maa, M.D. • Mercer
BRONZE SPONSORS Golden Gate Urology • St. Luke’s Hospital Medical Staff
MEDICAL COMMUNITY NEWS Saint Francis Robert Harvey, MD, MBA
It’s not just award season in Hollywood but here at Dignity Health Saint Francis Memorial Hospital, too, where we are celebrating a few honors of our own. We recently received several accolades, including recognition from The Joint Commission, The Leapfrog Group, and Healthgrades. The Joint Commission, the leading accreditor of health care organizations, recognized Saint Francis Memorial Hospital as a 2014 Top Performer on Key Quality Measures® as part of its 2015 annual report “America’s Hospitals: Improving Quality and Safety.” The Top Performer program recognizes hospitals for improving performance on evidencebased interventions that increase the chances of healthy outcomes for patients with certain conditions. Specifically, we were recognized for attaining and sustaining excellence in accountability measure performance for Heart Failure, Pneumonia, Surgical Care, Venous Thromboembolism, and Immunization. With our dedicated caregivers committed to keeping patients safe, we were proud when industry watchdog The Leapfrog Group recently recognized Saint Francis Memorial Hospital for our dedication to patient safety. We received an “A” grade in the Fall 2015 Hospital Safety Score, which rates how well hospitals protect patients from preventable medical errors, injuries, and infections within the hospital. The Hospital Safety Score uses 28 measures of publicly available hospital safety data to produce a single A, B, C, D, or F score, representing a hospital’s overall capacity to keep patients safe from preventable harm. Saint Francis Memorial Hospital also earned five stars for the quality of our total hip replacement, treatment of stroke, and esophageal/stomach surgeries care from Healthgrades, the leading online resource helping consumers make informed decisions in order to find the right doctor, the right hospital, and the right care. A five-star rating indicates that our clinical outcomes are statistically significantly better than expected when treating the condition or performing the procedure being evaluated. 32
Robert Weber, MD
I am proud to share that Dignity Health St. Mary’s Medical Center’s Acute Rehabilitation Center recently received a Three-Year Accreditation from the Commission on Accreditation of Rehabilitation Facilities (CARF). This is the highest level of accreditation possible for a rehabilitation center. This accreditation applies to both our Inpatient Rehabilitation Program and our Stroke Specialty Program, which provide specialized care for patients with complex medical rehabilitation needs, and those who will benefit from intensive skilled therapies. Conditions we treat include stroke, traumatic and non-traumatic brain and spinal cord injuries, bone marrow or organ transplantation, amputation, bilateral joint replacement, complex orthopedic injuries and neuromuscular diseases such as Parkinson’s, Multiple Sclerosis, and Guillain-Barré Syndrome. We also provide rehabilitation care to people with other medical conditions such as those who have experienced a recent, significant change in physical and/or cognitive function; have complex medical needs requiring 24/7 medical and nursing care; and those who will benefit from intensive therapies, including those with critical illness myopathy, hip fracture, and multiple trauma. CARF certification is an acknowledgment of our Acute Rehab team’s dedication and commitment to providing the highest quality services for more than thirty years. Our team of medical experts and rehabilitation professionals has a record of outstanding outcomes, leading to satisfied patients and families. Our mission is to provide a personalized rehabilitation program that treats each patient individually, based upon their condition and needs. The therapists, nurses, physicians, and other care providers at St. Mary’s are trained, experienced experts who utilize a medically-based team approach to provide comprehensive care to our patients. To receive the accreditation, the St. Mary’s Acute Rehabilitation Center was required to undergo a rigorous peer review process, demonstrating that its programs and services are measurable, accountable, and of the highest quality. Congratulations to our exceptional team.
