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INNOVATIONS

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TABLE OF CONTENTS

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MEDICAL INNOVATIONS Supporting San Antonio’s Expansion in Medical Technology Innovation By Gabriel Bietz, MD, RPVI .............................12 “Forced Inspiratory Suction and Swallow Tool” (FISST): A Novel Invention that Stops Hiccups Instantly By Ali Seifi, MD, FACP, FNCS, FCCM and Faraz Yousefian, DO .............14 Smoking Cessation and Internet Telehealth Resources By John J. Seidenfeld, MD and Neal Meritz, MD..................17 PRN: Take as Needed on Wearables, Health Care and Predictivve AI By David Alex Schulz, CHP........................20 First Man Pig-to-Human Cardiac Xenotransplantation: A Medical Student’s Perspective By John A. Treffalls, BS ........................................................22 Medical Innovations: The Rise of Telemedicine By Johnathon Harris and Matthew Cryer ..............................24 Technology Meets Medicine: Are We There Yet? By Alexandra Bailey and Baotran Vo ....................................26 More Than a Test for Illicit Drugs: Utilization of Urine Drug Tests to Manage Patients By James Shurko, PharmD, PhD and Niti Vance, PhD ..........30 The Role of Laser Therapy in Scar Management By Faraz Yousefian, DO, Graham Litchman, DO, MS and Chad Hinvor, MD, FAAD .........................................................................................................................................32 BCMS President’s Message .................................................................................................................................................8 BCMS Alliance President’s Message ..................................................................................................................................10 Understanding Long COVID By Sean Rumney, Ashley Chakales and Monica Verduzco-Gutierrez, MD...............................34 Dermatologic Manifestations of Pregnancy By Tue “Felix” Nguyen, Marie Vu and Cara Schachter ......................................36 2022 BCMS General Membership Meeting ........................................................................................................................38 In Memoriam: Douglas Wayne “Curly” Robinson Jr., MD; BCMS Ask a Doctor Event .........................................................39 Physicians Purchasing Directory.........................................................................................................................................40 Auto Review: 2022 Ford Mustang Mach 1 By Stephen Schutz, MD ...................................................................................44 Recommended Auto Dealers .............................................................................................................................................46

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SAN ANTONIO MEDICINE • May 2022

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MAY 2022

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VOLUME 75 NO.5

San Antonio M edicine is the officialpublication of Bexar C ounty M edicalSociety (BC M S). Allexpressions of opinions and statem ents of supposed facts are published on the authority ofthe w riter,and cannotbe regarded as expressing the view s of BC M S. Advertisem ents do not im ply sponsorship oforendorsem entby BC M S. EDITORIAL CORRESPONDENCE: BexarC ounty M edicalSociety 4334 N Loop 1604 W ,Ste.200 San Antonio,TX 78249 Em ail:editor@ bcm s.org MAGAZINE ADDRESS CHANGES: Call (210) 301-4391 or Email: membership@bcms.org SUBSCRIPTION RATES: $30 peryearor$4 perindividualissue ADVERTISING CORRESPONDENCE: Louis D oucette,President Traveling Blender,LLC . A Publication M anagem entFirm 10036 Saxet,Boerne,TX 78006 w w w .travelingblender.com

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BCMS BOARD OF DIRECTORS

ELECTED OFFICERS

Rajeev Suri, MD, President Brent W. Sanderlin, DO, Vice President Ezequiel “Zeke” Silva III, MD, Treasurer Alice Gong, MD, Secretary John J. Nava, MD, President-elect Rodolfo “Rudy’ Molina, MD, Immediate Past President

DIRECTORS

Vincent Fonseca, MD, MPH, Member Woodson "Scott" Jones, MD, Member Lubna Naeem, MD, Member Lyssa N. Ochoa, MD, Member Jennifer R. Rushton, MD, Member Raul Santoscoy, DO, Member John Shepherd, MD, Member Amar Sunkari, MD, Member Lauren Tarbox, Member Col. Tim Switaj, MD, Military Representative Manuel M. Quinones Jr., MD, Board of Ethics Chair George F. “Rick” Evans, General Counsel Jayesh B. Shah, MD, TMA Board of Trustees Melody Newsom, CEO/Executive Director Taylor Frantz, Alliance Representative Ramon S. Cancino, MD, Medical School Representative Lori Kels, MD, Medical School Representative Ronald Rodriguez, MD, PhD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative

BCMS SENIOR STAFF

Melody Newsom, CEO/Executive Director Monica Jones, Chief Operating Officer Yvonne Nino, Controller Mary Nava, Chief Government Affairs Officer Brissa Vela, Membership Director Phil Hornbeak, Auto Program Director August Trevino, Development Director Betty Fernandez, BCVI Director Al Ortiz, Chief Information Officer

PUBLICATIONS COMMITTEE John Joseph Seidenfeld, MD, Chair Kristy Yvonne Kosub, MD, Member Louis Doucette, Consultant Alan Preston, PhD, Member Rajam S. Ramamurthy, MD, Member Adam V. Ratner, MD, Member David Schulz, Community Member Faraz Yousefian, DO, Member Neal Meritz, MD, Member Jaime Pankowsky, MD, Member Moses Alfaro, Student Member Winona Gbedey, Student Member Cara J. Schachter, Student Member Niva Shrestha, Student Member Danielle Moody, Editor

SAN ANTONIO MEDICINE • May 2022

PRESIDENT’S MESSAGE

Data-Driven Healthcare – An Incremental or Disruptive Medical Innovation? By Rajeev Suri, MD, MBA, FACR, 2022 BCMS President

When the Institute for Healthcare Improvement recommended the framework for Triple Aim to improve healthcare outcomes, the ultimate aim was to provide value-based care globally. Triple Aim framework aimed to (1) improve patient experience of care (quality and satisfaction), (2) improve health of populations and (3) reduce the per capita cost of health care. One of the major innovations in achieving the targets of Triple Aim was the sharing, integration and analysis of healthcare data. Data-driven healthcare was aimed to be a disruptive innovation but has been plagued with challenges. One of the biggest challenges in healthcare delivery across organizations is the inability to access, integrate and analyze health care data from various sources, and efficiently use this data for decision making. For health care organizations to function with optimal efficiency, data needs to travel seamlessly across healthcare systems — not only within healthcare organizations but also externally to patients, payors, pharmaceutical & technological companies, and regulatory agencies. It is only then that healthcare outcomes and operational efficiencies will improve and cost will decrease. The data being mined has to be multi-dimensional, multifactorial and temporarily aligned i.e., not only be based on diagnosis-related groups (DRGs), but include factors like age, gender, comorbidities, labs/diagnostics and outcomes across specialties, across clinical settings and across time. The aim is that pattern analysis of quality data should shorten the path to diagnosis, avoid unnecessary exams and delays, and ultimately spend less money across the healthcare system globally. To allow data-driven healthcare to be a disruptive innovation, more however needs to be done to grease the wheels. Electronic medical records (EMR), lab data analytics and clinical decision support systems need to extend beyond the silos of individual organizations to payors and pharmaceutical companies, with the aim to promote a shared financial risk model. This is essential to improve consistent quality care, avoid duplication of tests and decrease the time to diagnosis and treatment. This is not however easy, as different entities have different interests. Quality indicators and management protocols differ across systems, and accordingly analyzed data and outcomes could change, making management decisions less predictable. Standardization of high-quality data and parameters to manage this difference become even more critical to ensure that analyzed outputs are real and not related to 8

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noise. Another challenge is the extrapolation of individual outcomes to population-based outcomes, hence the need to incorporate a broader range of data elements including social determinants of health − education, income, housing etc. As we extend data sharing to beyond the confines of healthcare organizations via data warehouses and data lakes, challenges include data privacy and security risks. Involvement of governmental regulatory agencies for protecting patient data is a boon but also a curse to datadriven health care, markedly slowing the transition to a seamless shared system. Another challenge is ownership of data and data governance. Who owns it — patients, or the organizations that care for them? Who owns the patent on transformational drugs, devices and protocols created from data-driven healthcare? There are still some unanswered questions and challenges in datadriven healthcare delivery, but we are not able to see its true potential due to the siloed healthcare delivery systems we live in. To break down these silos is key to unraveling the true potential of data analytics and decision management in healthcare. Some organizations have been more successful than others in implementing change, and the key is formal training and change management programs to facilitate culture change. A determined strategy that keeps patient and population health first is needed to transition data-driven healthcare delivery from an incremental to a disruptive medical innovation. References 1. Leading a new era in healthcare: Innovation through data-driven diagnostics. Harvard Business Review July 2019 (https://hbr.org/sponsored/2019/07/leading-a-new-era-in-healthcare-innovation-through-data-driven-diagnostics) 2. Suri A. Practical AI for Healthcare Professionals (https://link.springer.com/book/10.1007/978-1-4842-7780-5) Rajeev Suri, MD, MBA, FACR is the 2022 President of the Bexar County Medical Society, Tenured Professor and Interim Chair of the Department Radiology at UT Health San Antonio, and Chief of Staff at University Hospital San Antonio.

BCMS ALLIANCE

Innovations in Fitness and Health By Heather Davila, RDH

Spring has officially arrived. By now, many have undoubtedly seen massive progress after being one of the countless Americans who have chosen to commit themselves to live a happier, healthier lifestyle as part of their New Year’s resolution, right? Well, not necessarily. While many in the medical community may arguably be more cognizant of their health decisions and perhaps even prioritize them more, they are not immune to the variety of factors such as fatigue, laziness and listlessness that affect us all. In fact, according to Forbes, nearly 80% of people every year admit to abandoning their New Year’s resolutions by February. So where does that leave us now? For people truly wanting to improve their overall health, the objective should not be to tie goals to an arbitrary date on a calendar. Instead, the perfect time to get started on establishing health and fitness goals is right now. Nutrition apps, small exercise equipment, and online trainers have become the new norm and are easily accessible for people of all fitness levels, availability and interests. The old days of paying for gym memberships or meeting a personal trainer on a rigid schedule have become nearly obsolete. According to the European Journal of Social Psychology (Lally et al.,2009), it takes 66 days to automate a behavior. Digital apps can be a great starting point. They can monitor a person’s behavior, food consumption and exercise patterns. Most will give a user a goal to either lose, maintain or gain weight based on a person’s height, weight and activity level. Much like online banking, apps like MyFitnessPal or Lose IT allow a user to download a “calorie bank” on their smart device to track the food a person has consumed and allow them to adjust accordingly. Apps like WW (formerly WeightWatchers) or MyFitnessPal make it even easier – they allow a user to snap a photo of a meal and it calculates the data for them. In addition to apps, the health industry has also begun making fitness equipment more portable and convenient. Popular brands such as the Peloton bike, The Mirror, or Tonal take up no more than four feet in your home. Most of them also include a low-cost digital app for users who do not have access to or own the equipment. Apps like Peloton or iFIT have a wide range of strength, yoga, barre, running and meditation workouts that typically require no more than a mat. These options are all cheaper than a gym membership and save time. Lastly, as we work to improve our health, we should simultaneously be working to establish a solid foundation for the children in our lives. It is important to remember how the habits we formed in adolescence followed us into adulthood, and are shaping them today. This is where we can look to interactive gaming as an ally. Popular video games such as those available on the Nintendo Switch console or via Oculus headsets appeal to the younger population who have grown up with technology. These games integrate fantasy worlds and stimulate creativity, yes, but more importantly, make physical activity fun. If COVID-19 cancels school or the weather prevents school from taking place, these game consoles are a great way to get P.E. class in. For youngsters that come home from school and are not ready to start homework yet, doing a fun kickboxing class on the Switch can be a great way to expel energy and work on coordination skills. Innovations in fitness can be the game changer most of us didn’t know we needed. Since we can’t ask Amazon’s Alexa to work out and diet for us…yet, I encourage everyone to skim through the App Store and get excited over the volume of options and be pleasantly surprised by a universe of free content. After all, health and fitness are the best form of medicine and the key to youth. It’s time we learn to love and look forward to exercising instead of dreading it. Heather Davila, RDH is a Registered Dental Hygienist in the San Antonio area and a Bexar County Medical Society Alliance board member.

SAN ANTONIO MEDICINE • May 2022

MEDICAL INNOVATIONS

Supporting San Antonio’s Expansion in Medical Technology Innovation By Gabriel Bietz, MD, RPVI

an Antonio is home to over 100 early-stage medical technology and bioscience startups, all of whom are developing innovative new approaches designed to improve patient outcomes. As members of the local medical community, we have an opportunity to support these companies and colleagues by providing our input during various stages of product and clinical development. This insight is valuable to such organizations, in order to assist with moving their efforts forward through the product development phase, regulatory process and eventually, product commercialization. 12

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Many ideas for new medical technologies are originally conceived by physicians. When I was a vascular surgery fellow at the University of Kentucky, I had the opportunity to work with Dr. John Gurley, an interventional cardiologist who was the Director of their Structural Health Program. Dr. Gurley had invented an innovative new approach to achieving central venous access in patients who had obstructions of their thoracic veins, a condition which prevented the ability to place catheters or cardiac leads. He called this procedure the “inside-out” approach. To perform the procedure, Dr. Gurley used a variety of different

MEDICAL INNOVATIONS

devices available in his hospital to gain access through the right femoral vein, and then pass an instrument through the obstruction on the right side of the thoracic vasculature. He then passed a sharp wire through the veins and directed it externally, enabling the central venous access device to be pulled in from the outside. This life-saving approach pioneered the ability to achieve vascular access for dialysis, infusion of parenteral nutrition, antibiotics or chemotherapy, along with the placement of cardiac leads. Dr. Gurley founded Bluegrass Vascular Technologies in 2011, in order to develop and commercialize a device which would simplify performing this inside-out procedure, and therefore enable other physicians around the country to help patients with similar clinical issues resulting from venous obstructions. Coincidentally, after I left my fellowship and moved to San Antonio to join Peripheral Vascular Associates (PVA), Bluegrass Vascular received funding from a prominent local venture capital fund that invests

in early-stage life science companies, and relocated their headquarters to San Antonio. In conjunction with this, the company hired Dr. Gabriele Niederauer as their CEO. Dr. Niederauer is a bioengineer and experienced medical device company executive who is a long-time resident of San Antonio. She is one of a growing number of women who are now leading both small and large medical device companies in the United States, although nationwide, only 8% of medical device company CEOs are female. Since her arrival, the company has obtained U.S. and European regulatory authorization to commercialize the Surfacer® System, a device which is specifically designed to perform the Inside-Out® procedure more quickly and efficiently, when compared to Dr. Gurley’s initial approach, which used a variety of differing devices and instruments. The hard work paid off, as a new reimbursement code was recently granted to pay hospitals and ambulatory surgery centers for the procedure. I am honored to have had the opportunity to work with Bluegrass Vascular prior to, and throughout, their product development process assisted with validating the design of their device, to help ensure it would meet the needs of clinicians who would perform the procedure. This process, termed “human factors engineering,” assessed the physical requirements, skill demands and other aspects of the environment where the device will be used to identify and address end-user associated strengths and limitations in the design of the device. The involvement of experienced clinicians is an essential factor that allows these medical device companies to ensure that the design of their innovation takes into consideration all of the factors, which may impact the safety, performance and ease of use associated with their technology. I am proud to have been a part of the process in helping Bluegrass Vascular bring their life-saving product to the market; having the ability to come full circle, from observing Dr. Gurley first using the inside-out approach during my fellowship, to now using the Surfacer System in my clinical practice at Peripheral Vascular Associates. Additionally, I am proud to support an innovative San Antonio-based medical technology company, as this also supports the efforts by local organizations and incubators to attract similar companies to the area. Gabriel Bietz, MD, RPVI is a board-certified vascular surgeon who practices at Peripheral Vascular Associates (PVA). Dr. Bietz specializes in endovascular and minimally invasive procedures for vascular disorders and dialysis access, with expertise in using the latest treatment options for vascular disease. To learn more, please visit PVAsatx.com. Dr. Bietz is a member of the Bexar County Medical Society. Visit us at www.bcms.org

