January/February 2017

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MIEC Belongs to Our Policyholders!

Toni Brayer, MD Board of Governors

Over the last 20 years California policyholders have saved an average of 25% on premiums due to our Dividend Program*

Keeping true to our mission MIEC has never lost sight of its original mission, always putting policyholders (doctors like you) first. For over 40 years, MIEC has been steadfast in our protection of California physicians with conscientious Underwriting, excellent Claims California Dividends as % of premiums management and hands-on Loss Prevention ($1m/$3m limits) services; we’ve partnered with policyholders 60% to keep premiums low. MIEC Average Dividend Added value: No profit motive and low overhead n Supports Organized medicine in Califonria n

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January/February 2017 Volume 90, Number 1

Otolaryngology/Head and Neck FEATURE ARTICLES


10 Understanding Vertigo: Diagnosing and Decreasing Dizziness Jeffrey D. Sharon, MD


Membership Matters


President’s Message Man-Kit Leung, MD

12 Allergic Rhinitis: Updates in Diagnosis and Management Emily Kane, NP and Man-Kit Leung, MD 14 Hearing Aid Technology: Enhanced Speech in Noise Intelligibility and Wireless Connectivity Quentin P. Kennedy, AuD

16 Nasopharyngeal Carcinoma Epidemiology and Advances and Its Relevance in The Bay Area Alexander B. Geng, MD 18 HPV-Associated Throat Cancer: The Role of Transoral Robotic Surgery William R. Ryan, MD, FACS

20 OHNS at UCSF Update on the Otolaryngology-Head and Neck Surgery Department Andrew H. Murr, MD, FACS

22 Getting the Smoke Out: Strategies to Reduce the Impact of Tobacco in Otolaryngology John Maa, MD, FACS

Editorial and Advertising Offices: San Francisco Medical Society 2720 Taylor St, Ste 450 San Francisco, CA 94133 Phone: (415) 561-0850 Web: www.sfms.org


Guest Editorial David E. Smith, MD, David Pating, MD, and Steve Heilig, MPH

23 Classified Ads

23 Upcoming Events 26 Medical Community News

OF INTEREST 24 Ask the SFMS: Investing in Stocks

MEMBERSHIP MATTERS Activities and Actions of Interest to SFMS Members

CCHCA Physicians Join SFMS SFMS is pleased to welcome sixty physicians who are part of the Chinese Community Health Care Association (CCHCA) who recently joined SFMS. CCHCA is a non-profit association of doctors serving the San Francisco region since 1982. Joe Woo, MD, Medical Director of CCHCA, says “CCHCA is proud to support organized medicine. SFMS and CMA have always helped us in our times of need. And good luck to our own Dr. Man-Kit Leung in his presidency as we continue our strong legacy of leadership within SFMS.”

Be Prepared for Covered California Changes

In 2016, Covered California, California’s health benefit exchange, enrolled approximately 1.4 million individuals in qualified health plans. It is critical that physician practices understand their participation status, which products are being offered, and what changes to expect in 2017. To help physicians understand the changes taking place and how they will affect their practice, the California Medical Association has published a new tip sheet, “Surviving Covered California: Preparing for changes in 2017.” The tip sheet is available free to members at http://bit.ly/2hZl0nD. Read more about the 2017 changes at http://bit.ly/2jkmQo7.

Physician Corps Loan Repayment Program Now Accepting Applications

Applications are now being accepted for the next cycle of the Steven M. Thompson Loan Repayment Program. Award recipients will receive up to $105,000 to repay educational loans in exchange for a three-year service commitment in a medically underserved area of the state. The program was created in 2002 through legislation sponsored by the California Medical Association. This year’s application cycle began on December 1, 2016, and continues through February 28, 2017. To be considered for an award, you must: • Have a valid, unrestricted license to practice medicine in California • Be free of any contractual service obligations (e.g., the National Health Service Corps Federal Loan Repayment Program or other financial incentive programs) • Have outstanding educational debt from a government or commercial lending institution • Be currently employed or have accepted employment in a federally designated “health professional shortage area” in California For application, eligibility and program questions, contact the Health Professions Education Foundation at (800) 7731669 or email Jimmy.Miranda@oshpd.ca.gov. Visit http://bit. 4

ly/2iliyc3 for more information. The online application is available at www.oshpd.ca.gov/HPEF/Forms.html.

“Ask About PrEP” Toolkit Available For Your Practice

The City and County of San Francisco was one of the first and hardest hit epicenters of the HIV epidemic. While the number of new HIV cases in San Francisco is now declining, there is considerable work to do to reach our goal of Getting to Zero: Zero HIV transmissions, Zero deaths from HIV-related illness, and Zero HIV stigma. SFDPH’s “Ask about PrEP” toolkit for medical providers and staff contains clinical resources for your practice and educational materials for your patients. A Health Department representative is available to visit providers to discuss use of the “Ask about PrEP” toolkit in your practice. Visit http:// www.sfcityclinic.org/services/prep.asp#Providers for more information. View the public health message from SFDPH leadership at http://bit.ly/2iRgYSz.

CMS Launches New Online Tool to Make Quality Payment Program Easier for Clinicians

The Centers for Medicare & Medicaid Services (CMS) recently released a tool to automatically share electronic data for the Medicare Quality Payment Program. This new release is the first in a series that will be part of CMS’s ongoing efforts to spur the creation of innovative, customizable tools to reduce burden for clinicians, while also supporting high-quality care for patients. CMS released the Quality Payment Program website, an interactive site to help clinicians understand the program and successfully participate. Visit the site at https://qpp.cms.gov/. “An important part of the Quality Payment Program is to make it easier and less expensive to participate, so clinicians may focus on seeing patients,” said Andy Slavitt, Acting Administrator of CMS. “This first release is a step in that process, both for physicians and the technologists who support them.”

Time to Verify Your Patients’ Eligibility and Benefits For 2017

The beginning of a new year brings with it changes to your patients’ eligibility and benefits. Physicians are urged to be diligent in verifying each patient’s eligibility and benefits to ensure they will be paid for services rendered. The beginning of a new year also means that both calendar year deductibles and visit frequency limitations reset. And, with open enrollment, patients may even be covered by a new payor. Don’t get stuck with unnecessary denials or an upset patient. Do your homework before the patient arrives by obtaining updated insurance information at the time of scheduling, if possible, and making copies of the insurance card at the time of the visit.


DEA Sending Electronic Reminders to Renew Registration The Drug Enforcement Agency (DEA) published a notice that starting in January 2017, it will no longer send its second renewal notification by mail. Instead, an electronic reminder to renew will be sent to the email address associated with the DEA registration. The DEA will otherwise retain its current policy and procedures with respect to renewal and reinstatement of registration. Read more at http://bit.ly/2jddDK2. If you want to check your registration expiration date, contact the DEA Registration Service Center at (800) 882-9539 or email DEA.Registration.Help@usdoj.gov and include your DEA Registration number in your email.

Toolkit Available to Help Clinicians Taper Opioids for Patients with Chronic Pain

A detailed step-by-step guide from Partnership HealthPlan is designed to help clinicians taper opioids for patients with chronic pain. The toolkit, available at http://bit.ly/2hZKlO3, includes case studies and guidance on management of complications. Partnership designed the toolkit as part of its Managing Pain Safely program.

Free CME: Six Steps To Improve Physician Resiliency

Increasing administrative responsibilities—due to regulatory pressures and evolving payment and care delivery models—reduce the amount of time physicians spend delivering direct patient care. Physicians often experience burnout caused by demanding workloads, nights on call, and other common stressors. Learning resiliency helps physicians have longer, more satisfying careers and reduces the risk of burnout. The American Medical Association (AMA) STEPS Forward™ collection includes a module, “Improving Physician Resiliency,” that includes six ways to improve resiliency in a demanding practice environment and ways to prevent burnout. The module will help physicians identify tools and resources to increase resiliency, assess personal and professional contributors to stress, and identify and prioritize values in all aspects of their lives. Launched by AMA in June 2015, STEPS Forward now includes forty-three free interactive educational modules aimed at helping physicians redesign their medical practices to minimize stress and reignite professional fulfillment in their work. Continuing medical education (CME) credit can be earned from each module. For more information, visit www.stepsforward.org.

CMA’s Practice Manager Tip of the Month

Don’t lose revenue by not working on denials. It’s no secret that claim rejections and denials can result in a significant amount of lost revenue. While it might not be feasible for a solo or small physician group to appeal every single denial or rejection, practices can significantly reduce potential lost revenue by identifying and addressing the three most common reasons for denial or rejection. For more information, see “How much revenue is your practice losing by not working denials?” available free to members at www.cmanet.org/ces.

Enjoy SFMS Member Discount at the California Academy of Sciences

Did you know that SFMS members receive a fifteen percent discount on General Admission tickets at the California Academy of Sciences? Visit http://bit.ly/2iRwXAh for more information.


January/February 2017 Volume 90, Number 1 Editor Gordon Fung, MD, PhD Managing Editor Steve Heilig, MPH Production Editor Amanda Denz, MA Copy Editor Amy LeBlanc, MA 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 Man-Kit Leung, MD President-Elect John Maa, MD Secretary Brian Grady, MD Treasurer Kimberly L. Newell, MD Immediate Past President Richard A. Podolin, 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 Erin Henke Director of Administration Posi Lyon Membership Coordinator Ariel Young BOARD OF DIRECTORS Term: Jan 2017-Dec 2019 David T. Duong, MD Alexander B. Geng, MD Robert A. Harvey, MD Dawn D. Ogawa, MD Ray Oshtory, MD Justing P. Quock, MD Dennis Song, MD Joseph W. Woo, MD

Term: Jan 2016-Dec 2018 Charles E. Binkley, MD Benjamin L. Franc, MD Nida Degesys, MD Raymond Liu, MD David R. Pating, MD Monique D. Schaulis, MD Winnie Tong, MD

Term: Jan 2015-Dec 2017 Steven H. Fugaro, MD Todd A. May, MD Stephanie Oltmann, MD William T. Prey, MD Michael C. Schrader, MD Albert Y. Yu, MD (To be determined) CMA Trustee Shannon Udovic-Constant, MD AMA Delegate Robert J. Margolin, MD AMA Alternate Gordon L. Fung, MD, PhD




SFMS/CMA Member Benefit


Patient referral service via SFMS’ phone referral line and online physician finder tool . . . . . . . . . . . . . . . . . . . . . . . . . $300 Access to exclusive physician networking events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $400 Personal physician webpage for practice promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200 Subscriptions to San Francisco Medicine and SFMS Membership Directory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $110 One-on-one assistance with practice management experts from Center for Economic Services on . . . . . . . . .*$150/hour reimbursement and practice operation issues . *value hourly rate with a practice management consultant Access to objective written analyses of major health plan contracts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $500 Discounted employment contract review service with a contract attorney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $500 Special member rate for AAPC’s ICD-10 training seminars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200/session Discounted registration for the Western Leadership Academy (eligible for 16 CME credits) . . . . . . . . . . . . . . . . . . . . . $300 CME tracking and credentialing service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $24 HIPAA-compliant communication via DocBookMD, enabling physicians to instantly exchange patient information . . . . $100 with other physicians at the point of care . 15% off tamper-resistant security prescription pads and printer paper with Rx Security . . . . . . . . . . . . . . . . . . . . . . . $275 30% off your current bill for medical waste management and disposal services through EnviroMerica . . . . . . . . . .*$1,000 *based on average savings

Up to 25% discount on worker’s compensation insurance through Mercer Health & Benefits, as well as special . . . . . $750 pricing and/or enhanced coverage for life, disability, long term care, medical, dental and more . Member-only savings on office supplies and magazine subscriptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $500 Access to webinars and seminars ranging from business essentials for physicians, EHR adoption best practices, . . . $800 effective coding/billing strategies, and Medicare reporting compliance .

For a list of full member benefits, visit http://www.sfms.org/membership/membership-benefits/full-member-benefits.aspx.