Bill Black, MD, PhD
At Sutter Pacific Medical Foundation, our cardiac electrophysiologists see more than 2,500 patients annually for evaluation and treatment of atrial fibrillation, one of the most common heart rhythm abnormalities in the United States, affecting three to five million people. By 2050, due to an aging population and other comorbidities such as hypertension, diabetes and obesity, as many as 16 million people could have atrial fibrillation. Atrial fibrillation is an abnormal heart rhythm originating in the heart’s top chambers, the atria. Electrical impulses that usually travel down normal conduction pathways instead spread through the atria in a chaotic fashion, causing the heart to beat in a rapid, disorganized manner. There are three ways to treat atrial fibrillation, according to Steven Hao, MD, director of the atrial fibrillation and complex arrhythmias program at California Pacific Medical Center. If the atrial fibrillation is asymptomatic, blood thinners minimizing the risk for stroke can be prescribed to slow down the patient’s heartbeat. If the atrial fibrillation is symptomatic, drugs can be used to suppress and/or decrease the burden of atrial fibrillation. Drugs often only work up to 60 percent of the time. Some drugs can be toxic and all can have side effects. “Because of the limitations with drugs and issues of efficacy, we’ve worked hard to understand atrial fibrillation and design a more definitive option,” Dr. Hao says. Dr. Hao, Richard Hongo, MD, and colleagues effectively treat atrial fibrillation patients using an ablation catheter, inserting it into the heart from veins in the patient’s leg or neck. An advanced 3-dimensional mapping technology enables doctors to quickly and accurately work with the heart’s complex anatomy. Radiofrequency energy is used to burn specific cells in the heart’s lining to isolate the triggers for atrial fibrillation, restoring the normal rhythm. Dr. Hao and his colleagues perform about 450 atrial fibrillation ablations annually, with an over 90 percent cure rate.
SAN FRANCISCO MEDICINE FEBRUARY/MARCH 2016 WWW.SFMS.ORG
MEDICAL COMMUNITY NEWS CMPC
Barbara Bishop, MD
Over 100 neuroscience researchers, physicians and clinical research staff attended the fourth annual California Pacific Medical Center (CPMC) Calanchini Lecture last November. With presentations by some of CPMC’s leading stroke and cerebrovascular clinician-investigators affiliated with the hospital’s Comprehensive Stroke Care Center, topics ranged from new discoveries in the use of interventional devices and the latest approaches to intravenous tissue plasminogen activator (IV rt-PA/thrombolytic therapy) treatment, to novel strategies for organizing stroke care at Sutter Health. The CPMC Stroke Team and Davies Campus Staff recently completed a successful re-certification survey for JC Primary Stroke Center Certification. After much effort and rigorous review, CPMC was granted a full three-year accreditation by the National Accreditation Program for Breast Centers (NAPBC), a program of the American College of Surgeons. This is recognition that our program is held to the highest standards of care for patients with diseases of the breast. Becker’s Hospital Review has named CPMC to its 2015 edition of its annual list of 100 hospitals and health systems with great women’s health programs. The hospitals included offer award-winning care to women in a variety of specialties, including Gynecology, Obstetrics, women-focused heart care, and women-focused cancer care. According to new research summarized by CPMC Research Institute Senior Scientist Steven Cummings, MD, and colleagues at the University of California San Francisco and Harvard Medical School, high doses of vitamin D may increase the risk of falls. The findings and accompanying editorial by Dr. Cummings and colleagues were published online in the January 2016 issue of JAMA Internal Medicine. A new study shows that the common practice of people taking Vitamin D supplements to raise the levels in their blood to an “ideal” 30 ng/ML can cause—rather than prevent—falls. WWW.SFMS.ORG
Maria Ansari, MD
Many areas of medicine are advancing at rates unheard of even a decade ago, thanks in large part to technological innovations that enable physicians to perform procedures that were at one time more significantly invasive and are now less traumatic to the patient. One such area is within our Structural Heart Program where new medical devices offer patients with congenital and acquired defects less invasive options for their cardiac care. Using a cross-disciplinary, team-based approach that includes all members of the necessary medical staff to perform cardiac procedures, we use several innovative techniques to provide the best care possible to our patients. Such devices include trans-catheter heart valves, and devices for closing defects in the tissue between heart chambers and occluding the left atrial appendage where blood clots can form to reduce the risk of stroke. Using catheters to place devices in patients reduces the size of surgical incisions and can speed recovery. The MitraClip device is used to treat leaking mitral valves in patients who a cardiac surgeon thinks would be at excessive risk for open heart surgery. Similarly, transcatheter aortic valve replacement (TAVR) is a minimally invasive surgical procedure that replaces stenotic aortic valves without removing the old, damaged valve. Instead, it implants a replacement valve into the aortic valve’s place, permitting the surgery to be performed with an incision smaller than a thumb tip. There are technical reasons why some will not qualify for the treatments, including anatomical limitations and not meeting appropriate indications. However, there is substantial interest in these new techniques as they minimize the possibility of complications and infections. Additionally, they significantly reduce the time spent as an inpatient and, in some cases, patients can go home the same day. Looking towards the future, there are several other minimally-invasive options waiting for approval. We strive to remain on the cutting edge of cardiac procedures.
