COVID-19: A Disease of Insufficient Nitric Oxide Production By Nathan S. Bryan, PhD

from San Antonio Medicine July 2021

Present By Alan M. Preston, MHA, ScD

A Disease of Insufficient Nitric Oxide Production

By Nathan S. Bryan, PhD

COVID-19 is now a worldwide pandemic affecting millions of people around the world. As of mid-May 2021, over 160 million people have been infected, with over three million deaths. Early data coming out of China in January 2020 revealed that patients with underlying cardiovascular disease were more susceptible to infection, greater disease severity and ten times higher mortality. Among the patients studied, the median (range) age was 64 (21-95) years old, female (50.7%, and the median time to symptom onset was 10 days (interquartile range [IQR]), 1-30). Of this group, 82 (19.7%) had some type of cardiac comorbidity. It was apparent as the study went on that patients with cardiac morbidity and COVID-19 fared worse than the patients with COVID-19, but no history of cardiac morbidity. Patients with cardiac morbidity with diagnosed COVID-19, compared with patients without cardiac morbidity, had a higher mortality rate (51.2% vs 4.5%) and risk of death.1

In addition, over the past 18 months, reports from the U.S. database compiled by CDC report mortality from COVID-19 to have a racial disparity.2 A disproportionate number of COVID-19 fatalities among Hispanics and African Americans has been observed. This has been attributed to known disparities in health care, low economic resources and issues associated with social distancing: occupation, crowded residential spaces and transportation crowding. Additionally, Hispanics and African Americans have a high incidence of pre-existing and often untreated cardiovascular conditions.3 It is clear that older people with an underlying comorbidity such as high blood pressure, heart disease, kidney disease, obesity, smokers and patients with pulmonary disorders are at an increased risk of COVID infection. These are also the people that get the sickest and die from COVID.

Additionally, abnormal blood clotting is an increasingly recognized complication of this disease, both systemically and within the pulmonary circulation.4 In fact, one of the greatest predictors of death is a serum blood test that indicates elevated clotting activity (D-dimer). More recent clinical observations reveal endothelial cell infection and endotheliitis in COVID patients across vascular beds in multiple organs.5 The vascular endothelium is an active paracrine, endocrine and autocrine organ that is indispensable for the regulation of vascular tone and the maintenance of vascular homoeostasis.6 COVID-19-endotheliitis could explain the systemic impaired microcirculatory function in different vascular beds and their clinical sequelae in patients with COVID-19. Endothelial dysfunction and insufficient nitric oxide (NO) production is a principal determinant of microvascular dysfunction by shifting the vascular equilibrium towards more vasoconstriction with subsequent organ ischemia, inflammation with associated tissue edema and a pro-coagulant state. See illustration. Therefore, the people that are most susceptible and vulnerable to COVID infection are exactly the patients that have insufficient nitric oxide production in their body.

Restoring nitric oxide through drug therapy is reported to improve oxygenation,7,8 an action needed as the COVID-19 disease progresses and acute respiratory disease syndrome (ARDS) develops. NO decreases the propensity of blood to clot,9 a problem leading to multi-system damage in patients severely ill with the COVID-19 virus.

All these factors: decreased oxygenation, low NO levels in Hispanic and Africans American patients, decreased oxygenation in severely ill COVID-19 patients, increased clotting and increased inflammation, leads one to hypothesize that increasing NO levels in patients with COVID-19 would have a salutatory benefit. A Texas-based biotechnology company, Nitric Oxide Innovations, is conducting an FDAapproved Phase 3 clinical trial for a novel nitric oxide releasing drug therapy for Hispanic and African American patients aged 50-85 diagnosed with COVID in the last 72 hours. The clinical trial aims to investigate if restoring nitric oxide can prevent progression of disease and hospitalization, reduced need for ventilation and decrease death. Early data from the clinical study reveals that nitric oxide can improve oxygenation in patients within five minutes of taking the drug. Hispanics and African-Americans are known to be nitric oxide deficient and respond favorably to nitric oxide-based therapies. Patients are needed in the clinical study. Subjects will be randomly assigned to receive either an NO active drug lozenge or a placebo for 30 days. The primary outcome measures rates of hospitalization, admission into the intensive care unit and death in patients on the drug compared to the placebo. A secondary endpoint will be the fractional oxygen saturation of patients receiving the drug compared to those on the placebo.

