Western New York Physician Magazine

Page 1

Western New York

buffalo / rochester

PHYSICIAN the local voice of practice management and the business of medicine

Neuro-Navigation Improves Brain and Spinal Surgery

Making Health Care Human Improving Patient Experience in Your Practice

Lifetime Legacy vs. Leaving a Legacy

VOLUME 5 / 2019

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buffalo / rochester

Financial Insights 03 Lifetime Legacy vs. Leaving a Legacy

Perspective 17

In Defense of Cookbook Medicine

Practice Management 09 Making Health Care Human:


Improving Patient Experience in

05 Neuro-Navigation Improves Brain and Spinal Surgery Imaging advances with the 7D system in neurosurgery enhances visual acuity for the surgeon, dramatically reduces surgical prep and procedure time, totally eliminates radiation in the OR and provides the surgeon with an unprecedented level of precision.

Your Practice

23 The Proper Use of Patient Portals


Clinical Features


11 Dyspareunia: A condition often

13 Tailor-made for Older Adults, New


Clearing Damaged Cells out of the Body Helps Heal Diabetics’ Blood

Tools Improve Oncologist-Patient




13 New Strategy for Treating High 18 Physicians Create Guide for

Blood Pressure

22 Visualize Your Pain Away

Roswell Park Team Identifies New Tumor Suppressor Protein in

Identifying, Treating Vaping Lung

Prostate Cancer:


Study results support development of LRIG1 as novel anti-cancer

19 Pillar Primary Care Serves Residents


of Senior Living Communities



Roswell Park Earns Distinction for Cellular Immunotherapy Through BlueCross BlueShield


25 Radiation Breaks Connections in the Brain

26 Breast density notification laws not


effective for all women

Cover Photography courtesy of Rochester Regional Health System


Editorial Calendar


What's New


from the publisher

Western New York

Visit us Online www.WNYPhysician.com

PHYSICIAN the local voice of

practice management and the business of medicine


Welcome to the latest issue of Western New York Physician – where you will find informative stories and articles about and for physicians in western NY.

Andrea Sperry creative director

Lisa Mauro writers

Randi Minetor

In the neurosurgical subspecialty of the brain and spine, precision is everything and millimeters matter. In this issue we learn from Drs. Maurer, Petraglia and Lande, about the latest game changers in the specialty — offering precise guidance to the surgeon in neuro navigation and the promise of immunotherapeutic advances to treat difficult cancers of the brain. There is a lot of talk about the patient experience. It’s become an important metric for practices and increasingly efficient, streamlined, patient-centered care. Practices in the region have started to implement inventive changes within their practice to enhance the way they interact with the patient. In this issue, we hear from Katie Manetta, the Director of Health Management at BlueCross BlueShield of Western New York offering ideas which may help improve the patient experience in your practice. Coming up in the Heart Disease Issue • Cardiac Resynchronization Therapy • Tackling Obesity • Conceirge Medicine • Eye Disease

medical advisory board

Michael Silber, MD Chuck Lannon Thomas Hughes, MD


Randi Minetor RPCI Press URMC Press RPCI Press URMC Press Katie Manetta Andrew DelMedico, CFP Bani Aiello David I. Kurss, MD, FACOG, NCMP Thomas Hughes, MD Yale Press

Do you provide care or services in the above specialty areas? To be included in the issue. Email WNYPhysician@gmail.com. Share your expertise in a relevant way with your medical colleagues and referring physicians when you contribute an article, take part in a Q&A or share your expertise in an interview. Please email or call me directly to discuss topic, timing and submission criteria. In the meantime, please enjoy the numerous other articles within the issue. Thank you to each of our supporting advertisers — your continued partnership ensures that all physicians in the region benefit from this collaborative sharing of information and provides the WNYP editorial staff with a deep pool of expert resources for future interviews and articles. Best,



contact us

For information on being highlighted in a cover story or special feature, article submission, or advertising in Western New York Physician WNYPhysician@gmail.com Phone: 585.721.5238 reprints

Reproduction in whole or part without written permission is prohibited. To obtain pricing for an open PDF License of articles appearing in the magazine, please contact the Publisher. Although every precaution is taken to ensure the accuracy of published materials, Western New York Physician cannot be held responsible for opinions expressed or facts supplied by its authors. Western New York Physician is published bi-monthly by Insight Media Partners.

financial insights

Lifetime Legacy vs. Leaving a Legacy Andrew DelMedico, CFP Client Consultant

Traditionally, most retirees’ approach to retirement has been to live frugally to leave a financial legacy to their families, friends, and charities after they pass away. This approach helps to protect retirees against the fear and/or risk of outliving their wealth. However, many would argue it reduces the utility of wealth, is an inefficient use of capital, and means foregoing an opportunity to expand your real legacy. There is little point of having excess wealth if you aren’t going to use it. This is especially true if there is someone or something near-and-dear to your heart that could benefit from your generosity. More and more of today’s retirees are taking a lifetime legacy approach—placing emphasis on sharing their wealth while they are still alive. By funding family vacations, fulfilling charitable goals, and helping children/grandchildren/great-grandchildren with college tuition, wedding expenses, or first home purchases, retirees get to see their money make a difference. Enjoy More Time with Your Loved Ones Diligent retirement saving provides retirees with discretionary wealth. That wealth is usually tucked away within an estate in the form of cash, stocks, bonds, and mutual funds until the retiree passes away. However, if you were to ask someone who has lost a loved one whether they would prefer to have one more day with that person or to inherit a few extra dollars, the answer, almost universally, would be in favor of the extra day.

As a result, many retirees are choosing to put their excess wealth towards picking up the tab at dinner whenever possible, planning annual family vacations, buying plane tickets to see out of town family more often, and purchasing family vacation homes for time together. Given greater geographic separation of families and increasingly busy day-to-day schedules, we’re

seeing annual family vacations, typically funded by the family matriarch/patriarch, becoming a cherished new tradition.

Help When They Need It Most The current joint life expectancy of a 65 year old couple is approximately 88 years old. By that age, the couple’s children are likely in their sixties, and they have grandchildren in their thirties. Heirs, by that age, may have already surpassed some of the most challenging financial milestones. In fact, the couple’s children may very well be retired themselves. Some may be wary of providing too much financial assistance to children at a young age for fear of a sense of entitlement or decreased motivation. Those concerns should be weighed along with the potential benefits of providing timely financial support to your loved ones. Helping children during their thirties, forties, and fifties can help lighten the stressful financial goals of raising kids, funding their children’s college expenses, and saving for their own retirement. Providing financial assistance to younger heirs may allow them to make better long-term decisions rather than needing to make short-term decisions out of financial necessity. Studies have shown that college graduates who are free of student loans have nearly twice the retirement savings balance at age thirty compared to peers who have “average” student loan balances. The impact of additional retirement savings at an early age is significant. Helping children and grandchildren save for college (e.g., using college 529 plans), pay down post-college debt, afford their first home, and start a family can help lay a solid financial foundation that can pay dividends down the road. Clients happily express the sometimes unexpected personal joy they get from watching the growth and success of heirs that is partially the result of their financial assistance. Give to Charity So You Can See the Product of Your Generosity While many clients are charitably inclined, larger gifts are


often testamentary, (i.e., bequests under a will). The primary driver of this trend appears to be feeling financially secure enough to give a meaningful irrevocable lifetime gift. While the impact of charitable gifts can be tangible and personally rewarding, charitable gifts, as with any gift, should always be within your means. Retirees who have a good understanding of their financial position can make larger lifetime gifts with confidence and conviction, allowing them to see the product of their generosity. Of course, it takes planning to determine your ability to fund your inflation-adjusted spending throughout retirement, plus make gifts to friends, family, and charities. Plan First, Then Execute A growing subset of today’s retirees are adopting a lifetime legacy philosophy and eschewing the conservative mindset adopted by prior generations. However, much of the recent push to this approach is among clients who make a concerted effort to understand the impact potential gifts can have on their overall long-term wealth picture. In general, retirees embracing a lifetime legacy philosophy seem to have 3 things in common: 1. A desire to enjoy their wealth and/or benefit friends, younger generations, and charities today. 2. A willingness to accept a slightly lower margin of safety to achieve #1 above. 3. An understanding of their financial picture that arms them with the confidence to spend/ gift up to their means.

