MARCH/APRIL 2006 San Francisco Medicine
San Francisco Medicine MARCH/APRIL 2006
CONTENTS SAN FRANCISCO MEDICINE March/April 2006 Vol. 79, #2 Hands and High Technology: Minimally Invasive Surgery FEATURE ARTICLES
13 Is Coronary Bypass Surgery Obsolete in the Era of Drug-Eluting Stents? Peter Hui, MD, FACC, FSCAI
6 Letter to the Editor: David Smith, MD
16 Interventional Neuroradiology: Less Invasive Approaches For The Treatment Of Complex Cerebrovascular Diseases & Stroke Randall T. Higashida, MD
28 The San Francisco Earthquake 1906: Quick Action Saved Countless Lives Nancy Thompson, MD
19 Non-Surgical Techniques and Modalities for Skin Rejuvenation Gaetano Zanelli, MD 21 Screening for Abdominal Aortic Aneurism with Ultrasound can Save Lives Gretchen AW Gooding, MD 23 Phoenix Rising: And the Big Bird is Looking Through a Laparoscope Leonard Shlain, MD 25 The Past, Present, and Future of Laparoscopic Colectomy 2006 Laurence F. Yee, MD and Michael E. Abel, MD
30 Surgeons Volunteer Locally through Operation Access: Haile Debas, MD and Paul B. Hofmann, Dr.PH 33 Removing Bad Money from Good Medicine: Time for Some Bitter Pills: George Susens, MD and Steve Heilig, MPH 34 SFMS Annual Dinner Report 37 Report Links Environmental and Occupational Exposures to Cancers: Richard Clapp, DSc, MPH, and Molly Jacobs, MPH
4 On Your Behalf 31 Report from the San Francisco Department of Public Health: A Successful Community Hepatitis B Screening and Vaccination Program Janet Zola, MPH, Eric Sue, BA
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7 Executive Memo Mary Lou Licwinko, JD MHSA
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9 President’s Message Gordon Fung, MD
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MARCH/APRIL 2006 San Francisco Medicine
MARCH/APRIL 2006 Volume 79, Number 3 Editor Mike Denney, MD, PhD Managing Editor Amanda Denz Cover Artist Alex Rothwell Editorial Board Chairman Mike Denney Obituarist Nancy Thomson Stephen Askin Wade Aubry Toni Brayer Corey Maas Jaqueline Dolev Jerome Fishgold Alan Greenwald Erica Goode Gretchen Gooding Samuel Kao Thomas Lee Arthur Lyons Rita Melkonian Kenneth Maybury Judith Mates Ricki Pollycove Jordan Shlain Leonard Shlain David Smith Kathleen Unger Leo van der Reis Stephen Walsh Shieva Khayam-Bashi SFMS Officers President Gordon L. Fung President-Elect Stephen E. Follansbee Secretary Charles J. Wibbelsman Treasurer Stephen H. Fugaro Editor Mike Denney Immediate Past President Alan G. Greenwald SFMS Executive Staff Executive Director Mary Lou Licwinko, JD, MHSA Director of Public Health & Education Steve L. Heilig, MPH Director of Administration Posi Lyon Director of Membership Therese Porter Board of Directors Term: Jan 2006-Dec 2008 Mei-Ling E. Fong, MD Thomas H. Lee, MD Carolyn D. Mar, MD Rodman S. Rogers, MD John B. Sikorski, MD Peter W. Sullivan, MD John I. Umekubo, MD Term: Jan 2005-Dec 2007 Gary L. Chan, MD George A. Fouras, MD Jeffrey Newman, MD Thomas J. Peitz, MD John W. Pierce, MD Daniel M. Raybin, MD Michael H. Siu, MD Term: Jan 2004-Dec 2006 Richard L. Caplin, MD Lucy S. Crain, MD Jane M. Hightower, MD Brian J. Lewis, MD Michael Rokeach, MD Jordan Shlain, MD Alan M. Teitelbaum, MD CMA Trustee Robert J. Margolin AMA Representatives H. Hugh Vincent, Delegate Judith L. Mates, Alternate Delegate Judith L. Mates, AMA’s Women Physicians Congress Governing Committee
ON YOUR BEHALF A sampling of activities and actions of interest to SFMS members. to Carol Nolan at 561-0850, ext. 0 EditorialRSVP or firstname.lastname@example.org
San Francisco Medicine Continues to Publish:
The Editorial Board of San Francisco Magazine has been working diligently to maintain continuity of our publication after the abrupt loss of our previous Managing Editor. Because of the time delays caused by moving into the new SFMS offices, the vacancy while searching for a new Managing Editor, and the resultant disruption of the necessary flow of the publishing process, we have found it challenging to keep the presses rolling. We have thus found it necessary - temporarily - to combine a few issues this Spring rather than having one each month. As a result of the dedicated efforts of members like Gretchen Gooding, Nancy Thomson, Steve Walsh, Gordon Fung, Erica Goode, and many others, and with Steve Heilig gracefully and skillfully stepping into the breach, you are receiving a March/April issue about new minimally invasive procedures which we think you will find highly interesting and informative. We will then have a May/June issue with a theme of diversity and medicine. Our highly competent new Managing Editor, Amanda Denz, starts the first of April. So, we have taken a deep breath, hunkered down to work, and expect to return to normal schedule soon. Our website, www.sfms.org, is also still a work in progress. Those seeking to access the archives of this journal but have problems doing so should contact SFMS headquarters for assistance, as the contents dating to 1996 remain on the site. Our thanks go out to all members for your patience and support.
The SFMS Board of Directors Invites All members to: The SFMS Open House Come see our new headquarters in the Presidio Friday, April 28 3-6 PM Hors d’ouvres and refreshments 1003A O’Reilly Avenue Between Gorgas and Torney Avenues in the Presidio, San Francisco
San Francisco Medicine MARCH/APRIL 2006
Medicine and Patients Score Major Victory at Supreme Court In January the United States Supreme Court ruled in favor of patients and physicians in the longstanding case Gonzales (originally Ashcroft) vs. Oregon. The United States Attorney General(s) had sought to overturn Oregon’s legalization of “assisted suicide” by radically changing the regulation and scrutiny of prescribed medications. While the SFMS does not take a formal position on the assisted dying issue (due to the very divided opinions of our members on the topic), we did agree with experts who felt that the Ashcroft/ Gonzales proposal would likely add to the longstanding concerns of physicians about “overuse” of pain medications in particular. The SFMS took an opposing position to the proposal, convinced the CMA to do likewise, and joined in a “Friend of the Court” brief along with many nationally-known pain specialists and health policy figures. The case took years to wind its way to final resolution, but one attorney in the case remarked that the support of mainstream medical organizations such as ours was “invaluable” in the outcome.
CMA Coalition Stops 5 Percent Medi-Cal Rate Cut The governor signed a CMA-sponsored bill (SB 912) that eliminates the 5 percent Medi-Cal rate cut that took effect January 1. The cut—the result of a law signed in 2003 by Governor Davis—was scheduled to start January 1, 2004, and sunset January 1, 2007. In 2003 the CMA won a federal court injunction blocking the cut, but that injunction was overturned in August 2005. CMA and a broad coalition of patient and provider organizations immediately sought emergency legislation to stop the cut and protect access to care for the 3 million poor, children, elderly, and disabled who rely on Medi-Cal for their health care. The bill www.sfms.org
passed unanimously in both houses of the legislature, and was signed by the governor within 24 hours. Even without the cut, Medi-Cal rates have not kept pace with inflation, and perpatient Medicaid spending by California ranks last among the 50 states. CMA is committed to working with the governor, the legislature, and other advocacy groups on Medi-Cal reforms that will improve program efficiencies and control costs, while maintaining access, continuity, and quality of care for Medi-Cal patients. Contact: Lisa Folberg, 916/444-5532 or email@example.com.
CDC Advisory Panel Recommends Flu Shots for Children Under 5 The Centers for Disease Control & Prevention’s immunization advisory committee recommended that all children under 5 and over 6 months be vaccinated against influenza, current guidelines call for children 6 to 24 months old be vaccinated. Physicians should also be aware that effective July 1, it will be against California law to administer mercury-containing vaccines—including inactivated influenza vaccine from multidose vials—to pregnant women and children younger than 3 years old. Next flu season, only doses of influenza vaccine from single-dose syringes or vials with trace levels or no mercury may be given to these groups. Contact: Robin Flagg, 415/882-5110 or firstname.lastname@example.org.
misleading solicitations. AMA has assured CMA that it is working with Medem to stop this untoward marketing practice. In the meantime, physicians should inform their office staff of this issue. Contact: CMA’s legal information line, 415/882-5144 or email@example.com.
CMA Sponsors Bill to Eliminate Physician Participation in Executions Reacting to an attempt by state officials to have physicians take an active role in executing Michael Morales, a prisoner at San Quentin State Prison, CMA announced this week that it is sponsoring a bill that would eliminate physician involvement in all future executions. “Physicians should be treating people’s illnesses, not participating in their execution,” said CMA CEO Jack Lewin, M.D. “Participation in an execution goes against long-standing principles of professional ethics and is a violation of the Hippocratic oath: First, do no harm.” CMA has a long history of opposing physician participation in executions. Contact: CMA Media Relations, 916/444-5532 or firstname.lastname@example.org.
Physicians, Beware of Misleading Medem Invoices
This is just a sampling of courses available from the UCSF office of CME see https://www.cme.ucsf.edu/cme/index. aspx?Display=Date&year=C for a complete list. UCSF Office of Continuing Education Registration Office - 415-476-5808 Hours: 7:30-4:00
A number of physicians have reported to CMA that they have received unsolicited invoices from Medem, charging them $195 for “Practice Web Site and iHealth Services.” Physicians should be aware that these invoices are offers of service, not actual bills. While the services being offered are legitimate, you do not need to pay the “invoice” unless you actually want to sign up for Medem’s services. CMA has expressed its concern to AMA, a part owner of Medem, about these
CME and Pain Management and End-ofLife Care With the passage of California Assembly Bill 487 in October 2001, physicians licensed in California must complete 12 hours of CME in topics associated with pain management and/or end-of-life care by December 31, 2006. Due to limited patient interaction, radiologists and pathologists are exempt from this requirement. This is a one-time requirement meant to be completed by the end of 2006.
UCSF CME offers an annual live conference, which may be found on our website. UCSF also offers Challenges of Managing Pain Symposium (ChaMPS) at their Pain Management Center at Mt. Zion. They hold a bimonthly seminar in Herbst Hall (Room B-248) focusing on various topics of pain, and are designed to meet the requirements of AB487. You may contact them directly at 415.885.7272. If you have questions about this CME requirement, please contact the UCSF Office of CME at 415.476.4251. Pain Management and End-of-Life Care Sunday, June 04-Monday, June 05, 2006 San Francisco, Fairmont Hotel 27th Annual Advances in Infectious Diseases: New Directions for Primary Care Wednesday, April 26 - Friday, April 28, 2006 San Francisco, Hotel Nikko Current Issues in HIV Care: Pain Management and End-of-Life Care for HIV/AIDS Monday, May 15- Tuesday, May 16, 2006 San Francisco, Presidio Golden Gate Club Essentials of Women’s Health: An Integrated Approach to Primary Care and Office Gynecology Sunday, July 02 - Friday, July 07, 2006 Big Island, Hawaii, Hapuna Beach Prince Hotel
DMHC’s Financial Solvency Reporting Rules Do Not Apply to Individual Physicians, Do Apply to Risk-Bearing Groups/IPAs CMA has learned that the current issue of PacifiCare’s provider newsletter includes inaccuracies about the Department of Managed Health Care’s (DMHC) financial solvency reporting requirements (under SB 260). The article, “How to Comply with SB 260,” erroneously states that all physicians with health plan contracts must submit quarterly and annual financial statements and “corrective action plans” to DMHC and to each contracting health plan. CMA reminds physicians that the state’s
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MARCH/APRIL 2006 San Francisco Medicine
LETTER TO THE EDITOR David E. Smith, MD
End of An Era Dear Colleagues: I feel compelled to write to my friends and colleagues in the SFMS, as the medical society has supported me and the Haight Ashbury Free Clinics (HAFC) since our inception in 1967. You may have read or heard recently, in the Chronicle or on television, that I have resigned as medical director of the HAFC. The HAFC was founded with the motto “health care is a right, not a privilege” and we were committed to that vision for 39 years. Many local physicians have trained, worked, and contributed to us during those years and know that we provided primary and other care without regard to the patient’s ability to pay. During that time, many of you, and I, worked for far less than we would anywhere else. We struggled at times, but kept true to our vision and set standards in new treatments—especially in addiction medicine, clinic models, publications, and more. Those of us who spent much time there are proud of this, our chosen life’s work. In recent years the HAFC was victimized by embezzlement, a most destructive development. In the past year we had been recovering from that setback by instituting a more corporate structure and leadership team. This was, and is, essential, but it also poses some risk to medical standards, ethics, and particularly the guiding values of the HAFC. If there is one lesson I would like to impart to my colleagues in this era of “medical” foundations, let it be that you never lose medi-
cal control of wherever you choose to practice. I now fear that many of San Francisco’s neediest patients may suffer. My sincere gratitude goes out to every physician and those at the SFMS who have been supportive through the past 39 years. I will remain active in the fields that have inspired me through these decades and hope to see many of you again. Sincerely,
David E. Smith, MD
Dr. David E. Smith and George Harrison at Haight Clinic benefit concert, 1974
San Francisco Medicine MARCH/APRIL 2006
EXECUTIVE MEMO Mary Lou Licwinko, JD, MHSA Executive Director
We Have Moved and We are Moving
he San Francisco Medical Society successfully sold its headquarters in 2005 and made the move to our new location in the Presidio in January 2006. It was quite a feat downsizing from 15,000 square feet to just over 3,000 but the move went surprisingly well thanks to the hard work of the SFMS staff and the coordination efforts of our Director of Membership, Therese Porter. Our new address is 1003A O’Reilly Avenue and we encourage you to come by and see the new offices. We are holding an open house to show off our new place in April. This move marks the beginning of a new era for the Medical Society. Last November the Board of Directors held a planning session to strategize about the future of SFMS. From this session emerged four areas that SFMS will focus on for the next several years: membership, information technology, political advocacy and fellowship and wellness. Dr. Stephen Follansbee, the SFMS President-elect is serving as chair of the Membership Services Committee to develop our membership agenda. Dr. Tom Lee is heading the Information Technology Committee and is overseeing our website development. SFMS President, Dr. Gordon Fung, chairs the Political Advocacy Committee and immediate past-president, Alan Greenwald, is chairing the Fellowship and Wellness Committee. As a result of this planning session, SFMS will also be conducting a needs assessment of the membership in the next few months. The purpose will be to elicit from our members what the Society can do to best serve their needs and to determine the value of the services and information we currently provide. We hope that many of our members will respond to the short questionnaire that we will distribute. Another major event of the past year was the overhaul of our website. Our address remains the same, www.sfms.org, but we have changed the look and the content and will be working on developing interactive features that will better serve our membership and the public. Coinciding with our move and our self-assessment is a significant increase in our membership numbers for 2006. Perhaps our new spirit and our new direction are already paying off.