MEDICAL INNOVATIONS

“Forced Inspiratory Suction and Swallow Tool’ (FISST):

A Novel Invention that Stops Hiccups Instantly By Ali Seifi, MD, FACP, FNCS, FCCM and Faraz Yousefian, DO

lthough hiccups have occurred in humans for ages, Thomas Lupton first scientifically characterized them in 1627.1 Lupton described hiccups as involuntary, synchronous, clonic spasms of the intercostal muscles and diaphragm, producing a sudden inspiration followed by an abrupt characteristic ‘Hic’ sound.1 However, it was not until 1970 that the pathophysiology was described in medical literature.2 Any pathology that affects the brain, diaphragm, thoracic or abdominal viscera can stimulate vagal or phrenic afferents and activate the hiccup centers in the midbrain, brainstem and proximal cervical cord. Examples of these triggers include distention or irritation of the stomach by a large meal, pepper or alcohol, over-excitement or central nervous system triggers such as stroke.1-4 While the prevalence of hiccup episodes occurring outside of the hospital setting would be difficult to quantify, it appears to be a ubiquitous problem. One published editorial from Forbes in 2019 noted that a search for hiccup cures was the third most frequently “Googled” health question.5 While most episodes are transient and resolve soon after onset, some may last longer. Persistent hiccups are defined as episodes exceeding 48 hours, and intractable hiccups are defined as lasting longer than one month, and can be due to organic pathologies and have been associated with complications.1-3 In fact, hiccups are repetitive, myoclonic contractions of the diaphragm followed by abrupt suction of air into the upper airway, triggered by a ‘reflex arc’ involving the phrenic and vagus nerves, respectively.3,4 Usually, a stimulant such as spicy food triggers the phrenic nerve adjacent to the stomach. Close anatomical location of the nucleus of the phrenic nerve with the vagus nerve triggers the vagus nerve, which innervates the larynx. Subsequently, it produces the well-known “Hic” sounds due to the abrupt suction of air into the airways. This battery of events will repeat as a reflex with various frequencies between four to 60 times per minute.4 Several home remedies to relieve transient hiccups have been proposed, such as breath holding, recycled breathing in a paper bag and drinking water from the far side of a glass.2 However, there was not a simple tool available to stop hiccups until recently. Considering the inconsistent performance and poor effectiveness of home remedies, there has been a need for a simple and effective hiccup terminating tool. Fol14

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lowing the same physiologic principles as home remedies, Dr. Seifi at the University of Texas Health Science Center at San Antonio designed and patented a straightforward, easily accessible and low-cost device, which is scientifically referred to as the “Forced Inspiratory Suction and Swallow Tool (FISST)” and branded as “HiccAway®.”7 The motivation to make such a device was based on a patient in the neuro intensive care unit who had a neurosurgical procedure. He developed hiccups after the operation and had hiccups for 24 hours, which was painful and disturbing and did not relieve with any of the known remedies nor with chlorpromazine. The patient asked us with a desperate tone while he had hiccups that he was pleased with his brain operation but so disturbed with the hiccups. This challenging moment was the start of the FISST invention. FISST is a specially designed straw with a pressure valve that subjects with hiccups, required to generate approximately negative 80 to 100 cmH2O pressure in adults (negative 30-50 cmH2O in children), to sip the water through it and swallow the water immediately.7,8 This tool involves the concordance activity of the phrenic and vagus nerves. First, it induces diaphragmatic contraction by negative inspiratory force with phrenic nerve activity. Subsequently, the activity of the vagus nerve closes the epiglottis during swallowing. FISST induces the simultaneous activity of the phrenic and vagus nerve and resets the nerves, thus stopping the hiccups. The performance of this tool has been studied on 674 subjects with hiccups, and the results have been published previously in JAMA Network in 2021 with more than 90% effectiveness compared to home remedies.8 FISST is a pen-like tool that users put in a cup of water and then drink the water through it. The device has three segments: (Figure 1) I. The mouthpiece on the upper end, which the user should hold in the mouth between the teeth to sip the water through it. II. The body, which is a straw-like conduit that carries the water from the lower end to the mouthpiece on the upper end. The body is approximately 15 cm long and has a variable internal diameter with an average one cm caliber. III. The lower-end cap, which is a unique pressure valve. The cap is detachable and can be set to one of the two various pressures: -100 cmH2O for adults and -50 cmH2O for children.

MEDICAL INNOVATIONS

Figure 1

Figure 2

FISST has a one millimeter hole in the lower end cap that functions as a pressure valve and a large upper outlet at the mouthpiece. The function and dimensions of the FISST are designed based on the “Bernoulli Principle,” which states that for an ideal fluid, an increase in velocity occurs simultaneously with a decrease in pressure. When the fluid flows through a pipe (such as FISST) with a constriction (small size hole in the lower end cap), the fluid velocity increases at the constriction site to fulfill the continuity equation; however, its pressure must decrease because of the conservation of energy.1,7 Thus, the suction of water through FISST requires a relatively high suction pressure generated by the diaphragm muscle due to the high velocity of water that passes through a tiny hole in the lower end cap. This high negative vacuum is generated by voluntary forceful contraction and downward movement of the diaphragm muscle that is induced by the phrenic nerve. Subsequently during swallowing the water, as a spontaneous reflex, the vagus nerve is being activated to bend the epiglottis to cover the glottis. These batteries of operations which require simultaneous activity of phrenic and vagus nerves, reset the hiccups reflex arc, and thus stop the hiccups instantly (Figure 2). In summary, FISST is a novel tool that requires simultaneous activity of phrenic and vagus nerves and has greater than 90% effectiveness. FISST offers a scientific solution based on biomechanics, is easy to use, and is a publicly available tool that can help many people who suffer from hiccups. This novel invention became available to the public as an over-thecounter device to stop hiccups in 2020 and soon attracted the entrepreneurs at “Shark Tank,” a well-known invention and business platform by ABC television, in 2022. FISST was presented on the “Shark Tank” with the brand name of HiccAway to the angel investors and was backed up by Mark Cuban, the well-known entrepreneur from Dallas, Texas. The secret of our success at the pitch was the fact that this tool has been backed up by science, and the effectiveness of the tool has been studied and published in JAMA, after vigorous peer review by international experts.8 This device is an example of how physicians can see the challenging medical conditions around them as an opportunity to solve a problem. Clinicians are facing many puzzling situations during their practice, but each of these challenges are an opportunity. It is up to us to see this as the glass half full or the other empty half. Next time you are facing a demanding situation during work, remember that YOU can be the next potential inventor, so take each opportunity seriously at your practice. References 1. Calsina-Berna A, García-Gómez G, González-Barboteo J, PortaSales J. Treatment of Chronic Hiccups in Cancer Patients: A Systematic Review. J Palliat Med. 2012;15(10):1142-1150. doi:10.1089/jpm.2012.0087 continued on page 16 Visit us at www.bcms.org

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2. Launois S, Bizec J, Whitelaw W, Cabane J, Derenne JP. Hiccup in adults: an overview. Eur Respir J. 1993;6:563-575. 3. Davis JN. An experimental study of hiccup. Brain J Neurol. 1970;93(4):851-872. doi:10.1093/brain/93.4.851 4. Steger M, Schneemann M, Fox M. Systemic review: the pathogenesis and pharmacological treatment of hiccups. Aliment Pharmacol Ther. 2015;42(9):1037-1050. doi:10.1111/apt.13374 5. Lee BY. Here Are The Top 10 Most Googled Health Questions Of 2019. Forbes. Accessed January 31, 2021. https://www.forbes.com/ sites/brucelee/2019/12/22/here-are-the-top-10-most-googledhealth-questions-of-2019/. 6. Chang FY, Lu CL. Hiccup: mystery, nature and treatment. J Neurogastroenterol Motil. 2012;18(2):123-130. doi:10.5056/ jnm.2012.18.2.123 7. Seifi A, inventor. Hiccup relieving apparatus. U.S. patent application publ. U.S. 2020/0188619 A1. June 18, 2020.US20200 188619A1.pdf. Accessed October 24, 2021. 8. Alvarez J, Anderson JM, Snyder PL, et al. Evaluation of the Forced Inspiratory Suction and Swallow Tool to Stop Hiccups. JAMA Netw Open. 2021;4(6):e2113933. Published 2021 Jun 1. doi:10.1001/jamanetworkopen.2021.13933. 9. Bajpai, P. (2018). Biermann’s Handbook of Pulp and Paper (3rd Ed.). Elsevier Science. Retrieved from Https://Www.Perlego.Com/ Book/1829202/Biermanns-Handbook-of-Pulp-and-Paper-Pdf (Original Work Published 2018). Ali Seifi, MD, FACP, FNCS, FCCM is the Director of the Neuro-ICU and associate professor in the Department of Neurosurgery at the University of Texas Health Science Center San Antonio, and has been serving as an attending physician since 2012. He is the inventor of “Forced Inspiratory Suction and Swallow Tool (FISST),” branded as “HiccAway®.” Faraz Yousefian, DO is an intern at the Texas Institute for Graduate Medical Education and Research (TIGMER) in San Antonio, Texas. He is very passionate about mentoring medical students and educating the general population about skin diseases and the steps they can take to prevent them. Dr. Yousefian is a member of Bexar County Medical Society.

SAN ANTONIO MEDICINE • May 2022

MEDICAL INNOVATIONS

Smoking Cessation and Internet Telehealth Resources By John J. Seidenfeld, MD and Neal Meritz, MD

n high school, I smoked with friends down in a ravine near my home. The Seidenfeld home was near Lake Michigan in a Northern Illinois town with ravines memorialized in Ray Bradbury’s “Dandelion Wine.” These were quiet, dark, but sun-speckled places under the shade of large leafy trees where we could be alone and discuss the critical issues of teens. Through high school and then college, smoking continued up to two packages of cigarettes per day and many were unfiltered so that I inhaled burning paper and tobacco deep into the lungs. Attempts at quitting were often met with failure, as the lure of the cigarette and the nicotine drew me back. Just before medical school started, I found a boarding house near campus which was wonderfully clean and quiet. The landlady, Mrs. Bishop, was an elderly woman who climbed the stairs backward to the second floor each day to change towels and clean. Why did she do this? I probably should have done a history and joint exam, but did not know how and why to do either at the time. Her only request was that I not smoke. Her request was a great excuse to quit “cold turkey.” No matter how many times you quit, the last time is “cold turkey.” I imagine there were withdrawal symptoms, but they were lost in the first few weeks and then months and years of medical studies. Each day the desire became less until today, many years later, when I fantasize that I will start again at age 90 (as there are so few studies of the effects of smoking or vaping on nonagenarians). Such is the strength of this disorder.

Smoking tobacco products is the leading cause of preventable deaths throughout the world. The smoke contains thousands of chemicals, and many have been identified as carcinogenic. People who smoke the equivalent of more than 20 cigarettes per day for over 20 years account for approximately $300 billion per year of hospital and health care resources as well as lost productivity. Tobacco executives have testified that they know their products are addictive, and have marketed to young people for years by making the smoker look attractive and sophisticated in movies, commercials and other media advertisements. Many of the large cigarette producers now own companies that sell tobacco vaping products to increase their market share. Currently, many pulmonologists feel that vaping and smoking are equally damaging to the body so that all references to cigarette smoking apply to vaping also in this article. Nicotine in tobacco smoke is one of the most addictive substances known to man. While it is common for many teens to become addicted to tobacco and begin a lifelong habit, quitting is extremely difficult, and few effective resources have been available to help in this effort. Who wants to quit? The motivated smoker who has just had a myocardial infarction (MI) or a pregnant patient have a quit rate near 50% with doctors’ advice and some guidance. Quit rates are usually gauged at six to 12 months after cessation and recidivism is common. Multimodal therapy with long-term counseling support and medications continued on page 18 Visit us at www.bcms.org

MEDICAL INNOVATIONS continued from page 17

may improve the quit rate by more than 20%. Most doctors are not trained in motivational interviewing or in behavioral approaches to assist in quitting, and medications alone are less likely to help improve chances of remaining tobacco-free long-term. Some physicians also have misperceptions about the harmful effects of nicotine and are unwilling to use nicotine replacement therapy. It has been reported that 68% of adult smokers have voiced a desire to quit. What are the benefits of quitting smoking? In the first 20 minutes tobacco-free, blood pressure and pulse begin to drop. In 12 hours, carbon monoxide levels drop to normal, allowing blood to carry more oxygen. Within two to three weeks, circulation and lung function improve, and risk for MI is lower. Cough is reduced by nine months, and at one year, the risk for coronary artery disease (CAD) drops in half. Between two and five years off, risk for many cancers decreases by 50%, risk for CAD is reduced by two thirds, and risk for stroke equals that of non-smokers. At 10 years, the risk for lung cancer drops to 50%. After 15 years of abstinence, the risk for CAD equals that of non-smokers. What are the barriers to quitting? Nicotine enters the bloodstream quickly by inhalation. It reaches the brain within seconds and acts on the pleasure pathways of the meso-cortico-limbic system. There, it causes the release of dopamine which produces a mood-elevating effect that becomes highly addictive. If nicotine is withdrawn, the smoker may become irritable, depressed, anxious, insomniac, hungry and rest-