Diana Nicoll, MD, PhD, MPA
December 2015 marked the 20th anniversary of the San Francisco VA’s (SFVAHCS) transition from paper to electronic health records (EHR), and the 10th anniversary of our use of telehealth to provide access to specialists across our large geographic referral area. The Department of Veterans Affairs’ (VA) current focus on digital health is expanding mobile health access for patients and providers. The VA App Store (mobile.va.gov) provides more than a dozen apps to help patients cope with mental health issues, possible military hazard exposures, and concussion, along with a new text messaging application to integrate with VA care teams. To support home-based primary care teams in very remote settings, SFVAHCS deployed VA’s new Mobile Electronic Documentation tool which allows for secure patient data review and entry without an internet connection, synchronizing with the EHR once the connection is re-established. Because our EHR systems are comprehensive, SFVAHCS has been a leader in the use of e-consults. With a turnaround time of less than seven days, specialist opinions are available to primary care providers and their patients without requiring patients to travel from outlying clinics or take time off from work. Completed notes are available immediately for the requesting provider and after three days for the patient through MyHealtheVet. Since 2012, annual e-consult volume has grown ten-fold and now encompasses 22 clinical services. In 2015, SFVAHCS was one of eight sites awarded funding to build the VA Innovators Network. A primary theme for our site is to improve employee engagement, in part by providing new digital health tools that enhance the veteran and provider experience rather than creating new administrative burdens. Seed funding requests have included themes from incorporating wearable activity monitor data to creating automated, customized pill packs for complex medication regimens.
FEBRUARY/MARCH 2016 SAN FRANCISCO MEDICINE
Benjamin L. Franc MD, MS, CPE
UPCOMING EVENTS 3/16: SFMS Physician Networking Mixer
The term “personalized medicine” is frequently invoked, but what is it, really? In January, members of UCSF joined experts from across the healthcare and biotechnology sectors at the 10th Personalized Medicine World Conference in Mountain View, co-sponsored by UCSF. Cross-functional collaboration was the key message from the conference, and is one that UCSF will implement increasingly in 2016. The key to personalizing medicine is “precision medicine”, a movement to collect and connect data, synthesizing it to apply to health on an individual basis. This melding of basic science, information science, and clinical applications is happening both on campus and within the larger community. For example, UCSF recently announced development of an integrated health platform with Cisco, providing usable health data across numerous settings. As described by UCSF Precision Medicine leaders, the vision is to find intersections of basic, clinical, social, and behavioral sciences with digital, quantitative biologic, and computational tools. The result is predicted to be a knowledge network likened to “Google maps for health.”
6:00 p.m. to 8:00 p.m., Pa’ina (Japantown) Join SFMS for our March Physician Networking Mixer at Pa’ina in Japantown. Connect with your colleagues, meet SFMS leaders, learn about new member benefits, and hear SFMS’ efforts on the tobacco tax and Tobacco 21 initiatives. Visit https://www.sfms.org/ events.aspx for event details and to RSVP.
3/20-22: AMA/MGMA “Collaborate in Practice” Conference
Broadmoor Hotel, 1 Lake Avenue, Colorado Springs, CO Medical Group Management Association (MGMA) has partnered with the AMA to create a unique learning environment that focuses on the partnership between practice administrators and physicians to pave the way for future success. The MGMA/AMA 2016 Collaborate in Practice Conference emphasizes successful, practical approaches to achieving the quadruple aim: enhancing the patient experience, improving population health, reducing costs, and improving satisfaction among providers and staff. Conference details at http://www.mgma.com/education/conferences/collaborate.
4/6 Webinar: MACRA Implementation–A Review of the CMS Proposed Rule
12:15 p.m. to 1:15 p.m., CMA webinar Learn about the details of the proposed rule around the Merit-Based Incentive Payment System (MIPS) implementation. This webinar will also review any new details available regarding Alternative Payment Models (APM) and next steps. SFMS members receive complimentary access ($99 for non-members) and can register at http://bit. ly/1ROg6cR.