The SFMS Board of Directors Invites All members to:
THE SFMS OPEN HOUSE Come see our new headquarters in the Presidio
Friday, April 28 3-6 PM Hors d’ouvres and refreshments 1003A O’Reilly Avenue Between Gorgas and Torney Avenues in the Presidio San Francisco
RSVP to Carol Nolan at 561-0850, ext. 0 or email@example.com Directions from Lombard Street: Enter through the Lombard Gate. Take the second right onto Presidio Blvd.Take the second right onto Torney Ave. Drive to end and turn left onto O’Reilly Ave. Look for parking. OR Continue past the Lombard Gate, past Lyon Street and take the Chrissy Field exit on the far left At the stop sign turn left onto Gorgas Ave. Travel straight on Gorgas to O’Reilly Ave.(about one long block) Turn Right and look for parking.
MARCH/APRIL 2006 San Francisco Medicine
San Francisco Medicine MARCH/APRIL 2006
PRESIDENT’S MESSAGE Gordon L. Fung, MD, MPH President
Health Advocacy – A Good Lesson
ver the past years of involvement in the SFMS, I have been in awe of how some people were just more aware of the city and state political scenes and how they were able to intervene or give input to make a difference. They always seemed just as busy, if not busier, than me doing all the things necessary to run a full practice, but they seemed to be the go-to people—the people legislators turned who had the pulse of the city or state. And as soon as the public first heard of the actual problem or issue, these advocates were knee deep in the discussion trying to find the solution or were ready to announce a compromise. From the SFMS standpoint, the issues were always pertinent to the health of San Francisco residents and the resolutions were usually better with the input of the SFMS than prior to our involvement. Just last month, I had an opportunity to be one of those people who was able to respond to a serious problem that would have affected the health of the entire state and nation. The Environmental Protection Agency (EPA) was convening public hearings on its recommendations for air quality standards. When the EPA was established, the regulations stated that it must review the air quality standards every five years and revise them to protect the health of the American public. The scientific committee had reviewed the best scientific evidence to date and recommended that the Bush Administration and the EPA adopt air quality standards that would decrease the mortality from air pollution caused diseases – e.g., several kinds of cancers, lung disease, heart disease, and stroke. The American Lung Association, American Cancer Society, and other reputable healthcare organizations weighed in and supported the recommendations of lowering the annual standard PM2.5 to no greater than 12 micrograms per cubic meter and a daily standard of no greater than 25 micrograms per cubic meter. They also recommended that the EPA not allow a waiver for agricultural industry on large particulate matter. The EPA seemed to ignore the recommendations of all these reputable scientists, the scientific and health care communities, and their own science committee and recommended the status quo which had been estimated to account for over 1100 deaths per year. In order to support stronger standards the ALA, ACS, and ATS even modeled projections to predict the death rate from these particulate matters at different levels. The savings was over 600 lives. It seemed outrageous that the governmental organization established to set air quality WWW.SFMS.ORG
standards for the protection of the public’s health would ignore the recommendations of the scientific community. Asyourpresident,IwasaskedifIcouldspeakatthehearing.Aftera quick read of the situation and the fact sheet of recommendations of the scientificcommunity,Iwasmovedtomaketimetodothis.Airpollution issomethingthatweinourclinicalpracticescandonothingaboutexcept to recommend that our patients move to other parts of the country, or world,wheretheairqualityisbetter.SoIpreparedmyremarksandspoke as your elected officer. I presented my own experience of how air pollution has increased the number of my patients that end up in emergency wardsthroughoutthecityinasthmaticexacerbationsorwithchestpain, and how some of my patients who have heart attacks and strokes don’t have any measurable traditional risk factors and yet are victims of these devastating diseases. The current literature suggests that air pollution is a contributing factor. Afterwards, I was overcome with a great feeling of being able to help by being at the right place and time. I gave the EPA a perspective from the physicians caring for patients that would be the victims of their decisions on air quality. Even though the outcome is not yet known, participating in this advocacy effort has been a tremendous experience for me. Not only was I able to talk directly to the people who were going tomakethefinalrecommendations,Ilearnedmoreaboutenvironmental medicine and how much the government impacts the standards under which we live. Ilearnedmanythingsduringthisexperience,nottheleastofwhich is that the government through its agencies need to be carefully monitored as they make decisions that affect the health of the public and that physiciansneedtobewillingtospeakoutwhenmoreappropriateactions could save lives. As physicians we are expected to know a lot about a lot of things in medicine and non-medical things. When we don’t know we try to learn. And after we learn we use the criteria of doing what is best for our patients’ health based on the best science available. We need to advocate this type of thinking to our governmental officials. Another thing about advocacy is keeping up on the medical information and knowledge base to couple with our clinical experience and put the two together to practice more effectively. Just to let you know, the SFMS is sponsoring a major conference to discuss environmental pollution and its effect on heart disease and cancer in October. Keep your calendars open for a great educational conference. MARCH/APRIL 2006 SAN FRANCISCO MEDICINE
10 San Francisco Medicine MARCH/APRIL 2006
EDITORIAL Mike Denney, MD, PhD
Kind Wisdom, Gentle Hands
n Greek mythology, the extraordinary centaur Chiron, whose name means hand, was revered by all on Mount Olympus and acknowledged as being sometimes wiser than even the gods and goddesses. Apollo prepared his young son, Asclepius, to become the Greek god of healing by taking him to Chiron for training in the art and science of medicine and surgery. Chiron himself once cured the blindness of Phoenix II, and he taught Achilles and Hercules about surgical procedures such as treating various wounds of war. It was said that he was very kind and had a way of evincing the highest potential of his students. Chiron’s name is identified also with the ancient word for surgery, chirurgia, a conjunction of the noun chiron, hand, with the verb ergon, to work. Thus, the Random House dictionary defines surgery as: The art, practice, or work of treating disease, injuries, or deformities by manual operation or instrumental appliances. This practice of working manually with instruments has become amazingly high-tech over the years – diagnostic palpation and auscultation have developed into electrocardiograms, angiograms, and advanced imaging techniques, while therapeutic manipulations with scalpels and hemostats have progressed to minimally invasive endoscopic operations, sonographic guided manipulations, and even endovascular surgery. And, there is a twist to this mythological and historical narrative about the increasing use of hands and instruments for the treatment of patients. During the 18th century, when London hospitals first opened casualty departments, when doctors began to advocate hands-on first-aid and mouth-to-mouth resuscitation, and when the Italian naturalists Galvani and Volti presaged heart defibrillation by electrically “reanimating” the dissected muscles of dead frogs, the English physician, William Buchan, published his best-selling self-help handbook, Domestic Medicine, in which he stated flatly, “Every man is in some measure a surgeon whether he will or not.” Aside from the period gender bias of such a statement, perhaps this notion of the ubiquitous use of hands and appliances to help the sick and injured has manifested in the modern world by the reality that the bold manipulation with high-tech instruments has
become integral not only to surgery but in some measure to all specialties of medicine, including radiology, cardiology, internal medicine, and dermatology. As in this issue of San Francisco Medicine we read in wonder about sonographic screening for aortic aneurysms, endoscopic abdominal surgery, and neuroradiological endovasacular coiling and stents. We become highly impressed with how much more keen is the vision of advanced imagery than the human eye can possibly achieve even using various scopes, and we are astounded at how bold are these medical diagnostic and therapeutic pioneers who use such complex, high-tech techniques to probe and manipulate the human body. Obviously, we must be cautious about the increasing use of technology in the healing arts. Not only do new techniques bring new complications but technology can distance us from our patients and can cause us to view them too objectively – thus failing to acknowledge the healing power of hands-on human contact and caring. In response to those concerns, we notice that these new methodologies, in the hands of a variety of specialists, are more gentle and far less invasive and wounding than the scalpel. Patients need less anesthesia, suffer less tissue damage, and recover much more comfortably and rapidly. Yes, we might remember that on Mount Olympus Chiron was revered by all the gods and goddesses not only for his knowledge and wisdom. He was most admired for being kind and gentle. And so it is that although our increased technology can threaten to distract us from our patients, it can actually carry us to our highest potential if we follow the skills, wisdom, and kindness of Chiron. Indeed, our new extraordinary technology offers us eyes with the keenness of an eagle, hearts with the boldness of a lion, and hands that are ever and ever more gentle.
A surgeon must have . . . The eye of an eagle, The heart of a lion, The hands of a woman.
MARCH/APRIL 2006 SAN FRANCISCO MEDICINE
12 San Francisco Medicine MARCH/APRIL 2006
HANDS AND HIGH TECHNOLOGY: MINIMALLY INVASIVE SURGERY
Is Coronary Bypass Surgery Obsolete in the Era of Drug-Eluting Stents? Peter Hui, MD, FACC, FSCAI
ess than 3 decades ago, coronary bypass grafting was only treatment option for patients with medically refractory angina. In 2006 patients with complex, multivessel coronary artery disease can be successfully treated with drugeluting stents and be discharged within 24 hours post procedure. The patient whose angiogram is seen in figures 1 and 2 is such an example. With results like this, have drug-eluting stents rendered coronary bypass surgery obsolete? An 84 year old man underwent coronary angiography because of progressive angina despite medical therapy. He has severe three vessel CAD but declined surgery. Percutaneous intervention was performed and he received drug-eluting stents in all 3 major coronary vessels. He was discharged the day after the procedure and has been asymptomatic after one year of follow-up.
Brief history of percutaneous coronary intervention In 1977 Dr. Andreas Gruntzig pioneered the development of balloon angioplasty (percutaneous transluminal coronary angioplasty or PTCA) as a nonsurgical treatment of obstructive coronary artery disease. Compared to bypass surgery, patients treated successfully with balloon angioplasty had a lower risk of periprocedural MI, stroke and death and were able to resume normal physical activity within days. However, up to 30-40% of patients develop restenosis or renarrowing of the treated site within the first six months after WWW.SFMS.ORG
FIGURE 1: 90% stenosis of the proximal left anterior descending artery and 90% stenosis of the mid circumflex artery
angioplasty. More than 50% of those who developed restenosis have significant symptoms or noninvasive test abnormalities and will require a second revascularization procedure, either repeat PTCA or bypass surgery. The mechanism of restenosis is complex, but the three most important factors are elastic recoil, neointimal hyperplasia (scar tissue formation) and negative vascular remodeling (shrinkage of the treated segment). Multiple trials have failed to identify any effective pharmacotherapy to prevent restenosis. Several major clinical studies comparing PTCA to coronary artery bypass surgery have shown equivalent 3-5 year survival and MI rates in non-diabetic patients randomized to either treatment. However, the need for a second procedure was significantly higher in those treated
with PTCA. Restenosis has therefore been called the Achillesâ€™ heel of percutaneous intervention. In the mid 1990â€™s the Gianturco-Roubin stent was introduced to treat coronary dissections and threatened vessel closure during balloon angioplasty. This first generation coil stent was approved for bailout use only and it was able to reduce the rate of emergency bypass and improve the overall safety of PTCA. The PalmazSchatz (PS)stent was later released for treatment of de novo coronary stenosis. By providing mechanical scaffolding of the diseased segment, the stent prevents both elastic recoil and negative remodeling. In the pivot clinical trials comparing PTCA and stenting, the PS stent was found to lower the restenosis rate
In 2006 patients with complex, multivessel coronary artery disease can be successfully treated with drugeluting stents and be discharged within 24 hours post procedure.