Patients Before Politics The practice of medicine is nonpartisan. Our patients—regardless of political affiliation— share the same anatomy, possess the same physiology, and are afflicted by like pathology. Similarly, despite differences in political ideology, we as physicians who care for patients, share fundamental needs, including the need for our patients to have access to healthcare and medications, the need to improve health outcomes through evidence-based science, and the need to provide medical care without undue administrative burden. President-elect Donald Trump has promised sweeping reform to healthcare. Although specifics are unknown, Trump’s proposed plan to repeal elements of, if not entirely replace, the ACA has elicited trepidation among professionals in the healthcare industry. Change is coming and change can be unnerving; however, change can also be an opportunity for improvement. In order for healthcare reform to truly benefit our nation, physicians need to stand united to advocate for the fundamental needs that our profession demands. Now more than ever, we need organized medicine to be exactly just that—organized. In the clamor that is sure to come on the healthcare debate, physicians must speak in a concordant voice for our message to be heard loud and clear. Unfortunately, at the most inopportune time, dissonance has beset organized medicine at the national level. Hours after President-elect Trump named former orthopedic surgeon, Representative Tom Price, a Republican congressman from Georgia, as his nominee for Secretary of Health and Human Services, the AMA released a strong statement of endorsement. Within days, dissenting members penned open letters to the AMA Board of Trustees protesting this endorsement, citing Price’s voting record against the ACA, his support of defunding of Planned Parenthood, and his opposition to same-sex marriage. Some others released an online petition entitled “The AMA Does Not Speak for Us” and have created a competing medical professional organization. At a time when the nation’s public is looking at their trusted doctors to lead healthcare reform, organized medicine at the national level has spoken with garbled voice. Fortunately, this dissonance has largely not reverberated to the local level. SFMS has a long tradition of first listening to its members, then building consensus, and finally voicing a message that resonates with our constituents. For example, having heard alarm from several of SFMS members about the AMA endorsement of the Price nomination, our Immediate Past-President Richard Podolin convened an Executive Committee meeting to discuss the issue and based on prevailing consensus, wrote a letter to AMA expressing both “procedural and substantive” concerns of the Price endorsement. Simply put, SFMS is listening. We have heard from our members that in order to maintain the moral authority as respected doctors in the public eye, organized medicine cannot be a professional guild whose interest is only to promote physician wealth and autonomy. Instead, our members have told us that SFMS must rise above partisan politics and advocate for WWW.SFMS.ORG

policies that serve the core needs of all physicians, which include advancing public health and improving access to healthcare. Last year alone, SFMS was successful in championing legislation that tax soda and tobacco, that support funding for Medi-Cal, and that regulate firearms and ammunition. Although we have much more work to do, especially on issues such as drug pricing and physician burnout, we have made great progress. Regardless of what happens on the federal level, we cannot let that progress be lost. Perhaps it is timely that the current issue of San Francisco Medicine is dedicated to my specialty otolaryngology, the field that is focused in part on caring for the organs of hearing and speech. As an otolaryngologist and the incoming President of SFMS, I pledge to keep the “ears” and “voice” of the society in good health to the best of my ability this year. Change in healthcare is certain to come. Let us work together to ensure whatever reform that comes is for the betterment of our nation by listening attentively to the core needs of our profession and by collectively vocalizing that these needs are addressed. UPDATE: Since the submission of this article, AMA CEO and Executive Vice-President Dr. James Madara released an open letter emphasizing AMA’s core commitment to “health insurance coverage for all Americans, as well as pluralism, freedom of choice, freedom of practice, and universal access for patients.” He further discouraged Congressional leaders from actions that would undo progress made from the ACA and increase the nation’s uninsured. It is my hope that by staying true to our patients and our common core principles, organized medicine can retain the political and moral authority to advance healthcare delivery in this country. Man-Kit Leung, MD, is a board certified otolaryngologist/head and neck surgeon on staff at Chinese Hospital, CPMC, St. Mary's Medical Center, and St. Francis Memorial Hospital. He graduated summa cum laude from Harvard University and attended medical school at the UCSF where he was co-President of the Alpha Omega Alpha Medical Honors Society. He completed his internship in general surgery and residency in otolaryngology/head and neck surgery at the Stanford University Medical Center. He subsequently underwent fellowship training in rhinology and endoscopic sinus/skull base surgery at the Massachusetts Eye & Ear Infirmary at Harvard Medical School. He enjoys hiking, traveling, and spending time with his wife Cindy, who is a Kaiser OB/GYN, and their twin children, Ethan and Alexandra. He welcomes comments, thoughts, and advice at mleung@sfms.org. JANUARY/FEBRUARY 2017 SAN FRANCISCO MEDICINE



MARCH 13-14, 2017



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Immerse yourself in two days full of talks, breakouts, office hours and social events. Listen to, learn from and engage with thought leaders in palliative care…past, present and future! AUDIENCE Now in its 9th year, the Coalition for Compassionate Care of California and Children’s Hospice & Palliative Care Coalition Annual Summit is designed for physicians, nurses, social workers, nursing home administrators, chaplains, patients and consumers who are interested in palliative care best practices, quality and policy. ADULTS & PEDIATRICS The Summit is appropriate for providers caring for seriously ill people of all ages: pediatrics, adolescents and young adults, adults and geriatrics. MAIN STAGE PRESENTERS

Eric J. Cassell, MD, MACP Physician, Author

Jennifer Kent, MPA Application for CME credit has been filed with the American Academy of Family Physicians. Determination of credit is pending.

CA Department of Health Care Services

Betty Ferrell, RN, PhD, FAAN City of Hope

BJ Miller, MD

University of California, San Francisco

Jessica Nutik Zitter, MD, MPH

Highland Hospital, Oakland

Applications for CE credit have been filed with the California Board of Registered Nursing, the California Board of Behavioral Sciences, California Association of Marriage and Family Therapists, and the California Nursing Home Administration. This program may be used for continuing education credit for chaplains certified with the Board of Chaplaincy Certification, Inc.

QUESTIONS Call 916.489.2222 or visit ccccsummit.org/contact



GUEST EDITORIAL David E. Smith, MD, David Pating, MD, and Steve Heilig, MPH

The Surgeon General on Addiction: Another American Landmark? In 1964, the United State Surgeon General's report on tobacco ignited a generations-long effort to curtail smoking and the harms related to it. Just over a half-century later, that ongoing battle has saved countless lives and suffering by reducing smoking and exposure to secondhand smoke. The effort continues on many fronts and is continually under counterattack by the tobacco industry, but is still one of the great health successes of our time. Now comes the 2016 Surgeon General's (SG) report on substance abuse and addiction, titled "Facing Addiçtion in America." Released in November, it elicited much media and professional attention. Might it have a similar impact over time? The new report is certainly a logical extension of the landmark tobacco report; it broadens the focus on addictive substances to include opioids, alcohol, and stimulants as well as tobacco. It highlights addiction as a whole as a critical health issue, in line with many previous assessments, and an AMA statement from decades ago identifying substance abuse as the public health issue with one of the most significant and costly negative impacts on America's health. The national diagnosis is striking; more than 27 million people older than age twelve—or about one in ten Americans— used an illicit drug (or misused a prescription drug) in the past thirty days and 17 million reported heavy alcohol use in the past month. In 2015, approximately 21 million Americans older than age twelve had a substance use disorder related to their use of alcohol or illicit drugs in the past year—that's as many as those with diabetes and more than all cancers combined. Overdoses of various drugs, especially prescription opioids and heroin, have increased to crisis levels. No demographic or age is immune, from the homeless to affluent suburban families. Closer to home, San Francisco has long had a reputation as place of high use and abuse of psychoactive substances. From Gold Rush days onward, alcohol has been heavily used here, and this continues with one of the highest rates of use and density of sales anywhere. Our chronic homeless problem is intimately related to substance abuse, as is the ongoing gridlock in our hospital emergency departments. The American Society of Addiction Medicine (ASAM)—a subspecialty officially recognized in part due to long advocacy from SFMS and California—applauded the SG report. “The report confirms what we have known for a long time: addiction is a disease of the brain that can and should be treated with evidence-based, compassionate care,” said Dr. Jeffrey Goldsmith, ASAM President. “For too long, policy makers, the public, and even healthcare providers have misunderstood this disease as some sort of moral failing. We hope this report will put an end to that misperception once and for all.” WWW.SFMS.ORG

As for prescriptions to confront addiction, the report recommends many actions to expand access to evidence-based treatment services and prevention programs, and improved integration of addiction treatment services with general healthcare. This makes sense as improvements in treatment have been marked in recent years, despite perceptions that addiction is intractable. But access to such care is problematic without enough well-trained clinicians. Thus one central recommendation is that major changes to clinical professional school curricula will be required to ensure the next generation of professionals is equipped to screen and treat patients for addiction. This must include a more aggressive approach to training clinicians in treating pain as well. Further, much must be done to ensure patients can access services, which will require both expansion of services and requiring health plans and insurers to pay for them as they do general medical services. Some such requirements have been phased in under the ACA, but that is now in jeopardy. But the report also zeroes in on the issue of stigma. "Many people are scared that they will lose their jobs, or be ostracized by their friends or even be looked at differently by their doctors if they admit that they have a problem with addiction, and in that type of environment people don't feel comfortable coming forward and asking for help," Surgeon General Murthy said. As we have learned with other conditions such as HIV disease, this can be a huge obstacle to both prevention and care. Dr. Vivek Murthy deserves our nation’s sincere thanks and respect for issuing this report, however the follow-up to it unfolds. The American Society of Addiction Medicine holds that addiction should be responded to with a national public health response such as occurred with the HIV epidemic, with forceful and innovative interventions on all fronts. We concur. David Smith, MD, is founder of the Haight-Ashbury Free Clinics and a past-President of the American Society of Addiction Medicine. David Pating, MD, is chief of Addiction Medicine at Kaiser San Francisco, past-president of the California Society of Addiction Medicine and a San Francisco Health Commissioner. Steve Heilig is with the SFMS, a former Robert Wood Johnson substance abuse fellow, and with Dr. Smith a co-editor of the Journal of Psychoactive Drugs. The report: https://addiction.surgeongeneral.gov. The SFMS and others will be co-presenting an all-San Francisco conference on substance abuse and addiction issues on June 9 at UCSF; save the date, more to come. JANUARY/FEBRUARY 2017 SAN FRANCISCO MEDICINE


Otolaryngology/Head and Neck

UNDERSTANDING VERTIGO Diagnosing and Decreasing Dizziness Jeffrey D. Sharon, MD Vertigo is a confusing term, for physicians and patients alike. Many physicians consider vertigo to refer to

an illusory sense of spinning or turning, reflecting the word’s Latin roots. Recently, an international group of researchers, the Bárány Society, have begun an attempt to implement standard terminology in the classification of balance disorders. This ongoing effort, termed the International Classification of Vestibular Disorders, uses a broader definition for vertigo: “the sensation of self-motion (of head/body) when no self-motion is occurring or the sensation of distorted self-motion during an otherwise normal head movement.” However, patients can experience a full spectrum of perceptual balance impairments, including spinning, rocking, swaying, being pushed to one side, tilting, and generalized feelings of unsteadiness, imbalance, motion, lightheadedness, and blurring of the visual world with movement. Complicating matters, it is unclear whether or not any of these symptoms, which are commonly grouped together under the umbrella term “dizziness,” correlate with specific disease processes. Furthermore, there is even confusion as to whether or not vertigo is a symptom or a diagnosis. I’ve personally heard from many patients that they were seen for dizziness, which it turns out was caused by “vertigo.” This overwhelming glut of usages and connotations for vertigo can make one’s head spin! In this article, we will take a step back, and try to answer some basic questions about vertigo: Why does vertigo happen? What are some common causes? And what can be done about it? To understand vertigo, we must first briefly review the normal functioning of the human balance (vestibular) system. Unlike many other senses, like hearing or sight, our sense of balance is very much a behind the scenes player. This fact may help explain why balance is often marginalized, starting with its omission from the standard kindergarten codification of our “five senses.” Therefore, while many people have a clear appreciation of their ability to smell or taste, they only begin to see the importance of the balance system once it starts malfunctioning. Our inner ear balance system is an internal gyroscope located deep within the skull. It is able to sense both angular (rotational) and linear (straight line) acceleration, and tilt. This information is conveyed to several different neurological systems, including the one that controls eye movements. This feature allows us to keep a visual target in focus while running or walking. Furthermore, the balance system also sends information to the neural network that controls upright posture and muscle tone. Functionally, that implies that disorders of the vestibular system can manifest with a variety of symptoms, including sensations of spinning, turning, tilting, imbalance, poor control of posture, and blurring of the world with head movement. However, that balance system does not act alone. Several 10