We primarily use cash flow modeling to illustrate the financial impact of annual spending and one time/ongoing gifts. It helps give clients the confidence to execute on their vision. We work with our clients to help determine their progress towards meeting their goals, both financial and otherwise. Occasionally it means having difficult, but necessary conversations with clients who are not on track to meet their goals. Oftentimes, it means exciting conversations with clients about the financial flexibility to fund goals beyond providing for their own retirement spending needs. That financial flexibility may allow clients to fulfill goals in a way they never imagined, and enjoy the impact their wealth can have on heirs and charities during their lifetime.

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cover story

Neuro-Navigation Improves Brain and Spinal Surgery

Photography courtesy of Rochester Regional Health System

Randi Minetor

When a medical center’s

at Unity Hospital in Rochester—one

neurosurgery staff performs more

of the area’s smaller hospitals, but

than 1,250 brain and spinal cord

with a powerhouse combination

procedures a year, chances are they

of surgical skill and technological

have some kind of advantage in both


skill and technology. That’s the case WNYPHYSICIAN.COM VOLUME 5 I 2019 I 5

Photography courtesy of Rochester Regional Health System

Paul Maurer, MD “Neuro-navigation is a guidance technique that shows usexactly where we are in the anatomy of space, whether it’s the brain or spinal cord.” “Everything that is being done today was done before the technology, but it was potentially more hazardous,” said Paul Maurer, MD, who leads the neurosurgery team. “Today, though, we have maximized efficiency and safety.” Dr. Maurer knows from whence he speaks. His perspective spans nearly three decades and more than 12,000 surgical procedures, including his service as a U.S. Army chief of neurosurgery in combat in Operation Desert Storm. Now ranked as one of the top neurosurgeons in the United States for more than fifteen years, he is a clinical professor of neurosurgery at the University of Rochester, and he taught Army and Navy neurosurgeons and their teams about ballistics and head injuries at Walter Reed Army Medical Center in Washington, DC. Today he makes Unity his medical home, along with his former student and fellow neurosurgeon Anthony Liberato Petraglia, MD, who is also a specialist in treating concussion and other nervous system injuries in athletes. Their department became one of only a handful across the country to employ a new surgical system created by 7D Surgical in Toronto, Ontario: machine-vision image guided surgery, a new form of neuro-navigation. “Neuro-navigation is a guidance technique that shows us exactly where we are in the anatomy of space, whether it’s the brain or spinal cord,” Dr. Maurer explained. “The surgeon guides every part of the surgery—and must and should. You 6 I VOLUME 5 I 2019 WNYPHYSICIAN.COM

might think of it as akin to an autopilot device in an aircraft. In the last analysis, the pilot makes the calls.” As an instructor to the next generation of neurosurgeons, he emphasizes the need to hone the basic, geometric skills of surgery without the assistance of technology. “I use the wing man analogy,” he said. “I tell residents, ‘You have to be able to do this on your own. You have to be old school; you have to be able to do things without the technology.’ We map out the surgery, and we check it with the navigation.” Dr. Petraglia shares Dr. Maurer’s commitment to basic skills. “Good surgical outcomes don’t always come from the technology,” he said. “You definitely have to have the skill set. It comes from knowing who to operate on, when to operate— that makes for better outcomes.” Neuro-navigation technology is different from surgery using robotics, Dr. Maurer said. “The patient population has a little bit of a misunderstanding of the robot. In the robot situation, the surgeon still guides robotic hands and arms; the robot is an assist device, not a guidance device. The robot provides additional manual dexterity.” Neuro-navigation, however, provides an unprecedented level of precision. “The neuronav allows us to cross-check everything. It tells you within millimeters exactly where you are in the brain or spinal cord.” The 7D system takes neuro-navigation to a new level, dramatically reducing the preparation time before surgery. “Historically, neuro-navigation can be a little bit of friction in the operating room—a lot of devices, computer

Photography courtesy of Rochester Regional Health System

registering,” Dr. Maurer said. “The 7D system is all based on photographic facial recognition. Before we do the operation, we do one-millimeter MRIs. Then we bring in the 7D nav and it takes tens of thousands of photos of the face with the patient ready to go. The computer recognizes the facial features in seconds. It’s very simple—and the simpler it can be, the better, as long as it gets the job done. We tried out all of the systems available, and chose this one because it had the added advantage of being very efficient and simple. The simple plan is the best plan.” Dr. Petraglia has used the system on neck fractures and other cases where precision can become especially challenging. “With a patient, if I have to drop a 3.5 millimeter screw down a 4-millimeter window of bone, it only leaves you 0.25 millimeter on either side for margin of error. You have to be spot-on. We both already did a very good job technically— part of that is knowing the anatomy, knowing how to do safe moves. But this takes a really good surgeon and makes them even better.” The system also addresses an issue that has risen in importance recently among surgeons: radiation exposure for the doctors as well as the patients. Neurosurgery has long required intra-operative CT imaging or fluoroscopy for registration, exposing the surgical staff to significant amounts of radiation throughout nearly every procedure. The 7D system does not require this additional imaging,

however. “With the 7D, there’s no radiation in the OR,” he said. “In several minutes, we pull the machine out, there’s just one overhead light, and we’re ready to go.” “It’s the same technology they use in self-driving cars,” said Dr. Petraglia. “It takes thousands of photos, registering them with the patient’s CT scan done preoperatively, and then merging the two and using it as a frame of reference for the techniques and the things we do in the OR. It’s better for the operative staff, better for the surgeon, and better for the patient.” The ability to pinpoint the location of the incision within a millimeter has resulted in faster surgery, Dr. Maurer said. “It focuses the opening in the skull; it focuses the dissection direction in a very smooth manner, so there’s no wandering of any kind from the skin to the target. Whatever time is used to set up the machine is readily made up by the assistance and guidance. Just like cell phones evolved over time, this took neuro-nav and distilled it down to a technique that is stunningly accurate.”

Complex surgery in a community setting The team at Unity has broadened the hospital’s capabilities in all forms of neurosurgery, Dr. Petraglia said. “In general, the biggest thing for us right now is we are able to do what are very complex surgical cases and really bring them to a


community setting, where traditionally they were not being done,” he said. “We can take care of big fractures and major trauma, spinal tumors, my work with concussions, spinal cord injury, cervical myelopathy…we can provide very clean and efficient care.” Building a reputation for quality care in a smaller hospital can be a challenge, he said. “There’s a lot that goes into that. It’s the staff, the network of providers and therapists. We have been able to streamline the care for one of the finest neurosurgical units in the city. We are very judicious about what we are bringing into the system and what we’re rolling out from a service line standpoint. It allows us to keep our ears open for opportunities and to bring some of these advanced things to Rochester.” The result, he said, is a broader reputation and reach—not just in the greater Rochester community, but well beyond into other states. “People travel to come and see us,” he said. “It almost becomes like a destination – a place people are seeking out. I’ve had patients come in from Ohio and Indiana. There are plenty of good surgeons in Ohio and Indiana; it’s not because they can’t get good care in whatever city they’re in, but they want to go see the best. The need for spine care is so pervasive, it touches most people in their lives at some point, and the way we’re doing things and making smart surgical decisions, that’s what separates us from the rest.”