MARCH/APRIL 2006 SAN FRANCISCO MEDICINE
to 15-30% and the repeat revascularization to 10-15%. The rate of acute vessel closure and emergency bypass surgery during coronary intervention was also dramatically reduced. The improved safety and durability of results achieved with coronary stenting expanded the patient and lesion subsets which are able to be treated by percutaneous technology. Randomized trials of stenting versus bypass surgery have also shown equivalent clinical outcome in survival and MI rates FIGURE 2: 99% subtotal occlusion of the distal right coronary artery after 3-5 years of followup. However, patients treated with stents are still more likely to undergo repeat procedures be- substantially. Furthermore, patients which has been used in the treatment of cause of restenosis. treated with brachytheray for in-stent breast and ovarian carcinoma. Both drugs Although the development of the restenosis also have a higher risk of stent have been shown to be highly effective in stent was a major advance in interven- thrombosis. Despite the limitations of in- reducing neointimal hyperplasia. tional cardiology, restenosis still remained stent restenosis and stent thrombosis, the The release of the DES was greeted a challenging problem in a significant development of the stent was a landmark with great fanfare as the early clinical minority of patients. Despite its ability breakthrough in percutaneous coronary trials showed the angiographic restenosis to prevent elastic recoil and negative intervention. rate to be near zero. These spectacular remodeling, the metallic stent induces early results raised the hope that coronary a greater degree of neointimal hyper- The drug-eluting stent-a artery disease could be treated with drugplasia at the treated segment compared magic bullet? eluting stents, and that bypass surgery to balloon angioplasty. The ingrowth of In 2003 the sirolimus-eluting stent will become obsolete. However, over the intimal hyperplasia within and sometimes was approved by the FDA for treatment of last two years, larger clinical registries of beyond the stent is termed in-stent re- coronary artery disease. The current gen- “real world” use of the DES have shown stenosis. Management eration of drug-eluting that this stent is not a magic bullet and it of in-stent restenosis stent (DES) consists of has not completely eliminated restenosis is a difficult problem, a stainless steel mesh, . Compared to the bare metal stent, DES and until recently the a polymer covering has significantly reduced the restenosis only effective treatand an anti-restenosis rate to 5-10%. However diabetic patients ment has been brachydrug contained within and high risk, complex lesions such as therapy or localized the polymer. The two bifurcation disease, left main stenosis, radiation. In addition, FDA approved stents saphenous bypass grafts, and small vessels stent thrombosis has are the sirolimus and remain challenging problems. also been recognized In addition, the risk for stent thromthe paclitaxel eluting as a complication of stents. These drugs bosis is potentially greater in patients this new technology are released over a treated with a drug-eluting stent . While and occurs in up to 1% period of 30-90 days sirolimus and paclitaxel are highly effecof patients. The struts after implantation to tive in preventing intimal hyperplasia, of the stent are a nidus attenuate the devel- they also delay the complete endothelifor thrombus formation and the risk of opment of neointimal hyperplasia. alization of the stent struts. The naked stent thrombosis is greatest within the Sirolimus is a macrocyclic triene stent struts are therefore exposed to first four weeks until endothelialization antibiotic which has immunosuppressive blood for a longer period of time and 3-6 is complete. Although uncommon, stent and anti-proliferative properties. It was months of continuous dual antiplatelet thrombosis is a potentially catastrophic first discovered in Easter Island where the treatment with aspirin and clopidogrel complication and is associated with a 25- actinomycete Streptomyces hygroscopicus is recommended. Premature interruption 50% fatality. The use of dual anti-platelet was found to produce a macrolide antiobi- of anti-platelet therapy can lead to stent therapy is mandatory to minimize the risk otic with antimitotic and immunosuppres- thrombosis. Furthermore, there have been of stent thrombosis. If aspirin and clopi- sive properties. Paclitaxel is a drug isolated case reports of late stent thrombosis occurdogrel are discontinued prematurely, the from the Pacific yew tree (Taxus brevifo- ring more than six months following the likelihood of stent thrombosis increases lia) and is the active ingredient in Taxol, procedure. Based on these observations,
Over the last two years, larger clinical registries of “real world” use of the DES have shown that this stent is not a magic bullet and it has not completely eliminated restenosis.
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patients who have undergone multivessel or complex stenting have been recommended to receive 12 months or life long antiplatelet therapy to reduce the risk of late thrombosis. DES should therefore not be used in patients who are medically noncompliant or in those will require early stoppage of ASA/plavix because of anticipated surgery. In summary, the drug-eluting stent is an evolutionary technological advance in interventional cardiology. Compared to bypass surgery we are now able to successfully treat many patients who have complex coronary artery disease, achieving these results with a lower risk of periprocedural myocardial infarction, stroke and death. Compared to PTCA and bare metal stents, restenosis and the rate of repeat intervention are significantly reduced, but not entirely eliminated. Several randomized trials comparing outcomes achieved using DES versus CABG are ongoing in patients with com-
plex coronary anatomy such as left main and/or multivessel disease. The results of these important trials will hopefully help us develop the best treatment strategy for our patients. Until then the decision to perform percutaneous intervention or CABG in an individual patient will be influenced by the coronary anatomy, comorbid medical conditions, surgical risks and personal preferences. In patients with left main or multivessel disease and decreased left ventricular function, coronary artery bypass surgery is in general recommended. In 2006, coronary artery bypass surgery remains an important part of our therapeutic armamentarium.
RENEW is Coming to the San Francisco Medical Society! The Medical Society will be introducing a RENEW program for the members of the San Francisco Medical Society in the very near future. Founded and led by Linda Hawes Clever, MD, MACP, RENEWâ€™s methods are based on her 25 years experience as an internist and occupational health specialist. RENEW was developed to help people who juggle work, family and community commitments sustain - or regain - their enthusiasm, effectiveness and purpose. The personalprofessional intersection can be treacherous â€“ and RENEW helps people explore and reaffirm values, then tap deep sources of energy, motivation, and talent so we all can move ahead with optimism, as we build community and reclaim vitality and joy in our work and lives.
Dr. Hui is the Medical Director of the Coronary Care Unit at California Pacific Medical Center. He is recognized as one of the leading interventional cardiologist in the Bay Area and has implanted over 1200 drugeluting stents since 2003.
Dr Clever and the medical Society are developing a pilot program tailored to the unique needs of the Societyâ€™s membership. The first meeting will be in July, details to be announced in the next issue of San Francisco Medicine. For more information on RENEW, visit www.
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HANDS AND HIGH TECHNOLOGY: MINIMALLY INVASIVE SURGERY
Interventional Neuroradiology: Less Invasive Approaches For The Treatment Of Complex Cerebrovascular Diseases & Stroke Randall Higashida, MD
nterventional neuroradiology/endovascular neurosurgery has recently emerged as a new medical subspecialty over the past 2 decades, with its own specialized training program which is now ACGME approved. This relatively new subspecialty of medicine, combines the imaging technology based within Radiology, the technical skills derived from Neurosurgery, and the clinical evaluation and acumen of the Stroke Neurologist, from which to perform the “minimally invasive procedure of brain surgery through an endovascular approach from within the blood vessels of the brain”. Interventional neuroradiology began in the mid-1980’s as an adjuvant technology within diagnostic neuroradiology, to deal with the treatment of complex intracranial vascular diseases, such as cerebral aneurysms, arteriovenous malformations, and traumatic vascular injuries to the head, neck, brain, and spinal cord. It was initially offered to patients in whom traditional neurosurgical approaches by craniotomy, were not feasible, or in whom neurosurgery procedures had high rates of surgical morbidity and mortality. As an alternative to traditional open neurosurgery, interventional neuroradiology is now providing therapy for patients with ruptured and unruptured brain aneurysms by endovascular coiling techniques, carotid and intracranial atherosclerosis therapy by balloon angioplasty and stenting, acute stroke therapy with mechanical clot extraction and/or intra-arterial cerebral thrombolysis, and also an adjunct prior to surgery 16
FIGURE 1: Picture demonstrating a blood clot in the middle cerebral artery of the brain, a common location, due to carotid atherosclerosis or atrial fibrillation, leading to an embolic stroke. Techniques have now been developed, which allow the interventional neuroradiologist the ability to mechanically remove the clot, from an endovascular approach, under X-ray visualization, and open up the blockage in the brain blood vessel to restore normal blood flow.
for vascular tumors of the head, neck, brain, and spinal cord.
Acute Ischemic Stroke According to the American Heart Association, acute stroke in the United States resulted in >750,000 new cases per year, is the 3rd leading cause of death, is the leading cause of adult disability, and current costs now exceed $50B dollars annually for treatment and due to lost productivity. Following an acute stroke, one-fourth of
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patients die, and one third are significantly disabled. The major cause for stroke is due to thrombo-embolic disease, usually from carotid or cerebral atherosclerosis, small vessel occlusion, and/or atrial fibrillation. In 1996, the FDA approved the use of intravenous tissue plasminogen activator, given within 3 hours from acute stroke onset. Unfortunately, <3-5% of all stroke patients currently receive this treatment, due to the short time window. In 2005, the U.S. FDA approved a new device, the Concentric Merci Clot Retriever, indicated for use in patients between 3-8 hours of stroke onset, with an angiographically demonstrated clot in a major cerebral artery, amenable to this form of therapy. The national Principal Investigator for this trial, Dr. Wade Smith, is Chief of the Stroke Neurology Division at UCSF Medical Center. He successfully directed this large, multi-center, prospective trial in an effort to gain approval, as the first medical device worldwide, specifically indicated for clot retrieval, during an acute ischemic stroke. This study demonstrated that in patients suffering an acute stroke, and in whom clot extraction is successful, there is a significant rate of neurological improvement with a decrease in overall mortality, associated with successful reperfusion. (Figure 1)
Carotid Stenting For Cerebral Atherosclerosis Carotid atherosclerosis accounts for 15%-20% of all strokes in the United States. Last year it was estimated that there were WWW.SFMS.ORG
150,000-175,000 carotid revascularization procedures performed. Carotid surgery by endarterectomy has now been proven to be superior to best medical therapy for symptomatic patients with carotid atherosclerosis >50%, and in several other trials for asymptomatic carotid atherosclerosis >60%, for stroke prevention. In the past 5 years, a number of trials have now been reported comparing the less invasive technique of carotid artery stenting vs. carotid endarterectomy, as an alternative to “open” surgery. These studies have demonstrated that in “high-risk”
FIGURE 2: Placement of an endovascular stent in the carotid artery for treatment of carotid atherosclerosis.
surgical or medical patients with significant carotid atherosclerosis of >50%-70%, carotid artery stenting was equivalent to surgery, for prevention of recurrent stroke or death, and had less procedure morbidity and mortality, particularly for myocardial ischemia, since the procedure is performed under local vs. general anesthesia. (Figure 2) Based upon these trials, the FDA has recently approved the technique of carotid artery stenting as a treatment alternative to carotid surgery, in certain “high risk” groups of patients. The UCSF Interventional Neuroradiology section, participated in a number of these trials, and UCSF Medical Center is now currently approved by Medicare (CMS) as an approved site for performing carotid artery stenting. There are further on-going trials including the NIH sponsored CREST (CaWWW.SFMS.ORG
rotid Revascularization of Endarterectomy vs. Stenting Trial), which is now directly comparing carotid surgery vs. carotid stenting for “low risk” patients with moderate to severe carotid atherosclerosis for primary and secondary stroke prevention.
Cerebral Aneurysm Therapy Subarachnoid hemorrhage due to rupture of a brain aneurysm, carries a 30%-40% risk of death, and a 50% risk of irreversible brain injury in patients who survive their initial bleed. Traditional surgery involves a craniotomy, exposing the aneurysm, and placing a surgical clip on the neck of the aneurysm. In 2002, a landmark study called ISAT (International Subarachnoid Aneurysm Trial) was published, which was a prospective, randomized, multicenter clinical trial, directly comparing surgical clipping vs. the less invasive technique of endovascular coiling to treat patients who presented with a ruptured brain aneurysm. A total of 2143 patients were evaluated over an 8 year period. The trial was prematurely stopped by the Steering Committee, after the interim analysis demonstrated a 23% reduction in dependency or death in patients treated by endovascular coiling. The conclusion from this trial was that in “patients with a ruptured intracranial aneurysm, for which endovascular coiling and neurosurgical clipping are therapeutic options, the outcome in terms of survival free of disability at 1 year is significantly better with endovascular coiling”. This trial has significantly altered the way patients are now being treated worldwide, with a trend towards the less invasive technique of endovascular coiling performed in the neuroradiology suite instead of the operating room. The UCSF Cerebrovascular Service works as a team, and is composed of full time specialists in Interventional Neuroradiology, Vascular Neurosurgery, Stroke Neurology,
FIGURE 3: MRA brain scan demonstrating a large aneurysm of the basilar artery. The combined expertise of a “team approach” by interventional neuroradiologists, neurosurgery, stroke neurology, and neuro-anesthesiology, has significantly improved the overall outcome for many of these patients.
Neurocritical Care, and currently has one of the busiest services in the United States, treating >250 new patients per year with a brain aneurysm. (Figure 3) A recent analysis of patients treated, continue to demonstrate overall better outcomes for patients, when treated by this “team approach” in which expertise from multiple specialized services are involved in the overall management of these patients.
The FDA recently approved the technique of carotid artery stenting as a treatment alternative to carotid surgery in certain “high risk” groups of patients.
Minimally invasive neurosurgery, also known as interventional neuroradiology/endovascular neurosurgery, has made significant advances over the past 2 decades, and has now emerged as a new subspecialty within the overlapping fields of neurosurgery, neuroradiology, and neurology. Almost every major academic hospital now offers these treatments routinely to patients as an alter-
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native to traditional “open neurosurgical” procedures. In this very short time period, interventional neuroradiology is now being offered as a viable alternative to patients with both ruptured and unruptured brain aneurysms for therapy; treatment of “high-risk” carotid atherosclerosis by stenting vs. carotid endarterectomy; acute stroke therapy intervention when patients present within a 6-8 hour time interval from symptom onset; and other complex diseases such as intracranial atherosclerosis, traumatic vascular lesions, and vascular disorders of the head, neck, spinal cord, and other parts of the body.