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less. Often these withdrawal symptoms begin within a few hours after last tobacco use and can continue for longer than a month. Number of cigarettes smoked and time of day of first use are correlated with severity of dependence. Since cigarette smoking becomes a habit, behavioral change is needed to reduce dependence. Frequent daily use, social situations, and certain environments lead to rituals with cues and triggers that perpetuate habitual use. Since most patients begin smoking before age 18, adding this question to the vital signs for pediatrics, family medicine and internal medicine practices is a promising idea. Those who are not smoking should be encouraged to maintain their healthy habits. For smokers, the US (United States) Public Health Service recommends a Five A approach or 1) ask about smoking status, 2) advise cessation, 3) assess readiness to quit, 4) assist people to quit and 5) arrange follow-up visits and discussions. Listen to your patients and do not judge them to learn cues to readiness, desire for help, and ability and need to quit. Do not give up. Quitting may only occur after many attempts.1 The Canadian working group under Thabane et al. on smoking cessation in 2012 noted from the literature of randomized controlled trials in COPD (chronic obstructive pulmonary disease) patients, 1) “compared with usual care, abstinence rates are significantly higher in COPD patients receiving intensive counseling or a combination of intensive counseling and NRT (Nicotine Replacement Therapy), 2) abstinence rates are significantly higher in COPD patients receiving NRT compared with placebo 3) and abstinence rates are significantly higher in COPD patients receiving the antidepressant bupropion compared to placebo.”2 Intensive counseling is not standardized, and studies have looked at cognitive behavioral therapy, facilitated group therapy, online resources and telehealth resources with many showing similar usefulness. Many of these programs are run by nonprofit organizations at no or minimal cost to recipients, but some are offered for-profit. Lang noted that smoking cessation face-to-face could be continued with telehealth during COVID-19 and remain effective. Since smoking is one of the few readily modifiable risk factors for COVID-19, the group was able to run a successful telehealth to-

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bacco treatment program adapted to the pandemic. The authors described adaptation of their program to telehealth, described the process and lessons learned from this initiative, and suggested that the model is applicable and scalable to government and civilian health centers.3 The National Institutes of Health, the American Cancer Society and the American Lung Association are a few of the organizations that offer nicotine users web-based support for smoking counseling and cessation resources. Telehealth resources for counseling, and specifically nicotine cessation, are becoming more available through nonprofit organizations, apps and physician practices. If your patient is ready to quit, let them know about the available resources shown below. Cessation is most likely to be successful in those who want to quit, have reason to quit, can quit and need to quit. Intensive counseling in-person or by telehealth and medications will have a synergistic effect in helping achieve permanent cessation. When questioned about his experiences advising patients regarding smoking cessation, another former smoker, Dr. Neal Meritz, noted, “That as a longtime practicing Family Physician, I always felt that assisting a patient in smoking cessation was one of my most valuable medical interventions. Almost all smokers want to stop; my emphasis was mostly concerning how to quit, not why. I encouraged patients to utilize nicotine replacement therapies and bupropion. I advised the smoker that many of the pathophysiologic effects of nicotine addiction last only for a few days, and that many less-emotionally strong people than them had quit smoking successfully. I used tactics like ‘Find a new distraction such as exercise. When you want a cigarette, go for a walk.’ I advised adolescent male smokers that they were unlikely to attract a female partner who did not smoke, thus severely diminishing the pool of available potential girlfriends. Often these approaches were ineffective initially, but I kept trying, and the occasional successes were well worth it.” References 1. Manish S. Patel, MD, Sheetal B. Patel, MD,Michael B. Steinberg, MD, MPH. Annals of Internal Medicine, Volume 174, Issue 12, In the Clinic, December 2021 Smoking Cessation https://doi.org/10.7326/AITC202112210 2. Thabane M; COPD Working Group. Smoking cessation for patients with chronic obstructive pulmonary disease (COPD): an evidencebased analysis. Ont Health Technol Assess Ser. 2012;12(4):1-50. Epub 2012 Mar 1. PMID: 23074432; PMCID: PMC3384371. 3. Lang AE, Yakhkind A. Coronavirus Disease 2019 and Smoking: How and Why We Implemented a Tobacco Treatment Campaign. Chest. 2020 Oct;158(4):1770-1776. doi: 10.1016/j.chest.2020.06.013. Epub 2020 Jun 17. PMID: 32561438; PMCID: PMC7297684.

Support on the web https://medlineplus.gov/quittingsmoking.html www.cancer.org/search.html?q=smoking+cessation www.lung.org/help-support/lung-helpline-and-tobacco-quitline https://smokefree.gov/ https://www.uptodate.com The Microsoft Store, Apple Store and Google Play Store for smoking cessation apps (available but not researched for this article). There are many of these and if anyone knows of objective ratings of the apps, please write a letter to the Editor with a comparison or review. John J. Seidenfeld, MD is the Chair of the BCMS Publications Committee. Neal Meritz, MD is a retired Family Practice physician and a member of the BCMS Publications Committee.

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PRN: Take as Needed

On Wearables, Health Care and Predictive AI By David Alex Schulz, CHP

alloween, 1957: A Minneapolis child dies because an ACpowered pacemaker failed in a power outage. Before a month is out, local engineer Earl E. Bakken prototypes the world’s first battery-operated, transistorized, external pacemaker. The founder of Medtronic has ushered in a new paradigm for health care: portable wearable electronic devices. Before his death in 2018, Bakken saw Medtronic and other companies shrink devices, standardize them and interconnect them. From ‘fitness’ watches to devices monitoring blood pressure, electromyography, glucose, temperature and oxygen levels, portable wearable devices are ubiquitous. A similar revolution in implantable devices brought about infusion pumps, neurostimulators and cardioverter defibrillators (ICDs) to join the implanted pacemaker. All are members of the “IoT,” the Internet of Things, accessible to a network through either wifi or Bluetooth. Connectivity permits noninvasive monitoring and control of the device, but the collection and sharing of data is only barely secondary in importance. The question with new tech, as always: Just because we can do something, does it mean we should? Hazards are present such as Bakken and his successors never considered. It will take extraordinary strategic planning and deployment of equipment and its data to lower the risk to acceptable. Most obvious is the question of digital security, not only in the theft of data, but breaching the device controls themselves. Upon taking office, Vice President Dick Cheney insisted on disabling his pacemaker’s connectivity, fearful of assassination by hacking. In 2019, the Department of Homeland Security warned that hackers could wirelessly access implanted pacemakers made by Medtronic. Three months later, the company recalled some of its insulin pumps for similar reasons. The healthcare industry needs to address remote device security or it will be less prepared than it was for ransomware. The pandemic supercharged home health care, tele-medicine and Remote Patient Monitoring with an 20

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uptake in patients adopting pulse oximeters, digital thermometers, otoscopes, personal ECG and others. All carry inherent cyber-risk. Less obvious are problems due to peoples’ whims and personalities – call it the microcosm of medical anthropology. While generally thought that patients should take greater ownership of their own health care, we live in an age of extremes. Take Bill, whose lifelong tendency for anxiety led him to buy a Fitbit Sense in late 2020 during lockdown. CNET reporter Lisa Eadicicco relates the story, “He thought it would reassure him that he was healthy if he was able to take an electrocardiogram reading when he felt something abnormal, such as heartburn or an accelerated heartbeat.” Yet Bill only grew more anxious after receiving inconclusive ECG results his device, not unusual in casual, uncontrolled circumstances, where the device couldn't get a reliable reading. He began taking up to 20 ECGs a day because of his anxiety around springtime. Realizing he was hypering himself into a frenzy, he finally abandoned the device and his anxiety lessened. The industry is in its adolescence, and while data collection of consumer devices is continually more refined, companies are still figuring out the best ways to deploy wearables, and make sense

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of that data without overstepping the boundaries of what a non-medical device should do. "There is a distinction between measurements for wellness, which provide general guidance and would encourage you to exercise in a way that's helpful for you and to eat more healthy foods, and a medical device," Dr. Paul Friedman, a cardiologist in the Mayo Clinic's AI in Cardiology Work Group. "And I think the blurring of those is causing some confusion." While Apple will gladly point on its website to occasions the Watch was instrumental in lifesaving warnings, the company recognizes its limitations and makes no claims as a healthcare device. That’s why Medtronic went straight to Rockley Photonics, the company underlying Watch technology, to invent a super-enhanced Watch to monitor a whole host of health factors. The resulting devices track a range of data points, including body temperature, blood pressure, heart rate, pulse oximetry and hydration, as well as alcohol, lactate and glucose levels, among others. If users are educated in their purposes, and the data regularly downloaded and interpreted by healthcare providers, great potential for good can be seen, advancing wellness, and addressing chronic illness. A study was recently conducted by the American Society of Clinical Oncology (ASCO) involving 357 patients with head and neck cancer. One group of these patients used a Bluetooth-powered blood pressure cuff and a mobile app to track their symptoms – researchers observed fewer severe symptoms among these patients whose conditions were monitored regularly. Chronic patients are significantly more likely to visit the emergency room and are more likely to receive long-term medical care because they are unable to proactively manage their illnesses and keep up with their care plan. "This study demonstrates the power of leveraging smart technology to improve the care of people with cancer. These tools helped simplify care for both patients and their care providers by enabling emerging side effects to be identified and addressed quickly and efficiently to ease the burden of treatment. I hope that these or similar technologies will be broadly available to patients soon," said ASCO President Bruce E. Johnson, MD, FASCO. So we begin with Bakken’s wearable, add a variety of sensing capabilities to monitor vital stats, stir with IoT connectivity and the result is massive data collection. Massive data brings us to the threshold of artificial intelligence. Data-driven AI can spot patterns in healthcare data, uncovering significant trends and associations between factors previously thought to be unrelated. The promise is real, and so is the threat. Without consideration of both security and user education, the hacking

of the device (and the human) is a definite liability. This is where the National Institutes of Health enters the story, launching the All of Us research project in 2015 with a lofty goal: support research on many aspects of health, not just a single medical or biological research question. The data platform enables research that can increase wellness and resilience, and promote healthy living. All of Us will build a database of the fully sequenced genomes of at least one million Americans of diverse backgrounds that can then be used by scientists to improve diagnostic and drug development, clinical trial recruitment and our overall understanding of human disease. This spring, scientists are getting access to the genes of nearly 100,000 Americans in a uniquely diverse genomic database − part of the NIH’s quest to reduce health disparities and end cookie-cutter care. But the Genome Project is only one aspect of All of Us, and with the pandemic, the program focused on COVID. With 350,000 participants from all 50 states, some taking monthly detailed health questionnaires, other participants providing access to their EHRs, All of Us has the power to help answer questions that few other groups can. Now with more than half-a-million participants, 288,000 EHRs and 350,000 bio samples, scientists across the U.S. are able to access immense datasets, half of which come from people representing racial and ethnic groups that have been historically underrepresented in medical research. “There is a unique depth and dimensionality to the All of Us platform that sets it apart from other resources in the field. It’s also designed with team science in mind, allowing researchers to explore topics in an open and collaborative way,” said Gail Jarvik, MD, PhD, a principal investigator at one of the program’s sequencing centers at the University of Washington. FDA approval of wearables is inevitable – In 2021, the wearable medical devices market was estimated at $16.2 billion, and it is expected to reach $30.1 billion by 2026. The publics’ appetite for a connected lifestyle, happily adopting IoT devices from their refrigerator to their most intimate personal instruments, appears unlimited. If the NIH is right, solutions to previously unanswered medical mysteries may be found in data provided by your Fitbit, your neighbor’s EMG pain reducer and an unknown stranger’s insulin pump. Oh, Brave New World! David Alex Schulz, CHP is a community member of the BCMS Publications Committee.

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First in Man Pig-to-Human Cardiac Xenotransplantation: A Medical Student’s Perspective By John A. Treffalls, BS

fter completing the USMLE Step 1 exam at the end of my second year of medical school, I made a somewhat unorthodox decision to postpone my clinical clerkships at UT Health San Antonio to pursue a once-in-a-lifetime opportunity. I temporarily moved from San Antonio, Texas to Baltimore, Maryland to work in the University of Maryland Cardiac Xenotransplantation Laboratory under Directors Dr. Muhammed Mohiuddin and Dr. Bartley Griffith, both world-renowned for their contributions to the field of transplantation. I took this leap because, as an aspiring cardiothoracic surgeon, I was immensely fascinated with the work they were doing together and believed that it had the potential to one day save the lives of the tens of thousands of Americans on the transplant waiting list each year. I quickly became immersed within the fast-paced lab that was doing what few in the world could safely accomplish. While there, I helped conduct pivotal research which involved transplantation of genetically engineered pig hearts into nonhuman primate recipients. The genetic modifications aimed to “humanize” the hearts, thereby improving the compatibility of the porcine organs with primate recipients and increasing their longevity once transplanted. Over many years, the experiments progressed from heterotopic transplantation (nonlife-supporting) to orthotopic (life-supporting), with survival times gradually increasing up to nine months postoperatively. Improved outcomes were due to advancements in the novel immunosuppression pioneered by Dr. Mohiuddin, use of non-ischemic graft preservation, improvements in postoperative care and an unrelenting drive to succeed by all members of the research team. Decades of slow, incremental progress culminated on January 7, 2022, when David Bennett, a man repeatedly denied for cardiac allotransplantation and “stuck” on venoarterial extracorporeal membrane oxygenation (VA-ECMO) received a modified porcine heart identical to those that I helped transplant into baboons just a few months prior. While I had to return to San Antonio a few weeks earlier to start my clinical clerkships, I received real-time updates from the surgical residents who acted as my mentors, Dr. Corbin Goerlich, a general surgery resident at the Johns Hopkins Hospital and Dr. Aakash Shah, an integrated cardiothoracic surgery resident at the University of Maryland Medical Center. Though we all hoped for the best and felt confident that it would work based on our previous research experience, no one truly knew what the outcome of the first-in-man surgery would be. The results 22

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were better than we could have hoped for. The surgery proceeded smoothly, the VA-ECMO was slowly weened over the subsequent postoperative days and Mr. Bennett began the long recovery process, like that of a typical cardiac transplantation recipient. However, at the time of this writing and more than two months since the landmark surgery, Mr. Bennett has unfortunately passed away. The entire xenotransplantation team at the University of Maryland is currently conducting a full investigation to determine the cause of his death. Despite his death, this operation, made possible by the decades of tireless work preceding it, is truly paradigm-shifting for the field of organ transplantation. While much work remains to be done, xenotransplantation has the potential to provide an unlimited supply of donor organs for those suffering from end-stage organ failure. Without the perseverance of the research team and the incredible bravery of Mr. Bennett, this accomplishment would not have been possible. As a medical student at the very early stages of my training, I consider myself incredibly fortunate and truly humbled to have been able to contribute to it, no matter how small.

Figure 1. Research residents Corbin Goerlich, MD, Joshua Leibowitz, MD and John A. Treffalls, BS operating in the surgical suite of the University of Maryland Cardiac Xenotransplantation Laboratory in the months preceding Mr. Bennett’s pig-to-human operation.

John A. Treffalls, BS is a third-year medical student at the Long School of Medicine, University of Texas Health San Antonio. He is interested in pursuing a career in academic cardiac surgery and plans on applying to integrated thoracic surgery residency programs.