Calling ALL Medical Staff Leaders Come to the IMQ/PACE Stepping Up to Leadership Program March 10—11, 2016 in San Diego. Widely recognized as the “go to” course for acquiring knowledge and skills to successfully lead a medical staff! Best training available for empowering physician leaders. Dynamic, interactive training led by UCSD and IMQ faculty. Topics include: Communicating effectively
Handling disruptive or impaired professionals Collaboration and team building between the hospital and medical staff Being an effective leader and engaging the medical staff Aging Physician policies—development, implementation, and legal considerations Meeting management skills Minimizing stress and avoiding burnout Legal update
REGISTER TODAY!! Www.imq.org—Stepping Up to Leadership Conference Leslie Anne Iacopi—email@example.com or (415) 882-5167
4/13: SFMS Lobby Day/Legislative Leadership Conference 9:00 p.m. to 4:00 p.m., Sheraton Grand Sacramento, 1230 J St., Sacramento Join SFMS for the annual CMA Legislative Leadership Conference at the State Capitol. Learn about legislative issues affecting medicine, foster relationships with state legislators, and gain hands on experience in the practical aspects of physician advocacy. This one-day event include education sessions on effective advocacy and lobbying techniques, briefings on legislative issues currently before Congress from CMA’s Government Relations team, and afternoon meetings at the Capitol with legislators and their staffs. More than 400 physicians, medical students, and CMA Alliance members participated at the 2015 event. Event details at http://www.sfms.org/events/lobby-day.aspx or contact SFMS at firstname.lastname@example.org or (415) 561-0850 x268.
4/20 Webinar: How to Reduce Overhead Expenses and Increase Profitability
12:15 p.m. to 1:15 p.m., CMA webinar There are only three ways to realize increased net income: raise fees, increase productivity, or decrease overhead. With managed care contracting difficulty, increased fees are difficult to achieve. The doctor/ group may already be working at maximum capacity so this may not be an option. This webinar will provide tips for physician practices to control and reduce overhead expenses to assure profitability. SFMS members receive complimentary access to this webinar ($99 for non-members) and can register at http://bit.ly/1nPHZ7L.
SAN FRANCISCO MEDICINE FEBRUARY/MARCH 2016 WWW.SFMS.ORG
The CMA/SFMS’s exclusive new Workers’ Compensation program can help your practice save money! Savings
CMA members qualify for an additional 5% discount* on top of Preferred Insurance’s already competitive rates. Preferred’s rates are set for long term consistency, and are managed by focusing on safety and injury prevention, fraud prevention and the control of medical costs for your practice by getting employees back to work as soon as practical.
Service Mercer’s team of insurance advisors is knowledgeable about the needs of physicians and is available to walk you through the application process. Preferred’s claims examiners are experts in helping members with an employee injury or illness claim. Plus Preferred’s payroll management and flexible payment plans help you manage your premiums in the way that works best for you and your practice’s cash-flow needs.
Safety In addition to mandatory CalOSHA information and videos on workplace safety, Preferred’s team of Risk Advisors are available for consultations when you need them. They also have a strong fraud prevention policy and as a California-based carrier, they know exactly what it takes to do business successfully in this State.
Stability Preferred Insurance prides itself on its stability, which includes maintaining some of the best and most consistent pricing available for CMA members. And because of its Medical Provider Network of credentialed medical professionals, claim costs can be closely monitored and managed while providing quality care to injured employees.
Call Mercer today at 800-842-3761 for a premium indication. CMACounty.Insurance.email@example.com or www.CountyCMAMemberInsurance.com.
See how CMA/SFMS’s Workers’ Compensation team can help you save! Sponsored by:
Scan for info:
*Most practices will qualify for group pricing and receive the 5% discount; however some practices will need to be underwritten separately when they do not qualify for the special program terms and conditions. A minimum premium applies to very small payrolls.
Mercer Health & Benefits Insurance Services LLC • CA Ins. Lic. #0G39709 • Copyright 2016 Mercer LLC. All rights reserved. • 75192 (2/16) 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • www.CountyCMAMemberInsurance.com • CMACounty.Insurance.firstname.lastname@example.org
San Francisco Medical Society 1003A O’Reilly Ave. San Francisco, CA 94129 Return Service Requested
Advancing cancer research Advancing and care. cancer research and care. Our physicians and researchers are making new discoveries to help in thephysicians fight against With nationally recognized cancer experts Our andcancer. researchers are making new discoveries to help and of clinical trials, we nationally provide access to promising new in thedozens fight against cancer. With recognized cancer experts
cancer therapies. Comprehensive cancer access care at to Sutter Health new CPMC. and dozens of clinical trials, we provide promising It’s another way we plus you. cancer therapies. Comprehensive cancer care at Sutter Health CPMC. It’s another way we plus you.
San Francisco Medicine, Vol. 89, No. 2, February/March 2016