Neuro-navigation for Buffalo patients For Michael K. Landi, MD, FACS, at Invision Health in Buffalo, neuro-navigation technology is an important part of the armamentarium in treating patients who require brain surgery. “We have been using state-of-the-art intraoperative neuronavigating, intraoperative CT, and neurophysiology and monitoring for years,” he said. Michael K. Landi, MD, FACS “We consistently update the equipment as presented.” Dr. Landi serves as the chief of neurological surgery at Kenmore Mercy Hospital, where he is also director of the Brain and Spine Center, and he is a clinical assistant professor of neurosurgery at the University at Buffalo as well. His strong clinical and research interests in minimally invasive surgical techniques led him to invent the Minrad laser targeting system, which allows the surgeon to use a 8 I VOLUME 5 I 2019 WNYPHYSICIAN.COM

fluoroscope to locate a deep structure, turn off the X-ray, and retain the position information and guidance until the procedure is completed. This system not only reduces operating time and increases surgical accuracy, but it also significantly limits radiation exposure for both the patient and the surgeon. Minrad, approved for use in surgery by the FDA in 1997, is now employed by spine surgeons around the world. The biggest improvement in neurosurgery over the last twenty years, Dr. Landi said, has been in the quality of medical imaging. “We used to use awake surgery with intraoperative stimulation techniques,” mapping the patient’s brain function to determine which areas to avoid if at all possible. “When you superimpose functional MRI brain imaging on top of structural MRI, it allows a physician to perform safer surgery. Combine that with an intra-operative system that allows the surgeon to precisely locate an area of the brain, and this improves the safety factor. It allows you to make smaller incisions, and improves operative time.” The specific location of various brain functions used to be difficult and time-consuming to determine, Dr. Landi said. “For example, everyone wants to be able to talk and understand the spoken word, so if you know where the speech center is, you can avoid it in surgery. The speech center is generally in the left temporal lobe, but its exact location is variable within people. So if you can perform an MRI scan and determine where the expressive and receptive speech centers are, you can set the expectation with the patient of the potential outcomes of surgery.” This is particularly important for people with malignant tumors, he said. “We want to prolong life, but many tumors are not treatable by surgery alone. The patient may have limited life time gained by surgery, and they don’t want to spend that time being unable to talk or understand speech.” Beyond surgery, he said, the most promising treatments for malignant brain tumors are coming from immunotherapies. “We’ve been treating glioblastoma,” the most aggressive form of brain cancer, “the same way for the last twenty years. All of the things that have been talked about in the press have fizzled out. But as we learn more about the genetic bases of these diseases and how there’s a strong immunologic component to them, the future holds ways to use the body’s immune system to take care of cancer. By identifying the immunologics of brain cancer, we can modify the immune system to fight the cancer. These are being developed around the world. So that is the most promising therapy on the horizon.” Randi Minetor is the author of Medical Tests in Context: Innovations and Insights (Greenwood, 2019), and is a freelance journalist based in Upstate New York.

practice management

Making Health Care Human Improving Patient Experience in Your Practice By Katie Manetta, Director, Health Management BlueCross BlueShield of Western New York

Amazon, Netflix, and InstaCart are only a few examples of companies setting the pace – and consumers’ expectations – for easy and convenient services in nearly every area of our lives. In today’s increasingly fast-paced and technology driven world, we now expect personalized experiences. Health care is no exception. According to Ingrid Lindberg of Chief Customer, who was recently featured as the keynote speaker at BlueCross BlueShield of Western New York’s Provider Pathway to Excellence event for provider practices, there are three key things that drive customer experience: • how clearly you communicate • how helpful you are • how you make people feel So, with limited time and resources, how can you become part of this shift? Making small changes may help improve your patients’ health care experience: Communicate with patience No, that wasn’t a typo. To achieve better outcomes it’s critical that your patients understand their care plan and know how to ask the right questions. The National Assessment of Adult Literacy found that only 12 percent of U.S. adults had proficient health literacy and over a third of U.S. adults—77 million people—would have difficulty with common health tasks, such as following directions on a prescription drug label or adhering to a childhood immunization schedule using a standard chart.1 When communicating with patients, avoid jargon (for example, use “sudden” instead of “acute”) and simplify written instructions as much as possible. To gauge your patient’s understanding, ask them to explain your instructions back you. Be (extra) helpful This means different things to different people. Consider what may make it easier for patients in your practice to get the care they need. For example, how easy is it to make appointments and how soon can they be scheduled? Once patients arrive, how long is the wait? Do they need extra support, such as help scheduling appointments with specialists or for diagnostic services?

Does the patient have a caregiver who may need assistance? Consider outside factors that may be a barrier for your patients. Ask if they are struggling to adhere to treatment plans or take medications due to side effects, costs, or other concerns. Connect your patients to other services they may need, such as help with accessing food or nutrition services, mental health counseling, or care management services. CONVERSATIONS THAT SHOW SENSITIVITY TO PATIENTS’ FINANCIAL SITUATIONS AND INCLUDE THEM IN DECISIONMAKING BUILD TRUST IN THE DOCTOR-PATIENT RELATIONSHIP.2 People remember how you make them feel You have a short window of time with each person you care for, so try to make the most of it. The culture of your practice will come through as your patients walk in the door. Are they greeted with a smile? Is your waiting room relaxing and comfortable? Lindberg notes that using light gray color schemes is an easy way to help your patients feel welcome. During the visit, use your patient’s preferred name (make a note of this in the patient chart), make eye contact, ask questions, and show that you are listening carefully to what they say. The positive experience shouldn’t end when they leave; follow up consistently on test results, and consider connecting digitally. An American Journal of Managed Care study found that “patient engagement through email has potential in affecting higher quality outcomes.”3


With mobile options increasing, 93% of adult patients have indicated they would like to be able to email their doctor4, while 80% prefer the option to text5. Other options may include EMR messaging or recommending self-service tools you can connect with as well to monitor your patient’s health status between visits. Extra support for your practice Help your patients stay on track between visits by referring them to care management programs when appropriate. Care managers can work with you and your patients in between office visits to help them adhere to your care plan, while reducing some of the burden on your practice. Care management programs are commonly offered by your patients’ health insurance companies and are typically offered at no additional cost to eligible patients. Available programs may include: • Diabetes prevention or management • Behavioral health concerns, such as depression, substance use disorder, and ADHD • Cardiovascular conditions, such as stroke, hypertension, and congestive heart failure • Maternity, including high-risk pregnancy and NICU case management

• Spine and musculoskeletal pain management • COPD and asthma • Obstructive sleep apnea • Chronic kidney disease • HIV/AIDS • Transplants • Palliative care • Oncology These concepts can all help build positive customer experience, and many of them are factored into quality ratings for provider practices and health plans. As value-based payment programs continue to gain popularity, it’s not only good practice to meet and measure your patient’s expectations, but it can make good financial sense, too. 1 America's Health Literacy: Why We Need Accessible Health Information. An Issue Brief From the U.S. Department of Health and Human Services. 2008, www.health.gov/communication/ literacy/issuebrief. 2 Hardee JT, Platt FW, Kasper IK. Discussing health care costs with patients: an opportunity for empathic communication. J Gen Intern Med. 2005;20(7):666–669. doi:10.1111/j.1525- 1497.2005.0125.x 3 Reed, Mary, et al. “Patient-Initiated E-Mails to Providers: Associations With Out-of-Pocket Visit Costs, and Impact on Care-Seeking and Health.” AJMC, 21 Dec. 2015, www.ajmc.com/journals/ issue/2015/2015-vol21-n12/patient-initiated-e-mails-to-providers-associations-with-out-of- pocket-visit-costs-and-impact-on-care-seeking-and-health. 4 “93% Of Adult Patients Want E-Mail Communication With Physicians: The Vast Majority of Patients - 93 Percent - Are Likely to Select a Physician Who Offers Communication via e-Mail, According to Catalyst Healthcare Research.” Becker's Hospital Review, 13 May 2014, www.beckershospitalreview.com/healthcare-information-technology/93-of-adult-patients-want-e- mail-communication-with-physicians.html. 5 “80% of Consumers Open to Healthcare Interactions on Smartphones” Becker's Hospital Review, 7 July 2014, https://www.beckershospitalreview.com/healthcare-information-technology/80-of- consumers-open-to-healthcare-interactions-on-smartphones.html

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A condition often overlooked David I. Kurss, MD, FACOG, NCMP

A significant issue that frequently is not addressed during our day to day patient interactions. Who has the inclination, comfort level, or time while we are dealing with more seemingly urgent matters like hypertension, diabetes, UTI’s, and malignancy? So our patients muddle along . . . content that their main issues and prescription needs are covered. “My sexual issues will, once again, not be discussed.” “Perhaps everyone has these concerns and it’s just part of getting older?” Let’s plunge into this pressing and prevalent problem.

What is dyspareunia? It is defined as persistent and/or recurrent pain associated with sexual activity that causes marked distress or interpersonal conflict (ICD-10CM CODE N94.1). If a patient mentions discomfort during sexual intercourse that is not particularly troublesome then the complaint is not consistent with this diagnosis.

How common is it? Dyspareunia affects 10 - 20% of women, and is even more common among postmenopausal women. There are no other consistent demographic associations.

How bothersome is it? Dyspareunia can lower frequency of intercourse, the level of sexual desire and arousal, orgasmic response, physical and emotional satisfaction, general happiness and have a significant impact on the quality of one’s relationships and selfesteem.