For more information, please visit www.nocovidstudy.com.

If patients meet the following criteria, then they will qualify to participate in the study: 1. Hispanic or African American 2. Aged 50-85 3. Diagnosed with COVID in the past 72 hours 4. Have at least one comorbidity such as hypertension, diabetes, heart disease, kidney disease, obesity or a smoker.

References: 1. Shi, S., et al., Association of Cardiac Injury With Mortality in Hospitalized Patients With COVID-19 in Wuhan, China. JAMA Cardiol, 2020. 2. Yancy, C.W., COVID-19 and African Americans. JAMA, 2020. 3. Carnethon, M.R., et al., Cardiovascular Health in African Americans: A Scientific Statement From the American Heart Association. Circulation, 2017. 136(21): p. e393-e423. 4. Connors, J.M. and J.H. Levy, COVID-19 and its implications for thrombosis and anticoagulation. Blood, 2020. 5. Varga, Z., et al., Endothelial cell infection and endotheliitis in

COVID-19. Lancet, 2020. 395(10234): p. 1417-1418. 6. Bonetti, P.O., L.O. Lerman, and A. Lerman, Endothelial dysfunction: a marker of atherosclerotic risk. Arterioscler Thromb Vasc

Biol, 2003. 23(2): p. 168-75. 7. Allen, B.W., J.S. Stamler, and C.A. Piantadosi, Hemoglobin, nitric oxide and molecular mechanisms of hypoxic vasodilation. Trends

Mol Med, 2009. 15(10): p. 452-60. 8. Zhang, R., et al., Hemoglobin betaCys93 is essential for cardiovascular function and integrated response to hypoxia. Proc Natl

Acad Sci U S A, 2015. 112(20): p. 6425-30. 9. Radomski, M.W., R.M. Palmer, and S. Moncada, The anti-aggregating properties of vascular endothelium: interactions between prostacyclin and nitric oxide. Br J Pharmacol, 1987. 92(3): p. 639-46.

Nathan S. Bryan, PhD is the Founder and CEO of Nitric Oxide Innovations, LLC. Nitric Oxide Innovations, LLC is a Gold Circle of Friends Sponsor of the BCMS. For more information, you can contact him at nathan@pneumanitricoxide.com.

The Age of Heroic Medicine was ending. Harrowing techniques of bloodletting, sweating and purging to balance the four “humors” were giving way to gentler treatments. By the 1850s, wealthy patients began expecting effective results without agonizing therapy. Scientific medicine was a frontier pioneered by new schools, infirmaries and hospitals. Surgery was performed anesthetically but hazardously –Lister’s antiseptics were still a decade away.

The Blackwell sisters blazed the frontier; Elizabeth was the first woman to earn a medical degree in the United States, and Emily, its first woman surgeon. Their story and that of institutions they founded informs “The Doctors Blackwell: How Two Pioneering Sisters Brought Medicine to Women and Women to Medicine” by Janice P. Nimura (2021; W. W. Norton & Company). The sisters’ aspirations, endeavors and eccentricities, portrayed in an epically-scaled history, is a story not only of people but of a time and place, and a profession in growth.

Elizabeth (the third of nine children) and Emily (her next younger sister) were raised in a religious family following a progressive “English Dissenters” faith. Their father was ironically a sugar manufacturer and fervently antislavery: paradoxes run rampant in the feisty family story. The siblings rarely attended school, educated at home by private tutors. Experiencing little real-world academic competition, Elizabeth set her sights on becoming the first woman accepted by an American medical college.

Elizabeth’s motivation was not compassion for the sick, or a sense of vocation, but to demonstrate that women were up to the era’s premier challenge. Nor would she be satisfied by her own acceptance alone. Proof-of-concept required Emily follow suit so together they could establish a thriving medical practice. The Blackwells were never satisfied by second best: Elizabeth attempted admission only at the most traditional, prestigious colleges.