References Higashida RT: Evolution of a new multidisciplinary subspecialty: Interventional Neuroradiology/Neuroendovascular Surgery. American Journal of Neuroradiology. Volume 21, Pages 1151-1152. 2000. International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group: International Subarachnoid Aneurysm Trial (ISAT) of Neurosurgical Clipping vs. Endovascular Coiling in 2143 Patients With Ruptured Intracranial Aneurysms: A Randomized Trial. Lancet; Vol 360; October 26, 2002, 1267-1274. Dr. Randall T. Higashida is Chief of the Division of Interventional Neurovascular Radiology at the University of California, San Francisco Medical Center. He is a world expert in the area of stroke therapy, endovascular treatment of complex cerebral vascular disorders including brain aneurysms, arteriovenous malformations, and carotid and intracranial atherosclerosis.
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Hands and High Technology: Minimally Invasive Surgery
Non-Surgical Techniques and Modalities for Skin Rejuvenation Gaetano Zanelli, MD
he past decade has seen an explosion in the number of devices and techniques for rejuvenation of the aging face. This is undoubtedly fueled by an aging population substantially preoccupied with personal appearance, and a greater percentage of society with the financial means to pay for cosmetic procedures and products. The promotion of youth and physical beauty in the media and competition in the workplace are only some of the major external influences that drive procedures which people believe will enhance their beauty and thus their lives. The demand for non-surgical methods of rejuvenation with little healing time increases steadily, with a parallel increase in the number of physicians and non-physicians offering these services. This is a short overview of some of the new and not so new modalities for rejuvenation.
Botox Botulinum Toxin type A (BTX-A, “Botox”) has been used to counteract muscular hyperactivity for more than 20 years, and in 1990 the first published reports appeared concerning its use to cosmetically improve facial lines and wrinkles secondary to dynamic motion. This reduction of muscular activity is caused by chemodenervation due to acetylcholine blockade at the presynaptic neuromuscular junction. The first FDA approved cosmetic used of BTX-A was for glabellar furrows caused by the contraction of the corrugator supercilii, orbicularis oculi, and procerus muscles. At the same time it was also being used to improve wrinkles www.sfms.org
of the forehead due to contraction of the frontalis muscle, and “crows feet” around the eyes from contraction of the lateral portion of the orbicularis oculi. Skillful use of BTX-A can allow a physician to shape the eyebrow arch of a patient, female especially, and even open the eyes a few millimeters for a rejuvenated look. Botulinum toxin advanced techniques are now employed for the lower face — advanced because one must be very careful in the amount and placement of the BTX-A in order to produce the desired effect yet avoid over treatment of the target muscles which would result in undesired muscular laxity. Treatment of the orbicularis oris muscle will reduce perioral rhytides, and down-turning of the oral angles and melomental folds or so-called marionette lines can be improved by treatment of the depressor anguli oris muscles. BTX-A injected into the mentalis muscle will decrease chin creases and dimpling of the chin skin upon contraction. BTX-A may also be used for “bunny” lines of the nose, melolabial folds in certain patients, facial asymmetry, and upper gingival show. Horizontal creases of the neck skin, vertical platysmal banding, and décolletage wrinkling can also be improved with BTX-A.
The search for the ideal injectable material for effacement of facial rhytides and folds continues and in the past few years several new agents have made their appearance, and disappearance, from the American market. The perfect filler would be economical, safe, and effective. It would be free of adverse reactions and long lasting or even permanent. Medical grade silicone used in a micro droplet technique comes the closest of any material. At this time it is FDA approved for intraocular injection but not for soft tissue augmentation. Its overwhelming success for correction of facial lipoatrophy due to HIV disease and treatment will hopefully lead to its approval for this indication in the not too distant future. Until a few years ago the only approved injectable filler in the United States was bovine collagen, and since that time several other injectable collagens of human and porcine origins have appeared. In most cases their longevity of correction is disappointing and while addition of other elements such as polymethylmethacrylate microspheres will result in longer lasting augmentation, the side effect profile is unacceptable for many judicious physicians. Several grades of injectable hyaluronic acid (HA) are now available such as “Restylane” Hylaform”, and “Captique” with more on the horizon “Juvederm”.
The demand for non-surgical methods of rejuvenation with little healing time increases steadily with a parrallel increase in the number of physicians offering these services.
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While HA treatments often do last a few months longer than collagen, clinical experience does not seem to replicate the longevity claims of manufacturers and their spokespersons. Very often the best results are achieved with a large amount of material, and this is prohibitively expensive for most patients. Radiesse’ is an injectable form of calcium hydroxylapatite microspheres used by some for melolabial fold augmentation. It can last as long as a year but is not yet approved for that indication. Injectable poly-L-lactic acid (Sculptra”) was approved last year by the FDA for volume correction of lipoatrophy due to HIV disease and treatment. Subdermal injection of the material induces an inflammatory reaction that for some patients results in collagen deposition, which produces an often satisfying but temporary correction of the facial defects. The high cost, temporary effect, and relatively high rate of palpable and sometimes visible granuloma formation with Sculptra make it a disappointing option for soft tissue volumization. The manufacturer of Sculptra is aggressively marketing the product to patients and physicians for correction of nonHIV lipoatrophy due to general aging.
With the pulsed carbon dioxide laser and erbium laser one can achieve rhytid effacement equal to a deep chemical peel with the added benefit of collagen contraction secondary to the thermal injury by the lasers. The surge in popularity of this procedure in recent years has been tempered because of the unfortunate side effects of long-term erythema and even permanent hypopigmentation of the treated areas in many patients. Many patients and physicians are unwilling to bear the risks of infection, scarring and hypopigmentation as well as healing time associated with aggressive ablative procedures, and this is in part responsible for the ongoing search for methods of nonablative rejuvenation.
Chemical peels causing ablation of the stratum corneum and papillary dermis have long been the standard method for non-surgical rejuvenation of facial skin and in skilled hands the appropriate patient can receive beautiful results with resolution of dyspigmentation, rhytid effacement, reduction of solar keratoses, and general improvement of skin tone and texture. Lighter peels are performed with glycolic and salicylic acids and Jessner’s solution, medium depth peels with 30-35% trichloroacetic acid (TCA), and deeper peels with 50% TCA, and phenol and croton oil. As one would expect, the deeper the peel the more dramatic the results, but risks of scarring and hypopigmentation increase with the deeper peels.
New devices for facial rejuvenation such as lasers utilizing less immediately destructive methods of stimulating new collagen production appear almost monthly. The attraction of these modalities to patients and especially non-physician practitioners is their non-surgical approach with a short healing time. They often require several treatments for a desired effect, which may still not be very dramatic. The least invasive of these devices include microdermabrasion units utilizing aluminum oxide or salt crystals and suction to superficially ablate and massage the skin. Intense pulsed light (IPL) devices, unipolar and bipolar radiofrequency devices, Nd:YAG, diode and pulsed dye lasers, fractional photothermolysis erbium lasers (Fraxel’), and infrared heating units are all being used for nonablative rejuvenation. Fractional photothermolysis is an interesting and promising concept in which the skin is treated fractionally with patterns of microscopic laser spots, resulting in a unique wounding and healing process. The exact mechanism by which these devices produce skin rejuvenation has not been thoroughly elucidated but is thought to occur by stimulation of fibroblast production of new collagen through heat denaturing of tissue.
The Future of Skin Rejuvenation
The advent of lasers to treat aging skin, by the principle of selective photothermolysis, brought an exciting new tool into the discipline of non-surgical rejuvenation.
Results of nonablative rejuvenation are often not reproducible and it is the thought of many experts that the release of new devices is occurring before the sci-
Chemical Peeling Agent
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ence of the process is clearly established. Complications of scarring and dyschromia can and do occur even in the best of hands. Laser companies aggressively market their devices to physicians and other potential buyers with promises of exorbitant increases in their practice profits. This may happen temporarily, but as a result of the lack of long-term clinical experience with the devices the reality is that clinical trials are being played out in physicians’ offices and “medi-spas” on paying patients. Some devices which were touted by their companies and physician spokespeople just a few years ago as being miracles of rejuvenation are no longer being used because the technology is already obsolete or too many complications resulted with the devices. As an example: in the week of January 3, 2006, you may see offered on eBay an EpiLight’ device for $10,000 and a Cutera CoolGlide’ laser for $29,000. These units originally sold for $150,000 and $90,000, respectively, and were marketed by their companies as the solution for permanent hair reduction. Safer and more effective lasers and intense pulsed light devices have now superseded them. It is certain that in the near future we will see the continued introduction of new techniques and devices for skin rejuvenation as the technology progresses and the demand undoubtedly continues. Gaetano Zanelli is Assistant Clinical Professor in the Department of Dermatology at UCSF and has a practice at the Davies Campus of California Pacific Medical Center. He has been published in the Journal of the American Academy of Dermatology, Clinics in Dermatology, and the Journal of the American Society for Laser Medicine and Surgery.
HANDS AND HIGH TECHNOLOGY: MINIMALLY INVASIVE SURGERY
Screening for Abdominal Aortic Aneurysm with Ultrasound Can Save Lives Gretchen A.W. Gooding, MD
nabdominalaorticaneurysm(AAA)is a dilated aorta, usually below the renal arteries, that measures on anterior/posterior dimension, 3.0 cm or greater. Fig 1 Abdominal physical examination for abdominal aortic aneurysm is not accurate for anumberofreasons,includingmorbidobesity, which preclude detection of the abdominal aorta. At the other extreme, marked pulsation in a thin normal person may simulate disease. A noninvasive way to look at the abdominal aorta and screen for aneurysm is available with ultrasound. Since about 9000 patients die from AAA related disease each year in the United States, who should be considered candidates?
Q: Is your patient 65 to 75 years old , a male and a smoker or former smoker? A: HeisatriskforAAA.ConsiderAAA screening. Q: How important is the number of cigarettes smoked? A: Patients who have smoked over 100 cigarettes are felt to be at risk. Q: Is your patient 65 to 75 years old, a male that has never smoked? A: He may benefit from AAA screening, but the prevalence of AAA is less than for smokers and the benefit must be weighed with the potential that he could perhaps be harmed byearly surgery withrisks ofmorbidity and mortality.
Q: Should your 85 year old male patient WWW.SFMS.ORG
be screened? A: Patients over 75 years old may be at risk for AAA, but because of their decreased life expectancy and probable other co-morbid factors, they are probably not suitable candidates for screening. An alternate view from the consensus of the Vascular Surgery Society suggests screening men from 60 to 85 years.
Q: Does your patient have
FIGURE 1: This is an ultrasound examination of a large distal abdominal aortic aneurysm in an elderly man which shows flow in color on this longitudinal image with a large amount of avascular mural thrombus anteriorly
a brother with an AAA? A: Then, your patient is at risk for AAA, too. Male Patients 65 and over are at risk for development of an AAA. Brothers have a higher risk of AAA; sisters have a lesser risk.
Q: Is your patient an elderly woman? A: Since this is a low risk group, only consider screening with strong family and /or smoking history and serious cardiovascular risk factors in female patients 65 or over since screening probably does more harm than good in these patients causing unnecessary worry and also carries the risk of possible early probably unnecessary treatment.
Q: Is your patient less than 65 years and never smoked? A: You patient is at low risk and unlikely to benefit from AAA screening unless there is a strong family history of AAA.. Q: Is your patient diabetic?
A: Diabetes mellitus is not a risk factor for AAA.
Q: Is your patient African American? A: The risk of AAA is reduced. Q: If your patient was screened at age 65, when should he be rescreened? A: Those first screened at 65 years or greater with normal values for the aorta need no further followup since the risks of developing an AAA are quite low. Ultrasound Screening: Ultrasound (US) is both sensitive and specific for the diagnosis of abdominal aortic aneurysm. It is much cheaper than computed tomography (CT) or magnetic resonance imaging (MRI) which studies can also detect AAA, and ultrasound has no radiation or other risks and no contrast material is required for an abdominal aortic examination. Ultrasound is the cost-effective study of choice for
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abdominalaorticscreening.Thestudyrequires the patient to lie supine, have some acoustic gelplacedonhisabdomen,thenatechnologist glides a transducer over the abdominal skin to generate images of the abdominal contents that appear on a screen. Occasionally, portions of the abdominal aorta are obscured by overlying bowel gas. Although the aortic root can be identified by US at the heart, the thoracic aorta usually cannot be identified by ultrasound, since the surrounding air in the lungs diffuses the acoustic beam. An abdominal aorta that is 3 cm or greater in anterior/posterior diameter is aneurysmal. Patients with a small abdominal aortic aneurysm of 3 to 3.9 cm are usually followed annually. Those with 4 to 5.4 cm aneurysms are likely to be followed at six month intervals. Vascular surgeons prefer to see patients when the aortic diameter is greater than 4.5 cm. Those patients with aneurysms 5.5 cm or larger are candidates for consideration of surgery or endovascular stent. Surgical repair of large AAA of 5.5 cm or greater decreases AAA mortality. Surgical repair of AAA has a mortality of 4-5%. Screening of 65-75 year oldmenreducesby43%AAAspecificmortality. Screening for abdominal aortic aneurysm should alsoreduce thenumberofpatients who are first detected with huge abdominal aortic aneurysms of 8-10 CM AP who have little chance of survival with or without surgery or endovascular stent. For an examination of the highest quality, it is important that patients who are to get a screening ultrasound have it done by an accredited institution with credentialed technologists. Vascular accreditation is an indicator that the quality of the operation has been reviewed by peers and found worthy. The Intersociety for the Accreditation of Vascular Laboratories, the American Institute of Ultrasound in Medicine (AIUM), and the American College of Radiology (ACR) all have accreditation programs for the diagnosis of abdominal aortic aneurysm. The ACR/AIUM collaborative effort requiresthattheabdominalaortabeexamined proximal, mid, and distal, in two planes, transverse and longitudinal, that measurements be obtained from outer wall to outer wall., that a measurementof3cmorgreaterisindicativeof aneurysmalenlargement.Apermanentrecord 22
ofthestudy,availableforreview,withawritten interpretation of the findings for the medical recordisrequired,withtimelycommunication of the results to the referring physician. Ultrasound screening for abdominal aortic aneurysms is safe, effective, and can savelives.Weighingriskwithbenefit,consider screening for the 65 to 75 year old man., particularly if he is or has been a smoker.