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Medical Innovations:

The Rise of Telemedicine By Johnathon Harris and Matthew Cryer

he growth of telemedicine has greatly expanded during the COVID-19 pandemic, in part due to its unmatched ability to continue care with patients while ensuring patients could socially distance; dramatically reducing risk of transferring the COVID19 virus.1 From 2019 to 2020, telemedicine visits for patients using Medicare increased by a factor of 63, from 840,000 to 52,700,000.2 Though the number of telemedicine visits has declined since the start of the pandemic, as of February 2021, there was a stable 38-fold increase in telemedicine usage in the U.S., which represents 13-17% of all medical visits.3 In a national survey conducted by the Harris Poll published April 2020, 35% of respondents would consider replacing their primary care provider with on-demand telemedicine visits.4 As a result of both advancement in information technology and the unique demands imposed on providers in a post-pandemic world, telemedicine as a medium for delivering quality health care is here to stay. Telemedicine is considered a subset of telehealth and is defined as, “the exchange of medical information from two separate sites via electronic means to improve patient health.”1 It began over 70 years ago when hospitals started to share information via telephone.5 This audioonly form of telemedicine was improved upon by the 1960s when the University of Nebraska used a two-way interactive television, allowing its medical students to accomplish neurological examinations of standardized patients.6 With the invention of the internet and increased availability of transmitting devices, telemedicine has continued to evolve into an important tool for both clinicians and patients. It is currently used to provide high-quality health care to patients, regardless of their location or ability to travel. Today, telemedicine is being incorporated in medical school programs, graduate medical education and in physicians’ practices. At the University of the Incarnate Word School of Osteopathic Medi24

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cine (UIWSOM), telemedicine was successfully used to allow osteopathic students the ability to interact with standardized patients during times of quarantine. UIWSOM students were taught how to accomplish a medical interview and physical examinations to include musculoskeletal and skin exams through a program that allowed for video/audio exchange, all from the safety of their homes. In 2020, the Accreditation Council for Graduate Medical Education (ACGME) approved the use of telemedicine for residents in certain programs through the academic year of 2021.1 Resources have even been made to help assist physicians with telemedicine, to include a guide on how to accomplish a virtual physical examination, how to accomplish a musculoskeletal exam and even more guides for more specific examinations, such as a virtual dysphagia examination.1 Along with benefits of reduced exposure to infections and an increased reach of health care to anywhere in the world, physicians are able to learn more about their patient and their current living conditions in ways that were not possible before telemedicine, such as the ability to get a visual tour of the patient’s home.1 Moving into the near future, telemedicine will likely have increased usage as a tool to help patients determine if and when they need to physically come into the hospital. It has already made its way into some emergency departments as a first triage before their visit to the emergency department.7 This has helped patients get screened from the safety of their home, protecting both physicians and the patient during the pandemic. Expanding this in the near future, the authors of this article believe that telemedicine could serve as a way to cut down wait time at hospitals and emergency rooms, while also allowing for the receiving hospital to better prepare for their incoming patients. Instead of a patient walking into an emergency department unannounced and then having to wait for hours based on their triage

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position, the patient could call into the emergency department’s telemedicine line, be triaged at home, and then be told what time to come in. This would also allow the emergency department time to prepare for the patient and have all the needed equipment ready. Although the patient would wait about the same amount of time, it would be in the comfort of their own home, decreasing the amount of exposure to other illnesses, since less people would be in the emergency waiting room. Three major ways the authors envision telemedicine advancing are multi-provider conferences with patients, telemedicine across borders to address supply and demand disequilibrium, and continued developments in the field of remote patient monitoring. While it may seem obvious to most of us in the post-pandemic world that doctor-patient telemedicine conferences could include multiple providers, such as a patient’s primary care provider (PCP) and their specialist, the reality is that doctor-patient visits outside of formal hospital rounds rarely, if ever, include multiple providers. When dealing with providers that are not physically in the same space, it is understandable why this has traditionally been the case, but with the major advancements in teleconferencing technology we have seen in the last decade, the only major obstacles standing in the way of patients being able to converse with multiple providers at once are billing and scheduling. While billing and scheduling are not insignificant issues, in-hospital medicine has already accounted for both of them, and inasmuch as the providers are in the same health care system, this is not likely to be a major issue going forward. Supply and demand disequilibrium can be characterized as the demand for medical care outstripping the supply of those who are qualified to provide it (i.e., providers). Certain specialties in some areas of the U.S. and the world at large may at times develop a surplus, such that the local market for that particular specialty becomes oversaturated with specialists of that particular stripe. In those cases, future developments in multi-jurisdictional licensing could allow those specialists the experience of much local demand to provide their services to patients that live in areas without a sufficient supply of care. Through the Interstate Medical Licensing Compact, the ability for physicians to provide telemedicine care to patients across state lines exists today, with 37 states or territories having joined the compact to date.8,9 Cross-border health care has already been adopted in the European Union where patients in one country can use telemedicine to receive care from a provider in a different country.10 Given the ever-advancing interconnected nature of our global society, we predict that telemedicine across borders, be they state or national, will become increasingly more common and necessary as the supply and demand disequilibrium for doctors and patients continues to worsen. Although telemedicine has been around for the better part of a century, recent use and developments have made it an integral part of health care both today and into the future.

References 1. Ong, M. K., Pfeffer, M., & Muller, R. S. (2021). Telemedicine for Adults. UpToDate. https://www-uptodate-com.uiwtx.idm.oclc.org /contents/telemedicine-for-adults ?search=telemedicine &source=search_result&selectedTitle=1~128&usage_type=default&display_rank=1#H56211279 2. Samson, L., Tarazi, W., Turrini, G., & Sheingold, S. (2021). Medicare Beneficiaries’ Use of Telehealth Services in 2020 – Trends by Beneficiary Characteristics and Location. Issue Brief No. HP2021- 27. Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. 3. Bestsennyy, O., Gilbert, G., Harris, A., & Rost, J. (2021). Telehealth: A quarter-trillion-dollar post-COVID-19 reality? McKinsey & Company. https://www.mckinsey.com/industries/ healthcare-systems-and-services/our-insights/telehealth-a-quartertrillion-dollar-post-covid-19-reality 4. The Harris Poll. (2021). A year of life in the pandemic. https://theharrispoll.com/wp-content/uploads/2021/03/Harris-PollCOVID-1-year-FINAL-3.pdf 5. Teoli D, Aeddula N. R. (2021) Telemedicine. NCBI. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm. nih.gov/books/NBK535343/ 6. Institute of Medicine (US) Committee on Evaluating Clinical Applications of Telemedicine. (1996). Telemedicine: A Guide to Assessing Telecommunications in Health Care. Washington (DC): National Academies Press (US). https://www.ncbi.nlm.nih.gov /books/NBK45445/ 7. Kichloo, A., Albosta, M., Dettloff, K., Wani, F., El-Amir, Z., Singh, J., Aljadah, M., Chakinala, R. C., Kanugula, A. K., Solanki, S., & Chugh, S. (2020). Telemedicine, the current COVID-19 pandemic and the future: a narrative review and perspectives moving forward in the USA. Family medicine and community health, 8(3), e000530. https://doi.org/10.1136/fmch-2020-000530 8. Maheu, M. (2020). COVID-19: Telehealth across state lines and international borders. Telehealth.org. https://telehealth.org/covid19-telehealth-across-state-lines-borders/ 9. Interstate Medical Licensure Compact. (2021). https://www.imlcc.org/ 10. Glass, L. T., Schlachta, C. M., Hawel, J. D., Elnahas A. I., & Alkhamesi, N. A. (2022). Cross-border healthcare: A review and applicability to North America during COVID-19. Health Policy Open. Volume 3. ISSN 2590-2296. https://www.sciencedirect. com/science/article/pii/S2590229621000356 Johnathon Harris and Matthew Cryer are medical students at the University of the Incarnate Word School of Osteopathic Medicine.

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Technology Meets Medicine: Are We There Yet? By Alexandra Bailey and Baotran Vo

elemedicine is becoming increasingly important, especially during the COVID-19 pandemic. The need for virtual doctor visits is essential when social distancing is required. Telemedicine serves those who need to be seen by a physician in the comfort of their own home. However, telemedicine is limited by the inability of the physician to touch the patient, making the use of many traditional diagnostic tools impossible. To bridge this gap, new medical devices have been introduced to the market, making such vital examinations through telehealth platforms a reality. Such technology acts as the physician’s eyes, ears and hands even thousands of miles away. These innovations are perfect examples of the intertwined future of medicine and technology, working hand-in-hand to improve the health outcomes of all patients.

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One example that truly brings the annual checkup to your doorstep is the N9© device from Nonagon©, originally MyHomeDoc©.1 The FDA has cleared both the all-in-one device and interactive user application (app).2 The N9© simply allows the user to record abdominal sounds, photograph the inner ear, listen to the heart, record lung sounds, take body temperature, act as an oximeter to monitor oxygen levels, determine pulse rate and capture pictures of the throat and skin for tests.3 Patients or supervising adults are instructed on each process via an app on their cell phones. The significant number of capabilities makes this a great prospect in integrating telemedicine into health care. Conversely, it would not be sufficient to replace all instances of office visits. While the application may provide some assistance, acquisition and initial readings are still evaluated by the patients themselves, which may introduce

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areas of error in the procedure. To even reach a comparable level of accuracy to results taken by nurses and medical assistants with extensive experience would require extremely explicit guidance by the device or accompanying application, some which haven't been made available to the public yet. With the current thriving era of smartwatches, the technology of wearable devices that gather health information has been improving every day. We are familiar with the smartwatches that connect to our phone, tracking our fitness activities, sleep cycle, heart rate, heart rhythms and more. A new “fashionable accessory” device called the Oura© Ring has been developed. In addition to tracking heart rate 24/7 and sleep analysis, the Oura© Ring also has temperature sensors to monitor changes in body temperature as a sign of illness or correlation with changes in body hormones from monthly menstrual cycles.4 A new feature for the ring is SpO2 sensing to measure oxygen levels during sleep, therefore analyzing sleep quality. The technology for wearable devices is constantly growing and adapting. And along with the affordable cost, fashionable designs and user-friendly features, it will become a common household item in the near future. However, the different devices from different manufacturers come with various sensors, calibrations and readings, so the question for us physicians would be: which heart rate, temperature or oxygen level readings from the variety of these devices should we consider? During the pandemic, pregnant women are a particularly vulnerable group, and the risks increase with frequent office visits for ultrasound exams and checkups. For these expectant mothers, frequent visits to the obstetrics office for ultrasound appointments will become a thing of the past. Pulsenmore©5 is a prenatal home ultrasound device that allows the patients themselves to perform ultrasound exams and share the results with their physician. The Pulsenmore© acts as an attachment unit for the patient’s smartphone, the bottom of the unit being the ultrasound transducer that communicates with the phone via an app. The app also provides training and guidance to the user, and additional training from the physician’s office so the ultrasound scan can capture quality results. Captured images are then shared with the patient’s clinical team, and those can be used to guide further decisions. This new tele-ultrasound device provides vital information to determine if the baby is healthy, helping expectant mothers have assurance at home regarding the health of their fetus and avoid unnecessary trips to the emergency room. In most ultrasound videos captured by Pulsenmore©, the fetus’s heartbeat, movement and amniotic fluid were detected.6 However, a potential limitation for this device would be adequately training patients on probe placement and positioning that give clear and reliable images. Therefore, considering risk and benefit, usage of the device is dependent on the recommendation of the patient’s physician. In-office ultrasound visits might be warranted for at-risk pregnant patients in case emergency management is needed. Another new device is the BIOTRONIK© Biomonitor III Injectable

Cardiac Monitor©,7 a small implantable electrocardiogram (ECG) device capable of continuously recording heart rhythm over time and storing information about any arrhythmias. The sensors in this device provide remote monitoring for patients with atrial fibrillation (AF) or recurrent unexplained syncope. For these patients, this device will lessen the burden of being hooked up to an ECG for long hours of in-office studies. With the device already coming preloaded in an injectable tool, the BIOTRONIK© Biomonitor III is injected under the skin, in the left parasternal region. This is a quick and simple procedure that can be performed under local anesthesia in the physician’s office. Unlike a traditional external heart monitor, the cardiac monitor operates without cables or external attachments to the skin so that patients can maintain normal daily activities (and even go for an MRI) without any interference. Stored ECGs can be transmitted to the doctor through the BIOTRONIK© Home Monitoring Service Center daily. Therefore, physicians can use the recorded rhythms to correlate with the patient’s activities or the onset of symptoms as recorded in the patient’s activity journal or via the BIOTRONIK© patient app. In a 2020 trial,8 an adverse device effect was a permanent implantable device damaged by external cardioversion, requiring a new device replacement. In addition, the difficulty of removing the implantable device in order to implant a permanent pacemaker was classified as a device’s shortcoming. There is no doubt that medical device companies such as BIOTRONIK© are diligently improving their devices and engineering new technology to impact patient care positively. Many devices we have discussed above will gather health-sensitive information and will be transferred from the patient to the physician’s office via the internet. Therefore, there is a need for HIPAA-compliant software to allow patients to upload data, files, images or videos while maintaining a level of confidentiality. There are currently hundreds of HIPAA-compliant telehealth platforms, such as Zoom© for Healthcare, Doxy©, GotoMeeting© and many more. However, the privacy, security of patient information and usability of these platforms should be the main priority. Furthermore, each medical device comes with its application and platform from its manufacturer. As technology progresses, having a universal telehealth platform or platform that can interpret and store data from all different applications from individual monitoring devices would be highly efficient for clinical workflow. This final innovation is different than the above. Instead of focusing on how to bring health care home, Augmedix© has chosen to fix the problems still plaguing in-person office visits.9 While the devices and platforms emerging can bring health care to those who may not have the ability to access it, the gold standard will still be a history and physical examination, at least for the time being. With the rollout and integration of electronic medical records, patients and physicians alike feel that a computer screen gets between them, even though they are faceto-face. There is no doubt these records streamline things like insurance and billing, but can hinder the relationship between patient and physicontinued on page 28 Visit us at www.bcms.org