What are some of the causes of dyspareunia? Vulvar and vaginal atrophy/genitourinary syndrome (VVA/ GSM) of menopause is the most common cause of vaginal dryness and dyspareunia in women over 50 years old. Other causes include a history of pelvic pain, impaired lubrication, vaginismus, vulvar vestibulitis, vulvodynia, lichen sclerosis,

inadequate foreplay, hymenal factors, myalgia, neuralgia, organ prolapse, interstitial cystitis, sexually transmitted disease, endometriosis, history of abuse or trauma, episiotomy, previous surgery, structural abnormalities, infections, malignancy, previous radiation, undesired pregnancy, psychological disorders, stress, and relationship issues.

How do we bring it up? What do we say? Integrate it into your day to day questioning - make it sound to the patient as one of the twenty screening questions that you routinely ask. Let it sound matter of fact - not a last minute issue that you are reluctant to address. Do you have any headaches, blurred vision, chest pain, leg cramps, medication questions, hot flashes, discomfort with intercourse, itching, bleeding, safety concerns at home? A more focused history, if appropriate, can help uncover the likely etiology.

What do you look for in the physical exam? Gynecologists will inspect and gently touch, oftentimes with a moistened Q-Tip, the external and internal genitalia for tender areas that duplicate the patient’s chief complaint. Take note of lesions, tears, dryness/menopausal atrophic changes, canal narrowing, hypopigmented regions, organ prolapse, muscular tension, scarring, or discharge, in an attempt to correlate any findings with the patient’s symptoms. Determining whether the coital discomfort is upon entry, mid-position, or deep is crucial.

How can we help? Suggest, as appropriate, vaginal lubricants, OTC steroids, topical lidocaine, warm/cool soaks, avoiding deep penetration, overall and vaginal muscle relaxation techniques, proper hygiene, trigger point injections, acupuncture, nerve blocks, physical therapy, TENS, dilators, analgesics, patient reassurance, couple counseling, and cognitive behavior therapy. Prescription options may include antibiotics, antidepressants, stronger steroids, or estrogen therapy.


Generally daily systemic estrogen products (gels/patches/ sprays/oral tablets) that address vasomotor symptoms will also help ameliorate vaginal dryness. Always add a Progestin when prescribing systemic estrogen for a non-hysterectomized patient. Data supports a more robust response when intravaginal estrogen therapy (ex. Premarin/ Estrogen cream, Estring vaginal ring, Imvexxy tablets,) is utilized without or in concert with systemic therapy. Femring provides both intravaginal and systemic estrogen therapy for three months per vaginal ring. Products that are specifically indicated for postmenopausal moderate to severe dyspareunia include: 1. Intrarosa - a daily non-estrogen product (DHEA intravaginal pellets) which uniquely converts to Estrogen and Testosterone in the vagina. 2. Osphena, a daily oral estrogen receptor agonist/antagonist. The decrease in estrogen after menopause, as already noted, is frequently the underlying cause for hot flashes, bone loss, and vaginal dryness and is the predominant basis for dyspa-

reunia in the aging female. As such, I frequently prescribe menopausal hormone therapy for my postmenopausal patients with dyspareunia.

Initiate the conversation. Tailor your discussion with a patient based on your time constraints and comfort level. There may be several factors simultaneously in play. A multidisciplinary approach may be necessary. Feel free to refer to a Gynecologist and/or a sex therapist. Resolving dyspareunia may help with a variety of seemingly unrelated conditions such as anxiety, migraines, insomnia, self- esteem, and relationship challenges. Coupled with an honest, open, compassionate, non-judgmental demeanor, a comprehensive evaluation and the occasional outside consultation will usually ensure the optimum therapeutic approach to help these often silently suffering patients. David I. Kurss, MD, FACOG, NCMP Invision Health Buffalo, NY NAMS Certified Menopause Practitioner www.womenswellnesscenter.com

be a part of the conversation Editorial Calendar 2020 Jan / Feb – Vol 1

Heart Disease Cardiac Resynchronization Therapy Tackling Obesity in WNY Conceirge Medicine

March / April – Vol 2

Men's Health Joint Disease Eye Disease GI Disorders

Sponsored Columns

What’s My Liability? • Risk Management • Financial Insights In–Between Patients • Practice Tips • Medical Innovations • Best Practices

To secure a spot in one of the 2020 issues and join the conversation – contact Andrea Sperry at (585) 721–5238 or WNYPhysician@gmail.com. 12 I VOLUME 5 I 2019 WNYPHYSICIAN.COM

clinical notes

Tailor-made for Older Adults, New Tools Improve OncologistPatient Relations

Mohile and co-authors suggest that a GA summary should be considered standard care for older adults with cancer, and appropriate interventions based on the report should be used as needed. A case might look like this: Jane Doe recently fell at home, which was revealed through geriatric assessment. Evidence shows that falls increase the risk of chemotherapy side effects, and therefore the physician

We’ve shown that we can modify the behavior of oncologists if they have the right tools and guidance talks to the patient and her primary caregiver about those risks and recommends physical therapy to prevent additional falls. A Wilmot Cancer Institute-led study in JAMA Oncology shows that when physicians fully appreciate the concerns of older adults with cancer, such as function and forgetfulness, it elevates patient care and satisfaction. The study is believed to be the first to assess in a randomized clinical trial whether a tool known as geriatric assessment (GA) can meaningfully influence cancer care for vulnerable older people. Many oncologists in community practices are not aware of, or do not ask their patients who are 70 or older, about living conditions, functional ability, cognition, and family support, for example. But impairments in these areas are linked to chemotherapy toxicity, an inability to complete treatment, and an overall decline in health or risk of early death, said Supriya Mohile, MD, corresponding author and the Philip and Marilyn Wehrheim Professor of Hematology/ Oncology at the University of Rochester Medical Center. A geriatric assessment can personalize care and prompt better conversations between physicians, patients, and their families, the study found.

The study involved 541 older people with advanced cancer who were being treated at 31 oncology clinics across the U.S., through the UR National Cancer Institute Community Oncology Research Program (NCORP). The oncology practices either received a tailored GA assessment and summary with recommendations for the patient, or the usual alerts related to depression or cognitive impairment. Then, researchers measured patient and caregiver satisfaction with questionnaires and through audio recordings of physician visits.

New Strategy for Treating High Blood Pressure

“We’ve shown that we can modify the behavior of oncologists if they have the right tools and guidance,” said Mohile, who also co-leads the Cancer Survivorship and Supportive Care research program at Wilmot. “And when oncologists are better informed about the special needs of their older adult patients,” she added, “everyone’s experience is much improved.” WNYPHYSICIAN.COM VOLUME 5 I 2019 I 13

The key to treating blood pressure might lie in people who are “resistant” to developing high blood pressure even when they eat high salt diets, shows new research published in Experimental Physiology. With 1 in 4 adults suffering from high blood pressure in the UK, and over 1.1 billion people across the globe, it is one of the biggest unsolved global public health issues to date. High blood pressure is also the leading cause of several other diseases, including chronic kidney disease, stroke and heart disease. While some peoples’ blood pressure spikes when they eat high-salt diets, others, called salt-resistant, are able to get rid of salt more effectively and thus don’t experience changes in blood pressure. One way to combat blood pressure would be to mimic what these people are doing to avoid high blood pressure.

Researchers at Boston University School of Medicine looked at how cells in a specific part of the brain (called the hypothalamus) controlled salt-resistance and found a structural change in the cells that allows for them to change their response to salt.

Our findings have implications for the development of personalized anti-hypertensive therapeutics designed to target the pathway involved in changing cells to bring about salt-resistance in the body Commenting on the study, first author Jesse Moreira said: “Our findings have implications for the development of personalized anti-hypertensive therapeutics designed to target the pathway involved in changing cells to bring about salt-resistance in the body.”