other physiologic systems are necessary to maintain upright balance and posture, including musculoskeletal, somatosensory, and visual systems. Furthermore, dizziness and lightheadedness may occur with disruptions of adequate cerebral blood flow, as can occur with cardiac, orthostatic, neurologic, and vascular disorders. Finally, the vestibular system is deeply connected with anxiety and threat assessment centers within the brain, and therefore many primary anxiety disorders are complicated by feelings of dizziness and space and motion discomfort. Conversely, many primary vestibular disorders over time lead to feelings of anxiety. Unraveling it all can quickly become a futile exercise in determining whether the chicken or the egg came first. Therefore, any attempt at trying to sort out the cause of dizziness needs to include a thorough assessment of the whole patient. This begins with a detailed history, focusing on the nature of the dizziness, the timing (acute, chronic, recurrent, and length of each episode), provocative factors (e.g. lying back in bed, or transitioning from sitting to standing), concurrent symptoms (e.g. hearing loss, ear fullness, tinnitus, headache, light/sound sensitivity), and effects on quality of life and ability to function. Contributory physiologic systems, such as vision, muscle strength, sensation, and proprioception should also be assessed. One of the most common causes of dizziness, vestibular migraine (also called migraine associated vertigo), does not produce a consistent pattern of findings on exam or testing. Therefore, only detailed questioning can diagnose this condition, underscoring the importance of careful history taking. Per criteria from the Bárány society, the diagnosis relies on a history of migraine headaches per International Classification of Headache Disorders criteria, and migrainous features during dizzy spells, such as photophobia. The physical exam must also address the ears, the cranial nerves, and a general neurologic exam. However, examining the vestibular system is not as straightforward as examining some of the other special senses. This is because the vestibular system is deeply integrated with other neurological systems, and therefore it cannot be examined in isolation. To get around this problem, specialists usually focus on one incredibly quick, robust, and hardwired reflex between the inner ear and the eyes called the vestibulo-ocular reflex (VOR). The VOR is one of the quickest reflexes in the human body, occurring on an order of five to ten milliseconds. The VOR exists to solve a basic engineering problem: we can see things most clearly when the object of interest is focused on the part of the retina with the highest concentration of photoreceptors. However, during many activities, like walking, running, or sliding down a hill, there is so much head movement that keeping a visual object of interest (like say a preda-


tor in hot pursuit) in focus becomes impossible. Therefore, the VOR exists to sense head movements, and move the eyes in an equal and opposite direction. This explains our ability to perform many common tasks, like the now ubiquitous reading of smartphones while walking down the street. This reflex can be examined as well, by having the patient stare at a visual target while quickly rotating the head (an arc of ten to twenty degrees is all that is required, and that avoids creating neck problems). If the VOR is functioning, the eyes will stay on the target (the eye movement that keeps them on target is too quick for us to see). If the VOR is deficient, then the direction of gaze will rotate in line with the head, and once the visual information is processed that the subject is no longer focused on the target, a quick corrective eye movement will occur. This corrective eye movement is visible, and can alert the clinician that the inner ear balance system is malfunctioning. Of interest, form follows function, and a careful anatomic assessment of the three-dimension orientation of the inner ear rotation sensors and the paired eye muscles show that they are roughly located in the same planes, which allows for the speed of the reflex by minimizing processing time. When these corrective eyes movements (catch up saccades) are present, then weakness of the ipsilateral labyrinth can be diagnosed. When they are present in both directions, then bilateral vestibular loss is the likely culprit. Both unilateral and bilateral weakness of the vestibular system are treated with vestibular physical therapy, which is aimed at improving the speed and accuracy of the deficient VOR. Other important maneuvers can help shed light into the cause of vertigo as well. In benign paroxysmal positional vertigo (BPPV), microscopic calcium carbonate crystals shear off of the surface of the otolith organs. Trapped within the fluidfilled membrane-bound labyrinth of the inner ear, these crystals eventually settle in along the lower arc of the posterior semicircular canal. Similar to the U-bend under a sink, this is the most gravity dependent portion of the inner ear. During a provocative positioning maneuver where the posterior canal is tilted back, these micro-crystals float away from the sensory organ of the posterior canal, mimicking the fluid dynamics of an intense and sustained backwards cartwheel. Neural signals to the brain, fooled by this powerful stimulus, signal compensatory eye movements that direct a compensatory downward movement. However, the globe of the eye cannot continue to rotate indefinitely, and therefore another centrally mediated eye movement re-centers the eye. Quick repetition of these two opposing eye movements produces the seesaw pattern that is clinically termed nystagmus. In the case of BPPV, the nystagmus is upward beating (keeping in mind that nystagmus is named for the quick phase, which is the re-centering of the globe) and geotropic (the rotational component is directed towards the ground), when in primary gaze (looking straight ahead). Many other pathological processes can cause dizziness. Ménière’s disease is characterized by discreet attacks of spinning vertigo, fluctuating and progressive hearing loss, tinnitus, and ear fullness. While distension of the endolymphatic compartment of the inner ear is a consistent pathologic finding, the cause of the disorder remains a mystery. In superior canal dehiscence syndrome, a bony defect overlying the superior semicircular canal alters inner ear fluid dynamics, resulting in WWW.SFMS.ORG

a curious set of symptoms, including sound induced vertigo, and supra-threshold hearing to internal sounds. Therefore, normally inaudible sounds, like eyes moving or heart pulsing, are heard. In vestibular neuritis, sudden malfunction of the balance nerve resulting in a stark asymmetry of neural input between the two ears. This creates a spurious percept of intense rotation that generally subsides over a few days as the brain adapts. The list of vestibular maladies goes on. In summarizing this whirlwind tour of vertigo (pun intended), a few important features should be emphasized. Since the sensation of dizziness can be produced by the malfunction of several different organ systems, a little effort in understanding the patient complaint can go a long way in determining the most appropriate pathway of care. BPPV is common, especially in the elderly, and is effectively treated in the office without medications or surgery, and therefore familiarity is recommended. Migraine is also incredibly common, and is underappreciated as a cause of episodic dizziness. Finally, in many cases referral to a vestibular specialist can be helpful in advising patient care. With a careful and thoughtful team approach, most patients do achieve significant relief from their vertigo, which can drastically improve quality of life. Jeffrey Sharon, MD, is an Assistant Professor in the Otology, Neurotology, and Skull Base Surgery division, and he is also the Director of the Balance and Falls Center in Department of Otolaryngology–Head and Neck Surgery (OHNS) at the University of California, San Francisco. He received his medical degree from Mount Sinai School of Medicine in New York, New York. He completed both his one-year internship and his OHNS residency at the Barnes-Jewish Hospital/Washington University School of Medicine, Saint Louis, Missouri, followed by a Otology, Neurotology, and Skull Base Surgery fellowship at the Johns Hopkins School of Medicine, Baltimore, Maryland. Dr. Sharon is a member of the American Academy of Otolaryngology-Head and Neck Surgery, the American Auditory Society, and the American Neurotology Society. His research interests include patient outcomes in vestibular disorders, including vestibular migraine, superior canal dehiscence syndrome, and Ménière’s disease. In addition, he has published research on patient safety in lateral skull base surgery, magnetic resonance imaging in the setting of cochlear implantation, and osteoradionecrosis of the skull base. JANUARY/FEBRUARY 2017 SAN FRANCISCO MEDICINE


Otolaryngology/Head and Neck

ALLERGIC RHINITIS Updates in Diagnosis and Management Emily Kane, NP, and Man-Kit Leung, MD Did you know that allergic rhinitis is present in approximately twenty-five to thirty percent of the U.S. population? In fact, allergies are the sixth leading cause of

chronic disease in this country, costing the healthcare system eighteen billion dollars annually. Research shows uncontrolled symptoms of allergic rhinitis lead to 3.4 million days lost from work, 2.2 million days lost from school, and over twenty-two million visits to the doctor’s office annually.1 Allergic rhinitis is also associated with acute and chronic conditions such as rhinosinusitis, otitis media, Eustachian tube dysfunction, conjunctivitis, laryngitis, asthma, atopic dermatitis, and sleep apnea. It’s very likely that you’re seeing these patients in your clinic on a routine basis.

What Is Allergic Rhinitis?

Allergic rhinitis is a type 1 IgE-mediated hypersensitivity, often inherited, in which the immune system reacts to harmless substances when they are inhaled. The nose filters airborne particulates such as seasonal pollens, pet dander, mold spores, and dust mite matter. Patients with allergic rhinitis react to these harmless substances, or inhalant allergens, as though they are “enemy invaders,” like a virus or bacteria. When allergens bind to IgE-receptors on mast cells, these cells release histamine into the blood and incite the allergic cascade. Common signs and symptoms of allergic rhinitis include repeated sneezing, runny nose, postnasal drip, nasal stuffiness or itching, itchy/watery eyes, dark circles under the eyes, a crease across the bridge of the nose, diminished or lost sense of taste/smell, recurrent ear and sinus infections, chronic fatigue or “foggy” feeling, coughing or wheezing, and cold symptoms that linger for longer than ten days. If these symptoms persist in your patients, consider further evaluation and treatment of allergic rhinitis.

How Is Allergic Rhinitis Diagnosed?

Clinical diagnosis is made by taking a comprehensive patient history and performing a physical examination. Identify patients’ symptoms and determine which symptoms are most bothersome; what triggers and alleviates their symptoms; whether symptoms coincide with seasonal changes or if they occur year-round; what exposures do patients have at home or work, such as pet dander, dust, or mold; if there is a family history of allergies; what medications have been tried and which ones are effective; and how symptoms impact overall quality of life. In addition to a thorough history, administering a validated questionnaire called the SNOT-20 may be useful in measuring the severity of your patients’ sino-nasal symptoms. Physical manifestations of allergic rhinitis may affect the 12

eyes, ears, nose, throat, and chest. Ocular findings may consist of watering, scleral injection, cobblestoning of conjunctivae, allergic shiners, and Dennie’s lines. Allergic rhinitis may cause sneezing and itching, facial grimacing from nasal pruritus, as well as transverse crease formation on the external nose. Intranasally, mucosal lining may appear edematous with clear watery rhinorrhea, and nasal turbinates tend to appear bluish and boggy. Clear drainage with or without lymphoid hyperplasia is often seen on the pharyngeal wall in allergic patients. Asthma is the most common lower respiratory manifestation of allergic rhinitis. Untreated allergies may worsen over time, may lead to the development of more allergies, and may also lead to asthma. The most common and most sensitive way to confirm IgEmediated allergic disease is through allergy skin-testing, an invivo challenge test. With this testing method, the skin is pricked and a droplet of allergen is applied. Mast cells reside in the subepithelial layer of the skin and when sensitized mast cells are exposed to an allergen, chemical mediators are released and a wheal and flare response with itching occurs. Sometimes intradermal testing is performed following skin prick testing for additional sensitivity. The offending allergen(s) is identified within thirty to sixty minutes. Positive and negative controls should always be included in the skin prick testing to ensure test accuracy. Allergy skin-testing should be performed in a specialist’s office, with personnel trained in prompt recognition and management of adverse reactions, including anaphylaxis. Not all allergic patients are candidates for allergy skintesting. In-vitro testing is a blood test alternative that measures allergen-specific IgE in the serum. This testing should be considered for patients with the following skin-testing contraindications: severe or uncontrolled asthma, a history of anaphylaxis, dermatographism or other dermatologic conditions, patients who are unable to come off of certain medications that may in-


hibit the skin response (antihistamines, H2 blockers, tricyclic antidepressants, and some sleep medications), patients on beta blockers (which may make anaphylaxis more difficult to treat), patients with extensive tattoos, and patients who are uncooperative. When compared with skin prick testing, in-vitro testing correlation varies with individual allergens and can range from less than fifty percent to greater than ninety percent.2 Clinical correlation is necessary, particularly with negative in-vitro testing, as in-vitro testing has a lower specificity compared to skintesting.

Who Is A Candidate For Allergy Testing?

When allergic rhinitis is suspected, the clinician should refer the patient for IgE-specific testing when attempts to control symptoms have been unsuccessful, when the diagnosis is uncertain, or when knowledge of the specific causative allergen is needed to target therapy.3 The minimum age for inhalant allergy testing is around five or six years old, and there is no maximum age.

What Treatment Options Exist?