References U.S. Preventive Services Task Force. Screening for Abdominal Aortic Aneurysm: Recommendation Statement. Annals of Internal Medicine 2005;142:198-202. Fleming,C, Whitlock, EP, Bell, TR, Lederle, FA. Screening for Abdominal Aortic Aneurysm: a Best-Evidence Systematic Review for the
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U.S. Preventive Services Task Force. Annals of Internal Medicine 2005;142:203-211. Dr. Gretchen AW Gooding is Professor in Residence, Department of Radiology, at the University of California, San Francisco, and Chief of Ultrasound at the Dept of Veteran Affairs Medical Center in San Francisco. She is a Fellow of the ACR, AIUM, Society of Radiologists in Ultrasound, and the American Association of Emergency Radiologists. She currently serves as Chair of the American College of Radiology Ultrasound Guidelines and Standards Committee.
Hands and High Technology: Minimally Invasive Surgery
Phoenix Rising: And the Big Bird is Looking Through a Laparoscope Leonard Shlain, MD
t was no fair. General surgery made the endangered species list at a time when my colleagues in ophthalmology, ENT, transplant, and orthopedics were inventing new operations – seemingly on a daily basis. Total hips, laser corneal surgery, arthroscopic this and that, and don’t even get me started talking about the plastic surgeons. They churned out novel techniques like some kind of a sorceress. It was the late 1980s and prospects were not looking good for my field. Where, oh, where were our new procedures? How times had changed. I can still recall the excitement crackling among my fellow surgical residents when I began training at Bellevue in the sixties. Innovative means to cure disease by applying judicious aliquots of tincture of cold steel abounded. Trumpeted in our journals were spleno-renal shunts, rectopexies for people whose guts were falling out their rectum, and axillo-axillo-femoral artery bypasses. A few courageous souls even tried to remove 95 percent of the pancreas. Those were the days my friend, we thought they’d never end. It seemed that no krank bedeviling the human species could confound a skillful general surgeon. And then came “The Great Wasting”. One by one, the OR scheduler erased from the morning’s operating board the procedures that had formed the very foundation of general surgery. The gastroenterologist snared sigmoid polypectomies. Tagamet swallowed nearly all the gastrectomies. CT scans cooked the goose of that old popular standby, the exploratory laparotomy, makwww.sfms.org
ing it as rare as a sighting of the dodo bird. Alarmingly, radiologists began to breach the barrier guarding the surgeon’s inner sanctum. First, they honed their skills rotorootering arteries and soon there seemed to be no “-itis” they couldn’t heal with their magic twisty wands. My God! Even the cardiologists were muscling in on our world, showing up in our dressing lounge trying on scrubs. As if these troubles were not enough, The Great Wasting coincided with the time of “Terrible Turf Wars”. The head and neck guys planted their flag in our thyroid, while at the other end, a new breed of colon and rectal surgeons first staked out the hemorrroid and then moved up the rectum on to the sigmoid with the intent on wresting the cecum from the general surgeon. As Jimmy Durante once cracked, “Everybody wants to get into da’ act.” The future for general surgery bleakened. We circled the wagons around breast biopsies, gallbladders and hernias planning to make our last stand. But deep down, we were demoralized. General surgery was edging toward the precipice of, if not extinction, irrelevancy. One morning I attended grand rounds and sat through a presentation by a UC radiologist. He announced (not without a hint of malevolent glee in his voice) that he and his department were working out the kinks on a percutaneous means to extract gallstones. I left depressed. Determined that we surgeons could not cede this vital organ to the radiologists, I began to collaborate with my friend,
urologist Rob Kahn, to develop a similar percutaneous means to remove gallstones using ultrasound to identify where to puncture the gallbladder. We performed six of these (lame) procedures with my colleagues looking on doubtfully. One afternoon, a rep walked into my office and played a video of an operation called a lap chole performed by Eddie Joe Reddick, a general surgeon in private practice in Tennessee. Through the use of four tiny incisions and a scope connected to a video display using miniaturized lengthened instruments he demonstrated how he could disconnect the gallbladder from its attachments underneath the liver, suction out its contents and then with a flourish, extract the now flaccid sac through the tiny hole in the belly button. Patients went home the same day with a smile on their faces. I asked the rep to play the clip again and again. By coincidence, later that afternoon I was chatting with a good friend and surgeon in Atlanta. Shoptalk turned to this obscure surgeon Reddick and his new technique. Oh yes, my friend replied, he had heard of him and the operation was gaining traction in the South. Fortuitously, my friend and I planned to observe a day’s worth of lap choles at Georgia Baptist Hospital the next morning. I hung up the phone and made reservations on the red-eye to Atlanta that night, arriving in the operating room the next morning. After observing Ed Mason remove five gallbladders in record time, each discharged the same day, I became a true believer. This operation was just what
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the doctor ordered to cure The Great Wasting. Within weeks of each other, Jonathon Leightling, Sam Esterkyn, and I introduced this operation to San Francisco. Barry Gardiner and William Otero in the East Bay were the first to accomplish the feat in the Greater Bay Area (I should mention that the gynecologists had been light years ahead of us in this department. They, however, only pointed their scopes south. Not until general surgeons pointed the same scope in the opposite direction, did they realize that there was a rich northern load waiting to be mined). Many of my colleagues’ attitudes towards lap choles was a combination of caution mixed with skepticism. Too much paraphernalia, they muttered. Damned gimmickry was the scuttlebutt in the OR lounge. Then, like a flock of starlings, as if on some prearranged signal all swerving simultaneously, the surgical community in the entire Bay Area did a one hundred and eighty on a dime. Within months, surgeons performed lap choles at every hospital. Few innovations in the history of surgery so utterly transformed the field in as short a time and as dramatically as did this new technique. And so, in the spring of 1990 began the era of laparoscopic surgery in San Francisco.
The Technique First, we insufflate the peritoneal cavity with carbon dioxide gas until it attains beach ball status. This maneuver lifts the abdominal wall away from the intestines by about four inches. Next, we puncture the skin near the umbilicus with a trochar. After removing its sharp obturator, the trochar becomes an airtight sleeve. We then place a highly sophisticated telescope through it and Voila! Similar to a fifth row center seat at the Hollywood Bowl, we have a panoramic view of the abdominal contents. A few more trochars, and then we thread very long instruments with tiny heads through the sleeves. Now for the hard part. The instruments act as levers balanced on the fulcrum of the abdominal wall. I observe the tip of the instrument on a video display. If I want the tip to move to the right, I must move my hand to the left. If I want the tip to move 24
up, I move my hand down. So far, so good. However, if I want the tip to go in, then I must move my hand in. Therein lies the problem. If all the movements of one’s hand were the opposite, then it would be a skill easier to master. Unfortunately, two of the three vectors of Euclidian space are the opposite but one remains the same. The brain of a surgeon in its first attempt at making any complex three-dimensional movement laparoscopically will precipitate a serious neuro-hiccup because the instructions the brain must send to the hand violate intuition-sort of like trying to cut a nose hair in the mirror. Surgeons overcame these difficulties because laparoscopic surgery was a major adrenaline rush. One by one, traditional operations transformed into keyhole operations. First gallbladders, then hernias, appendectomies, gastric fundoplications, colon resections, and even cardiac bypasses became doable. The current craze to sweep the field is bariatric surgery.
rejuvenated the field of general surgery. Speaking for myself, it made me feel like an excited schoolchild. I had to learn an entirely new set of skills. I had to familiarize myself with exceedingly hi-tech toys while I acquired an exotic vocabulary and mastered a new body of knowledge. But topping the list, laparoscopic surgery is the best damn video game I have ever played. Leonard Shlain is the chairman of lapaoscopic surgery at California Pacific Medical Center and is also the author of three national best-selling books. His latest, Sex, Time and Power: How Women’s Sexuality Shaped Human Evolution, recently won the Quality Paperback Book Club Award for the Best NonFiction in its category. He may be contacted at Lshlain@aol.com.
Double-Edged Swords Prior to the advent of the laparoscope, surgeons used instruments that were modified variants of a knife, fork, and a spoon. Compared to orthopedics or neurosurgery, we were definitely low tech. Since the advent of laparoscopic surgery, however, new star-wars technologies emerge every year enabling surgeons to convert old standby open procedures to laparoscopic ones. However, Sophocles once warned, “Nothing vast enters the life of mortals without a curse.” So, we might ask, what has been the downside of all this technology? Many a misadventure has occurred in the performance of laparoscopic surgery. These disasters have been chalked up to the learning curve. But it is now 15 years later and there is still a lot of learning going on. Regrettably, there is no Journal of Bad Results and many of these misadventures go under-reported. Gnawing at the edges of the remarkable advances that constitute much of laparoscopic surgery lurks the hubris of the surgeon’s bugaboo-the triumph of technique over judgment. Just because it is feasibly possible to do, does not mean that a surgeon should do it...laparoscopically. This caveat aside, laparoscopic surgery
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HANDS AND HIGH TECHNOLOGY: MINIMALLY INVASIVE SURGERY
The Past, Present, and Future of Laparoscopic Colectomy 2006 Laurence F. Yee, MD and Michael E. Abel, MD
ith the successful introduction of laparoscopic cholecystectomy in 1987, the laparoscopic approach for other operations such as Nissen fundoplication, splenectomy, gastric bypass for obesity, and appendectomy have been established and embraced. Laparoscopic colectomy, conversely, has been slow to gain widespread utilization over the past 15 years. This slow acceptance has been primarily due to two concerns inherent to laparoscopic colectomy: 1) the quality of resection for colon cancer, and 2) the lack of standardization and training in a technically demanding operation. As a result of these concerns, only 5% of all colectomies were performed laparoscopically in the US in 2004. However, with the recent publication of multiple trials comparing laparoscopic and open colectomy for colon cancer and vast improvements in new technology, experts predict that by 2010 70% of all colectomies will be performed using a laparoscopic approach.
Rationale for laparoscopic colectomy Compared to open colectomy, laparoscopic colectomy is performed using much smaller incisions, which can lead to less postoperative pain, decreased narcotic usage, improved pulmonary function, faster return of bowel function, shorter hospital stay, earlier return to work and normal activity, improved cosmesis, and decreased hospital costs. The rapid acceptance of laparoscopic cholecystectomy as the â€œgold standardâ€? was a result of providing patients WWW.SFMS.ORG
provided by the laparoscopic approach may benefit cell-mediated immunity resulting in superior oncologic outcomes.
Indications for laparoscopic colectomy
FIGURE 1: Port Placement for Laparoscopic Right Colectomy
all of these advantages, including a decrease in operative time and dramatically reducing hospital stay. In addition to the small incisions, the surgical precision of the laparoscopic approach to colectomy may lead to improved outcomes. Recent technologic advances in digital optics allow for magnification and clarity much superior to the naked eye during open surgery. This can allow for more accurate recognition of anatomic detail which translates into more precise dissection. Innovative new instruments and sealing devices have allowed for more delicate handling of tissues, which can result in decreased blood loss, less contamination and wound infection, decreased adhesion formation and a lower rate of post-operative small bowel obstruction. Furthermore, the overall decrease in stress to the host immune system
Virtually any patient who has an indication for an open colectomy is a candidate for a laparoscopic colectomy. Indications for laparoscopic colectomy include cancer, large polyps, diverticular disease, inflammatory bowel disease, volvulus, ischemia, and stricture. There are, however, patients who are less likely to benefit from a laparoscopic approach due to longer operative times. Relative contraindications for laparoscopic colectomy include patients with complete or high grade obstruction, locally invasive tumors (T4), peritonitis, rapid bleeding, and multiple abdominal operations for adhesive disease.
Oncologic concerns regarding laparoscopic colectomy With the introduction and rapid acceptance of laparoscopic cholecystectomy in 1987, it was natural for surgeons to apply the laparoscopic approach to colectomy for benign and malignant disease. By 1994, however, several case reports of port site metastases (tumor implantation in the laparoscopic incisions) were published leading to essentially a moratorium on a laparoscopic colectomy for colon cancer by the American Society of Colon and Rectal Surgeons (ASCRS). This real concern that the laparoscopic approach to
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colon cancer may result in tumor spread and/or inadequate resection led to the development and initiation of parallel clinical trials in 1994. Both the Clinical Outcomes of Surgical Therapy trial (COST) sponsored by the ASCRS in the US and the CLASICC trial in the UK began accruing patients in 1996 comparing laparoscopic and open colectomy for colon cancer resection. In May 2004, the results of the COST trial comparing open and laparoscopic colectomy for cancer were published in the New England Journal of Medicine. 872 patients with colon cancer were randomized to open or laparoscopic colectomy in 48 centers in the US (1996-2002). Surgeons performing these operations were almost exclusively board-certified colon and rectal surgeons. With a 4.4 year follow-up, the laparoscopic colectomy did not result in higher rates of recurrent cancer and demonstrated equivalent complication and mortality rates compared to open colectomy. In addition, the COST study found that laparoscopic colectomy was advantageous in reducing both narcotic usage and hospital stay. Similar results from the CLASICC trial comparing open and laparoscopic colectomy for cancer were published in May 2005 in Lancet. 794 patients with colon cancer were randomized to laparoscopic or open colectomy in the UK (1996-2002). Their findings were similar to the COST
consisted of 2 surgeons and 1 optical port and 2 operating ports without the use of hand-assist devices (Figures 1 & 2).