MEDICAL INNOVATIONS continued from page 27

cian. A HIPAA-secured system oversees pre- and post-visit documentation in addition to providing accurate medical notes during interactions. With a combination of natural language processing, machine learning and medical data specialists, the Augmedix© platform takes care of charting while doctors can care for the patients. During consultations, the Augmedix© platform extracts pertinent clinical information from conversations and then uses AI to generate and organize detailed medical notes for electronic records. Leveraging a multifaceted system to accurate, detailed medical data, the information can be reviewed and then signed off by the physician. Services even prepare clinicians with relevant information prior to a visit. This technology currently augments physician care without replacing the physician and their expertise. In all, Augmedix© claims to save physicians up to three hours a day on charting, improving efficiency and work satisfaction.10 There is no doubt that technology will be an integral part of the medical future. However, it would be naïve to look past the immediate limitations of such a world. This technology is undoubtedly miraculous, but without the understanding and infrastructure associated with such a system, it remains out of reach for many patients. If a patient is not versed in the technology that houses the application, such as the elderly, vulnerable population, it makes little difference. While it may seem that such groups with less technology-savvy literacy are disappearing, this is surely not the case. There is much to celebrate and look forward to for the future of telehealth, but there is still a long way to go. With the changing world, as we can see from the COVID-19 pandemic, technology and medicine are evolving and adapting to serve mankind. References 1. NONAGON. MyHomeDoc Announces Rebrand as NONAGON - Reflecting Commitment To Make Healthcare Accessible To All. PR Newswire. https://www.prnewswire.com/il/news-releases/myhomedoc-announces-rebrand-as-nonagon---reflecting-commitment-to-make-healthcare-accessible-to-all-301277917.html. Published April 27, 2021. Accessed March 2, 2022. 2. NONAGON LTD. Nonagon MHD-100-02-001 Medical Device Identification. FDA; 2021. https://fda.report/GUDID/ 07290018446102 3. How It Works. NONAGON. Published April 17, 2021. Accessed March 2, 2022. https://nonagon-care.com/how-it-works/ 4. Ouraring.com. https://ouraring.com/. Published 2022. Accessed March 18, 2022. 5.Editors M. Medgadget. https://www.medgadget.com/ 2020/08/pulsenmore-at-home-tele-ultrasound-for-pregnantwomen.html. Published August 10, 2020. Accessed March 2, 2022. 6. Israeli startup offers at-home pregnancy ultrasounds with handheld device. KrASIA. https://kr-asia.com/israeli-startup-offers-at-homepregnancy-ultrasounds-with-handheld-device. Published August 20,

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2020. Accessed March 18, 2022. 7. BIOMONITOR IIIM Cardiac Monitoring. Biotronik. https://www.biotronik.com/en-us/healthcare-professionals/professional-education/biomonitor-iiim-cardiac-monitoring. Published 2019. Accessed March 2, 2022. 8. Mariani JA, Weerasooriya R, van den Brink O, et al. Miniaturized implantable cardiac monitor with a long sensing vector (BIOMONITOR III): Insertion procedure assessment, sensing performance, and Home Monitoring Transmission Success. Journal of Electrocardiology. 2020;60:118-125. doi:10.1016/j.jelectrocard.2020.04.004 9. Augmedix. Our Solutions. Augmedix. Published 2022. Accessed March 2, 2022. https://augmedix.com/solutions/ 10. Augmedix. Physicians and Group Practices. Augmedix. Published 2022. Accessed March 6, 2022. https://augmedix.com/physiciansand-group-practices/ Alexandra Bailey is in her final year at the University of Texas at Austin, getting her BS in Biomedical Engineering with a focus in Cellular and Biomolecular Engineering. She has past experience with image acquisition technology innovations. Alexandra plans to attend medical school this fall. Baotran Vo is a fourth-year medical student at the University of the Incarnate Word School of Osteopathic Medicine. She is graduating in May 2022, pursuing residency in Internal Medicine. Baotran completed her BS and MS at the University of Southern California in Biomedical Engineering with an emphasis on Medical Device. Baotran worked as a Design Quality Engineer for a medical device company prior to medical school.

MEDICAL INNOVATIONS

More Than a Test for Illicit Drugs: Utilization of Urine Drug Tests to Manage Patients By James Shurko, PharmD, PhD and Niti Vanee, PhD

linicians are faced with a number of challenges on a daily basis. When treating patients, they are tasked with evaluating medication safety and effectiveness, assessing medication adherence and identifying medication diversion. In some cases, the effectiveness of medications can easily be observed by simple physical assessment e.g., ACE inhibitors and blood pressure. In other instances, however, treatment relies heavily on patient response to subjective rating scales. Treatment with analgesics and anti-depressants are prime examples. Medication non-adherence is a common problem with 20-30% of prescriptions remaining unfilled and 50% of medications used for the treatment of chronic diseases being taken in a manner other than prescribed. Further, healthcare costs due to nonadherence have been reported as approximately $20,000 per patient per year and upwards of $300 billion annually.1,2 Finally, drug diversion, characterized by the sale, loss or theft of medication has been reported in 45% of patients and is common in many medications including opioids and benzodiazepines.3 These challenges pose problems for clinicians when creating or modifying a current drug regimen since the medications are not being utilized as assumed. Urine drug testing through antibody-based screens and chromatography-based confirmation offer a way to assess medication utilization and therefore serve as a tool to mitigate these challenges. The concept of medication monitoring is well established. Digoxin levels, prothrombin times, vancomycin troughs and non-protein bound phenytoin levels represent a mere fraction of the instances in which 30

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medications are monitored. Notably, these practices all require blood tests and can be invasive, especially in the outpatient setting where drawing from an IV is rarely an option. Herein lies the value of urine drug testing (UDT). While UDT is commonly employed in the work, sporting or legal arenas, these tests can be implemented by clinicians seeking to gain insight into medication effectiveness and evaluate medication utilization in scenarios when blood testing is not an ideal option or commonly practiced. Comparatively, UDT are relatively easy to implement and non-invasive. For example, urine drug screens (UDS) can be performed as a point of care test by using urine testing cups. These tests work through immunochromatography in which antigen linked compounds are separated by capillary beds and then detected through binding with corresponding antibodies.4 Positive tests can then be sent for further analysis as a “reflex” test for confirmation. Alternatively, urine cups or tubes can be sent directly to toxicology labs to identify specific compounds. These compounds are generally identified in a two-stage manner. First, a screening method, such as an antibody/antigen-based immunoassay is conducted to detect drugs or metabolites within a panel of compounds. Second, a confirmatory test is performed. Confirmatory tests are performed to account for limitations associated with UDS. Despite incorporating sample validity tests to identify adulteration such as urine creatinine, nitrites, pH and specific gravity, UDS can still be affected by masking agents leading to a negative result. Additionally, UDS are prone to false positive results due to cross-reactivity. For example, ibuprofen has been shown to crossreact with and lead to false positive tests for barbiturates and THC.5

MEDICAL INNOVATIONS

Lastly, immunoassay-based screens primarily offer qualitative positive or negative results, but generally do not provide specific drug levels. While drug screens rely on immunoassay, confirmation utilizes a more sensitive and specific chromatography-based method. With high performance liquid chromatography-mass spectrometry (LCMS) for example, samples are mixed with a solution (mobile phase) and under high pressure sent through a small column (stationary phase) containing different functional groups. The affinity of a compound to the mobile phase compared to the stationary phase determines how long it stays in the column (retention time). This technology is combined with mass spectrometry where compounds are ionized, fragmented and detected based on a resulting mass to charge ratio. The result is a test that can provide the clinician with a wealth of information since drug and metabolite concentrations can be evaluated in a quantitative manner. When drug diversion is suspected, a negative UDT may support the clinician’s hypothesis. When assessing medication adherence, a confirmatory test can not only inform the clinician of whether or not the drug was ingested through a positive or negative result, but also provide insight into when the drug was last taken. For example, a scenario where a drug is not detected but its metabolite is present is suggestive of a patient with inconsistent adherence. In this case, the drug may have been ingested several days prior but was cleared to a point that it remained undetected. Further, simply conducting UDT has been shown to improve adherence theoretically as a result of a more thorough follow-up.6 Finally, these tests can provide insight into lack of efficacy. Oral medications are subject to the “first pass effect” in which drugs cross the gastrointestinal mucosa, enter the hepatic portal system and become metabolized by the liver before entering the circulatory system. High levels of a drug with low levels of its metabolite may suggest that the drug is being poorly metabolized, for example. Whether the parent drug exerts activity or has to be metabolized to an active compound will then determine the effect on a patient. Codeine, for example, is commonly thought to exert its analgesic effect largely through its conversion to morphine.7 A patient with a UDT showing high levels of codeine in the absence of morphine may experience less analgesia than a patient with both compounds present. Additionally, if low levels of codeine and high levels of morphine are detected, this patient would likely be metabolizing codeine quickly and the high levels of morphine could lead to adverse drug effects. Overall UDT gives clinicians insight into the utilization and effects of a given drug regimen and provides them with a tool to make more informed decisions when managing patients. When considering using a UDT, be sure to verify whether or not the cost will be covered by the patient’s insurance.

For more information on lab testing services, please contact iGenomeDx Inc. at (210) 257-6973 or visit their website at https://www.igenomedx.com/contact-us. References 1. Viswanathan, M., Golin, C. E., Jones, C. D., Ashok, M., Blalock, S. J., Wines, R. C. M., Coker-Schwimmer, E. J. L., Rosen, D. L., Sista, P., &amp; Lohr, K. N. (2012). Interventions to improve adherence to self-administered medications for chronic diseases in the United States. Annals of Internal Medicine, 157(11), 785. https://doi.org/10.7326/0003-4819-157-11-201212040-00538 2. Cutler RL, Fernandez-Llimos F, Frommer M, et al Economic impact of medication non-adherence by disease groups: a systematic reviewBMJ Open 2018;8:e016982. doi: 10.1136/bmjopen-2017016982 3. Walker, DNP, M. J., &amp; Webster, MD, L. R. (2012). Risk factors for drug diversion in a pain clinic patient population. Journal of Opioid Management, 8(6), 351–362. https://doi.org/10.5055/jom.2012.0135 4. Blurapids Drug Test Cup insert - tanner scientific. (n.d.). Retrieved March 18, 2022, from https://tannerscientific.com/manuals/BluRapids-Drug-Test-Cup-Insert.pdf 5. Alec Saitman, Hyung-Doo Park, Robert L. Fitzgerald, False-Positive Interferences of Common Urine Drug Screen Immunoassays: A Review, Journal of Analytical Toxicology, Volume 38, Issue 7, September 2014, Pages 387–396, doi.org/10.1093/jat/bku075 6. Yee DA, Hughes MM, Guo AY, Barakat NH, Tse SA, Ma JD, Best BM, Atayee RS. Observation of improved adherence with frequent urine drug testing in patients with pain. J Opioid Manag. 2014 Mar-Apr;10(2):111-8. doi: 10.5055/jom.2014.0200. PMID: 24715666. 7. Gasche, Y., Daali, Y., Fathi, M., Chiappe, A., Cottini, S., Dayer, P., &amp; Desmeules, J. (2004). Codeine intoxication associated with ultrarapid CYP2D6 metabolism. New England Journal of Medicine, 351(27), 2827–2831. https://doi.org/10.1056 /nejmoa041888 James Shurko, PharmD, PhD is a laboratory scientist at iGenomeDx Inc. Niti Vanee, PhD is the CEO of iGenomeDx Inc. iGenomeDx is a gold level Circle of Friends sponsor of the Bexar County Medical Society.

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The Role of Laser Therapy in Scar Management By Faraz Yousefian, DO, and Graham Litchman, DO, MS and Chad Hivnor, MD, FAAD

lthough scars may partially fade with time, the mark they leave behind are a constant reminder of the incident that initially caused the skin injury. Some of our patients are able to embrace these marks as a part of their identity, however, the majority endeavor to hide and treat these unpleasant and sometimes symptomatic cicatrices. Scar formation can have various etiologies of skin injury such as trauma, burn, gun powder, medical and surgical procedures, and occupational accidents which can lead to functional and psychological morbidities.1,2 In Texas, we encounter many patients with scars, especially in the veteran and oil field worker population, and we can improve their quality of life by offering a variety of available treatment options. There are various forms of scars: contracture, depressed (atrophic), flat, keloid, raised (hypertrophied) and stretch marks. Scar formation or fibrosis is a normal physiological healing response that is primarily mediated by proinflammatory cytokines and transforming growth factors. There are six phases of wound healing: (1) rapid hemostasis; (2) appropriate inflammation; (3) mesenchymal cell differentiation, proliferation and migration to the wound site; (4) suitable angiogenesis; (5) prompt re-epithelialization (re-growth of epithelial tissue over the wound surface) and (6) proper synthesis, cross-linking and alignment of collagen to provide strength to the healing tissue.1,3 Scars may become painful, itchy or numb as nerve endings are often damaged initially, but these symptoms often improve over time.1,2,4 Educating patients on both injury prevention and proper wound care is paramount. Patients should promptly seek medical attention to minimize scarring – first and foremost by having a clinician evaluate for primary versus secondary wound healing options. Gently cleaning the wound with soap and water, keeping it moist with an ointment such as petroleum jelly, protecting it from sun exposure and maintaining ade32

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quate nutrition with high-quality proteins, Vitamin C and Vitamin D is essential for improving wound healing. The Patient Scar Assessment Scale and Observer Scar Assessment Scale are tools physicians can utilize to evaluate the scar before providing different treatment modalities such as polyurethane or silicone scar reduction patches, silicone gel, oral or topical tranilast (an inhibitor of collagen synthesis), pressure dressing, surgical excision, intralesional corticosteroids, intralesional 5-fluorouracil, cryotherapy, skin needling, subcision and/or laser therapy.2–5 There are numerous laser systems available that provide successful treatment of different types of scars with various etiologies. The detailed evaluation of individual patient and scar characteristics (location, size and type) is the foundation for prompt therapeutic planning such as non-ablative lasers for mild scars, and ablative lasers for deeper scars with reduced range of motion.6,7 There are many factors that are considered, such as the period after injury, depth, color, texture, symptoms, skin phototype, medicine usage and prior treatment to help select the best course of management. After careful assessment, Low-level Laser (LLL), Pulsed Dye Laser (PDL), Q-Ruby, Q- Alex and Q-YAG can be utilized to tackle the scar in multiple sessions.2,4–6 Initial treatment focuses on color; however, subsequent attention directed toward configuration of the scar allows the resurfacing process to provide improved skin elasticity, increased vascularization and overall symptom reduction.2,4,6 It should be noted that scars do not to be new to be considered for laser treatment. A dermatologist with expertise in lasers should be consulted for a careful scar assessment prior to constructing a plan for management. By utilizing intimate knowledge of the latest technology, including lasers, the medical and surgical skills of a licensed dermatologist will effectively provide the most appropriate treatment plan to improve the patient’s quality of life.