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medical research

Clearing Damaged Cells out of the Body

Roswell Park Earns Distinction for

Helps Heal Diabetics’ Blood Vessels

Cellular Immunotherapy Through

Research recently published in Experimental Physiology shows that ramping up one of the body’s waste disposal system, called autophagy, helps heal the blood vessels of diabetics. Complications with blood vessels (known as vascular complications) are major risk factors for morbidity and mortality in the diabetic patients. These complications are divided into microvascular (damage to small blood vessels) and macrovascular (damage to larger blood vessels). Microvascular complications include damage to eyes which can lead to blindness, to kidneys which can lead to renal failure and to nerves leading to impotence and diabetic foot disorders (which lead to amputation). Autophagy is the body's way of cleaning out damaged cells, in order to regenerate newer, healthier cells. Impaired autophagy has been reported to be involved in Type 2 diabetes, but researchers weren’t sure why. This study, from researchers at the Yonsei University College of Medicine is the first to demonstrate a protective role of autophagy stimulation in the vascular dysfunction of Type 2 diabetes. The researchers used mice that have similar features as human Type 2 diabetes, and measured the diameter of small arteries, which is an indication of how healthy the arteries are. Soo-Kyoung Choi, first author on the study said: “We are excited about these results because our study suggests that targeting autophagy could be a potential target for the treatment of vascular problems in Type 2 diabetic patients.”

BlueCross BlueShield Cancer center is one of two New York State Blue Distinction Centers for CAR-T As Roswell Park Comprehensive Cancer Center continues to utilize the latest immunotherapies that spell hope for so many of our patients, BlueCross BlueShield of Western New York has recognized us as a Blue Distinction Center for Cellular Immunotherapy — CAR-T (chimeric antigen receptor). The center is one of two to receive this distinction in New York State. BlueCross BlueShield defines Blue Distinction Centers as centers committed to bettering patient safety and health outcomes. For the CAR-T designation, hospitals must be certified by a U.S. Food and Drug Administration program to provide such therapies and commit to system-wide monitoring of patient outcomes. In 2018, Roswell Park received approval to offer two FDA-approved CAR-T therapies, Yescarta® (axicabtagene ciloleucel) and Kymriah® (tisagenlecleucel). These cellular therapies are designed to help a patient’s immune system fight specific types of leukemia and lymphoma. The treatment process starts with collecting a patient’s T-cells from the blood, then genetically modifying those cells to include a new gene that helps strengthen their ability to find and kill cancer cells. “These are options for certain leukemia and lymphoma patients whose disease has persisted or recurred after initial therapy,” says Philip McCarthy, MD, Director of Roswell Park’s Transplant and Cellular Therapy Center. “Many of these patients have had a prior blood or marrow transplant, are not eligible for a BMT or are in the situation where the CAR-T cell therapy is a ‘bridge’ to control their disease until a transplant is possible. We are honored to be acknowledged by BlueCross BlueShield as a Blue Distinction Center for Cellular Immunotherapy. These treatments have resulted in long-term disease control and possibly cure for many of our patients, leading to improved quality of life and activity.”



Roswell Park Team Identifies New Tumor Suppressor Protein in Prostate Cancer Study results support development of LRIG1 as novel anti-cancer therapeutic

Roswell Park's Dean Tang, PhD, led a team that has identified a new prostate cancer suppressor protein.

A research team led by a scientist at Roswell Park Comprehensive Cancer Center has identified the molecule LRIG1 as an important endogenous tumor suppressor in prostate cancer. Writing in the journal Nature Communications, the team documents their findings from preclinical studies showing that overexpression of the LRIG1 protein inhibits prostate cancer development, while reducing naturally occurring LRIG1 promotes prostate tumor development. Dean Tang, PhD, Professor and Chair of Pharmacology and Therapeutics at Roswell Park Comprehensive Cancer Center, is the senior author of the study, whose findings, he says, have compelled researchers to look at how best to incorporate LRIG1, a protein naturally expressed in patient tumor cells, into treatment for prostate cancer patients. “Interestingly, the LRIG1 gene is induced in developing tumors, presumably representing the patient’s defense mechanism against tumor growth,” Dr. Tang says. “The LRIG1 expression levels in patients’ tumors could potentially be developed into a prognostic biomarker — the higher the expression level, the better prognosis for prostate cancer patients.” 16 I VOLUME 5 I 2019 WNYPHYSICIAN.COM

While the protein is not yet available as a therapeutic, Dr. Tang and team are working to develop it into an LRIG1derived peptide, which, if those efforts are successful, could be used as anti-cancer therapeutic via intravenous injection. This approach could potentially be an effective strategy for treating patients with inoperable prostate cancer. Prostate cancer is one of the most common and treatable types of cancer in men, with five-year survival rates reaching nearly 100% thanks to advances in detection and treatment. However, prostate cancer remains the second-leading cause of male cancer deaths, because those with more advanced or aggressive forms of the disease eventually experience progression or recurrence despite treatment. Standard therapy uses drugs that target and block the androgen receptor (AR), a protein that binds to androgens (male hormones) to stop or inhibit prostate cancer cell growth. But the results often don’t last, and many patients develop castration-resistant prostate cancer — an aggressive, treatment-resistant form of the disease — within a year of anti-androgen therapy. “The good news for prostate cancer patients is that LRIG1 also possesses therapeutic efficacy and is actually up-regulated in tumors, in response to several oncogenic signals,” notes Dr. Tang. “This new research represents a comprehensive exploration of LRIG1 expression, functions and mechanisms in prostate cancer, and advocates a novel conceptual paradigm that LRIG1 represents a pleiotropic-feedback tumor suppressor induced by multiple oncogenic signaling pathways.” This research was supported by grants from the National Cancer Institute (project nos. R01CA155693, R01CA237027, R01CA240290, R21CA218635 and P30CA016056), U.S. Department of Defense (award nos. W81XWH-14-1-0575, W81XWH-16-1-0575 and W81XWH-15-1-0366), Chinese Ministry of Science and Technology (grant 2016YFA0101201) and the National Natural Science Foundation of China (grant nos. 81602592 and 81802973). The study, “LRIG1 is a pleiotropic androgen receptorregulated feedback tumor suppressor in prostate cancer,” can be read at www.nature.com.


In Defense of Cookbook Medicine Thomas Hughes, MD Chief Medical Officer at Optimum Physician Alliance The idea of guideline driven medical decision making has been around for decades, but remains poorly accepted in most parts of the medical community. Not only has it not been embraced, but it has been cast as a bogeyman and the antithesis of good healthcare. As a young medical student, I was taught to treat the patient and not the protocol. The argument was made that no person’s care can be reduced to a template sketched on a sheet of paper, and those who taught me were right, but only to a point. Every person - every patient - is unique and worthy of individual attention, but in our zeal to provide personalized care to each patient, we have failed to ensure every patient gets the basic care they deserve. The facts are inescapable, according to the Institute for Health Improvement (IHI.org) more than a thousand patients die every day in hospitals across the United States from preventable medical errors. Beyond this, significant numbers of patients are not on the appropriate therapy for diseases such as heart failure and diabetes which have well-established and well-known agreement regarding appropriate care. None of these gaps in care occur because people don't care enough. Healthcare is a mission and not merely an occupation. No one goes to work with the intention to do “just enough,� but the field of medicine has become too vast and too complex to rest comfortably on the shoulders or in the memory of any one person. We don't expect pilots to fly without a crew and we don't expect chefs to cook without a staff, but we still continue to expect that people providing our healthcare to do it on their own. We need to stop thinking about healthcare as a one-on-one solo sport and begin thinking about it as a team activity where collaboration is at the heart of what we do.

In healthcare, much of the physicians time is spent addressing issues for which there is no real disagreement. We all agree that mammograms and colonoscopy should be done. We all agree that diabetics should have their sugars checked. This is where the much-maligned cookbook is ideal. It codifies and shares what we believe in. It allows every member of the healthcare team including the patient to know what is intended and what is expected and allows others to share in the burden of the clinician. It allows us to understand when things are being missed. It allows us to support one another. No one thinks of a cookbook as a compulsory guide. It is an instruction manual, but it is one where the chef is free to change the ingredients. The beauty of the cookbook is that it allows us an understanding of what was originally planned so that we can better evaluate the final product. Was the change an improvement or not? Having a common guide in healthcare would allow us to begin a real conversation about quality. It does not mean that every patient needs to get the same therapy, tests and treatments, but it does mean that we would have a common standard of what to expect. This is an opportunity for those providing care to lead - in much the same way as a pilot does in her plane or a chef in his kitchen. Let us take this time to explain the work we do and why we do it. In making this effort, we will find others to share the burden along the way.