Treatment of allergic rhinitis includes allergen-specific avoidance measures, appropriate pharmacotherapy, and possible immunotherapy. Environmental control measures, such as placing dust mite covers on bedding and using HEPA air purifiers, can reduce a patient’s exposure to allergens. While strict avoidance of allergen exposure is not always possible, there are multiple ways in which patients can curtail exposures. The bedroom tends to be the most important place to reduce allergen exposure given how much time is spent there. Keeping pets out of the bedroom reduces exposure to allergenic dander. Dust mites thrive in warm, humid environments and in places such as bedding, drapes, upholstered furniture, and carpet. Removing carpet and replacing with hardwood floors where possible is recommended. The use of a dehumidifier (keeping humidity less than fifty percent), dust mite acaricides, washing bed linens in hot water (>130 degrees Fahrenheit) weekly and encasing pillows, mattresses, and box springs in dust mite-proof covers should also decrease allergen exposure. Some data has shown that use of dust mite-proof covers alone is insufficient to effectively reduce exposure to dust mite matter, and therefore a more comprehensive approach is recommended.4 On days with high pollen counts, allergic patients can minimize pollen exposures by keeping windows closed, drying clothes inside, staying off grass, and showering/washing clothes after having spent significant time outdoors. Mold may grow indoors after spores land on a wet surface so patients should guard against and clean any noticeable mold growth in basements, bathrooms, closets, and refrigerator drip trays. Pharmacotherapy can help temporarily control or mask symptoms of allergic rhinitis. The American Academy of Otolaryngology-Head And Neck Surgery (AAO-HNS) recommends oral second-generation/less sedating antihistamines (such as loratadine, cetirizine, and fexofenadine) and topical nasal steroid sprays (such as fluticasone) as first-line treatment. Antihistamines are recommended for symptoms such as sneezing, itchy/ watery eyes, runny nose and posterior nasal drainage. Topical WWW.SFMS.ORG

nasal steroid sprays target tissue inflammation/congestion as well as nasal drainage. Additional medical options include topical antihistamine sprays (azelastine, olopatadine), oral and topical decongestants (pseudoephedrine, oxymetazoline respectively), leukotriene modifiers (montelukast, zileuton), and anti-IgE omalizumab injections (not FDA-approved for allergic rhinitis alone; expensive and administered in select patients with allergic asthma and chronic idiopathic urticaria). Oral decongestants such as pseudoephedrine may be more helpful than nasal steroid sprays for moderate to severe congestion and facial pressure. Leukotriene modifiers are not a firstline treatment for allergic rhinitis but may be useful for the later-phase reaction of the allergic cascade. They work gradually to reduce inflammation/constriction in both the upper and lower airways, reduce mucus and fluid production, and are most often targeted toward patients with asthma. Saline irrigations may benefit allergic patients by rinsing out inhaled particulates and soothing intranasal mucosa. Patients with evidence of IgE-specific antibodies to clinically relevant allergens with persistent disease burden despite allergy avoidance strategies and use of pharmacotherapy should be considered for immunotherapy. Patients ranging in age from five or six to elderly age may be candidates for immunotherapy. This treatment, which is administered either through subcutaneous injections in the clinic (SCIT) or sublingual drops or tablets at home (SLIT), is the only scientifically proven way to reduce the immune system’s propensity to react to allergens. The selection of allergens for use in immunotherapy is based on patient clinical history, IgE-specific antibodies, and allergen exposure. Vials of allergenic extracts are prepared individually for each patient, to customize treatment specific to the patient’s identified allergen sensitivities. The clinician should review with the patient the risks, benefits, costs, and dosing schedules associated with immunotherapy before initiating treatment. Immunotherapy is effective approximately eighty percent of the time in patients who are receiving their appropriate major allergens at appropriate intervals and for an appropriate length of time. SCIT injections are administered in the clinic weekly during the buildup phase, which may last up to six months. During the buildup phase, patients are given increasing amounts of allergen(s) for the purpose of desensitizing the immune system to allergy symptoms and Ig-E mediated inflammation. Once maintenance dosing, or maximum-strength concentration, is achieved, the time in between injections is gradually increased until injections are administered once monthly. Patients continue on this therapeutic dose for the duration of treatment: three to five years. SLIT has a more favorable safety profile and drops may be escalated more rapidly, with buildup phase completion in one to twelve weeks. Patients administer drops of allergenic extract underneath the tongue and hold in place for two minutes before swallowing. The convenience of administering treatment outside of the clinic, as well as the increased safety profile make SLIT an attractive option for many patients. However, the U.S. Food and Drug Administration (FDA) still considers SLIT drops an “off-label” use of the SCIT serum, and most insurance companies do not currently cover its treatment cost which usually fall between sev-

Continued on page 15 . . .



Otolaryngology/Head and Neck

HEARING AID TECHNOLOGY Enhanced Speech in Noise Intelligibility and Wireless Connectivity Quentin P. Kennedy, AuD Device manufacturers continue to research and heavily market noise attenuation features, accessories, and promote design updates, but how do healthcare providers and consumers know which are truly beneficial? From rechargeable hearing aids, to

remote microphones, to frequency lowering algorithms, this article is intended to inform the reader of current and effective technology. Ponder this: By virtue of electronically modifying sound, hearing aid output is an intentionally distorted signal. Ultimately, the output is processed by the delicate and compromised sensory cells of the cochlea. Therein lies a problem: the damaged auditory system is left to make sense of a distorted signal. Some hearing aid features have managed to overcome the problem of compromised speech intelligibility, while some provide questionable benefit. Hearing aid manufacturers have addressed the problem of speech intelligibility using 1) directional microphones (DMs), 2) digital noise reduction (DNR), and 3) frequency lowering. DMs aim to improve signal to noise ratio, and therefore speech intelligibility, by enhancing sound received from an anterior microphone and reducing sound received from a posterior microphone. DMs show small but demonstrative improvements in the literature, and are now widely available from all manufacturers, even for entry-level devices. Different than DMs, DNR attempts to improve speech intelligibility by removing non-speech sounds. Even though hearing aid manufacturers charge a premium for enhanced DNR, there is little evidence to support its efficacy. Over the last decade, research has concluded questionable benefit with regard to speech perception when comparing devices with varying DNR sophistication.2,3 Another study has led to a similar conclusion for a pediatric cohort.5 While recent improvements in binaural coordination (inter-ear communication) might contribute to enhanced speech intelligibility as a result of DNR, more research is needed to declare conclusive benefit. Frequency lowering is a feature aimed at restoring clarity for those with cochlear dead regions. Non-functional “dead” sensory cells are those that once encoded high frequency information and have often been damaged by loud noise exposure or aging. The highest frequency sounds are lowered so that the preserved low frequency-responsive cells can encode the signal. Recent studies have concluded that frequency lowering contributes to improved speech intelligibility.1,5 This feature is now commercially available through select manufacturers. In addition to enhanced processing algorithms, wireless features also continue to improve. Remote microphones are now smaller and more widely available. These assistive devices 14

improve signal to noise ratio by transmitting speech received by a lapel microphone directly to the listener’s hearing aids. The device allows the signal to bypass distracting sounds, better preserving dominant speech. This technology is available through major manufacturers and is appropriate for those who have continued difficulty listening in group settings, even after optimal hearing aid fitting. For healthcare providers with hearing loss, Bluetooth® stethoscopes are becoming more prevalent as each major hearing aid company has developed wireless binaural streaming capabilities. The benefit of hearing aid compatible stethoscopes is in ease-of-use; healthcare providers need not remove or bump their hearing aids when placing stethoscope earpieces. That said, the providers that are most interested in the nuances of cardiac or respiratory acoustics may prefer traditional analog or amplified stethoscopes because these devices are more likely to occlude the ear canal, preventing spill-out of important bass frequencies. Other worthwhile wireless advances include binaural streaming for telephone use and smaller and more efficient CROS (contralateral routing of signal) devices. A CROS device transmits sound from the poorer to the better ear in cases of single-sided or asymmetric hearing loss. Previous generations of CROS devices were bulky and came with complaints of distortion, short battery life, and connectivity issues. Each of these issues has improved with recent updates. Binaural telephone use is advantageous because it encourages redundancy in the signal, and the brainstem supplies a natural 3 dB voltage boost when similar inputs are received from both ears. Perhaps one of the most anticipated improvements to hearing aid technology came in 2016 with the advent of fully rechargeable small behind the ear hearing aids. Frustration with battery size and longevity are improved with this technol-


ogy. Consumers will likely see rechargeable devices available in a wider variety of sizes and styles in the next few years. Fully waterproof hearing aids became available in 2014, and general dust and moisture resistance improvements contribute to increased device longevity. Although recent studies have suggested that otoprotective agents may lessen the toxic effects of loud noise exposure and chemotherapy medications, modern science lacks a magic pill to reverse inner ear hearing loss.4 In the absence of medical intervention, amplification is the primary treatment method for cochlear deficits. With improvements in speech intelligibility and features to promote ease of use, hearing aid manufacturers have come a long way, but as long as amplification is the standard of care, the world of hearing aids will continue to see refinements to technology. Quentin Kennedy, AuD, holds a BA in physics from Carleton College, Northfield, MN, and is a 2013 graduate of Northwestern University’s Doctor of Audiology Program. He has a special interest in musician’s hearing and hearing conservation, has been an editor of medical writing for the American Hearing Research Foundation, and is a dispensing audiologist at San Francisco Ear Nose and Throat Medical Group Inc. He has recently been a guest lecturer for the Pacific Voice Foundation and The San Francisco Conservatory of Music.

References 1. Alnahwi M, AlQudehy ZA. “Comparison between frequency transposition and frequency compression hearing aids.” Egypt J Otolaryngol 31 (2015): 10-18. 2. Bentler, Ruth A. “Effectiveness of directional microphones and noise reduction schemes in hearing aids: A systematic review of the evidence.” Journal of the American Academy of Audiology 16.7 (2005): 473-484. 3. Bentler, Ruth, et al. “Digital noise reduction: Outcomes from laboratory and field studies.” International Journal of Audiology 47.8 (2008): 447-460. 4. Campbell, Kathleen CM, et al. “Prevention of noise-and drug-induced hearing loss with D-methionine.” Hearing Research 226.1 (2007): 92-103. 5. McCreery, Ryan W. et al. “An Evidence-Based Systematic Review of Directional Microphones and Digital Noise Reduction Hearing Aids in School-Age Children With Hearing Loss.” American Journal of Audiology 21.2 (2012): 295–312, 313-328. doi:10.1044/1059-0889(2012/12-0015).


Allergic Rhinitis Continued from page 13 . . . enty to one hundred dollars per month. The duration of treatment for SLIT drop treatment is also three to five years. The U.S. FDA recently approved three SLIT tablet products in 2014 for treatment of pollen-induced allergies. The tablets include Ragwitek for the treatment of ragweed pollen allergies, and Oralair and Grastek for treatment of grass pollen allergies. A SLIT dust mite tablet in is clinical trials at this time. The tablets only treat one kind of allergen whereas with SLIT drops or SCIT serum, multiple allergens may be treated simultaneously. As with SLIT drops, SLIT tablets are safely administered at home and are given either co-seasonally or continuously throughout the year. Research over the last twenty years has shown that both SCIT and SLIT are relatively safe and effective options for desensitizing the immune system to IgE-mediated hypersensitivities, however more research is needed to establish comparison between the two routes of administration. Patients receiving immunotherapy should follow up routinely with their physicians every six to twelve months to assess efficacy, reinforce safety protocols, monitor for adverse reactions, assess compliance, adjust dosing if necessary, and to determine when therapy may be discontinued. All patients on immunotherapy should be prescribed an epinephrine autoinjector in the rare event of anaphylaxis.


Allergic rhinitis is a common, chronic respiratory condition that affects millions of patients annually. Treatment options exist to reduce disease burden including environmental control measures and allergen avoidance, pharmacotherapy, and immunotherapy. The clinician and patient should develop treatment strategies based on the patient’s severity of symptoms and lifestyle considerations. Emily Kane, NP, is a nurse practitioner with over a decade of experience directly treating patients with inhalant allergies. She currently manages the Allergy Clinic at San Francisco Ear Nose Throat medical group. Man-Kit Leung, MD, is a Fellow of the American Academy of Otolaryngic Allergy, Director of the Allergy Clinic at San Francisco Ear Nose Throat medical group, and president of the SFMS.