MEDICAL INNOVATIONS References 1. Guo S, DiPietro LA. Factors Affecting Wound Healing. J Dent Res. 2010;89(3):219-229. doi:10.1177/0022034509359125 2. Fu X, Dong J, Wang S, Yan M, Yao M. Advances in the treatment of traumatic scars with laser, intense pulsed light, radiofrequency, and ultrasound. Burns & Trauma. 2019;7(1):1. doi:10. 1186/s41038-018-0141-0 3. Acne scarring: A review and current treatment modalities - Journal of the American Academy of Dermatology. Accessed March 31, 2022. https://www.jaad.org/article/S0190-9622(08)00659-2/fulltext 4. Isotretinoin and Timing of Procedural Interventions: A Systematic Review With Consensus Recommendations - PubMed. Accessed March 31, 2022. https://pubmed-ncbi-nlm-nih-gov.uiwtx. idm.oclc.org/28658462/ 5. Iyengar V, Orengo IF. Surgical techniques for cutaneous scar revision. Journal of the American Academy of Dermatology. 2001;45(4):648. doi:10.1016/S0190-9622(01)70075-8 6. Xiao A, Ettefagh L. Laser Revision Of Scars. In: StatPearls. StatPearls Publishing; 2022. Accessed March 31, 2022. http://www.ncbi.nlm.nih.gov/books/NBK539686/ 7. Ohshiro T, Ohshiro T, Sasaki K. Laser Scar Management Technique. Laser Ther. 2013;22(4):255-260. doi:10.5978/islsm.13-OR-20

Faraz Yousefian, DO is an intern at the Texas Institute for Graduate Medical Education and Research (TIGMER) in San Antonio, Texas. He is very passionate about mentoring nascent physicians and educating the general population about skin diseases and the steps they can take to prevent them. Dr. Yousefian is a member of Bexar County Medical Society. Graham Litchman, DO, MS is a PGY-3 dermatology resident at St. John's Episcopal Hospital in New York. He was a Melanoma Clinical Research Fellow at the National Society for Cutaneous Medicine. Chad Hivnor MD, FAAD is the Chief of Dermatology at South Texas Veterans Health Care System and clinical associate professor at Uniformed Services University Health Sciences and UT Health Science Center. He is also in private practice part-time in San Antonio. Dr. Hinvor is a member of the Bexar County Medical Society.

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Understanding Long COVID By Sean Rumney, Ashley Chakales and Monica Verduzco-Gutierrez, MD

In January 2020, SARS-CoV-2 was identified as the causative agent in an outbreak of pneumonia in Wuhan, China. In the last two years, our understanding of the clinical presentation of a SARS-CoV-2 infection has improved with acute disease classically resulting in the symptoms of severe upper respiratory infection.1 In addition to the symptoms of acute infection, a small portion of patients reported symptoms lasting for weeks to months after initial diagnosis. These patients, calling themselves ‘long haulers’ in some early reports, remained symptomatic weeks after PCR and lab studies showed evidence of no active infection with the virus. For some, symptoms of acute COVID infection might fail to improve, while others will report new or worsening symptoms weeks later in their disease course. While most COVID-19 patients make a full functional recovery, the health status of patients post-infection has been found to be lower than the general population.2 This pattern of symptoms has provided a challenge for primary care clinicians throughout the pandemic, as these chronic symptoms can prove difficult to manage, and in some cases can result in severe exercise intolerance and debility. What is Long COVID? Long COVID is defined as new or persistent clinical symptoms due to SARS-CoV-2 infection lasting for greater than 28 days.3 Different authors use different terms to describe the prolonged symptoms following COVID-19. Some of these include Long COVID, Persistent Post-COVID Syndrome (PPCS) by the CDC and Post-Acute Sequela of SARS-CoV-2 (PASC).3,4 What are the symptoms of Long COVID? COVID-19 can produce systemic effects, thus Long COVID is associated with a wide range of symptoms. Prominent symptoms of Long COVID include fatigue, headache, dysgeusia, anosmia, shortness of breath, cough, chest pain, abdominal pain, myalgia, sleep disturbance, anxiety, depression, “brain fog” and cognitive impairment.3,5,6 What is the pathophysiology behind Long COVID? The pathophysiology of Long COVID is unclear, however many symptoms have been attributed to a systemic inflammatory response following infection. In some patients, COVID-19 infection results in an inflammatory response characterized by the overproduction of proinflammatory cytokines. This period of pro-inflammatory response is compensated by an overproduction of anti-inflammatory factors, resulting in compensatory anti-inflammatory response syndrome 34

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(CARS).7 The production of these anti-inflammatory factors can progress to a persistent state of inflammation, immunosuppression and catabolism. This syndrome, called PICS, is seen in post-sepsis patients, and is characterized by immune dysregulation and inflammation, and shares similarities to manifestations of Long COVID. The differing inflammatory/anti-inflammatory responses in individual patients may be the cause of variable presentations of post-COVID syndromes. Fibrogenic cytokines are implicated in many known post-COVID complications including pulmonary fibrosis, and may be responsible for the CNS effects of Long COVID.8 Others suggest the delayed resolution of inflammation, autoimmunity and viral persistence may contribute to the pathogenies of Long COVID. Patients with Long COVID have demonstrated persistent elevation of interferons and proinflammatory cytokines post-infection, suggesting a delay in the resolution of inflammation and a consequent persistent systemic inflammation. The development of autoimmune response against self-tissue antigens is thought to contribute to the pathogenesis, as several studies have reported the presence of autoantibodies among COVID-19 patients.9 Who is at risk for Long COVID? Long COVID can be found in patients with relatively mild initial infections to those with severe infections. Long COVID has been reported in pediatric, adult and geriatric populations. A study performed by the NIH that analyzed self-reported symptoms of individuals with a confirmed positive SARS-CoV-2 PCR attempted to categorize Long COVID symptoms. There were several predictive factors during initial infections that indicated a relative risk for developing Long COVID symptoms. Advanced age (>70 years old) and greater than five concurrent symptoms within the first week of COVID-19 infection were found to increase the risk of developing Long COVID symptoms. The most predictive symptoms were found to be, in order of risk: fatigue, headache, dyspnea, hoarse voice and myalgias. Comorbidities were not strongly predictive in the younger age group apart from a prior diagnosis of asthma, which significantly increased the chance of patients later reporting symptoms consistent with Long COVID.10 How is Long COVID managed? Long COVID is diagnosed based on a patient’s history of COVID19 paired with the exclusion of other causes, as there is no one diagnostic test. A multidisciplinary approach in an assessment and treatment plan is recommended.

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Fatigue and cognitive impairment are the some of the most commonly reported symptoms in patients with Long COVID.11 The American Academy of Physical Medicine and Rehabilitation published recommendations for the outpatient management of these patients, and states that patients should be evaluated for fatigue if symptoms do not improve within four weeks.12 Mild fatigue can be monitored by a provider, while functionally limiting fatigue may warrant further workup. After a diagnosis of fatigue due to Long COVID has been made, treatment options may be discussed. As fatigue has shown a tendency to improve slowly over time, patients might choose to defer treatment. If the patient chooses to pursue treatment, an individualized plan can be built to help return them to baseline. Standard treatment plans include a structured and titrated return to activity plan, energy conservation strategies and encouraging healthy dietary patterns. Post-exertional malaise must be considered and screened for. Rehabilitation needs to be designed on an individual basis, as these patients will not benefit from these traditional therapy models.13 Pharmacologic treatment might be helpful in managing brain fog and chronic fatigue, and some clinics targeting Long COVID patients have prescribed antidepressants, cytokine inhibitors, leukotriene receptor antagonists, stimulants and antivirals. These treatment options have limited evidence through clinical trials and should be considered on a case-by-case basis after evaluation by a health care provider. Two local post-COVID rehabilitation clinics run by Monica Verduzco-Gutierrez, MD through UT Health and University Health have promoted a holistic approach to the management of patients with Long COVID-associated cognitive impairment and fatigue. Energy conservation, titrated return to activity programs, and tailored cognitive rehabilitation are being used to aid recovery and return to function in these clinics. References 1. Post-covid conditions. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/long-termeffects/index.html. Accessed March 10, 2022. 2. Huang L, Yao Q, Gu X, et al. 1-year outcomes in hospital survivors with covid-19: A longitudinal cohort study. The Lancet. 2021;398(10302):747-758. doi:10.1016/s0140-6736(21)01755-4 3. Nalbandian A, Sehgal K, Gupta A, et al. Post-acute COVID-19 syndrome. Nature Medicine. 2021;27(4):601-615. doi:10.1038/ s41591-021-01283-z 4. CDC COVID-19 Response Team. Severe outcomes among patients with coronavirus disease 2019 (COVID-19) — United States,

February 12–March 16, 2020. MMWR Morbidity and Mortality Weekly Report. 2020;69(12):343-346. doi:10.15585/ mmwr.mm6912e2 5. Gupta A, Madhavan MV, Sehgal K, et al. Extrapulmonary manifestations of covid-19. Nature Medicine. 2020;26(7):1017-1032. doi:10.1038/s41591-020-0968-3 6. Graham EL, Clark JR, Orban ZS, et al. Persistent neurologic symptoms and cognitive dysfunction in non‐hospitalized Covid‐19 “long haulers.” Annals of Clinical and Translational Neurology. 2021;8(5):1073-1085. doi:10.1002/acn3.51350 7. Chippa V., Aleem, A., & Anjum, F. Post acute coronavirus (COVID19) syndrome. In StatPearls. StatPearls Publishing. 2022. http://www.ncbi.nlm.nih.gov/books/NBK570608/ 8. Oronsky B, Larson C, Hammond TC, et al. A review of persistent post-covid syndrome (PPCS). Clinical Reviews in Allergy & Immunology. 2021. doi:10.1007/s12016-021-08848-3 9. Mehandru S, Merad M. Pathological sequelae of long-haul covid. Nature Immunology. 2022;23(2):194-202. doi:10.1038/s41590021-01104-y . Sudre CH, Murray B, Varsavsky T, et al. Attributes and predictors of Long Covid. Nature Medicine. 2021;27(4):626631. doi:10.1038/s41591-021-01292-y 11. Ceban F, Ling S, Lui LMW, et al. Fatigue and cognitive impairment in POST-COVID-19 syndrome: A systematic review and metaanalysis. Brain, Behavior, and Immunity. 2022;101:93-135. doi:10.1016/j.bbi.2021.12.020 12. Herrera JE, Niehaus WN, Whiteson J, et al. Multidisciplinary collaborative consensus guidance statement on the assessment and treatment of fatigue in postacute sequelae of SARS‐COV ‐2 infection ( PASC ) patients. PM&R. 2021;13(9):1027-1043. doi:10.1002/pmrj.12684 13. Twomey R, DeMars J, Franklin K, Culos-Reed SN, Weatherald J, Wrightson JG. Chronic fatigue and postexertional malaise in people living with Long Covid: An observational study. Physical Therapy. 2022. doi:10.1093/ptj/pzac005 Sean Rumney and Ashley Chakales are medical students at the UT Health San Antonio Long School of Medicine. Monica Verduzco-Gutierrez, MD is an accomplished academic Physiatrist and Professor and Chair of the Department of Rehabilitation. She is a member of the Bexar County Medical Society.

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SAN ANTONIO MEDICINE

Dermatologic Manifestations of Pregnancy By Tue “Felix” Nguyen, Marie Vu and Cara Schachter

Introduction There are many dermatologic conditions that occur during pregnancy which can appear distressing and affect our patients’ self-image and how they present themselves to the world. In this article, we will explore the following three common cutaneous conditions that affect pregnant women: 1) Striae Gravidarum 2) Telogen Effluvium 3) Melasma and Linea Nigra Striae Gravidarum Stretch marks, or specifically striae gravidarum (SG), is a skin condition that affects pregnant women during gestation. Common sites include the abdomen, breasts, medial upper arms, lower back, hips and legs.1 Initially, these lesions present as flat, reddish stripes (striae rubra) that over time fade, atrophy and appear more scar-like (striae alba) (Figure 1). The epidemiology of SG is not completely known, and its prevalence is estimated to be between 55 to 90%.2,3 Risk factors for SG include family history, personal history and race, which indicate that genetic factors play a significant role in the formation of SG in addition to metabolic changes that occur during pregnancy.2 The pathophysiology of SG is not fully understood and more research is needed. Current evidence suggests that because of a multifactorial process (including both physical and endocrine components), the elastic fiber network found within the dermis is damaged, yielding scars that appear as stretch marks.3,4,5 A very common inflammatory skin condition known as pruritic urticarial papules and plaques of pregnancy (PUPPP) is associated with SG and presents as itchy, edematous papules and plaques found 36

SAN ANTONIO MEDICINE • May 2022

on the abdomen originating from stretch marks.6 While SG is a benign condition, many women are bothered by their appearance and seek out methods to prevent and treat their scars. As of yet, preventative measures have limited success. A common remedy involves applying cocoa butter to the skin, but a study showed no effect on the appearance or development of SG.7 Current treatments available for SG include applying topical tretinoin or receiving non-ablative fractional laser therapy to improve the appearance of these scars.8 While there are cosmetic treatments available, it is important to address the stigma surrounding stretch marks to help improve patient selfconfidence.

Figure 1: Striae Alba8

Telogen Effluvium Telogen effluvium is the excessive shedding of hair that occurs one to five months following pregnancy. This condition is common, as it affects between 40 to 50% of women in the postpartum period.9 In the normal hair cycle, each follicle on the human scalp cycles independently through three major phases including anagen (growth), catagen (transformation) and telogen (rest). The anagen phase accounts for approximately 90% of hair follicles, while <1% are in the catagen

phase and 10% are in the telogen phase. The result of the telogen phase is marked by shedding of hair from the follicle. Telogen effluvium occurs when a larger proportion of hair follicles, about 7 to 35% more, enter the telogen phase. The mechanism is not completely understood; however, the theory of delayed anagen release may be related to postpartum telogen effluvium. The increase in estrogen during pregnancy is thought to prolong the duration of the anagen phase, thereby delaying the onset of the telogen phase. Hair loss is noted once this stimulus ends and the affected follicles enter the telogen phase. Thus, the most common period of hair loss occurs approximately three months after delivery when hormonal levels begin to normalize.10 Fortunately, the hair loss related to telogen effluvium is temporary and returns to normal within six to twelve months without medical intervention. It is recommended to eat a healthy and balanced diet, as well as use volumizing shampoo and conditioner to promote healthy hair until it regains normal fullness.11 Melasma and Linea Nigra Hyperpigmentation may manifest itself in different ways during pregnancy, notably through melasma and linea nigra. Melasma is a hyperpigmented brown to gray-brown patch that typically presents in body areas with high amounts of sun exposure, especially the face (Figure 2). Although it may affect women of all ages, it is often associated with pregnancy, lending its name the “mask of pregnancy.” According to a multinational study across nine countries, 26 and 42% of melasma cases in 324 women occurred during or after pregnancy, respectively.12 Linea nigra, often referred to as a “pregnancy line,” is a hyperpigmented vertical line that com-

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monly appears on the abdomen (Figure 3). Similar to melasma, linea nigra may affect women of all ages, but is often associated with pregnancy as the prevalence is greater than 90%. The pathogenesis of increased pigmentation related to pregnancy is not entirely understood but may be influenced by hormonal changes. Increased levels of estrogen and progesterone regulate stimulation of cells which produce pigment in the skin, thus leading to pigmentation changes. These changes may fade in the postpartum period; however, some women may have lasting results for years or even a lifetime. Although benign, these conditions can be bothersome and lead to women seeking dermatologic treatment. Hydroquinone is a common first treatment medication for hyperpigmentation, as it is a skin-lightening agent. To enhance skin lightening, dermatologists may also prescribe a second medication that includes a tretinoin or corticosteroid. Sometimes, a triple cream may be prescribed which contains hydroquinone, tretinoin and a corticosteroid all in one formulation. If medications are not successful in treating hyperpigmentation, procedures such as chemical peels, microdermabrasions, laser treatment or a light-based procedure may prove effective.13