Dr. Thomas Hughes serves as the Chief Medical Officer of the Optimum

Physician Alliance/Great Lakes Integrated Network and is also a practicing physician with an office in Elma. Dr. Hughes received his medical

degree from SUNY-Buffalo School of Medicine, remained in Buffalo

to complete his residency and is board certified in family medicine and bariatrics.



Physicians Create Guide for Identifying, Treating Vaping Lung Illness Clinicians’ tool for EVALI treatment published in The Lancet Respiratory Medicine The nationwide epidemic began in the spring and to date, the CDC has charted more than 2,000 cases, including 40 deaths. The cause of the illness remains a mystery, though many patients used products containing THC, the psychoactive component in marijuana. Patients experience devastating lung injury, some requiring long hospitalizations and treatment in the intensive care unit, followed by a slow recovery.

As lung injuries from vaping continue to rise across the United States, Rochester physicians and New York health leaders developed a new tool to assist in the diagnosis and treatment of e-cigarette, or vaping, product use associated lung injury (EVALI). The diagnostic/treatment algorithm, published in The Lancet Respiratory Medicine, complements and expands upon early guidance from the Centers for Disease Control and Prevention for managing the condition. It was created by pulmonary and toxicology experts at the University of Rochester and the New York State Department of Health. “This illness has been vexing for physicians across the country and we continue to see people suffering from the dangerous effects of vaping,” said Daniel Croft, MD, MPH, pulmonologist at the University of Rochester Medical Center’s Strong Memorial Hospital. “We expect the guide will help minimize missed diagnoses as cold and flu season ramps up.” “As the Department of Health continues our investigation into this ongoing outbreak of vaping-associated illnesses, we are in close contact with health care providers across the state and are pleased to provide them with a new tool to help with proper diagnoses, ”said Health Commissioner Howard Zucker, MD, JD “We continue to urge New Yorkers to stop using vape products until the investigation is complete.” 18 I VOLUME 5 I 2019 WNYPHYSICIAN.COM

“This is a practical and user-friendly algorithm for clinicians when they are evaluating EVALI. It provides a flow-chart for information-gathering, evaluation and treatment of patients who are experiencing this life-threatening condition,” said Aleksandr Kalininskiy, MD, a lead author with Christina Bach, MD, at URMC. Rochester physicians were first in the state to report unusual symptoms to the NYSDOH, and those early discussions led to an extensive and collaborative effort to track symptoms and identify appropriate testing, treatment and follow-up care. Data and samples of vaping materials from URMC’s nearly 20 patients were shared with NYSDOH, and its poison control centers, for analysis. The first cases identified at Strong Memorial date back to June, said Nicholas Nacca, MD, medical toxicologist and emergency physician, when a colleague asked him to review a young man’s “weird symptoms.” Nacca discussed it with other toxicologists in a professional organization’s online forum, where similar cases were shared, providing an early indication of the epidemic to come. URMC is home to the Center for Inhalation and Flavoring Toxicology Research, one of the nation’s leading laboratories for study of the health effects of flavorings found in electronic cigarettes, tobacco and non-tobacco products. Scientists have analyzed vaping samples as part of the investigation into the source of the illness.

special feature

Pillar Primary Care Serves Residents of Senior Living Communities Randi Minetor For elderly residents in a senior living community, maintaining a relationship with a primary care physician can be challenging. Keeping regular appointments, even when the senior person is healthy, can involve mobility issues, problems remembering schedules, weather-related cancellations, and younger Brian Heppard, MD, CMD relatives taking time away from work to provide transportation. If the person has an illness or injury, treatment and follow-up appointments can become particularly complicated to arrange—and running to an off-site doctor for chronic conditions can be an exhausting process for patients and their families. The National Council on Aging determined that 75 percent of seniors have at least one chronic health issue, and most have two or more—with cardiovascular diseases, arthritis, diabetes, Alzheimer’s disease, and osteoporosis as the most common conditions. At the same time, the US Centers for Disease Control (CDC) finds that men and women who reach the age of 80 are likely to live another eight to ten years on average. This can mean plenty of doctor appointments for senior living communities’ oldest residents. St. Ann’s Community recognized the need and established their own primary care practice in 2004. Today, the practice is known as Pillar Medical Associates, PC, a geriatrics-only practice, and provides this service to their residents. In 2017, St. Ann’s Community partnered with Episcopal SeniorLife Communities to expand this service to Episcopal’s residents as well. “The average age of our patients is mid-80s,” said Brian Heppard, MD, CMD, who serves as Pillar’s medical director. “Our oldest patient is 104, and we actually have a number of centenarians in the practice.”

Dr. Heppard brings more than two decades of experience in geriatric medicine. His credits include a period as vice president of medical services at Jewish Senior Life, where he founded the area’s only physician house calls practice—an effort recognized by the Rochester Business Journal with its Health Care Achievement Award. His interest in geriatric medicine began as far back as his teen years, when his paper route in New Jersey required him to ring the doorbells of residents to collect fees. “A lot of them were older people who were shut-ins,” he said. “I liked stopping to talk with them. Also, one of my grandmothers lived to be 106.” Later, as he began to study the scope of geriatrics, he found the complexity of it particularly

“I like the holistic care piece. I like that it requires taking care of their medical needs, their mental health, and their spiritual and emotional health.” compelling. “I like the holistic care piece. I like that it requires taking care of their medical needs, their mental health, and their spiritual and emotional health.” He and fellow partners Rebecca Kant, DO, Jarvis SanchezRivera, MD, and Krupa Shah, MD, MPH, AGSF, see patients on site at all of Episcopal’s communities throughout the continuum of care: independent living, assisted living, memory care, and skilled nursing. At St Ann’s, Pillar provides care in the independent and assisted living levels of care and partners with the long established on-site nursing home medical practice that includes several more geriatricians. “We have physicians who are full time, dedicated onsite staff at the nursing homes,” Dr. Heppard said. “Dr. Kant and


Pillar Medical Associates provides care in the independent and assisted living communities of St. Ann’s. The Pillar Medical team from L to R: Anne May, RN, BSN, Rebecca Kant, DO, Trisha Ferrara, MA, CMBS, Brian Heppard, MD, CMD and Mary Resch, RN.

I do the majority of the care in the assisted and independent settings. All of us are fellowship-trained geriatricians. We enjoy working in teams, and that includes the staff in the communities. We also work with the family members of these folks—our family members will come to appointments and we welcome that, because they are a key part in taking care of their parent, aunt or uncle.”

The Pillar model includes a registered nurse (RN), an advanced practice provider (APP) such as a nurse practitioner or physician assistant, and the doctor. “It’s a three-legged stool,” McRae said. “We not only have some of the top geriatricians in town working for Pillar, but if a patient has to go to a hospital, we have a holistic approach with a case manager. Our RN can track the patient in the hospital, and make it the smoothest transition back to their home.”

Individualized medicine for seniors

“They know what the patients want for their care. It’s like having a consultant with you.”

Having the opportunity to build relationships with patients at this time in their lives makes a major positive difference in patients’ health, noted Michael McRae, chief executive officer of St. Ann’s Community. “I came from a health system where physicians were contracted,” he noted. “I think what we have designed is far superior. We are able to have that continuity of care by employing our own physicians. There are some residents who have a doctor and are very comfortable with them, and they maintain that relationship. But when they have an appointment, someone has to accompany them. On a snowy day in December, they have to change that appointment. Here the doctors come right to their building, so they don’t have to do anything but put on a pair of slippers and come down.” 20 I VOLUME 5 I 2019 WNYPHYSICIAN.COM

When residents move from independent living into assisted living, they keep the same medical team, an advantage that can raise spirits at a particularly difficult time for the patient making the transition. “It’s not like you have to start all over again,” said Eileen Ryan-Maruke, vice president of marketing and community relations for St. Ann’s. “They know what the patients want for their care. It’s like having a consultant with you. It makes the process so much less stressful, and the family know what’s going on.”