References 1. Koberlein. Curr Opin Allergy Clin Immunol 2011;11:192-199. 2. Bernstein, L. et al. “Allergy Diagnostic Testing: An updated practice parameter.” Annals of Allergy, Asthma, and Immunology. March 2008; 100:S44. 3. Seidman, M. et al. “Clinical Practice Guideline: Allergic Rhinitis.” Otolaryngology Head Neck Surg. February 2015; vol. 152 no.1 suppl S1-S43. 4. Custovic, A. and van Wijk, R. G. “The effectiveness of measures to change the indoor environment in the treatment of allergic rhinitis and asthma: ARIA update (in collaboration with GA2LEN).” Allergy, 60: 1112–1115 (2005). doi:10.1111 /j.1398-9995.2005.00934. JANUARY/FEBRUARY 2017 SAN FRANCISCO MEDICINE


Otolaryngology/Head and Neck

NASOPHARYNGEAL CARCINOMA Epidemiology and Advances and Its Relevance in The Bay Area Alexander B. Geng, MD Nasopharyngeal carcinoma (NPC), a malignancy arising from the nasopharynx, is a relatively rare tumor in the U.S. overall. Its incidence ranges from 0.5 to 2

per hundred thousand. However, in the arena of oncologic care in San Francisco and the Bay Area at large, this is a very important illness that affects many patients, particularly in immigrant populations from Southern China and its nearby regions. NPC is endemic in Southern China with incidence up to twenty-five cases per hundred thousand persons per year. Elevated incidence is also seen in the Middle East and North Africa. The Bay Area is home to a diverse population, including many immigrants from endemic regions and people with ancestry from endemic areas. In my oncology practice, NPC is one of the two most common cancer diagnoses in middle-aged and older adult men of Southern Chinese or Southeast Asian ancestry. Though to a lesser extent, it also disproportionately affects women of a similar immigration background and ancestry. To understand NPC in the Bay Area, one must examine data from endemic regions where sample sizes are much larger. NPC in endemic regions features a bimodal age-related incidence with its primary peak incidence in late middle age to early advanced age. A secondary increase in incidence is seen in late teens and early adulthood. NPC afflicts men and women at a two-to-one ratio. Fortunately, incidence and mortality have been decreasing in endemic areas in the last two decades thanks to earlier diagnosis, advances in curative modalities of radiotherapy, and systemic therapy.

What is the risk of NPC in the San Francisco Bay Area then? Compared to the population in the endemic area, the portion of Bay Area residents who emigrated from the same regions continues to have an elevated incidence of NPC. However, this risk decreases with increasing time away from the endemic area. Additionally, the risk decreases significantly with each successive generation in the U.S. The etiology and risk factors of NPC are complex. In the U.S., in populations with no connections to endemic areas, the risk of NPC is closely associated with classic and general risk factors that increase head and neck cancer risks, such as smoking and alcohol use. Nasopharyngeal cancers in such patients often show a keratinizing squamous cell carcinoma histology (WHO Type I). This is quite distinct from the most common histology of NPC in endemic areas, which is a non-keratinizing undiffer16

entiated type (WHO Type III). It is no coincidence that the latter type (Type III) is also the dominant histology of NPC seen in the Bay Area. Such a difference in histology is likely at least in part due to distinct contributing factors in tumorigenesis in endemic areas, where at least three factors have been investigated and identified. Epstein-Barr Virus (EBV) infection, genetic predisposition, and environmental factors likely engage in complex interactions through which they contribute to the high incidence. EBV, in particular, has been extensively studied in nasopharyngeal carcinoma. Tumor cells are frequently found to harbor the viral genome and express viral proteins, which led to strategies of screening and treatment directed at the virus. Studies of precancerous lesions have revealed genetic alterations and their association with EBV infections, suggesting an important role of EBV infections in malignant genetic transformations. Observation studies and case control studies revealed a strong familial association, suggesting genetic predisposition. One such study observed a seven-fold increase in risk if a first degree relative develops NPC. Environmental factors such as regular consumption of salted meat and fish have been found in endemic areas and postulated to contribute to carcinogenesis due to increased nitrosamine content in such food. NPC often arise from the fossa of the Rosenmuller, a posterolateral recess in the nasopharynx. Due to its relative inaccessibility and this tumor’s propensity for early nodal metastasis, symptoms at diagnosis are not often caused by the primary tumor alone. Otalgia (referred pain), neck mass (nodal metastasis), dysphagia (cranial nerve palsy or tumor related obstruction), headache, and facial numbness (maxillary nerve involvement) are frequent complaints. Epistaxis and nasal congestions due to an enlarging primary tumor in the nasopharynx are also relatively common. The mainstay of treatment is radiotherapy, delivered with a curative intent for both early and advanced stages of NPC. Radiotherapy achieves excellent locoregional control of early stage NPC. Patients can expect a ninety percent, five-year overall survival after treatment. In advanced stage NPC, radiotherapy is highly effective in providing locoregional control as well. However, survival decreases to eighty percent or less due to a higher incidence of distant metastatic disease. This led to investigations of the use of chemotherapy. Clinical trials in the last twenty years further refined treatment strategies and showed that chemotherapy, when added concurrently to a course of radiotherapy, can further improve disease control and median survival by approximately ten percent, bringing ten-year overall survival to nearly sixty percent even in very advanced stages of NPC (Stage IV A and IV B), quite an impressive feat in cancer care.


As overall survival and tumor control increase, a shift in focus in NPC treatment is toward reducing treatment toxicity. Radiotherapy technology and techniques underwent rapid and tremendous changes in the last twenty years with a transition from 2D radiotherapy to the widespread use of 3-Dimensional Conformal Radiotherapy (3D CRT), followed by the advent and standardization of Intensity Modulated Radiotherapy (IMRT). With each evolution of treatment technique from 2D to 3D, then to IMRT, radiation oncologists gained greater control over the distribution of ionizing radiation in the treatment fields to maximize tumoricidal doses of X-ray into the cancerous lesions and high risk regions while maximally avoiding the numerous critical structures in the head and neck region, such as the retina, lens, pituitary, brain parenchyma, salivary glands, temporomandibular joint, larynx, oral cavity, and uninvolved mucosal surface in the alimentary tract, etc. Surgery, though not often utilized in the primary treatment setting of NPC in today’s care, continues to play an important role in managing residual metastatic lymph nodes in the neck after radiotherapy and chemotherapy. Surgery is also used in salvaging isolated recurrence in the neck or in the nasopharynx. On the horizon of cancer treatment is the frontier of molecular targeted therapy. They have shown great effects in lung, colon, and breast cancers among many others. These agents target specific molecular pathways critical to the self-sustaining and growth mechanisms of tumors and tend to be less toxic than conventional chemotherapy. In NPC, a number of well-known molecular targeted agents, such as cetuximab and bevacizumab, are under investigation. In addition, immunotherapy, such as toll-like receptor (TLR) agonists and checkpoint inhibitors, is a highly active and intense area of translational and clinical research with the understanding that NPC’s tumorigenesis is closely associated with the EBV virus. I will end our discussion on a final note regarding the latest advance in radiotherapy technique and its evolving role in managing recurrent cancer. This technique has been variously called radiosurgery, Stereotactic Ablative Radiotherapy (SABR), or Stereotactic Body Radiotherapy (SBRT). SABR is a non-invasive technique that features an extremely sharp radiation dose falloff from the prescription radiation dose inside a tumor to the immediately adjacent normal tissue surrounding the tumor. Combined with its submillimeter accuracy, SABR is a platform of radiotherapy that greatly increases the therapeutic ratio while further minimizing treatment toxicity. Its application in NPC is currently defined in clinical scenarios that involve difficult retreatment, or treating metastatic disease to the brain, spine or other critical locations. Nasopharyngeal carcinoma is a cancer of unique significance to the San Francisco Bay Area due to our diverse population from many regions of the world. Its carcinogenesis is multifactorial with EBV playing a central role in the dominant histology (WHO Type III) in the Bay Area. Tumor control and overall survival have improved over time while toxicity decreased, due to advances in treatment techniques of radiotherapy. The addition of concurrent chemotherapy to radiotherapy further enhances tumor control and improves survival. WWW.SFMS.ORG

Alexander B. Geng, MD is a radiation oncologist, specializing in Stereotactic Radiosurgery (SRS) and Stereotactic Ablative Radiotherapy (SABR). He is the Medical Director of the CyberKnife Radiosurgery Center at Saint Francis Memorial Hospital, and serves on faculty for the Radiation Oncology Residency Program at California Pacific Medical Center. Dr. Geng received his medical doctorate from University of California, San Diego, School of Medicine. He completed his internship in internal medicine at St. Mary’s Medical Center, and served as chief resident at California Pacific Medical Center where he completed his radiation oncology residency. Dr. Geng completed specialized SRS and SABR training at Stanford University and University of California, San Francisco.

Don’t Lose Your SFMS Benefits – Renew Today! Make sure you continue to receive the benefits of SFMS and CMA membership by renewing before the March 1st drop date. There are three easy ways to renew your dues: • Mail/fax your completed renewal form when you receive it in the mail; • Renew online at www.sfms.org with your credit card; or • Enroll in Easy Pay Automatic Dues Renewal Plan* (quarterly installments) by contacting SFMS at (415) 5610850 or membership@sfms.org. *Easy Pay Automatic Dues Renewal Plan (quarterly installments) is available to full dues-paying members only.



Otolaryngology/Head and Neck

HPV-ASSOCIATED THROAT CANCER The Role of Transoral Robotic Surgery William R. Ryan, MD, FACS The rise of human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (HPV-OPSCC) (a form of throat cancer) has coincided with the emergence of the use of transoral robotic surgery (TORS). HPV-OPSCC is one of the fastest growing cancers

in incidence in our population with rates that are surpassing that of cervical cancer. The HPV-OPSCC epidemic has been met with intense new attention by various practitioners, researchers, medical societies and the press. The good news is that the disease appears to be relatively controllable with approximately eighty-five to ninety-five percent cure rates for even advanced stages with the various forms of treatment available. The cure rate is significantly higher for advanced cases (approximately thirty percent better) in comparison to the non-HPV type of OPSCC that is highly associated with smoking and alcohol intake. This cure rate coupled with the relatively younger age of many of the afflicted patients (resulting in many collective life years to live) has motivated the push for deintensification of treatments with the hope of improving quality of life while hopefully achieving similar control rates. Traditional open surgery through the neck tissues has played a role over the last few decades for oropharyngeal cancer but has really been secondary to concurrent chemoradiation for advanced stage cases given the morbidity of surgery. TORS is now positioned well as a less morbid therapy in not only providing a less invasive surgical approach but also in potentially reducing the dose of or even the need for radiation and also potentially sparing patients the need for chemotherapy all together. HPV generally afflicts the oropharynx and/or genitals of most people during their nascent sexually active years. Approximately eighty to ninety percent of patients clear the infection rarely without any perceptible manifestations of the disease within two years of inoculation. A very small percentage of those that harbor the virus ever develop cancer. Moreover, the time from exposure to the development of cancer appears to be at least fifteen to twenty years. For unclear reasons, HPV-OPSCC generally arises in the lingual tonsil tissue of the base of tongue (back part of the tongue) or the palatine tonsil tissue (lateral mouth). Approximately ninety percent of cases present with neck lymph node metastases and a primary site of the cancer in the throat that is relatively small and usually asymptomatic. Given the lymph node metastases, most patients are treated as “advanced stage� cancers. However, given the generally favorable prognosis, efforts are underway to reclassify the stage of varying presentations to better reflect the less aggressive biology and natural history of the disease. TORS has emerged as an effective and reproducible treat18

ment mode for various tumors of the upper aerodisgestive tract, especially for oropharyngeal cancer. The current Da Vinci robot produced by the company Intuitive Surgical, Inc. (Santa Clara, CA), has three arms for use in transoral situations, with the central arm holding an endoscopic camera and the other two holding various instruments. The robot arms are inserted through the mouth to access the oropharynx and larynx for improved visualization and manipulation of structures beyond the physical impediment of the curvature of the tongue. The surgeon controls the surgical robot via a remote console across the room from the patient. An assistant is also able to sit at the patient’s bedside providing instrument action with both arms in between the robot arms. Tumor excisions can thus be performed with reasonable agility in the confined spaces of the throat and voice box area. This approach helps avoid the operations traditionally performed through the neck that violated the swallowing muscles and thereby resulted in increased risks of long term major swallowing dysfunction (and possible gastrostomy tube dependence) as well as blood loss, poor wound healing, infection, need for a tracheostomy, and other complications. Currently, most high volume surgeons in the burgeoning TORS field propose the following indications for TORS: smaller cancers (T1-T2 (0-4 cm) tonsil or base of tongue) that do not cross midline and have a low risk of having positive margins surgically. Multiple studies have shown the safety and efficacy of these operations to the point where TORS equals that of definitive radiation or chemoradiation in terms of disease control and survival. Currently national guidelines (in particular those by the National Comprehensive Cancer Network (NCCN)) give patients with early stage oropharyngeal cancer (HPV+ or not) the choice of surgery alone or radiation alone given the similar cancer control rates and patient survival. Personally, my philosophy and usual recommendation in this situation is for TORS first with the exceptions being when the tumor appears too large or deep to confidently excise fully without a positive margin or the patient is either medically not suitable for a general anesthetic or personally favors radiation. For early stage, the surgery would involve a TORS with an elective neck dissection (or a removal of the at-risk lymph nodes for microscopic cancer spread), unilaterally for tonsil cancer and bilaterally for base of tongue cancer. Most of the time, the lymph nodes are found not to have microscopic cancer (approximately eighty percent) and negative margins are achieved (approximately ninety percent). In this situation, the patient can then be spared radiation all together. I think this is a big win for the patient. Radiation to the head and neck area, and particularly the back of the mouth, is a five days a week for six to seven weeks process with several difficult acute and