5 steps in laparoscopic colectomy 1) Pre-operative localization of
FIGURE 2: Port Placement for Laparoscopic Left or Sigmoid Colectomy
lifted the 10 year moratorium on laparoscopic colectomy for cancer. In response to these findings, many expert colon and rectal surgeons have predicted a rapid increase in laparoscopic colectomy from its current 5% to upwards of 70% of all colectomies in the next five years.
Operative technique of laparoscopic colectomy Unlike the standardized approach to laparoscopic cholecystectomy, there are a number of â€œacceptableâ€? approaches to laparoscopic colectomy. Approaches described have included up to four surgeons, eight ports, hand assist devices, and multiple
FIGURE 3: California Pacific Medical Center Experience in Colectomies
trial, demonstrating equivalent oncologic outcomes and complication rates for laparoscopic and open colectomy. In addition, laparoscopic colectomy resulted in decreased hospital stay. Overall, the recent publication of these and other clinical trials have, in essence, 26
patient positions. In addition, the operative approach can either begin by devascularizing the colon followed by mobilization, or vice versa. The heterogeneity of approaches makes laparoscopic colectomy difficult to learn Since 2000, our standard approach has
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tumors with colonoscopy is essential. India ink tattoo at the time of colonoscopy is especially useful for any tumors or polyps in the colon and rectum as they are readily seen on the colon wall during laparoscopy. 2) Exploratory and staging laparoscopy to assess the liver and peritoneal surfaces, perform biopsies, lyse adhesions, and to localize tumors and tattoos 3) Devascularize the segment of colon to be resected. Dissection is done in a medial to lateral fashion (mesenteric resection prior to lateral mobilization). Laparoscopic clips or sealing devices are used to divide the vascular supply and resect the lymph node bearing mesentery. 4) Mobilize the colon from retroperitoneum, omentum, splenic or hepatic flexures using laparoscopic cutting and sealing devices using a two instrument approach. 5) Resect the colon and create the anastomosis through a 4-5 cm incision. This step-by-step comprehensive approach has facilitated organization and economy of time and equipment in the operating room. The simplicity of this approach allows for a minimal requirement in the number of surgeons, incision sites, and equipment utilization, yet provides excellent ergonomics, flexibility, and precision of dissection.
Results of laparoscopic colectomy at California Pacific Medical Center (CPMC) Our program in laparoscopic colectomy at CPMC began in 1998 and the volume has increased every year (Figure 3). Our mean operative time (143 minutes) and conversion rate to open colectomy (2.4%) compares favorably to those reported in the COST trial (150 minutes and 21.0%, respectively). As a result of our experience and the recent introduction of new instrumentaWWW.SFMS.ORG
tion, many patients now experience a 90 minute operation and a 3-4 day hospital stay. Furthermore, similar to laparoscopic cholecystectomy, we are now carefully applying laparoscopic colectomy to selected elderly or higher risk patients who would otherwise not be good candidates for open colectomy.
Future of Laparoscopic Colectomy With the ever-growing stream of new technology and instrumentation, the ability to perform an increasingly more precise and less invasive laparoscopic colectomy is on the horizon. Clinical trials and evidencebased outcomes will be essential to guide the careful introduction of novel surgical instrumentation and products. Forthcoming new technology include devices to improve the creation of the intraabdominal anastomosis using colonoscopic stapling devices, biological “glue” to replace sutures and staples, robotic and tele-robotic laparoscopic colectomy, and novel pro-motility agents to reduce postoperative ileus. Integration of these new devices and techniques into laparoscopic colectomy should facilitate a further reduction in operative
time, decrease incision number and size, improve precision of dissection, decrease infection rate, decrease hospital stay, and improve oncologic outcomes. Perhaps “outpatient” laparoscopic colectomy will be in our near future.
References Berends FJ, Kazenmier G, Bonjer HJ, Lange JF. Subcutaneous metastases after laparoscopic colectomy. Lancet 1994;344:58. The Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 2004;350:2050-9. Pappas TN, Jacobs DO. Laparoscopic resection for colon cancer - the end of the beginning? N Engl J Med 2004;350:2091-2 MRC CLASSIC trial group. Short term endpoints of conventional versus laparoscopically assisted surgery in patients with colorectal cancer. Lancet 2005;365:1718-26. Visser BC, Reilly LM, Volpe, PA, Garcia-Aguilar J, Abel ME, Chiu YC, Sternberg J, Russell, TR, Yee LF. Laparoscopic colectomy: Who will be trained to do it? Presented at the 76th Annual Meeting of the Pacific Coast Surgical Association February 17th, 2005.
Dr. Yee is the Vice-Chairman of Surgery at California Pacific Medical Center, a member of San Francisco Surgical Medical Group, and an Assistant Clinical Professor of Surgery at UCSF. Dr. Abel is a member San Francisco Surgical Medical Group and an Associate Clinical Professor of Surgery at UCSF.
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MARCH/APRIL 2006 SAN FRANCISCO MEDICINE
HISTORICAL PERSPECTIVE Nancy G. Thomson, MD
The San Francisco Earthquake 1906: Quick Action Saved Countless Lives
n April 18, 1906 at 5:13 am, an earthquake, the greatest natural disaster (at that time) in the United States, struck cities along the West Coast of Northern California. In San Francisco, “The Paris of the West”, it was followed by a fire which, with disruption of the water supply, burned for three days. The San Francisco Medical Society, founded in 1868 and housed in the YMCA building downtown, found its library of 6000 volumes and its records destroyed. Fortunately, Emmett Rixford, the treasurer, had taken his cash records and buried them in the yard of his home and office on the corner of Franklin and California streets. Although the fire jumped Van Ness at that point for six blocks, they were retrieved intact. As we observe the centennial of the great quake and fire, this article focuses on the activities of the Army personnel in the Presidio who were instrumental in treating the wounded and providing sanitation to prevent the spread of disease in the various refugee camps located in the western part of the city. Although the official death toll is still given as 478, so as not to scare away investors, modern estimates place it nearer to 5,000. However, this number would have been much higher had it not been for the efforts of the military, many of whom have been commemorated by streets named after them in the Presidio - including Army Surgeon General Robert O’Reilly, the street on which the Medical Society is now located. The Army personnel were headed by Lt. Colonel George Henry Torney (1850-1913) Deputy Surgeon General and Chief Surgeon of the Department of California, who had been placed in command of Presidio General Hospital in March 1904. Torney acted immediately after the earthquake by ordering a survey of damage done to the hospital and medical supplies. He filed a report of his activities (by telegraph) to Major General A.N. Greely, commander of the Pacific Division on May 14. The Army General Hospital (later known as Letterman) was badly wrecked
by the earthquake with damage to the structure, power plant, water supply, and communications system. In addition, throughout the city, both water supply and sewage disposal had been affected. On April 18th all available Medical Department Officers were alerted for work, and Company B Hospital Corps, accompanied by troops from the Presidio, went into the city for active relief work in fighting the fires which were a continuing problem especially throughout the next three days. The actual relief for the refugees and the sick and injured began at the General Hospital 4/18. Army personnel were instructed to give relief where needed and notify the city authorities that this hospital was open. By 1 PM, seventy-five patients had been admitted. By 11 PM the total had reached one hundred and twenty seven. The next day 145 patients were admitted to the General, mostly from other hospitals in the city which were either burning or threatened by fire. The numbers lessened but the bed capacity of the wards at the General Hospital was exhausted so four barracks of the men of the Hospital Corps at the Presidio were evacuated and established as wards. The hospitals at the post of the Presidio and Fort Mason were ordered open April 19 and received large numbers of refugee patients. That same day, because of the great demand on the General Hospital for first-aid work, a tent emergency hospital was organized and established on the plain in front of the hospital reservation. Capt. H.H. Rutherford, U.S. Army was placed in charge to advise patients arriving from the city, direct them to the proper hospitals, and to render assistance, treatment and first-aid dressings for those on the ground. On the morning of April 20th, the president of the Health Commission of the City of San Francisco requested Lt. Colonel Torney to act as the head of the Sanitary committee to coordinate action between the Army and civilian authorities on the sanitation of the city. Brigadier-General Funston authorized this and Lt.
Although the official death toll is still given as 478, modern estimates place it nearer to 5,000. This number would have been much higher had it not been for the efforts of the military.
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Colonel Torney immediately transferred command of the General Hospital to Capt. James M Kennedy, U.S. Army. The many thousands of people still wandering the roads and streets seeking refuge were assisted. The camps in the Presidio, Golden Gate Park, Fort Mason, and the small city parks (such as Lafayette Square) were provided with tents, tools and conveniences for cooking and carrying out necessary sanitary measures. In addition, persons causing disturbance in the camps were ejected, and not to be admitted elsewhere. The Health Commission of the city selected sites for permanent camps. These were provided with a community kitchens, corresponding to the company kitchens in military camps, and sanitary troughs and medical supplies sent by the War Department. In addition, on April 21 by the authority of the Mayor of San Francisco, Harbor View Park adjacent to the Presidio with tents, bedding and hospital appliances was established as a place for infectious diseases. It had admirable facilities including its own water supply, its own laundry and a large pavilion which could accommodate 200 patients. In this, cases of measles, scarlet fever and diphtheria were cared for. Fortunately, the General Hospital had a supply of medical supplies, since those of the city had been destroyed by fire. More supplies, including vaccine virus were supplied from relief stores,
On Your Behalf continued from p5 financial solvency regulations apply only to risk-bearing medical groups/IPAs. The financial solvency standards and the reporting requirements do not apply to individual physicians. The PacifiCare article also incorrectly implies that the regulations require risk-bearing organizations (RBOs) to submit financial statements to each health plan with which they are contracted. The regulations only require RBOs to submit financial statements to DMHC. Some health plan capitation contracts may require RBOs to regularly submit financial statements, but this is not something that is required by state law. Contact: Aileen E. Wetzel, 916/4445532 or firstname.lastname@example.org.
CMA’s 9th Annual Leadership Academy Is May 5-7 Physicians can now register online for CMA’s 9th Annual Health Care Leadership Academy. The conference is May 5-7 at the Renaissance Esmeralda Resort near Palm Springs. A dynamic multidisciplinary faculty will discuss trends affecting your economic future as a physician and teach essential leadwww.sfms.org
and twenty-six free dispensaries were set up receiving their supply of medicines from the Medical Supply Depot of the Army. On April 23, at the Santa Fe Depot in Point Richmond, thirteen railway cars were examined, removing seven barrels and nineteen boxes of drugs and disinfectants, originally intended for Langley and Michaels, wholesale drug distributor in San Francisco whose business had been destroyed by the fire. These were delivered to the Presidio dock by Captain Badger of the U .S. Navy and the tugboat, Vigilance. Also, milk was made available. This well-coordinated effort, about which little is known, did much to save lives and relieve suffering and the spread of infectious disease.
Acknowledgments: 1. Richard Torney, great-grandson of George Henry Torney whose much more detailed article will appear in the Argonaut, published by the San Francisco Museum’s Historical Society 2. 1906 by James Dalessandro. A well-researched work treated as fiction 3. The History of the San Francisco Medical Society 1850-1900. 4. There is also a wonderful display of earthquake/fire photographs currently at the Palace of the Legion of Honor.
ership skills. This year’s conference, “Reengineering Health Care: Meeting Future Expectations Without Breaking the Bank,” will address the challenges of cost, quality, and access to care as “locomotives” of health system reform. Noted economists and leaders from the government, business, and labor sectors, as well as from the health care industry itself, will present a variety of perspectives on how to avert a “train wreck” and put the system on track toward a viable future. The academy also will feature a powerful slate of nuts-and-bolts leadership skills workshops including: • Leadership skills for managing change • Conflict resolution techniques • How to prepare a compelling presentation • How to maximize committee effectiveness • How to deliver medicine’s (or your organization’s) message to the public Participants can earn up to 17 hours of Category I CME. To register: http://www.cmanet.org/leadership/ Contact: Leadership Academy Hotline, 800/795-2262 or email@example.com.