Continuity of care can be crucial as patients age, Heppard said, because most people develop more than one medical issue later in life. “Our patients are medically complex, and they’re frail in many cases,” he said. “We schedule 30-minute appointments with them, and we pull community resources together to keep people as independent as they can be for as long as they can be. Valuing people’s goals as they change over time, and tailoring their medical care to meet their goals, is a key piece in quality of life. What a 75-year-old person needed may change a lot when they’re 95.” Every patient is different, especially as they reach an advanced age, he added. “I think people have this idea that all 95-year-olds are alike, and they’re not. There’s a huge range of how people are doing. People who are 50 are more homogeneous than people 90 or 95. Taking care of these folks requires a conversation to figure out what their values and goals are in that part of their lives, and then make decisions based on their values and prognosis.” It’s easy for younger people to assume that an elderly person is reaching the end of his or her healthy years, but that decline could still be a long way off, Heppard noted. “My 104-year-old patient could live several years yet, so we might treat her differently than someone 20 years younger than her, because the two have very different goals. I think a big part of

“...when something goes wrong at any hour, our doctors answer the phone.” The intimate relationship between Pillar’s medical team and its patients makes it possible for residents to get very specialized care whenever they need it. “Nothing goes wrong between 9 a.m. and 5 p.m. Monday through Friday,” McRae said with a chuckle. “But when something goes wrong at any hour, our doctors answer the phone. They know immediately that this issue isn’t the patient’s baseline, and that they need to do something right away. That’s personalized medicine.” Randi Minetor is the author of Medical Tests in Context: Innovations and Insights (Greenwood, 2019) and is a freelance journalist based in Upstate New York.

“We have very high satisfaction in general, but it’s even higher with our patients who use Pillar.” our job is helping people navigate the health system, and to help people make decisions that are right for them.” The outcomes of this approach to primary care, McRae said, have been very positive. “We have very high satisfaction in general, but it’s even higher with our patients who use Pillar. We have 120 apartments in Chapel Oaks, our independent living building, and for those with Pillar, we see longer lengths of stay in their apartment before they need to go to a higher level of care.” The Pillar doctors can even coordinate mobile x-ray and other in home testing, eliminating the need for the patient to travel to an urgent care facility or imaging center.

That’s what an organ donor is to someone waiting for a transplant—forever appreciated for giving the ultimate gift. Live life to the fullest. Help others do the same. Join the donor registry at www.PassLifeOn.org



Visualize Your Pain Away By Bani Aello www.baniaello.com

Most people believe that the mind has power over our emotions, physical symptoms and overall wellbeing. The problem is that believing it’s true and having the tools to train the mind to work in our favor rather than against us is a different story. It takes more than knowing it is true. It takes learning and practicing certain mind sets that focus on things that contribute to positive feelings and physical wellness. Most of us grew up in a generation where worry was the expected responsibility of the most caring of individuals. It was the sign of a good parent, grandparent, worker, citizen, etc. Now we understand that worry doesn’t help situations, it just puts the worrier into the “fight or flight” response where poor decisions are made and the cortisol levels run high contributing to physical ailments, disease and increased physical and emotional pain. We’ve all heard the wonderful and wise advice, “Don’t worry!” Well, all of us have tried that, usually with little success. It seems that instead of us controlling our mind, our mind controls us! Unfortunately, there is no “Worry Switch” that we can just turn off ! There is a saying that “The Mind is a wonderful servant, but a terrible master.” People try to stop worrying by “pushing” the worries aside. Just like a rubber band, almost as soon as we push them away, they snap back at us and continue to play in our head like a broken record! The key to worry less so that you can feel better is a twopart process. We do not try and push the worries away but rather choose another focus, close your eyes and visualize! The second part of this formula is to cultivate positive feelings of peacefulness, gratitude, ease and love while you’re visualizing.

Visualization + Positive Emotion = Less or no pain The most effective things to visualize are parts of nature or animals. Below is a list of things to choose from. We all know how relaxing and healing nature is but most of us think that we have to actually “go” on a vacation in a beautiful place in nature in order to feel the positive effects from it. The body doesn’t know the difference between us really being there and us imagining we are there! Of course it is wonderful to go to the woods or the beach, but often times we can’t. Besides, if the mind is untrained, you can be on the most beautiful beach 22 I VOLUME 5 I 2019 WNYPHYSICIAN.COM

in the world and still be worrying about work or the difficulty playing out in our family situation.

Most Effective Things to Visualize that Reduce Pain

• Trees or a favorite tree from any part of your life • The woods, or a hiking or camping memory • The beach • Mountains • Lakes, Rivers, Streams • A garden ( a favorite one that you’ve seen or one that you make up) • Your pet from the past or present • A favorite animal and how it moves in nature • Any piece of nature such as a rock, seashell, a starry sky, a sunset, etc

Once you choose one of these, close your eyes and picture all the details of it! Try not to “think” about it, but just sense and feel and have awareness. There is a big difference between “thinking” about something and having “awareness” and it’s critical for this to work! For example, if you decide to picture the woods in a place that you used to camp with your family as a kid, the mind may want to go to thinking about “the good old days” and then thinking thoughts of wishing you were back in that time period when things were “so much easier” and how now life is so hard, etc…! This line of thinking will not help at all. Awareness is very different that thinking. To have awareness of the woods that we used to camp in, you would consider things like the size and shape of the trees and rocks, the colors and designs in the water and the sky, how it smelled and felt to be there, etc. Set a timer for one to twenty minutes just visualizing all of the characteristics and attributes of it. Most of all feel what it would feel like. While you’re doing this, breath slowly and deeply. Feel the peace, the freedom, the gratitude and the love for nature. This will take your mind off the thoughts contributing to higher cortisol levels and induce a peaceful calm state where the brain will begin to produce the chemistry that contributes to health, wellness, peace and decreased pain!

risk management

The Proper Use of Patient Portals The Risk: Patient portals are an effective tool to actively engage patients in their care to improve health outcomes. However, healthcare professionals must be aware of the potential risks presented by this technology. Some of these risks include: reliance on the patient portal as a sole method of patient communication; patient transmission of urgent/emergent messages via the portal; the posting of critical diagnostic results prior to provider discussions with patients; and possible security breaches resulting in HIPAA violations. Implementing appropriate policies and procedures in the use of portals will enhance patient communication and mitigate liability risks for the practice. Recommendations: 1. Develop comprehensive patient portal policies which include: • patient username and password requirements (minimum number of characters including capitals and non-alphabet characters); • a privacy/confidentiality statement on all outgoing messages; • encryption updates; • account lockout after a specified number of failed login attempts; • a mechanism to ensure termination of user access when indicated (e.g., the patient leaves the practice, death, inappropriate use of the portal, etc.); • timeframes for responding to patient communication; • designated responsibility for replying to patients when the primary provider is not available; • utilizing a two patient identifier system for importation of diagnostic studies into the patient portal; • monitoring patient access to posted diagnostic results; • a follow-up system for patients that do not access the portal; and • a mechanism to notify patients if the portal is not functioning properly. A notification should be placed on the practice’s website, and also included on any prerecorded telephone message. 2. Advise patients of the reporting mechanism for: • email address changes; • questions regarding portal use; • potential errors in their information; and • suspected breaches of privacy. 3. Providers should not use the portal as the means to communicate critical/significant diagnostic results. Diagnostic results should not be posted to the portal until this communication occurs. 4. Instruct patients that the portal is not to be used to evaluate and treat new problems.


5. Utilize a disclaimer on the portal that clearly states it is not to be used for emergencies/ urgent problems and include instructions for patients to call 911 or go to the nearest emergency department. 6. Consider the use of a patient portal user agreement that: • defines the information patients may access (e.g., appointments, medication refills and referral requests, form downloads, routine appointment reminders, and laboratory reports); • prohibits requests for narcotic medication refills; • states that the patient portal is the only permissible method of electronic communication with the practice; and • includes the disclaimer statement regarding urgent/emergent/new problems. 7. Have staff educate patients regarding the use of the portal and the contents of the portal user agreement upon patient sign-up and as necessary. Reprinted with permission from Dateline, published by MLMIC, 2 Park Avenue, Room 2500, New York, NY 10016.All Rights Reserved. No part may be reproduced or transmitted in any form or by any means, electronic, photocopying, or otherwise, without the written permission of MLMIC.