chronic side effects and risks, including difficulty swallowing, dry mouth, potential significant jaw bone/spine bone damage, and even the small chance years later of radiation induced cancers. The impact of surgery when done well has minimal impact on the patient’s quality of life. For more advanced staged HPV-OPSCC, when the tumor is unlikely to be resected fully with a negative margin or there is definite invasion of the lymph node metastases into neck anatomic structures, I believe chemoradiation is currently a better treatment modality given it’s preservations of anatomic structures. But if the oropharynx tumor can be confidently resected fully and the neck metastases appear radiologically confined to the lymph nodes, the patients have a choice between surgery with a possible/likely lower dose radiation or higher dose chemoradiation based on the NCCN guidelines and current medical literature. This choice is difficult and complex for physicians and most of all patients. Currently, the chemoradiation treatment route is still more commonly used throughout the country and the world for advanced oropharyngeal cancer. But it may be time for select patients to be considered for robotic surgery first. Given the equivalent survival metrics (disease free, disease specific, and overall survival), TORS with whatever adjuvant treatment is necessary based on the histopathologic stage offers a few unique advantages compared to chemoradiation beyond potentially avoiding the toxicities of chemotherapy: Surgery alone including the hospitalization is approximately half the cost of radiation alone and a fifth the cost of chemoradiation. Surgery and postoperative radiation is about half the cost of chemoradiation. Surgery of any kind brings the histopathologic analysis and the staging information it provides. Physical exam and radiologic staging are only so accurate in predicting final pathologic staging with an approximately sixty to eighty percent predictive ability of depending on the specific situation. Thus, making decisions based on clinical assessment come with some chance of over-calling (or under-calling) the extent and aggressiveness of a cancer. Surgery alone (without radiation) and surgery with reduced dose postoperative radiation appear to likely have better functional swallowing outcomes compared to high dose definitive radiation (+/- chemotherapy). Because no randomized controlled nor two armed prospective trials exists to compare the functional outcomes (or the survival outcomes) of surgery versus non-surgery for HPV-OPSCC (or non-HPV SCC for that matter), some of the best comparisons are retrospective matched-paired analyses. Such studies that have been performed show significantly better patient-reported swallowing function and lower gastrostomy tube reliance rates (two to three times lower) in the TORS/lower dose postoperative radiation groups versus the higher dose definitive chemoradiation groups. The reduction of radiation dose and the elimination of the chemotherapy even with the presence of surgical scarring are quite possibility the protective measures for improved swallow function. Certainly TORS comes with its own set of drawbacks, including the inherent time, costs, consequences, and complication risks of the operation and hospitalization. The main risk, beyond the rare meaningful inadvertent anatomic injury, is the WWW.SFMS.ORG

possibility of a postoperative hemorrhage, an event that can occur three to even ten percent of cases up to two weeks after surgery. There have even been a few reported deaths from bleeding around the country (deaths have been reported from radiation and chemotherapy as well). One technique that has been implemented to reduce bleeding that has been shown to reduce at least the incidence of catastrophic bleeds is to perform a ligation of the lingual and facial arteries during the neck dissection (removal of neck lymph nodes) portion of the operation. Ultimately, the current choices of surgery versus radiation for early stage or surgery and postoperative reduced dose radiation (+/- chemotherapy) for advanced stage should be made by the patient with guidance of a multidisciplinary team and tumor board. TORS is a great tool to use in select situations in the multidisciplinary context. Also, fortunately, most patients with HPV-OPSCC who received appropriate and careful treatment by physicians with expertise do very well and achieve cure. Future research and innovation are needed and are actively being pursued to optimize the management of this increasingly impactful disease. William R. Ryan, MD, is an assistant professor of head and neck oncologic and endocrine surgery at University of California, San Francisco (UCSF) Helen Diller Family Comprehensive Cancer Center. He directs the UCSF Robotic Head and Neck Surgery program. Dr. Ryan earned his medical degree from Stanford University School of Medicine, where he also completed his residency in otolaryngology-head and neck surgery. Following his residency, he completed a fellowship in head and neck oncologic/endocrine/ skull base surgery at UCSF.

PRINCESS LEIA ULTIMATELY KILLED BY THE REAL DARTH VADER By Stanton Glantz, PhD, UCSF Stuart Kriesman, a Canadian physican, recently published an excellent column making the case that Carrie Fisher's smoking contributed to her early heart attack death. (Most people don't know that smoking causes heart attacks.) He ends with, "Most importantly, recruit Hollywood’s help and take control of smoking’s image—show that it truly is not cool, but instead, a never-ending beauty-and-health-destroying, poverty-inducing, pathophysiological battle against nicotine withdrawal that mostly traps society’s weakest (and least enviable) members. "Maybe Princess Leia can help us defeat true organized evil after all." Read his full article here - http://vancouversun.com/ opinion/opinion-princess-leia-ultimately-killed-by-the-realdarth-vader



Otolaryngology/Head and Neck

OHNS AT UCSF Update on the Otolaryngology-Head and Neck Surgery Department Andrew H. Murr, MD, FACS

It is amazing to consider how far we have progressed in the nearly fifty years since Frank Sooy became the inaugural Department Chair of Otolaryngology-Head and Neck Surgery (OHNS) at the University of California, San Francisco (UCSF). It is

an honor for me to be entrusted with stewardship of the department and a pleasure to provide the San Francisco Medical Society with a current state of affairs. Since I mentioned Frank Sooy, I must start with cochlear implantation (CI) given Frank’s vision for this technology. Our Chief of otology/neurotology is Dr. Charles Limb, who is an international expert in cochlear implantation, and head of the Douglas Grant Cochlear Implant Center. Charles also oversees our children’s programs and has been instrumental in leading UCSF Benioff Children’s Hospital San Francisco and UCSF Benioff Children’s Hospital Oakland in amalgamating their two excellent CI programs. We have grown our otology division dramatically with the addition of Jeffrey Sharon, who is an expert on vestibular otology, and Aaron Tward, who trained in Michael Bishop’s oncogenetics laboratory when he did his work leading to his PhD degree. Steve Cheung continues his close collaboration with our neurosurgical colleagues and concentrates on acoustic neuroma and skull base surgery; he remains busy as a funded investigator with Department of Defense (DOD) support. Our Coleman Laboratory, headed by Christosph Schreiner, is focused on central auditory processing and our Epstein Lab is focused on cochlear physiology. This year, Mike Merzenich traveled to Oslo, Norway to receive the Kavli Prize in neuroscience for his lifetime contribution to our understanding of neural plasticity. The previous year, Mike won the Russ Prize in bioengineering for his pioneering contributions to the development of the cochlear implant. All of this work stemmed from our department’s unwavering contributions to understanding the mechanisms at play in the function of the cochlear implant. Frank Sooy (former UCSF Chancellor) and Robin Michelson (pioneering bioengineering visionary) would be very proud! Bob Schindler (former UCSF Chair and Professor Emeritus) has the privilege of actively enjoying the acknowledgement of the successful and consistent direction of otology research within his old department. While our interest in otology is long standing, our position in pioneering advancement in oncology research is young but vigorous. Renowned scientist Jennifer Grandis joined our department as a Professor of Otolaryngology-Head and Neck Surgery and as Associate Vice Chancellor for the Clinical & Translational Science Institute (CTSI) about two years ago. She moved her head and neck tumor laboratory with her and she 20

is now headquartered at the Diller Building on the Mission Bay campus. We also recruited Patrick Ha, MD, to lead head and neck surgical oncology at the Helen Diller Family Comprehensive National Cancer Institute-designated Cancer Center at UCSF’s new Mission Bay campus. Patrick’s ablative team includes Will Ryan, Chase Heaton, Jonathan George, and Ivan El-Sayed. We have an active robotic surgery program using the latest technology to combat the Human Papillomavirus (HPV) epidemic as it relates to oropharyngeal squamous cell carcinoma. While Jon George concentrates on thyroid and parathyroid tumors, Ivan concentrates on minimally invasive endoscopic anterior skull base tumors in addition to ablative surgery. We also have one of the most prolific and skilled microvascular reconstructive teams in the country headed by Daniel Knott with his partners Rahul Seth and Chase Heaton. These reconstructive surgeons have tremendous experience in closing tumor defects and maximizing swallowing, speech, and communication function. Meanwhile, at the Mt. Zion campus, Knott and Seth also perform aesthetic facial plastic surgery and partner with our colleagues in dermatology to camouflage skin cancer excision defects. Using the resources of our UCSF Tumor Board and close partnerships with Sue Yom in radiation oncology, Alain Algazi in medical oncology, Annemieke Van Zante in pathology, and Christine Glastonbury in neuroradiology, the UCSF team is able to deliver the latest treatment technology—including participation in clinical trials and expert rehabilitation—to patients with challenging cancers. Our rhinology and skull base surgery practice is mature and expert. Led by Andy Goldberg on the rhinology side and Ivan El-Sayed, who is our Chief of Skull Base Surgery, the UCSF team is facile at minimally invasive sinus surgery using advanced approaches to frontal sinus pathology and tumors that cross the dural boundary. Utilizing close partnerships with our neurosurgery colleagues (Aghi, McDermott, Theodosopoulos, and Kunwar), masses that were heretofore thought to be unapproachable are now removed without craniotomies and with short hospital stays, often without extended Intensive Care Unit care. The team is constantly advancing by leveraging its partnership with the skull base surgical approaches laboratory led by Arnau Benet. Additionally, the team advances investigation into the cause of sinusitis. Andy Goldberg, Steve Pletcher, Emily Cope, and Susan Lynch have published landmark articles (including one in Science Translational Medicine) on the contribution of the human biome to sinusitis using advanced polymerase chain reaction (PCR)-based techniques to solve the puzzle of chronic sinusitis. Three other divisions are also worthy of mention. Our laryngology practice headed up by Kathy Yung, MD and our speech and language pathology team with Sarah Schneider at the helm


are extremely busy and extremely expert at managing voice and swallowing disorders. Our institution has also made it easier than ever for professional voice patients to access our practice, even at short notice, to leverage the cutting edge evaluation and treatment encompassed within this departmental division. On the research side, John Houde and Sri Nagarajan use functional imaging technology to help unravel the mysteries of neurological disorders such as dystonias, which can affect speech. If you have not checked our pediatric division lately, check again! UCSF has seven fellowship-trained pediatric otolaryngologists on its staff covering both UCSF Benioff San Francisco and UCSF Benioff Oakland. We have convenient satellites in Marin, Walnut Creek, Brentwood, and San Ramon in addition to practices at our flagship hospitals. Kris Rosbe leads this division, which strives to give the highest level of expert evaluation to tertiary as well as secondary problems affecting children. Finally, our general otolaryngology division remains vigorous including our pioneering hospitalist program led by Matt Russell and our sialendoscopy practice manned by Jolie Chang and Will Ryan. UCSF is the West Coast pioneer in sialendoscopy and runs a well-attended Continuing Medical Education course devoted to disseminating knowledge of this technique, which combines ultrasound and minimally invasive duct cannulation surgery to treat problems such as salivary duct stones and duct stenosis caused by chronic salivary disease. In addition, our Sleep Surgery program, headed by Dr. Jolie Chang with support from Andy Goldberg, David Claman in the sleep lab and our oral maxillofacial surgery colleagues, is involved in cutting edge technology and even some first-in-man clinical trials. Our department has worked very hard to improve access for general otolaryngology patients and we strive to provide highly insightful evaluation in our comfortable and newly renovated office building devoted to our ambulatory practices at the corner of Divisidero and Sutter on the Mount Zion campus. I must also report that our contribution to the Zuckerberg San Francisco General Hospital (ZSFGH) and Trauma Center is stronger than ever. Led by Marika Russell, MD, our team at the brand new and beautiful ZSFGH is vigorously woven into the fabric of the institution. We have a major presence in facial trauma, head and neck oncologic surgery, head and neck endocrine surgery, otology, and general otolaryngology, including rhinology, at the Z. Dr. Patricia Loftus has been newly recruited to ZSFGH, and with her background in rhinology, sinus surgery, and skull base surgery, she brings a new perspective to our team. We have a long and storied contribution to ZSFGH and with Marika Russell as the Chief of Service, we know we will continue our partnership for many years to come. Likewise, we continue to have an excellent team at the San Francisco Veterans Administration Medical Center, led by Steve Pletcher, that continues as a major residency training site and a major clinical practice site. Ultimately, where does the department stand today? We have grown to twenty-seven clinicians and more than fifteen scientists. U.S. News has us ranked eleventh in the nation, and first in Northern California. Using National Institutes of Health grant support as a metric, the UCSF Department of OtolaryngologyHead and Neck Surgery is number one in the United States. For residency training (twenty residents), fellowship training (head and neck surgical oncology, facial plastic surgery, pediatric otoWWW.SFMS.ORG

laryngology), and medical student education, we have an excellent program in a highly mentored environment that sets a high standard for lifting off a successful career. In fact, about twenty five percent of all OHNS programs in the U.S. have a faculty member in OHNS who trained at UCSF. We have a cutting edge perspective on research and the breadth and infrastructure to provide the highest level of service and care to your patients in need of otolaryngology evaluation. Finally, I must congratulate Man-Kit Leung on his leadership of the San Francisco Medical Society. A former UCSF medical student, Man-Kit is a valuable contributor to our community and we are very proud of his dedication and contributions to the society. Andrew H. Murr, MD, FACS, is Professor and Chairman of the Department of Otolaryngology-Head and Neck Surgery at the University of California, San Francisco, School of Medicine.