Figure 2: Malesma 14

Conclusion Women experience physiologic changes throughout gestation that result in the development of peri- and post-partum dermatologic conditions. Many of these conditions are well-documented but the exact mechanism by which they occur is still poorly understood. Women affected by any of the aforementioned conditions should be evaluated by a dermatologist and establish routine follow-up care to best optimize their treatment. References 1. MacGregor JL, Wesley NO. Striae distensae (stretch marks). In: Post TW, ed. UpToDate. UpTodate; 2022. Accessed February 13th, 2022. https://www.uptodate.com/contents/striae-distensaestretch-marks 2. Chang AL, Agredano YZ, Kimball AB. Risk factors associated with striae gravidarum. J Am Acad Dermatol. 2004;51(6):881-885. https://doi.org/ 10.1016/j.jaad.2004.05.030 3. Goldsmith LA, Katz SI, Gilchrest BA, et al. Fitzpatrick’s Dermatology in General Medicine. 8th ed. McGrawHill Medical. 2012 4. Cordeiro RC, Zecchin KG, de Moraes AM. Expression of estrogen, androgen, and glucocorticoid receptors in recent striae distensae. Int J Dermatol. 2010;49 (1):30-32. doi:10.1111/j.1365-4632. 2008.04005.x 5. Watson RE, Parry EJ, Humphries JD, et al. Fibrillin microfibrils are reduced in skin exhibiting striae distensae. Br J Dermatol. 1998;138(6):931-937. https://doi.org/ 10.1046/j.1365-2133.1998.02257.x 6. Chouk C, Litaiem N. Pruritic Urticarial Papules And Plaques Of Pregnancy. In: StatPearls. Treasure Island (FL): StatPearls Publishing; August 6, 2021. 7. Buchanan K, Fletcher HM, Reid M. Prevention of striae gravidarum with cocoa butter cream. Int J Gynaecol Obstet. 2010;108(1):65-68. doi:10.1016/j.ijgo. 2009.08.008

8. Farahnik B, Park K, Kroumpouzos G, Murase J. Striae gravidarum: Risk factors, prevention, and management. Int J Womens Dermatol. 2016;3(2):77-85. Published 2016 Dec 6. doi:10.1016/j.ijwd.2016. 11.001 9. Pregnancy and Hair Loss. American Pregnancy Association. Accessed February 13, 2022. https://americanpregnancy.org/ healthy-pregnancy/pregnancy-health-wellness/hair-loss-during-pregnancy/ 10. Bergfeld W. Telogen Effluvium. In: Post TW, ed. UpToDate. UpTodate; 2022. Accessed February 13th, 2022. https://www.uptodate.com/contents/telogen-effluvium 11. Hair Loss in New Moms. American Academy of Dermatology Association. Accessed February 13, 2022. https://www.aad.org/public/diseases/hair -loss/insider/new-moms 12. Pomeranz MK. Maternal adaptations to pregnancy: Skin and related structures. In: Post TW, ed. UpToDate. UpTodate; 2022. Accessed February 13th, 2022. https://www.uptodate.com/contents/maternal-adaptations-to-pregnancy-skin-andrelated-structures 13. Melasma: Diagnosis and Treatment. American Academy of Dermatology Association. Accessed February 13, 2022. https://www.aad.org/public/diseases/az/melasma-treatment 14. Melasma. Skin of Color Society. https://skinofcolorsociety.org/patientdermatology-education/1406-2/. Accessed February 22, 2022. 15. Linea Nigra. DermNet NZ. https://dermnetnz.org/topics/linea-nigra. Accessed February 22, 2022. Tue “Felix” Nguyen, Marie Vu and Cara Schachter are medical students at UT Health San Antonio Long School of Medicine. Cara is a member of the BCMS Publications Committee.

Figure 3: Linea Nigra15

Visit us at www.bcms.org

SAN ANTONIO MEDICINE

2022 BCMS General Membership Meeting

University Health System hosted the Bexar County Medical Society members to a CME lecture presented by Dr. Allen S. Anderson, Chief, Janey & Dolph Briscoe Division of Cardiology, Director UT/UHS and Vascular Institute, UT Health San Antonio. Circle of Friends sponsors had the opportunity to interact with our physician leaders. The BCMS had Oakwell Private Wealth Management, UT Health SA Mays Cancer Center, iGenomeDX, Synergy Federal Credit Union, Elizabeth Olney, Edward Jones and TMAIT. Thank you to UHS for their continued support of physician development opportunities for BCMS members!

Above: Dr. Anderson giving his presentation on “Heart Failure Today: An Evolution in Understanding and Therapeutics.” Right: Dr. Rajeev Suri, BCMS President and Dr. Allen S. Anderson, CME Lecture Speaker attend.

SAN ANTONIO MEDICINE • May 2022

IN MEMORIAM: Douglas Wayne “Curly” Robinson Jr., MD

SAN ANTONIO MEDICINE

Douglas Wayne “Curly” Robinson Jr., MD was a general surgeon who practiced medicine for over 40 years. He was born in Gilmer, Texas, on November 12, 1947. Dr. Robinson graduated from the University of Texas Medical Branch at Galveston and completed his surgical residency at the University of Texas Health Science Center. He served as Chief Resident in 1978. After residency, Curly became a partner with General Surgical Associates and remained with them until his retirement in 2018. Dr. Robinson was married to his wife, Cynthia Kolb, for 52 years and had three daughters, 12 grandchildren and extended family members. He had a special bond with the “Liberty Boys” spanning 70 years. Dr. Robinson was Doctor of the Year at Community Hospital in 1980, served on the Methodist Hospital System Board for five years where he was Chief of Staff in 1996, assisted Methodist Healthcare Ministries for 10 years, was a member and past president of the Aust Society, was a longtime member of the Texas Surgical Society and President in 2021 and was a member of the Bexar County Medical Society. He was an avid fisherman and hunter, and loved to hike, ski, play golf and spend time with his family. He was also a longtime member of Alamo Heights United Methodist Church, served on the Wesley Community Board, participated in the Canopus Club and loved attending the “Retired Doctor” lunches on Wednesdays. The Bexar County Medical Society extends sympathy to the family and friends of Dr. Robinson.

BCMS Ask a Doctor Event The BCMS Ask a Doctor table at the National Public Health Week event held on April 7 was a tremendous success! The Bexar County Medical Society surveyed over 100 attendees about their COVID-19 vaccination status. Physicians were on hand to answer questions and got at least two unvaccinated attendees vaccinated. Several also received their boosters while there. A huge THANK YOU to Drs. Vincent Fonseca, Norys Castro Pena and Veronica Nieves-Garcia! BCMS has signed up for more fairs and events promoting our Find a Doctor program. If you are interested in volunteering, please call Chief Operating Officer Monica Jones at 210-301-4373. Visit us at www.bcms.org

PHYSICIANS PURCHASING DIRECTORY Support BCMS by supporting the following sponsors. Please ask your practice manager to use the Physicians Purchasing Directory as a reference when services or products are needed. ACCOUNTING FIRMS

Sol Schwartz & Associates P.C. (HHH Gold Sponsor) Sol Schwartz & Associates is the premier accounting firm for San Antonio-area medical practices and specializes in helping physicians and their management teams maximize their financial effectiveness. Jim Rice, CPA 210-384-8000, ext. 112 jprice@ssacpa.com www.ssacpa.com “Dedicated to working with physicians and physician groups.”

ACCOUNTING SOFTWARE

Express Information Systems (HHH Gold Sponsor) With over 29 years’ experience, we understand that real-time visibility into your financial data is critical. Our browser-based healthcare accounting solutions provide accurate, multi-dimensional reporting that helps you accommodate further growth and drive your practice forward. Rana Camargo Senior Account Manager 210-771-7903 ranac@expressinfo.com www.expressinfo.com “Leaders in Healthcare Software & Consulting”

ATTORNEYS

Kreager Mitchell (HHH Gold Sponsor) At Kreager Mitchell, our healthcare practice works with physicians to offer the best representation possible in providing industry specific solutions. From business transactions to physician contracts, our team can help you in making the right decision for your practice. Michael L. Kreager 210-283-6227 mkreager@kreagermitchell.com Bruce M. Mitchell 210-283-6228 bmitchell@kreagermitchell.com www.kreagermitchell.com “Client-centered legal counsel with integrity and inspired solutions”

ASSETT WEALTH MANAGEMENT

Bertuzzi-Torres Wealth Management Group (HHH Gold Sponsor) We specialize in simplifying your personal and professional life. We are dedicated wealth managers who offer diverse financial solutions for discerning healthcare professionals, including asset protection, lending and estate planning. Mike Bertuzzi First Vice President Senior Financial Advisor 210-278-3828 Michael_bertuzzi@ml.com Ruth Torres Financial Advisor 210-278-3828 Ruth.torres@ml.com http://fa.ml.com/bertuzzi-torres

BANKING

Broadway Bank (HHH Gold Sponsor) Healthcare banking experts with a private banking team committed to supporting the medical community. Shawn P. Hughes, JD Senior Vice President, Private Banking 210-283-5759 shughes@broadway.bank www.broadwaybank.com “We’re here for good.”

The Bank of San Antonio (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community. Brandi Vitier 210-807-5581 brandi.vitier@thebankofsa.com www.thebankofsa.com Synergy Federal Credit Union (HH Silver Sponsor) Looking for low loan rates for mortgages and vehicles? We've got them for you. We provide a full

SAN ANTONIO MEDICINE • May 2022

suite of digital and traditional financial products, designed to help Physicians get the banking services they need.

FINANCIAL ADVISORS

Synergy FCU Member Services 210-750-8333 info@synergyfcu.org www.synergyfcu.org “Once a member, always a member. Join today!”

Oakwell Private Wealth Management (HHH Gold Sponsor) Oakwell Private Wealth Management is an independent financial advisory firm with a proven track record of providing tailored financial planning and wealth management services to those within the medical community. Brian T. Boswell, CFP®, QKA Senior Private Wealth Advisor 512-649-8113 SERVICE@OAKWELLPWM.COM www.oakwellpwm.com “More Than Just Your Advisor, We're Your Wealth Management Partner”

BUSINESS CONSULTING

Medical Financial Group (★★★ Gold Sponsor) Healthcare & Financial Professionals providing core solutions to Physicians from one proven source. CEO is Jesse Gonzales, CPA, MBA Controller & past CFO of (2) Fortune 500 companies, Past Board President of Communicare Health Systems. Jesse Gonzales, CEO CPA, MBA 210-846-9415 information@medicalfgtx.com Linda Noltemeier-Jones Director of Operations 210-557-9044 lindanj@medicalfgtx.com www.medicalfgtx.com “Let’s start with Free Evaluation and Consultation from our Team of Professionals”

CREDENTIALS VERIFICATION ORGANIZATION

Bexar Credentials Verification, Inc. (HHHH 10K Platinum Sponsor) Bexar Credentials Verification Inc. provides primary source verification of credentials data that meets The Joint Commission (TJC) and the National Committee for Quality Assurance (NCQA) standards for health care entities. Betty Fernandez Director of Operations 210-582-6355 Betty.Fernandez@bexarcv.com www.BexarCV.com “Proudly serving the medical community since 1998”

Elizabeth Olney with Edward Jones (HH Silver Sponsor) We learn your individual needs so we can develop a strategy to help you achieve your financial goals. Join the nearly 7 million investors who know. Contact me to develop an investment strategy that makes sense for you. Elizabeth Olney, Financial Advisor 210-858-5880 Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabeth-olney "Making Sense of Investing"

FINANCIAL SERVICES

Bertuzzi-Torres Wealth Management Group ( Gold Sponsor) We specialize in simplifying your personal and professional life. We are dedicated wealth managers who offer diverse financial solutions for discerning healthcare professionals, including asset protection, lending & estate planning. Mike Bertuzzi First Vice President Senior Financial Advisor 210-278-3828 Michael_bertuzzi@ml.com Ruth Torres Financial Advisor 210-278-3828 Ruth.torres@ml.com http://fa.ml.com/bertuzzi-torres

Aspect Wealth Management (HHH Gold Sponsor) We believe wealth is more than money, which is why we improve and simplify the lives of our clients, granting them greater satisfaction, confidence and freedom to achieve more in life. Michael Clark, President 210-268-1520 mclark@aspectwealth.com www.aspectwealth.com “Get what you deserve … maximize your Social Security benefit!”

SWBC (HHH Gold Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying. For You Practice: HR administration, payroll, employee benefits, insurance, and exit strategies. SWBC’s services supporting Physicians and the Medical Society. Michael Leos, Community Relations Manager Cell: 201-279-2442 Office: 210-376-3318 mleos@swbc.com swbc.com

Banking 210-343-4558 karen.leckie@amegybank.com Robert Lindley Senior Vice President | Private Banking 210-343-4526 robert.lindley@amegybank.com Denise C. Smith Vice President | Private Banking 210-343-4502 Denise.C.Smith@amegybank.com www.amegybank.com “Community banking partnership”

HEALTHCARE TECHNOLOGY SOLUTIONS SUPPLIER

Nitric Oxide innovations LLC, (★★★ Gold Sponsor) (NOi) develops nitric oxide-based therapeutics that prevent and treat human disease. Our patented nitric oxide delivery platform includes drug therapies for COVID 19, heart disease, Pulmonary hypertension and topical wound care. info@NitricOxideInnovations.com 512-773-9097 www.NitricOxideInnovations.com

HOSPITALS/ HEALTHCARE FACILITIES

HEALTHCARE BANKING

First Citizens Bank (HHH Gold Sponsor) We’re a family bank — led for three generations by the same family-but first and foremost a relationship bank. We get to know you. We want to understand you and help you with your banking. Stephanie Dick Commercial Banker 210-744-4396 stephanie.dick@firstcitizens.com https://commercial.firstcitizens.co m/tx/austin/stephanie-dick “People Bank with People” “Your Practice, Our Promise” Amegy Bank of Texas (HH Silver Sponsor) We believe that any great relationship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability. We work hard and together with our clients to accomplish great things. Jeanne Bennett EVP | Private Banking Manager 210-343-4556 Jeanne.bennett@amegybank.com Karen Leckie Senior Vice President | Private

UT Health San Antonio MD Anderson Cancer Center, (HHH Gold Sponsor) UT Health San Antonio MD Anderson Cancer Center, is the only NCI-designated Cancer Center in South Texas. Our physicians and scientists are dedicated to finding better ways to prevent, diagnose and treat cancer through lifechanging discoveries that lead to more treatment options. Laura Kouba, Manager, Physician Relations 210-265-7662 NorrisKouba@uthscsa.edu Lauren Smith, Manager, Marketing & Communications 210-450-0026 SmithL9@uthscsa.edu Cancer.uthscsa.edu Appointments: 210-450-1000 UT Health San Antonio MD Anderson Cancer Center 7979 Wurzbach Road San Antonio, TX 78229

INFORMATION AND TECHNOLOGIES

INSURANCE

TMA Insurance Trust (HHHH 10K Platinum Sponsor) TMA Insurance Trust is a full-service insurance agency offering a full line of products – some with exclusive member discounts and staffed by professional advisors with years of experience. Call today for a complimentary insurance review. It will be our privilege to serve you. Wendell England Director of Member Benefits 512-370-1776 wendell.england@tmait.org 800-880-8181 www.tmait.org “We offer BCMS members a free insurance portfolio review.”