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medical research

Radiation Breaks Connections in the Brain URMC Press One of the potentially life-altering side effects that patients experience after cranial radiotherapy for brain cancer is cognitive impairment. Researchers now believe that they have pinpointed why this occurs and these findings could point the way for new therapies to protect the brain from the damage caused by radiation. The new study – which appears in the journal Scientific Reports – shows that radiation exposure triggers an immune response in the brain that severs connections between nerve cells. While the immune system’s role in remodeling the complex network of links between neurons is normal in the healthy brain, radiation appears to send the process into overdrive, resulting in damage that could be responsible for the cognitive and memory problems that patients often face after radiotherapy. “The brain undergoes a constant process of rewiring itself and cells in the immune system act like gardeners, carefully pruning the synapses that connect neurons,” said Kerry O’Banion, MD, PhD, a professor in the University of Rochester Del Monte Institute for Neuroscience and senior author of the study which was conducted in mice. “When exposed to radiation, these cells become overactive and destroy the nodes on nerve cells that allow them to form connections with their neighbors.” The culprit is a cell in the immune system called microglia. These cells serve as the brain’s sentinels, seeking out and destroying infections, and cleaning up damaged tissue after an injury. In recent years, scientists have begun to understand and appreciate microglia’s role in the ongoing process by which the networks and connections between neurons are constantly wired and rewired during development and to support learning, memory, cognition, and sensory function. Microglia interact with neurons at the synapse, the juncture where the axon of one neuron connects and communicates with another. Synapses are clustered on arms that extend out from the receiving neuron’s main

body called dendrites. When a connection is no longer required, signals are sent out in the form of proteins that tell microglia to destroy the synapse and remove the link with its neighbor. In the new study, researchers exposed the mice to radiation equivalent to the doses that patients experience during cranial radiotherapy. They observed that microglia in the brain were activated and removed nodes that form one end of the synaptic juncture – called spines – which prevented the cells from making new connections with other neurons. The microglia appeared to target less mature spines, which the researchers speculate could be important for encoding new memories – a finding that may explain the cognitive difficulties that many patients experience. The researchers also observed that the damage found in the brain after radiation was more pronounced in male mice. While advances have been made in recent years in cranial radiotherapy protocols and technology that allow clinicians to better target tumors and limit the area of the brain exposed to radiation, the results of the study show that the brain remains at significant risk to damage during therapy. The research points to two possible approaches that could help prevent damages to nerve cells, including blocking a receptor called CR3 that is responsible for synapse removal by microglia. When the CR3 receptor was suppressed in mice, the animals did not experience synaptic loss when exposed to radiation. Another approach could be to tamp down the brain’s immune response while the person undergoes radiotherapy to prevent microglia from becoming overactive. Breast Density Notification Laws not Effective for all Women Yale Press A new study suggests that state-mandated notifications on mammogram reports intended to inform women of the health risks related to breast density are not worded effectively.


The study, conducted by researchers at Yale and New York University, found that although dense breast notification (DBN) laws did help some women understand they had increased breast density, those women were not more likely to know that breast density is associated with a higher risk of breast cancer or that dense breasts limit the ability of mammograms to detect cancer. The finding was particularly pronounced for women with a high school education or less. The study appears in the Journal of General Internal Medicine. “We know that women with less education are less likely to receive high-quality breast cancer screening and treatment,” said senior author Cary Gross, MD, a Yale professor of medicine and member of the Yale Cancer Center. “Our study underscores one potential mechanism for this disparity. Ensuring that notifications are written in simple language may help improve understanding of breast density for all women.” Thirty-eight states have enacted DBN laws. Critics of the laws have raised concerns that they might increase


women’s anxiety about getting breast cancer. There have also been concerns about the readability of language used in the notifications. The FDA recently announced a proposal to extend DBN requirements to all mammogram facilities. For the new study, researchers surveyed 1,928 women across the country. They found no difference in breast cancer-related anxiety between women in DBN and non-DBN states. Women in DBN states were more likely to know if they have increased breast density, but only when those women had higher than a high school level of education. “The goal for these state laws is not being met,” said NYU’s Kelly Kyanko, MD, first author of the study. “Women who lived in states with DBN laws were not more likely to understand the implications of breast density — that having dense breasts meant they were at increased risk of breast cancer or that the radiologist would have a harder time seeing a cancer on their mammogram.” A grant from the American Cancer Society funded the research.




Healthcare NIAGARA FALLS MEMORIAL Dr. Lohrasbi joins medical staff at OB/GYN Center Safa J. Lohrasbi, DO, will join the medical staff at the OB/GYN Center at Niagara Falls Memorial Medical Center effective Jan. 5.

He most recently served as a staff physician at The Chautauqua Center, Dunkirk, where he provided outpatient care, supervised mid-level providers and created evidence-based gynecologic and obstetric protocols. He is a member of the American College of Osteopathic Obstetricians and Gynecologists and the American Osteopathic Association

Dr. Kappus joins surgical team at Niagara Falls Memorial Mojdeh S. Kappus, MD has joined the surgical team at Niagara Falls Memorial Medical Center where she will practice minimally invasive general surgery and bariatric surgery.

A graduate of the University of Puget Sound, Washington, Dr. Lohrasbi earned his Doctor of Osteopathy degree at the Pacific Northwest University of Health Science and served his internship at St. John’s Episcopal Hospital in Far Rockaway (Queens) NY, where he also completed his residency in obstetrics and gynecology.

Dr. Kappus, who grew up in Newfane, is a graduate of Harvard College and the University at Buffalo School of Medicine and Biomedical Sciences. She completed both her internship and residency in general surgery at the Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, N.Y., where she was administrative chief resident, and subsequently completed an advanced gastrointestinal-minimally invasive surgery fellowship at Harvard Medical School/Beth Israel Deaconess Medical Center, Boston. A former Sarnoff Cardiovascular Research Foundation fellow, Dr. Kappus completed post-graduate training in laparoscopic and robotic surgery. She has received numerous awards for achievement and has published several peer-reviewed research studies.

GENERAL PHYSICIAN, PC General Physician, PC to Partner With OB•GYN Associates Collaboration aimed at improved patient care General Physician, PC is pleased to announce a new partnership with OB•GYN Associates of WNY. The collaboration, which officially launches in January, partners OB•GYN


Associates’ 30 providers with more than 250 providers at General Physician, PC. General Physician, PC’s President, Darryl Ernst, said the partnership

was driven by a desire to continue the organization’s strategic growth aimed at improving quality, increasing access and enhancing services for patients. “OB•GYN Associates of WNY has a tremendous reputation in the community,” Ernst said. “We are pleased to partner with their physicians and their team to continue to deliver outstanding care to their patients. “This partnership forms the most comprehensive women’s health services practice in the region,” Ernst continued. “This will enable us to share best practices and strengthen the overall quality and accessibility of healthcare for women in the community.” Carlos Santos, MD, is the managing partner of OB•GYN Associates of WNY.


“The alliance with General Physician, PC will provide us the ability to explore new and better opportunities to serve our patients and improve the care of this community,” he said. “The engagement will help us build on our existing network of providers and hospitals and expand the services available to those we care for." Dr. Santos stressed there will be no interruption of patient care, and patients of the practice will continue to have the same access to providers and facilities as they currently have under their insurance plans. “Access to quality, individualized heath care is always a challenge. We want to reassure our patients that we Physician, PC and Dr. Santos and his are looking for new and exciting ways team at OB•GYN Associates of WNY, to deliver the care they deserve,” Dr. improving access to the highest quality Santos said. “Together, we will strive care for women and infants throughout to offer great facilities, professional, Western New York,” Jaros said. friendly staff, and the most advanced That care includes the hospital’s obstetric and gynecologic care in the designation as the only Level IV area." Neonatal Intensive Care Unit in With this partnership, OB•GYN Western New York, as well as its Associates will be aligned with designation as the Regional Perinatal a growing number of General Center for Western New York. Physician, PC practices in the Southtowns, including offices in East Aurora, Hamburg, Orchard Park and West Seneca, offering Cardiology, Gastroenterology, Neurosurgery, ADVERTISERS Orthopedics, Pain Management, Primary Care, General Surgery, Manning & Napier Advisors - Inside back cover and Women’s Health Medical Liability Mutual Insurance Co. - back cover services. John R. Oishei Plastic Surgery Group of Rochester - 26 Children’s Hospital partners with providers St Ann's Community - inside front cover from both organizations. Allegra Jaros is the West Ridge Obstetrics & Gynecology - 24 president of the hospital. General Physicians, PC - 10 “We look forward to furthering our Vascular & Endovascular Center of Western New York - 3 partnership with General

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