As of This Month The Uncertain Prognosis for Obamacare ACA/Obamacare architect Ezekiel Emanuel, MD, PhD, spoke at UCSF in January, and gave a somewhat more optimistic picture than many. He has met with President-Elect Trump and said, "He told me he really doesn't want to hurt anybody and just wants a better system, and I believe him. The problem is that it is really unclear what that might mean." The SFMS's Steve Heilig asked Emanuel if "the incoming regime has promised to perform euthanasia on the ACA, is now backing off towards a very invasive procedure such as a heart/lung transplant, but might wind up doing a mainly cosmetic procedure?" Emanuel laughed and replied "That is a hopeful and eloquent scenario that could turn out to be very close to what unfolds." Here is a report from another local talk by Dr. Emanuel: Mercury News: Obamacare's Architect: Five Points About Health Care Reform—In a wide-ranging conversation Wednesday night at the Commonwealth Club in San Francisco, Dr. Ezekiel Emanuel, Obamacare’s main architect, talked about health care reform and the debate over President-elect Donald Trump’s pledge to repeal and replace the Affordable Care Act, which has helped insure at least 20 million more Americans, including five million Californians. Emanuel is still a strong advocate of the law, saying it has contributed to keeping U.S. health care costs more under control than at any time in the last fifty years. But like many other health care experts, he acknowledges room for improvement—and hopes it can now be done a bipartisan fashion.



Otolaryngology/Head and Neck

GETTING THE SMOKE OUT Strategies to Reduce the Impact of Tobacco in Otolaryngology John Maa, MD, FACS Tobacco remains the leading preventable cause of death and disability in America, and is also a key risk factor for the development of head and neck malignancies. The National Cancer Institute reports

that more than seventy-five percent of head and neck cancers are related to the combination of tobacco and alcohol use; according to the U.S. Surgeon General, smoking is causally linked to carcinoma of the oropharynx, larynx, and esophagus. The American Academy of Otolaryngology reports that smoking increases the risk of head and neck cancer by fifteen fold. A number of benign conditions are also exacerbated by smoking, including sinusitis, ear infections, hoarseness and reflux disease, among others. The health hazards also extend to smokeless tobacco, highlighted best by the story of San Diego Padres player Tony Gwynn who attributed his lethal salivary cancer to a lifelong chewing tobacco habit that began as a college baseball player. In 2015 the San Francisco Medical Society successfully advocated for a new San Francisco law to ban the use of all tobacco products at playing fields in San Francisco, and focused on ending the use of chewing tobacco in public by Major League baseball players at AT&T Park. Within the field of otolaryngology, many opportunities exist on the clinical frontlines to reduce nicotine’s deadly toll, by harnessing the powerful "teachable moment" when a patient is diagnosed with a head and neck cancer to finally convince them to stop smoking. At least one-third of patients with head and neck cancers continue to smoke after diagnosis, which increases the risk of developing other tobacco-related illnesses. Active smoking is associated with a higher incidence of perioperative respiratory and cardiovascular complications than in non-smokers, and can contribute to cancer recurrence, reduced treatment efficacy, and increased toxicity and side effects of adjuvant radiotherapy and chemotherapy. Cigarette smoke contains more than 4000 toxic compounds, many of which impair wound healing and may lead to the need for reoperation after failed reconstructive procedures. Studies have demonstrated that smoking cessation can reduce the rate of wound complications, infections, and impaired wound healing observed after flap reconstruction and plastic surgical procedures. The burden of smoking on the healthcare system translating into increased costs results from poorer surgical outcomes, reduced survival, prolonged hospital stay and increased rates of hospital readmission, increased risks of respiratory failure and the need for reintubation/prolonged ICU stay, and the need for reoperation. Quitting is associated with reduced pain, higher quality of life, and better performance status, but can be particularly challenging in the head and neck patient population. Cancer treatment in the oropharynx can result in difficulty eating, mucosi-


tis, and a dry mouth that may limit the effectiveness of standard cessation aids such as nicotine gum, lozenges, and inhalers. Limited studies have suggested that high-intensity, multi-component tobacco control interventions are best for cessation, including healthcare professional and physician counseling and guidance, support groups, and behavioral therapy, but more research needs to be funded. One of the core benefits of the passage of Proposition 56 (the two dollar cigarette tax championed by the SFMS) in November 2016 is a substantial increase in research funding for the UC Office of the President Tobacco Related Disease Research Program, which can support future clinical research grants in smoking cessation. A dual benefit form Prop 56 is the expansion of MediCal funding, which will help to support patient access to care and tobacco cessation counseling, which was included as a defined coverage benefit by legislation in Sacramento in 2015. Another strategy that may help encourage more smokers to quit is to require a several week preoperative smoking cessation course before being allowed to undergo elective surgery, as has been done in the United Kingdom. Practicing otolaryngologists were among the first specialists to recognize the hazards of active smoking on their patient outcomes. Recognizing the deleterious impact of smoking on outcomes after flap procedures and bone healing, some plastic and orthopedic surgeons refuse to perform elective surgery on active smokers, requiring complete abstinence to be documented with cotinine testing on the morning of surgery. One advocacy champion in this arena has been Dr. Robert Jackler, who is the current Chair of OHNS at Stanford University Medical Center. In 2015 Dr. Jackler published a paper in Laryngoscope demonstrating that despite contrary scientific evidence, a small group of otolaryngologists repeatedly testified on behalf of Big Tobacco to dispute any connection between heavy smoking and the development of head and neck cancer. Dr. Jackler wrote “I was shocked by the degree to which these physicians were willing to testify, in my opinion in an unscientific way, to deny a dying plaintiff—suffering the aftermath of a lifetime of smoking—a fair trial.” Fortunately, the opportunity now exists for practicing otolyarngologists across America to raise awareness with their patients by discussing the risks of tobacco products, and establishing a referral link (one option is 1-800-QUITNOW) for tobacco cessation. John Maa MD, FACS, is the President-elect of the San Francisco Medical Society and has served as Chair of the UC Office of the President Tobacco Related Disease Research Program.


UPCOMING EVENTS Developmental Disabilities Conference: An Update for Health Professionals March 2-3, 2017 | UCSF Laurel Heights Conference Center The 16th annual interdisciplinary conference celebrates informed health care for individuals with developmental disabilities, offering a unique update for primary care and subspecialty health care professionals and others who care for children, youth, and adults with developmental disabilities and complex health care needs. The 2017 conference continues to cover topics across the lifespan on a broad range of developmental disabilities including autism spectrum disorders and Down syndrome. The 2017 conference will feature special focus on the emerging topic of Zika virus infection and associated intellectual and developmental disabilities with subspecialists from infectious disease, developmental pediatrics, obstetrics, and environmental health. For more information, visit http://bit. ly/2iZQprx.

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9th Annual Palliative Care Summit

March 13-14, 2017 | Sacramento, CA Now in its 9th year, the Coalition for Compassionate Care of California and Children’s Hospice & Palliative Care Coalition Annual Summit is designed for physicians, nurses, social workers, nursing home administrators, chaplains, patients and consumers who are interested in palliative care best practices, quality and policy. Discover best practices for creating meaningful and engaging patient experiences to improve care for all who are seriously ill or nearing the end of life. For more information visit http://ccccsummit.org.

~ Physicians ~ Nurse Practitioners Physician Assistants

AMWA's 102nd Anniversary Meeting

March 20-April 2, 2017 | San Francisco, CA Join the American Medical Women's Association Annual Meeting in San Francisco, March 30-April 2, 2017 at the Embassy Suites SFO Waterfront. Highlights include: talks from luminary women physician leaders, networking, mentoring, free CV review, free professional coaching, over 24 CME credits. First time attendee discount: AMWAGrant. For more information, visit www.amwa-doc.org/amwa102.

Voice: 800-919-9141 or 805-641-9141 FAX: 805-641-9143 tzweig@tracyzweig.com www.tracyzweig.com

Save the Date: CMA’s 43rd Legislative Advocacy Day

Tuesday, April 18, 2017 | Sheraton Grand, Sacramento, CA More information to follow in the next issue of San Francisco Medicine.


S.F. Medicine 02-20-14









Businesses sell shares of stock to investors as a way to raise money to finance expansion, pay off debt, and provide operating capital. Each share of stock represents a proportional share of ownership in the company. As a stockholder, you share in a portion of any profits and growth of the company. Dividends from earnings are paid to shareholders, and growth is realized by the increase in value of the stock. Stock ownership also generally gives you the right to vote on management issues. Company executives work for the shareholders, who are represented by an elected board of directors. The goal of management is to increase the value of the corporation’s equity. If shareholders are dissatisfied with the corporation’s performance, they can vote for a change in management.

Why invest in stocks?

The main reason that investors buy stock is to seek capital appreciation and growth. Although past performance is no guarantee of future results, stocks have historically provided a higher average annual rate of return over long periods of time than other investments, including bonds and cash alternatives. Correspondingly, though, stocks are generally considered to have more volatility than bonds or cash alternatives.

Can you lose money?

Yes, you can. There are no assurances that a stock will increase in value. Several factors can affect the value of your stocks: Actions of investors: If a large number of investors believe that the nation is entering a recession, their actions can affect the direction of the stock market. Business conditions: A new patent, an increase in profits, 24













a pending merger, or litigation could affect investor interest and stock prices. Economic conditions: Employment, inflation, inventory, and consumer spending influence the potential profit of a company and its stock price. Government actions: Decisions on interest rates, taxes, trade policy, antitrust litigation, and the budget impact stock prices. Global economy: Changes in foreign exchange rates, tariffs, or diplomatic relations can cause stocks to go up or down.

All investing involves risks, and there can be no assurance that any investing strategy will be successful. However, understanding these factors can help you make sound investment decisions and keep losses to a minimum.

What are the different classifications of stocks?

Stocks are often classified in the following ways: Growth stocks have earnings that are increasing at a faster rate than the market average. These are usually in new or fast growing industries and have the potential to give shareholders returns greater than those offered by the stocks of companies in older, more established industries. Growth stocks are the most volatile class of stock, however, and may be just as likely to go down in price. Value stocks are those of companies with good earnings and growth potential that are currently selling at a low price relative to their intrinsic value. Due to some problem that may be only temporary in nature, investors are ignoring these stocks. Since it can take quite some time for their true value to be reflected by their price, value stocks are usually purchased for the long term. Income stocks are generally not expected to appreciate greatly in share price, but typically pay steady dividends. Utili-


ties are an example of companies that have historically been considered income oriented. Blue chip stocks are the stocks of large, well-known companies with good reputations and strong records of profit growth. They also generally pay dividends. Penny stocks are very risky speculative stocks issued by companies with short or erratic performance histories. These stocks are so named because they sell for under five dollars per share. Their low price appeals to investors willing to assume a total loss in exchange for the potential for explosive growth. It is usually best to diversify among the different classifications and not own stock in just one or two companies or industries (though diversification alone cannot guarantee a profit or ensure against a loss).

How are stocks bought and sold?