Guardian (★★★ Gold Sponsor) Live Confidently. Every financial dream deserves a well-crafted plan. Ned Hodge 210-332-3757 ned@nedhodge.com www.nedhodge.com | www.Opesone.com “Take care of today then plan for tomorrow”

Humana (HHH Gold Sponsor) Humana is a leading health and well-being company focused on making it easy for people to achieve their best health with clinical excellence through

coordinated care. Jon Buss: 512-338-6167 Jbuss1@humana.com Shamayne Kotfas: 512-338-6103 skotfas@humana.com www.humana.com

INSURANCE/MEDICAL MALPRACTICE

Texas Medical Liability Trust (HHHH 10K Platinum Sponsor) With more than 20,000 health care professionals in its care, Texas Medical Liability Trust (TMLT) provides malpractice insurance and related products to physicians. Our purpose is to make a positive impact on the quality of health care for patients by educating, protecting, and defending physicians. Patty Spann 512-425-5932 patty-spann@tmlt.org www.tmlt.org Recommended partner of the Bexar County Medical Society

The Bank of San Antonio Insurance Group, Inc. (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community. Katy Brooks, CIC 210-807-5593 katy.brooks@bosainsurance.com www.thebankofsa.com “Serving the medical community.” MedPro Group (HH Silver Sponsor) Rated A++ by A.M. Best, MedPro Group has been offering customized insurance, claims and risk solutions to the healthcare community since 1899. Visit MedPro to learn more. Kirsten Baze 512-658-0262 Kirsten.Baze@medpro.com www.medpro.com ProAssurance (HH Silver Sponsor) ProAssurance professional liability insurance defends healthcare providers facing malpractice claims and provides fair treatment for our insureds. ProAssurance Group’s rating is AM Best A (Excellent). Mike Rosenthal Senior Vice President,

continued on page 42 Visit us at www.bcms.org 41

PHYSICIANS PURCHASING DIRECTORY Business Development 800-282-6242 MikeRosenthal@ProAssurance.com www.ProAssurance.com

INTERNET TELECOMMUNICATIONS

Unite Private Networks (HHH Gold Sponsor) Unite Private Networks (UPN) has offered fiber optic networks since 1998. Lit services or dark fiber – our expertise allows us to deliver customized solutions and a rewarding customer experience. Aron Sweet , Account Director 210-788-9515 aron.sweet@upnfiber.com Jim Dorman, Account Director 210-428-1206 jim.dorman@upnfiber.com Tammy Carosello, Account Director 210-868-0420 tammy.carosello@upnfiber.com www.uniteprivatenetworks.com “UPN is very proud of our 98% customer retention rate”

INVESTMENT ADVISORY REAL ESTATE

MEDICAL BILLING AND COLLECTIONS SERVICES

Medical Financial Group (★★★ Gold Sponsor) Healthcare and Financial Professionals providing core solutions to Physicians from one proven source. CEO is Jesse Gonzales, CPA, MBA Controller and past CFO of (2) Fortune 500 companies, Past Board President of Communicare Health Systems. Jesse Gonzales, CEO CPA, MBA 210-846-9415

information@medicalfgtx.com Linda Noltemeier Jones, Director of Operations 210-557-9044 lindanj@medicalfgtx.com www.medicalfgtx.com “Let’s start with Free Evaluation and Consultation from our Team of Professionals” Commercial & Medical Credit Services (HH Silver Sponsor) A bonded and fully insured San Antonio-based collection agency. Henry Miranda 210-340-9515 hcmiranda@sbcglobal.net www.cmcs-sa.com “Make us the solution for your account receivables.”

MEDICAL PAYMENT SYSTEMS/CARD PROCESSING

continued from page 41

MOLECULAR DIAGNOSTICS LABORATORY

iGenomeDx ( Gold Sponsor) Most trusted molecular testing laboratory in San Antonio providing FAST, ACCURATE and COMPREHENSIVE precision diagnostics for Genetics and Infectious Diseases. Dr. Niti Vanee Co-founder & CEO 210-257-6973 nvanee@iGenomeDx.com Dr. Pramod Mishra Co-founder, COO & CSO 210-381-3829 pmishra@iGenomeDx.com www.iGenomeDx.com “My DNA My Medicine, Pharmacogenomics”

MORTGAGES First Citizens Bank (★★★ Gold Sponsor) We’re a family bank — led for three generations by the same family-but first and foremost a relationship bank. We get to know you. We want to understand you and help you with your banking. Stephanie Dick Commercial Banker 210-744-4396 stephanie.dick@firstcitizens.com https://commercial.firstcitizens.co m/tx/austin/stephanie-dick “People Bank with People” “Your Practice, Our Promise”

MEDICAL SUPPLIES AND EQUIPMENT Henry Schein Medical (HH Silver Sponsor) From alcohol pads and bandages to EKGs and ultrasounds, we are the largest worldwide distributor of medical supplies, equipment, vaccines and pharmaceuticals serving office-based practitioners in 20 countries. Recognized as one of the world’s most ethical companies by Ethisphere. Tom Rosol 210-413-8079 tom.rosol@henryschein.com www.henryschein.com “BCMS members receive GPO discounts of 15 to 50 percent.”

SAN ANTONIO MEDICINE • May 2022

SWBC MORTGAGE - THE TOBER TEAM (HHH Gold Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying. For You Practice: HR administration, payroll, employee benefits, insurance, and exit strategies. SWBC’s services supporting Physicians and the Medical Society. Jon Tober, Sr. Loan Officer Office: 210-317-7431 NMLS# 212945 Jon.tober@swbc.com https://www.swbcmortgage.com /jon-tober

PROFESSIONAL ORGANIZATIONS The Health Cell (HH Silver Sponsor) “Our Focus is People” Our mission is to support the people who propel the healthcare and bioscience industry in San Antonio. Industry, academia, military, nonprofit, R&D, healthcare delivery, professional services and more! Kevin Barber, President 210-308-7907 (Direct) kbarber@bdo.com Valerie Rogler, Program Coordinator 210-904-5404 Valerie@thehealthcell.org www.thehealthcell.org “Where San Antonio’s Healthcare Leaders Meet”

San Antonio Medical Group Management Association (SAMGMA) (HH Silver Sponsor) SAMGMA is a professional nonprofit association with a mission to provide educational programs and networking opportunities to medical practice managers and support charitable fundraising. Alan Winkler, President info4@samgma.org www.samgma.org

REAL ESTATE SERVICES COMMERCIAL

Alamo Capital Advisors LLC (★★★★ 10K Platinum Sponsor) Focused on sourcing, capitalizing, and executing investment and development opportunities for our investment partners and providing thoughtful solutions to our advisory clients. Current projects include new developments, acquisitions & sales, lease representation and financial restructuring (equity, debt, and partnership updates). Jon Wiegand, Principal 210-241-2036 jw@alamocapitaladvisors.com www.alamocapitaladvisors.com Foresite Real Estate, Inc. (HH Silver Sponsor) Foresite is a full-service commercial real estate firm that assists with site selection, acquisitions, lease negotiations, landlord representation, and property management. Bill Coats 210-816-2734 bcoats@foresitecre.com https://foresitecre.com “Contact us today for a free evaluation of your current lease”

RETIREMENT PLANNING

STAFFING SERVICES

Favorite Healthcare Staffing (HHHH 10K Platinum Sponsor) Serving the Texas healthcare community since 1981, Favorite Healthcare Staffing is proud to be the exclusive provider of staffing services for the BCMS. In addition to traditional staffing solutions, Favorite offers a comprehensive range of staffing services to help members improve cost control, increase efficiency and protect their revenue cycle. Cindy M. Vidrine Director of Operations- Texas 210-918-8737 cvidrine@favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.”

Visit us at www.bcms.org

AUTO REVIEW

2022 Ford Mustang Mach 1 By Stephen Schutz, MD

SAN ANTONIO MEDICINE • May 2022

AUTO REVIEW

“When dinosaurs roamed the earth” is a popular expression that occurred to me often as I was enjoying the 2022 Ford Mustang Mach 1. This wonderful car might not be an actual dinosaur, but it is certainly facing extinction. Too bad, because the latest Mach 1 is a joy to drive. For the record, Ford, along with numerous other automotive manufacturers, has pledged to halt the production and sale of gasoline and diesel-powered cars in major markets by 2035. So there probably

Mustang dates back to 2015, and its look has aged very well for a seven-year-old design. The same can’t be said for the Mach 1’s interior, which is starting to look old. The digital indicators and gauges are generally okay, although the dual screens ahead and to the right of the driver are smaller and more difficult to see than I’d like, and the whole thing just looks seven years old, which it is. What would an ideal Mach 1 dashboard look like? Um, probably

won’t be any new V8-powered Ford Mustangs for sale in a few years (I’d be surprised if any were offered for sale after 2025, candidly). Thankfully, you can still buy V8 Mustangs now, and my recent experience with the best one currently available, the Mach 1, was excep-

a lot like what you’ll find in the current Mustang Mach-E. One observation that I’ve made about performance versions of other “normal” cars like the Subaru WRX STi also applies to the Mach 1: taking a $35,000 car and turning it into a $50,000 - $60,000

tionally pleasant. The best thing about the Mach 1 is undoubtedly its engine, the same 480HP 5.0L naturally aspirated V8 used in the (no longer available) Bullitt Mustang. Loud, revvy and seriously potent, this gem of a motor sings, especially highly in the rev range. And when paired with the stout Tremec 6-speed manual borrowed from the Shelby GT350 — OMG please don’t get the 10-speed automatic in this car! — it loves to boogie. The best boogie-ing is found when you head out to a lightly traveled and twisty back road near you and GO. The engine springs to life, and you’ll find yourself shifting up and down through the gears more than necessary. And you’ll smile because, in 2022, this Ford is as fun to drive as any other new car on the market, regardless of price. The manual transmission’s no-lift-shift and rev-matching features (for up- and downshifting, respectively) absolutely enhance the experience, by the way. Despite its impressive athleticism, the Mach 1 is docile around town — although its loud exhaust note may annoy your neighbors — and quite comfortable on the highway. The relatively tall sixth gear helps keep the revs (and noise levels) down while cruising, something I wish the BMW M3/M4 and Subaru WRX STi were better at. Is the Mach 1 the perfect automotive all-arounder? No. It’s tough to get in and out of, the rear seats are microscopic and there’s not much trunk space. And then there’s its fuel consumption problem noted below. The exterior design is best described as the classic Mustang, updated. Deliberately evocative of the first- and second-generation fastback Mustangs, the current model manages to blend many contemporary styling cues with some retro touches in a way that even non-Ford fans would likely find attractive. The current generation

car for enthusiasts means that your fancy sports car ends up with a mostly entry-level interior. It’s not ugly or bad, but it’s not the same as what you’ll find in a $50,000 BMW or Audi either. If you guessed that a 480HP V8 engine is not going to produce excellent fuel economy figures, you’d be correct. The Mach 1’s numbers are, gulp, 14MPG City/22MPG Highway. Pricing starts at around $54,000, but loading it up with options can easily add $10,000 or more to the MSRP. My two cents on speccing your Mach 1: unless you plan to track your car, the $3,500 Handling Package (with its sticky Michelin Pilot Cup Sport 2 tires) and $1,600 Recaro seats are probably unnecessary. Despite guzzling fuel and lacking a lot of space for people or things, the Mustang Mach 1 is Big Fun to drive and own. It’s one of the last cars you can buy with a V8 and manual transmission, and when it goes the way of the dinosaurs, it probably won’t come back. Get one while you can. Note for readers: A trauma surgeon friend and I have launched an automotive podcast that may interest you. It’s called, “Cars on Call,” and it features discussions about a myriad of automotive subjects from two physicians’ perspective. It’s available on Apple, Spotify and other platforms, and I hope you give it a listen. As always, call Phil Hornbeak, the Auto Program Manager at BCMS (210-301-4367), for your best deal on any new car or truck brand. Phil can also connect you to preferred financing and lease rates. Stephen Schutz, MD, is a board-certified gastroenterologist who lived in San Antonio in the 1990s when he was stationed here in the US Air Force. He has been writing auto reviews for San Antonio Medicine since 1995.

Visit us at www.bcms.org

11911 IH 10 West San Antonio, TX 78230

Audi Dominion 21105 West IH 10 San Antonio, TX 78257

Northside Chevrolet 9400 San Pedro Ave. San Antonio, TX 78216

Chuck Nash Chevrolet Buick GMC 3209 North Interstate 35 San Marcos, TX

Coby Allen 210-696-2232

Rick Cavender 210-681-3399

Charles Williams 210-912-5087

William Boyd 210-859-2719

Bluebonnet Chrysler Dodge Ram 547 S. Seguin Ave. New Braunfels, TX 78130

Northside Ford 12300 San Pedro San Antonio, TX

Northside Honda 9100 San Pedro Ave. San Antonio, TX 78216

14610 IH 10 West San Marcos, TX 78249

Matthew C. Fraser 830-606-3463

Marty Martinez 210-477-3472

Paul Hopkins 210-988-9644

Mark Hennigan 832-428-9507

Kahlig Auto Group

Land Rover San Antonio 13660 IH 10 West San Antonio, TX

North Park Lexus 611 Lockhill Selma San Antonio, TX

North Park Lexus at Dominion 25131 IH 10 W Dominion San Antonio, TX

North Park Lincoln 9207 San Pedro San Antonio, TX

Cameron Tang 210-561-4900

Tripp Bridges 210-308-8900

James Cole 210-816-6000

Sandy Small 210-341-8841

North Park Mazda 9333 San Pedro San Antonio, TX 78216

Mercedes Benz of Boerne 31445 IH 10 West Boerne, TX

Mercedes Benz of San Antonio 9600 San Pedro San Antonio, TX

9455 IH 10 West San Antonio, TX 78230

John Kahlig 210-253-3300

James Godkin 830-981-6000

Al Cavazos Jr. 210-366-9600

Douglas Cox 210-764-6945

Kahlig Auto Group

North Park Subaru 9807 San Pedro San Antonio, TX 78216

North Park Subaru at Dominion 21415 IH 10 West San Antonio, TX 78257

Cavender Toyota 5730 NW Loop 410 San Antonio, TX

North Park Toyota 10703 Southwest Loop 410 San Antonio, TX 78211

Raymond Rangel 210-308-0200

Phil Larson 877-356-0476

Gary Holdgraf 210-862-9769

Justin Boone 210-635-5000

Kahlig Auto Group

San Antonio Medicine May 2022

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