Medical Board Mail Stolen in Sacramento; Physicians Encouraged to Guard Against Identity Theft An unknown quantity of mail was stolen March 4 from the general mailbox at a Department of Consumer Affairs (DCA) facility in Sacramento, which houses the Medical Board of California and seven other professional licensing boards. As license applications and renewals contain personal and financial information, physicians who mailed medical license applications, renewals, or other mail containing personal information between February 25 and March 3 to the DCA Howe Avenue facility are encouraged to contact the medical board (916/2631080) to determine if their applications have arrived safely. If your application has not arrived, please visit the DCA Office of Privacy Protection (COPP) website at http://www.privacy.ca.gov for information on steps you can take to protect yourself from the possibility of identity theft. COPP can also be reached by phone at 866/785-9663
MARCH/APRIL 2006 San Francisco Medicine 29
ANNOUNCEMENTS Paul B. Hofmann, Dr. PH and Haile Debas, MD
Surgeons Volunteer Locally through Operation Access
t all began with a question. In the early 1990’s, Operation Access co-founder Dr. Douglas Grey attended an American College of Surgeons conference and heard this question asked by a presenter: “Why don’t surgeons do more to help people in their own community, instead of flying on surgical missions to foreign countries.” Dr. Grey thought about it . . . and decided to take action. Dr. Grey and Dr. William Schecter, Chief Surgeon at San Francisco General, together with a senior health care executive, decided to start a program (now called Operation Access) to provide free outpatient surgical care to people in our community with no health care insurance. Uninsured patients who are unable to afford non-emergency surgery face overwhelming financial obstacles to obtaining necessary treatment. Excluding professional fees, for example, an uninsured patient would be charged approximately $12,000 by a private hospital in the San Francisco Bay Area to repair a hernia. The vision to create opportunities for surgeons and other medical professionals to give back to their local community began with 1 hospital and 15 medical volunteers. In 1994 25 surgical procedures were performed. Last year 368 people received surgical care. Operation Access has now grown to become a network of over 300 physicians, nurses, and surgical technicians, 60 referring community clinics and 16 participating hospitals in the six county Bay Area. When it began, there was no comparable organization in the country that coordinated a broad range of free surgical procedures for uninsured, low-income populations through the mobilization of medical professionals and private hospitals. In recognition of its unique attributes, the program received the American Hospital Association’s prestigious NOVA Award in 2002. Over 150 physicians currently donate their time and expertise to provide the uninsured with outpatient surgical procedures that significantly improve their health, ability to work, and quality of life. Anesthesiologists, general surgeons, and sub-specialists (from otolaryngologists to urologists) volunteer, thus allowing Operation Access to offer a wide variety of ambulatory surgical procedures. Potential patients are referred to Operation Access from community primary healthcare clinics, such as the San Francisco Free Clinic. Operation Access staff screen the individuals for eligibility. Eligible patients are matched with a surgeon volunteer who, without charge, provides the surgical consult, surgery if necessary and post 30
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operative care. Patients return to their primary care provider for any ongoing health care needs. All of the participating hospitals offer their facilities and supplies without charge. Through this model program of providing non-emergent surgical care, over 1,950 individuals have received surgical services ranging from breast biopsies to hernia repairs to gall bladder removal. The opportunity to make a contribution locally has been welcomed by all the volunteers. One said, “medical care should be available to everyone. We are happy to volunteer for Operation Access and to provide surgical care to those in need.” Operation Access volunteers and participating hospitals have proven that donated medical care can have a significant impact in improving access for a targeted patient population that would otherwise likely go without care or utilize the emergency room. The charity care impact, based on medical provider billing charges, but waived through Operation Access, was $1,837,162 in 2005, and now totals over $10 million dollars since the program began. The words of a former patient speak to what may be the most important impact: ”I want to give infinite thanks to Operation Access and the medical volunteers who give ... their time to exercise their excellent profession. The experience was excellent; the hernia had made it impossible to work, and today it is different because I can...” To learn more about Operation Access, go to www.operationaccess.org. Paul B. Hofmann, Dr. P.H., president of the Hofmann Healthcare Group in Moraga, California, worked with Drs. Grey and Schecter in establishing Operation Access, and serves as a consultant to health systems and hospitals. Haile T. Debas, MD, is the Executive Director, UCSF Global Health Sciences and Vice Chancellor Emeritus for UCSF Medical Affairs. WWW.SFMS.ORG
PUBLIC HEALTH update Janet Zola, MPH and Eric Sue, BA
A Successful Community Hepatitis B Screening and Vaccination Program
hronic hepatitis B (HBV) infection is currently one of the top five causes of premature mortality in the Asian community in San Francisco. Recently, the San Francisco Department of Public Health, in partnership with the Asian Liver Center at Stanford University (ALC), completed a community based pilot project called â€œ3 For Lifeâ€? targeting adult Asian Pacific/Islander (API) residents of San Francisco for hepatitis B screening and vaccination. With an API population of over 250,000 and an estimated rate of chronic hepatitis B infection at 10% in this population, there are potentially 25,000 chronically infected residents (infection in this population is transmitted vertically from mother to infant at birth). Enormous strides have been made in the last 10 years in the treatment options for chronic HBV, but the only way to know if someone is chronically infected is through blood tests. A significant number of infected individuals are unaware of their HBV status. Without treatment or regular screening, one in four of those who are chronically infected is at risk of premature mortality from liver cancer or liver failure. The greater San Francisco Bay Area has 33% of the Stateâ€™s API population and has the highest incidence of liver cancer in California and in the country. The 2004 Comprehensive Cancer Control in California Report states as one of its goals for 2010 that all Asian/Pacific Islanders be screened for hepatitis B to decrease the liver cancer mortality rate among this group.1 In September of 2004 the 3 For Life Project was launched at the Richmond District YMCA. Three of the primary goals were: To raise awareness among API adults of the importance of being tested for hepatitis B, being vaccinated if unprotected and being monitored if chronically infected with the hepatitis B virus; To gain information about the barriers to hepatitis B screening and vaccination for the API population; And to raise awareness among health care providers of the need to test and/or monitor the hepatitis B status of API patients. The program provided low-cost2 hepatitis A and hepatitis B vaccinations and free hepatitis B testing (surface antigen and surface antibody) two Saturdays a month for a year. During those 72 clinic hours over 1,200 adults were screened and more than 3,000 shots were administered. This translated to approximately 1 shot every 2 minutes! SFDPH supplied the vaccine and the nurses to administer the vaccine while ALC provided the phlebotomist, transported the blood to Stanford, and mailed test results to clients with a comprehensive, bi-lingual letter explaining the test results and what steps to take next. In addition, ALC recruited, trained and coordinated the utilization of www.sfms.org
120 volunteers ranging in age from 16 to 66. The data collected indicated 10% of the clients are surface antigen positive (chronically infected) and 40% are surface antibody positive (immune due to previous infection), leaving 50% vulnerable to infection and in need of protection. Nearly 54% have health insurance yet only 16% said their doctor had ever suggested hepatitis testing to them. Among those who tested positive for chronic infection, 75% indicated that their doctor had never suggested testing, or that they did not know if testing had ever been suggested. As anticipated, these statistics highlight the need for further education and outreach to both the at-risk population and the providers who care for them. The Communicable Disease Prevention Unit is responding to this need by embarking on creative and collaborative strategies to raise awareness and improve knowledge levels among primary care providers of the importance of screening API patients for hepatitis B, educating patients about their status and risk factors, following-up on the chronically infected and vaccinating the vulnerable. This effort includes making sure these providers know that the household and sexual contacts of their chronically infected patients may be eligible for free testing and vaccination through the appropriate channels at the Health Department. The widespread participation in the 3 for life program indicates that accessibility, convenience, and affordable vaccination are important factors in an effective outreach program. Locally, a new hepatitis B collaborative at UCSF is about to establish the 3 For Life concepts in the community one Saturday a month, indefinitely. Earlier this year the Chinese Christian Herald Community Center of Los Angeles launched the program for its own community. The state of Hawaii is also preparing to replicate 3 for Life in the coming year. Primary care physicians who are not already addressing this heath issue in their practice can contact SFDPH for information and guidance. 1Comprehensive Cancer Control in California, 2004. Oakland, CA: California Dialogue on Cancer, April 2004. 2 Charge for vaccination: combination hepatitis A and B, $90 for three shot series; hepatitis B only, $60 for three shot series; hepatitis A only, $45 for two shot series.
Janet Zola is the Health Educator of the Communicable Disease Control and Prevention Section. She can be reached at firstname.lastname@example.org. Eric Sue is the Special Projects Coordinator for the Asian Liver Center at Stanford University. He can be reached at email@example.com. MARCH/APRIL 2006 San Francisco Medicine 31
32 San Francisco Medicine MARCH/APRIL 2006
ON MY MIND George Susens, MD and Steve Heilig, MPH
Removing Bad Money From Good Medicine: Time for Some Bitter Pills
edicine, besides being founded on science and compassion, is built on trust. And trust, between patient and physician and among physicians and medical researchers, requires assurance that financial incentives have not skewed research or treatment. Controversy about the intrusion of marketing and other incentives into medical research and treatment protocols is not new, but does seem to have intensified in recent years. Real or perceived monetary issues have damaged public and patient trust in medicine as a profession, and efforts to avoid such intrusions, and to restore trust, are lagging behind the need for corrective action. The pharmaceutical industry spends $13,000 per physician per year to market their products. This does not mean those products are bad, of course, but physicians can and will learn the facts about them without such marketing. Medical journals must clean their own houses, and seem to be attempting to do that. Physicians, in organizations and as individuals, should do likewise, and have made some attempts with voluntary restrictions on marketing activities. However, the evidence is that voluntary efforts are rarely sufficient. Thus ‘stronger medicine’ seems necessary
Kaiser Permanente’s New Policy: This past December, the Permanente Medical Group (TPMG) adopted stringent new policies regarding “Conflict of Interest.” The organization has denied pharmaceutical sales representatives from physician offices for fifteen years, and the new policies are strengthening that restriction. We quote from the introduction: “TPMG physicians shall not engage in any activities which create, or appear to create, a conflict of interest, and which could (1) Adversely impact the independence and objectivity of their judgment in carrying out their responsibilities as a TPMG physician, or (2) Conflict with the interests of TPMG, the Kaiser Permanente Medical Care Program, or Kaiser Permanente members and patients, or (3) Create the appearance of impropriety from an ethical, legal or compliance perspective. “Conflict of interest” means any personal relationships or interests, including financial interests, which interfere or have the potential to interfere with professional roles, responsibilities or judgments of TPMG physicians…” Note that even the “appearance” of or “potential” conflict is to be avoided. The policy goes on to prohibit any financial relationships of physicians with equipment, drug, service or other vendors, including serving as a director or consultant, or ownership in stocks – including www.sfms.org
by physicians’ family members. Then come some sections (excerpted here) that might involve a bit of pain for some physicians: Gifts: “TPMG physicians may not accept products or services from Vendors, Consultants or organizations doing business or seeking to do business with TPMG, or with Kaiser Permanente, which are free, or at reduced or discounted prices, and which are for the benefit of the physicians or their family members.” Commercial Support for CME/Education: “Commercial entities providing unrestricted grants for CME may not disperse separate from the contract, and TPMG physicians may not accept directly from the commercial entity, honoraria, faculty expenses, travel reimbursement, gifts, gratuities or other compensation. Drug, device, equipment and biotech companies (Vendors) and other commercial entities may not provide funding for meals, snacks, gifts or other forms of compensation for departmental meetings, CME meetings or non-CME educational meetings… Vendor support for meals provided to all participants as part of a CME meeting or professional society meeting which is open to all physicians is considered to be a legitimate part of attendance at the meeting and is allowed.” “TPMG physicians may not receive remuneration, gifts, gratuities, travel expenses or honoraria from Vendors for participation in a Vendor’s Speakers’ Bureau…TPMG physicians may not accept and retain honoraria from a Vendor for teaching or giving presentations, including payment for time, travel expenses, meals, entertainment, recreational or social activities….TPMG physicians may not accept reimbursement from Vendors for the cost of travel and/or attendance at product demonstrations, conferences, or non-CME educational programs.” Harsh medicine? Perhaps. But Yale’s medical group has adopted similar policy, and Harvard Medical School authors, writing in JAMA recently, note that “Conflicts of interest between physicians’ commitment to patient care and the desire of pharmaceutical companies and their representatives to sell their products pose challenges to the principles of medical professionalism.” So we are in good company in feeling that these undeniably restrictive policies are indicated in these times, and are recommended for other medical organizations who wish to truly join in the effort to clean medicine’s house and regain trust. Dr. George Susens is an internist at Permanente Medical Group and SFMS past-President and Steve Heilig is on the SFMS staff and editor of the Cambridge Quarterly of Healthcare Ethics. MARCH/APRIL 2006 San Francisco Medicine 33
SFMS Annual Dinner January 26, 2006
he San Francisco Medical Society’s 2006 Annual Dinner was held at Town Hall, Delancey Street Catering in San Francisco. The 2006 SFMS President, Gordon Fung, MD, served as emcee for the memorable evening. The evening began with Immediate Past President, Alan Greenwald, MD, passing the gavel to Dr. Fung, who became the 138th President of the SFMS. Dr. Fung’s inaugural remarks celebrated past accomplishments and provided a vision for the future of SFMS. A number of special guests enjoyed the evening, including Dr. Edward Chow, President of the San Francisco Health Gavel is passed from Immediate Past President Alan Greenwald, MD to Commission, and Commissioner Dr. John 2006 President Gordon Fung, MD Umekubo; Dr. Michael Sexton, President of the California Medical Association, and Dr. Jack Lewin, Executive Many Thanks to Vice President and CEO of the CMA; William Guertin, Executive Our Sponsors Special thanks to Director of the Alameda-Contra Costa Medical Association; and Lamont Paxton, MD, President of ACCMA, and his wife JoAnn the following sponPaxton. Dr. Fung also recognized all SFMS past presidents in at- sors for supporting this year’s event: California tendance, board members, outgoing officers, and the SFMS staff. A highlight of the evening was the recognition of 50-year Pacific Medical Cenmembers of SFMS. Dr. Fung presented 50-year member pins to Dr. ter, Chinese Hospital, Pedro Pinto, who graduated from the Central University of Ecuador Kaiser Permanente in 1952 and specialized in Family Practice at St. Luke’s Hospital for San Francisco, Marsh 40 years; Dr. Byron Pevehouse, who graduated from Baylor College Affinity Group Serof Medicine in 1952 and specialized in neurosurgery at UCSF and vices, St. Francis MePresbyterian Medical Center; and Dr. Louise Taichert, who gradu- morial Hospital, St. ated from the University of Colorado in 1954 and specialized in Mary’s Medical Center, University of Calipediatrics and psychiatry. The evening’s featured speaker was Robert Wachter, MD, fornia San Francisco Professor of Medicine at UCSF and noted expert on improving the Medical Center, Wells SFMS 2006 President Gordon quality and safety of medical care. His thought-provoking presenta- Fargo Bank, Whiskey Fung, MD tion was entitled, “Internal Bleeding: What We Need to Know and Hill Financial Center in Woodside, and Duramed Pharmaceuticals, a subsidiary of Barr Do to Cure Our Epidemic of Medical Mistakes.” As in past years, Dr. Steve Walsh provided piano accompani- Pharmaceuticals, Inc. The program was also sponsored in part by an educational grant from Eli Lilly and Company. ment for the cocktail hour. 34
SAN FRANCISCO MEDICINE MARCH/APRIL 2006
SFMS Officers: Mike Denney, MD, Editor; Gordon Fung, MD, President; Steve Follansbee, MD, President-Elect Alan Greenwald, MD, Immediate Past President; Charles Wibbelsman, MD, Secretary
Robert Larson, MD and Robert Wachter, MD
Dottie Low, Kelly Fung, Peggy Fung, and Randall Low, MD
Byron Pevehouse, MD and President Gordon Fung, MD WWW.SFMS.ORG
Pedro Pinto, MD, with wife Alicia and sons Richard, Dennis, and Stephen MARCH/APRIL 2006 SAN FRANCISCO MEDICINE
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MEDICAL REPORT Richard Clapp, D.Sc, MPH Boston University School of Public Health Molly Jacobs, MPH U. Mass.- Lowell School of Health and Environment
Report Links Environmental and Occupational Exposures to Cancers Editor’s note: This project was supported with private funds via the SFMS Community Service Foundation; it is part of an ongoing series of scientific and educational efforts in environmental health being conducted by the Collaborative on Health and the Environment, a network founded at the SFMS in 2002. The University of Massachusetts Lowell released a report in late 2005 that links dozens of environmental and occupational exposures to nearly 30 types of cancer. The new study by the University’s Lowell Center for Sustainable Production reviewed scientific evidence documenting associations between environmental and occupational exposures and certain cancers in the United States—marking the first time this massive body of material has been summarized in one accessible document. We need to pay attention to environmental and occupational risk factors. Known and preventable exposures are clearly responsible for tens of thousands of excess cancer cases each year. It is unconscionable not to implement policy changes that we know will prevent sickness and death. Environmental and Occupational Causes of Cancer: A Review of Recent Scientific Evidence shows that many cancer cases and deaths are caused or contributed to by involuntary exposures. These include: bladder cancer from the primary solvent used in dry cleaning (PCE), breast cancer from endocrine disruptors like bisphenol-A and other plastics components, lung cancer from residential exposure to radon, non-Hodgkin’s lymphoma from solvent and herbicide exposure, and childhood leukemia from pesticides. The sum of the evidence makes an airtight case for reconsideration of chemicals policies in the U.S. We need to follow the example of the European Union’s REACH program, which prevents the use of known or suspected carcinogens when suitable substitutes are readily available. Despite notable gains in reducing incidence and mortality rates for certain cancers, especially lung cancer in U.S. males, we found that cancer constitutes a growing burden on society. We note that the mortality rate for all cancers combined (excluding non-melanoma skin cancer) is approximately the same today as it was in the 1940s and the annual rate of new cases increased by 85 percent over the past 50 years. www.sfms.org
“Major cancer agencies have largely avoided the urgency of acting on what we know to prevent people from getting cancer in the first place,” says fellow researcher Genevieve Howe. The report disputes the often-cited, 25-year-old analysis by Sir Richard Doll and Richard Peto that attributes only 2 to 4 percent of cancers to involuntary environmental and occupational exposures. Our review makes it clear that new knowledge about multiple causes of cancer, including involuntary exposures, early-life exposures, synergistic effects and genetic factors, renders making such estimates not just pointless, but counterproductive. The full press release, executive summary, and report are available at: www.sustainableproduction.org/pres.shtml and www.healthandenvironment.org.