During an initial public offering (IPO), new issues of stock are sold on the basis of a prospectus (a document that gives details about a company’s operation) that is distributed to interested parties. Investment bankers or brokerage houses buy large quantities of the stock from the company and sell them to investors. After the IPO, the stock may trade on a stock exchange or over the counter. Normally, stock is purchased through a wealth management or brokerage account. The buy orders you or your investment advisor places will be directed to the appropriate stock exchange. When someone who owns the stock is willing to sell at the price you are willing to pay, the sale takes place. A commission or fee may be charged on your transaction. Stock certificates may be transferred from one owner to another since they are negotiable instruments. The certificates are issued in the buyer’s name or, more typically, held by your financial institution or brokerage house in street name (i.e., the financial institution’s or brokerage firm’s name) on your behalf. The advantage of a street name registration is that if you decide to sell, you do not have to sign and deliver the stock certificates before the sale can be completed. And you don’t have to worry about losing the stock certificates.

How do you set up a wealth management or brokerage account?

You will need to complete a new account agreement and make three important decisions: Who will make the investment decisions? You will unless you give discretionary power to your broker or portfolio manager. Discretionary power allows a broker or portfolio manager to make decisions based on what he or she believes is best for you. Unless you limit the broker’s or portfolio manager’s discretion, this may be done without consulting you about the type of security and number of shares involved, or about the time and price at which to buy or sell. Do not give discretionary power to your broker or portfolio manager without seriously considering if it is right for you. How will you pay for the stock? A cash account requires you to pay for each stock purchase in full at the time you buy it. A margin account allows you to borrow money from the brokerage firm. Securities that you own are held as collateral, and interest is charged on the loan. If the account value falls below WWW.SFMS.ORG

the specified amount required to maintain the loan (even as the result of a one-day market decline), you must pay down the loan balance to an amount determined in relation to your new account balance. This is known as a margin call and can potentially require the payment of a sizable amount of money. What level of risk can you handle? You will be asked to specify your investment goals in terms of risk. Choices such as income, growth, or aggressive growth may be given. Make sure you understand the meaning of each term, and be certain that the level of risk you choose truly reflects your ability to handle risk. Any investment your broker or portfolio manager recommends should be based on the category of risk you selected.

Read the account agreement

Never sign a document without reading and fully understanding it. Early precautions can prevent later misunderstandings. Keep good records of: • Documents you sign • Documents outlining the details of an account or investment • Periodic account statements • Transaction confirmations • Documents verifying an account error was corrected • Correspondence with your broker or portfolio manager

Review these as soon as you receive them. Discuss any discrepancies you find with your broker or portfolio manager at once, and follow up on any actions taken until you are satisfied. Never allow your broker or portfolio manager to mail statements and transaction confirmations to someone other than you. It’s important that you check the accuracy of your own accounts.

Be patient

Some stock investors have made money quickly. But they are the exception rather than the rule. Investing in stocks requires a long-term outlook. Read books, attend seminars, and take advantage of professional advice. Education, good judgment, common sense, and above all, patience increase your chances of achieving your goals. Questions and answers provided courtesy of the wealth management team at Mechanics Bank. At Mechanics Bank, we provide medical professionals with industry-specific solutions that can help you manage your finances more efficiently. From specialized loans and equipment financing, and advanced cash management tools to comprehensive trust and wealth management services, Mechanics Bank’s services are delivered to you through experienced, knowledgeable, tenured associates who know your name and commit their personal best to you. If you have questions related to the information in this article, please contact John Osborn, CTFA, Vice President & Regional Trust Manager, Wealth Management, Mechanics Bank, (415) 249-8312.




Robert Osorio, MD, FACS

Head and neck surgery performed by our surgeons at California Pacific Medical Center (CPMC) aims to provide patients with the ability to combine cancer resection with immediate, state-of-the-art reconstruction. Dr. Mark Singer of Sutter Pacific Medical Foundation (SPMF) is a pioneer in the field of head and neck cancer, laryngeal surgery, and voice restoration. Throughout his career he has seen the importance of collaboration in the care of head and neck cancer patients. These patients are often faced with aesthetic and functional deformities after cancer excision. This is especially true for oral cavity squamous cell carcinoma as well as cutaneous malignancies, especially facial melanoma, which requires wide excision in cosmetically sensitive areas. In the past, patients with significant head and neck cancer were often not immediately reconstructed after surgical resection, resulting in significant deformities that were reconstructed in a delayed fashion months to years later. By working in close collaboration with SPMF plastic surgeon Dr. Brian Parrett, patients with head and neck malignancies obtain cancer resection with immediate reconstruction. Reconstruction often involves microsurgery—the connecting of blood vessels and nerves under the microscope. By using microsurgical techniques, immediate reconstruction of facial nerve and spinal accessory nerve defects with nerve grafts after oncologic resection has demonstrated excellent functional results. This collaboration has led to published research showing the safety of clopidogrel in major head and neck surgery and the reliable use of intra-oral flaps in patients with a history of radiation. It has also demonstrated the safety of immediate reconstruction of head and neck melanoma defects, which helps patients avoid additional surgeries and significant deformities. This is important as the Center for Melanoma Research and Treatment at CPMC sees a large volume of head and neck melanoma patients who benefit from this collaboration physically and psychologically. 26


Marika Russell, MD FACS

The Otolaryngology-Head and Neck Surgery (ENT) service at Zuckerberg San Francisco General Hospital provides a full spectrum of Otolaryngology care for the safety-net population of San Francisco. The clinical service includes up to 5000 ambulatory visits per year, and 450 surgical procedures per year. Consultation services are provided in the inpatient and Emergency Room setting, and call is staffed around the clock by UCSF residents and attending physicians. Electronic consultations services are also provided through the SF Health Network electronic referral system. The spectrum of clinical care includes General Otolaryngology, Otology, Laryngology, Rhinology/Skull base surgery, trauma/Facial Plastic and Reconstructive surgery, and Head and Neck Oncologic and Endocrine surgery. Audiology services are also provided, housed within the same physical space as our outpatient Otolaryngology clinic. A particular focus of our efforts has been in the care of head and neck cancer patients. Many of these patients present with advanced disease and are burdened by psychosocial conditions that make it difficult for them to comply with treatment (including surgery and/or radiation and chemotherapy) and post-treatment surveillance. Several efforts are underway to facilitate care coordination for these challenging cases. In addition, efforts are underway to develop a registry that will facilitate monitoring of patient compliance during treatment and the five-year surveillance period which follows, with the hope of improving outcomes for this vulnerable population.

Kaiser Permanente Maria Ansari, MD

In the past few years, the Head and Neck Surgeons of the Permanente Medical Group have developed a culture of group excellence. We now view the Head and Neck Service (HNS) as one big department rather than separate isolated groups at various medical centers. Working together as a group allows us to leverage our subspecialists. In 2012, the group focused on cancer care and developed a mission statement: “To establish a comprehensive H&N cancer program which would have all new head and neck cancer patients presented to a regional tumor board for evaluation and treatment plans. The goal of the board is to set our Northern California community standard for cancer care to be the highest quality of care.” After eighteen months of planning, the Regional HNS Tumor Board launched in June 2013. All newly diagnosed cancer patients are seen or reviewed at one of three hub medical centers by a multidisciplinary clinic followed by a group discussion to determine a treatment plan. The tumor board involves twenty to thirty participants including HNS cancer surgeons, General HNS Clinicians, Radiation & Medical Oncologists, Nuclear Medicine, Radiologists, Pathologists, Nurse Cancer Care Coordinators, Dieticians, and Speech Pathologists with representatives from every medical center in Northern California. The Regional HNS Tumor Board has been tremendously successful in meeting its goals. Reviewing the early data from the first two years, there has been an across the broad improvement in overall survival. In the next phase, the HNS group will implement a Regional Quality Review process. The Regional HNS Tumor Broad is unique in its size and its level of coordination between every Kaiser Permanente Medical Center in Northern California. Other oncological surgical services such as Breast, Colorectal, and Hepatobiliary cancer services are now developing tumor boards based on the HNS model.



Robert Harvey, MD, MBA, CPE

The Dignity Health Saint Francis Memorial Hospital Orthopedic Institute now offers minimally invasive rotator cuff-sparing total shoulder arthroplasty. Orthopedic Surgeon Dr. Robert Purchase was the first to use this highly specialized technique in California, which allows access to the shoulder joint using a small opening between the rotator cuff tendons rather than cutting through the tendons, as is done with conventional total shoulder replacement. This new technique leaves the tendons completely intact allowing patients improved post-surgical function, substantially less pain, and a quicker recovery. Saint Francis has expanded its robotic surgery services with the addition of Dr. Mona Orady, who recently joined the Dignity Health Medical Foundation—Saint Francis/ St. Mary’s. Dr. Orady is board certified in obstetrics and gynecology and fellowship trained in minimally invasive gynecology and robotic surgery. She completed her OB/GYN residency at Ohio State University Medical Center in Columbus, Ohio, and received her medical degree from the University of Western Ontario. Dr. Orady has been an invited speaker and moderator at a multitude of gynecologic summits and workshops throughout the world. She joins the da Vinci Robotic Surgery team at Saint Francis, which includes gynecologic surgeons Dr. Leslie Kardos and Dr. Heidi Wittenberg and urologic surgeons Dr. David Duong and Dr. Curtis Ross. Saint Francis’ Orthopedic Institute continues to receive accolades for its hip replacement program. The hospital received five stars for the quality of its total hip replacement procedures for the third year in a row from Healthgrades. Dr. Nicholas Mast, medical director of the Orthopedic Institute, made headlines earlier this year when he performed the Bay Area’s first outpatient hip replacement surgery. Saint Francis was also recently recognized for its dedication to patient safety with an “A” grade in the Fall 2016 Leapfrog Hospital Safety Score. WWW.SFMS.ORG



Edward Eisler, MD

Carl Bricca, DO

Forced labor and human trafficking are an estimated one hundred fifty-billion-dollar global industry, which is a major public health concern. San Francisco in particular is one of the nation’s largest hubs for human trafficking due to its proximity to three international airports, a tourism-driven economy, and a transient population. Dignity Health has launched a systemwide initiative to respond to human trafficking. This includes development of clinical protocols and procedures to better equip health care providers to identify victims and connect them to community resources. These resources can help victims regain their health, freedom, and lives. Dignity Health St. Mary’s Medical Center is leading efforts in the Bay Area by hosting several trainings under the Human Trafficking Response Program. Recent studies indicate that nearly eighty-eight percent of trafficked persons will have a health care encounter while being exploited. The Human Trafficking Response Program involves ongoing training for our emergency department staff, social workers, chaplains, hospital security, and registration and admitting staff. These clinical providers and care coordinators are trained to look for red flags that include homelessness, discrepancy between reported and apparent ages, lack of identification, and a dominating or controlling companion who refuses to leave the patient alone. Once identified, victims are provided with patient-centered, trauma-informed care. This includes working closely with law enforcement and other organizations to help empower victims to make their own choices, as appropriate, in seeking support and assistance from community agencies. Our Human Trafficking Response Program sheds light on the unique role of health care providers to help break the cycle of human trafficking. By raising awareness and action, we can help save victims’ lives.

CPMC's ontinuing Medical Education (CME) program has been awarded the Institute for Medical Quality’s (IMQ) highest level of accreditation, Accreditation with Commendation. Accreditation with Commendation is awarded to organizations that demonstrate compliance in all CME criteria and accreditation policies. Only an estimated ten percent of CME providers accredited by IMQ achieve this level of recognition, which is accompanied by a six-year reaccreditation term. An Open House was held in November for the new Sutter Pacific Medical Foundation (SPMF) clinic and Health & Healing Store at 899 Valencia Street in San Francisco. The event featured locally crafted, eco-friendly gifts, mindful living products and quality supplements. There were also chair massages, raffles for healing gifts, and discount coupons. As a new community partner for healthy living, the store joins the new SPMF clinic in providing holistic care in the Mission. Scott Ciesielski, RN, was recently appointed as CPMC’s Chief Nursing Executive. Mr. Ciesielski joined CPMC in 2009 as the Senior Director for Surgical Services and has worked closely with Diana Karner, RN, since assuming his previous position last year as Associate VP of Nursing. Many thanks to Ms. Karner for her twenty-seven years of service at CPMC. CPMC Research Institute’s Dr. Steven Cummings presented one of the largest summaries of findings suggesting treatment gaps in reaching at-risk patients in preventing debilitating hip fractures in people with serious medical illnesses. People with major medical illnesses such as Parkinson’s disease, recent stroke, HIV, and heart failure have a high risk of these potentially debilitating bone breaks. A relatively small percentage of these people receive drugs shown to reduce their risk. New approaches to improve prevention and treatment could include direct outreach to at-risk patients, measuring bone mineral density, using emergency medical records for earlier identification of at-risk patients, and at-home treatment by home nursing services.




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