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HOSPITAL NEWS Chinese Fred Hom, MD
Chinese Hospital celebrated the “Year of the Dog” with another beautiful float at the Chinese New Year Parade. The float featured statues of the three immortals, representing longevity, happiness and prosperity. The three “live” representatives from the hospital were Dr. Joseph Woo, our illustrious chief of staff, community leader and Board member Mr. Franklin Fung, and Ms. Grace Gong, RN, who recently retired after 35 years of service to Chinese Hospital. The medical executive committee had originally selected Dr. Collin Quock to represent the medical staff on the float, honoring him for his past leadership as chief of staff and chair of the last International Conference on Healthcare of the Chinese in North America. A previous celebration, also with a lion dance, was held January 17 to mark the grand opening of the Excelsior Health Services. Located at 888 Davis Street, this clinic joins the busy Sunset Health Services Clinic (at Noriega St. and 31st Avenue) as Chinese Hospital’s two satellite clinics, serving the community outside of the Chinatown area.
MD) have joined forces to offer a combined service to Kaiser Permanente members. Each specialty offers a unique perspective with advantages not offered if they were to compete with each other or work by themselves. Our belief is that the combined service will deliver a higher quality service to members. The organization afforded by this cooperative venture should spill over into routine services and, consequently, create opportunities for innovative ideas and techniques. Recently, Kaiser Permanente San Francisco has added two Interventional Radiologists (Shelley Marder, MD and George C. Lai) and two Vascular Surgeons (Hong Hua, MD and James O’Dorisio, MD). Interventional Cardiology offers a regional service, consisting of eight Interventional Cardiologists who deliver their interventional care at Kaiser Permanente San Francisco, performing approximately 1,800 coronary interventions annually. Another cooperative aspect to KP San Francisco’s Endovascular medical care is the acquiring and sharing of equipment for diagnostics and procedures. One specific project involves a carotid stent program where the three specialties have combined to develop a system, which includes short and long-term follow-up of patients. Carotid stent procedures cross specialties and provide an opportunity to join forces for better health care.
tion, a goal we all are seeking for our patients.” This procedure was developed in Germany by orthopedic surgeons Kurt Schellnack and Karin Buttner-Janz and has been available in Europe for the past two decades. Anecdotal studies from Germany show patients playing tennis 20-years post-op and pain free. An innovative new technology has come to Saint Francis with the use of the Stryker computer navigation system for total knee arthroplasty surgery. Orthopedic surgeons Thomas Sampson, MD, Dominic Tse, MD and Victor Prieto, MD, have all been certified in the use of the system. The system uses an infrared camera and markers, along with unique instrument tracking software to continually monitor the position and mechanical alignment of the implant components relative to the patient’s knee or hip anatomy. The use of this technology has helped to shorten the length of stay, led to fewer post-operative complications, improved knee joint stability and assures leg length equality. With National Doctors Day just around the corner, March 30th, on behalf of my colleagues at Saint Francis Memorial Hospital, let me congratulate the members of the Medical Society on your commitment to patient care and to improving the health of our community.
St. Luke’s Jerome Franz, MD
St. Francis Guido Gores, MD
Bruce Blumberg, MD, Physician-in-Chief
Kaiser Permanente San Francisco is creating a unique and integrative system in its approach to interventional procedures, and that is one of collaboration and departmental cooperation. This method is not only cost-effective and efficient, but it also promotes teambuilding and resource sharing. The medical center is approaching endovascular medical care by circumventing the usual turf battles that take place when specialties compete. Interventional Cardiology (Howard Luria, MD), Interventional Radiology (John Rego, MD), and Vascular Surgery (Doug Grey, 38
Here at Saint Francis we have implemented two new surgical approaches: the Charite disc replacement procedure and computer navigational knee and hip replacement. Spine surgeons Kenneth Light, MD and Clement Jones, MD have added the Charite artificial disc replacement procedure to our complete array of spine services. This artificial disc procedure offers several distinct advantages including a 1.5-hour operation through the anterior approach, a shorter postoperative course and greater preservation of spinal motion. Dr. Light reports that the latter is part of the orthopedic creed, “Preservation of motion means the simulation of normal func-
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St. Luke’s has created a new position for Medical Director of Surgical Services as part of an ongoing plan to improve quality of care and increase surgical cases. Sam Michaels, who has been Chair of the Department of Anesthesia for 12 years, will assume the new position as well as continue his current role. He will first focus on OR availability and scheduling, but all physician concerns are under his purview. His work will be particularly important in facilitating the integration of surgical services with CPMC as our proposed merger takes place. In related news, St. Luke’s has created a physician committee to review capital and budget allocations. It is modeled after a CPMC program that was initiated by Martin Brotman during his first years as CEO. Dr. Brotman credits their work WWW.SFMS.ORG
for many of the improvements and successes at CPMC, because physicians have decided where moneys should be spent. A major investment facing St. Luke’s at this time is replacling the emergency department, which is overcrowded and underequipped for the volume of patients seen there. Marc Snyder, current Chair of the department and ER director for many years, has been closely involved in the planning and looks forward to completion in 2007. We regret the retirement of Mary Fedak, Medical Staff Coordinator, November 30. For four years she brought order out of chaos in an increasingly complex operation. Our Director of Performance Improvement, Judy Newman, has taken over Mary’s office and will attempt to manage both roles with adequate clerical assistance. I’m counting on her.
tion survey. This survey has an excellent response rate and has been administered biannually for the past seven years. Such diverse areas such as spirituality, feeling valued, retention and health and safety issues are monitored. This information is shared with the medical staff, administration and the board and is used in for strategic planning and process improvement. It is just one of many reasons our turnover rate is exceedingly low.St. Mary’s submits a Mission Report and a report of its charity care each month to Catholic Healthcare West. It’s this mission and values driven approach to healthcare while commanding clinical excellence and stewardship of our resources that moves us forward.
Veteran’s Diana Nicoll, MD, PHD, MPA
St. Mary’s Kenneth Mills, MD
Excellence is one of the five core values of St. Mary’s Medical Center and clinical excellence is the expectation especially of the medical staff. Peer review is the mainstay of monitoring our quality, measuring our success and finding ways to continuously improve. Peer review is a requirement of the Joint Commission, CMS, IMQ and other regulatory agencies and is carried out in Ssome fashion at every hospital. But peer review itself, as a discipline i undergoing evolution and change. To that end, Catholic Healthcare West has engaged the Greeley Company to assist St. Mary’s and all its facilities to look at what currently is being done and than challenge the institution to improve the process to reflect the need for more practitioner specific information and to apply more sophisticated tools to measure our successes, opportunities for improvement and to identify issues of immediate risk and patient safety.This will be a collaborative venture between medical staff and the community board that have been delegated authority for credentialing and maintaining quality at the medical center.Developing Organizational Capacity (DOC) is the tool that St. Mary’s uses for its employee satisfaction and values integraWWW.SFMS.ORG
The San Francisco VA Medical Center (SFVAMC) opened a newly remodeled and relocated outpatient clinic at Third and Harrison Streets in January 2006 called the VA Downtown Clinic. The new site is near Moscone Center and offers a wide range of clinical and social services to homeless veterans, as it did when the clinic was located at 13th and Mission. To serve the health care needs of veterans in the downtown San Francisco area, the clinic now offers expanded primary care. Veterans in the area may schedule appointments to see a primary care provider and eliminate the commute to SFVAMC, located on the western edge of the City. The VA Downtown Clinic is officially designated by VA as a Comprehensive Homeless Veterans Center where veterans are offered mental health care, substance abuse services, and post traumatic stress disorder treatment targeted for the homeless. It also provides compensated work therapy for homeless veterans to help them gain the skills and habits for employment. SFVAMC geriatric researchers, Sei Lee, M.D., and Kenneth E. Covinsky, M.D. M.P.H., conducted a study to predict mortality among older adults. The study, entitled “Development and Validation of a Prognostic Index for 4-Year Mortality in Older Adults,” was published in the February 15, 2006 issue of JAMA. Dr. Lee and his colleagues developed a 12-question index
that accurately predicts the likelihood of death within four years among people 50 and older. The index, based on a simple point system, is easy to use and can be obtained in a few minutes with an interview or an intake form. For patients and caregivers, predicting near-term likelihood of death is useful when making decisions about medical tests and clinical care.
Seton Stephen Conrad, MD
Although we work in Daly City, our cardiologists are fond of singing that we ‘Left Our Hearts In San Francisco.’ Seton recently celebrated the 40th anniversary of its migration from San Francisco to the sand dunes of Daly City. The move in 1966 was necessitated by patient overflow, limited prospects for expansion, and the new seismic regulations of the 1950s. Sound familiar? As you are aware, annual mammography is now recommended for all women over the age of 40. The Seton Breast Health Center now has a CAD (Computer Aided Detection) system, which scans mammograms and assists the radiologist with the identification of malignancies. If the lesion is suspicious, a minimally invasive Stereotactic Breast Biopsy can be performed. These new devices have reduced the need for open biopsy. Our GI Department has acquired an Endoscopic Ultrasound (EUS) device. This apparatus consists of an ultrasound processor, which is located at the tip of the endoscope and will allow detailed imaging of GI lesions. (What will they think of next?) Seton now has a PET/CT Scanner. The marriage of CT technology and PET technology allows for localization of lesions with greater accuracy. Our medical staff is alive, well, and even flourishing. On 28 April 06, we will hold a historic event---the first annual Physicians Recognition Dinner for the members of the Active Medical Staff. During this festive evening, awards will be given for length of membership and lifetime achievement. The good sisters intend to give a Values Award. Music will provided by the Anton Schwartz Jazz Quartet.
MARCH/APRIL 2006 SAN FRANCISCO MEDICINE