Even the best medical schools were a far cry from the clinical training and residency now integral. Students were taught by rote in a series of lectures for which they had to purchase tickets. The entire course, from admission to graduation, was two 16-week semesters, repeated the following year. Students hoped to gain some practical experience during the summer. “She sought interviews with Philadelphia’s leading physicians and sent letters of inquiry to medical colleges in both Philadelphia and New York. At the University of Pennsylvania, the oldest and most august American medical school, Dr. Samuel Jackson burst out laughing at her request.”

Rejected by every institution to which she had applied, Elizabeth sent off a flurry of applications to a dozen provincial medical colleges across New England. Lightning struck in the form of a rebellious student body at Geneva Medical College (later transferred to Syracuse University in Syracuse, New York).

The Dean announced to faculty that “A young lady, studying privately with an eminent physician in Philadelphia, applied with her mentor’s endorsement for admission to their school.”

The faculty put the decision to the student body. The students recognized faculty skittishness and their power to make serious mischief.

Astounding the college, students approved and before long, Elizabeth Blackwell rose from a classroom curiosity to class-leader in academic achievement.

Elizabeth performed clinical work over break at Philadelphia’s refuge for the destitute, Blockley Alms House. “Blockley is the microcosm of the city,” wrote one observer. “Here is drunkenness; here is pauperism; here is illegitimacy; here is madness; here are the eternal priestesses of prostitution, who sacrifice for the sins of man; here is crime in all its protean aspects; and here is vice in all its monstrous forms.” Serving two thousand indigents in such a place offered a sense of clinical work that the lecture hall never provided.

In January 1849, she became the first woman to earn a medical degree in the United States. A year later, Dr. Elizabeth Blackwell moved to France for practical residency: she could enter La Maternité, France’s largest public maternity hospital, not as a qualified doctor but as a student.

At La Maternité, Dr. Blackwell saw a thousand cases — vastly more than she might see anywhere else — under the tutelage of Paul Antoine Dubois, a distinguished professor of

Women Doctors and American Medical History: Trials and Triumphs in Service of the Most Needful

By David Alex Schulz, CHP

obstetrics. “In this one branch of medicine, there was no better practical education.”

La Maternité showed her that medical and social issues were inseparable, particularly in terms of hygiene and household. It was a philosophy she would carry throughout her life. Unfortunately, the lesson left her the permanent loss of her left eye from an infection of purulent ophthalmia, an aggressive form of conjunctivitis related to gonorrhea.

For medical school, Emily Blackwell had greater choices and was less selective. She introduced herself to the president of Rush Medical College in Chicago. Previously, Emily had distinguished herself attending lectures at Bellevue Hospital given by Columbia faculty. “The endorsement of the Bellevue Brahmins made all the difference: it was easier for Rush’s leaders to act boldly on Emily’s behalf when they could point to men of large reputation who had already done so.”

The Doctors Blackwell found opening a practice more challenging than earning their credentials. In a time “female physician” equated to abortionist, patients were hard to recruit. Patrons were easier. Ever the institutionalists, Elizabeth and Emily opened the first hospital staffed by women in 1857, the New York Infirmary for Indigent Women and Children.

Decades of medical advancement and social turmoil are portrayed through the eyes and experiences of the Blackwells. They served both the indigent in the Infirmary and their Patrons in private practice until they reach the height of their combined efforts: The Woman’s Medical College of the New York Infirmary.

It was the first school entirely devoted to the medical education of women. The Doctors Blackwell ran it under a different and better philosophy. Students had to attend for three years instead of the standard two, and would have hands-on lessons. Their course of lectures would build progressively year to year, rather than simply repeating the same material. And theirs would be the first medical school of any kind to feature a professor—Elizabeth herself—devoted to the subject of hygiene.

Janice Nimura paints these stories as if in companionship with the Blackwells, perhaps with an overzealous reliance on their own writings in letters and diaries. “The Doctors Blackwell” can be a reader’s challenge (“valetudinarian”?) and the principals not especially likeable characters, but stalwart readers will find themselves immersed in a pivotal time of health care and more aware of their heritage for the effort.

All quotes and images from: Nimura, Janice P. “The Doctors Blackwell: How Two Pioneering Sisters Brought Medicine to Women and Women to Medicine” (2021) W. W. Norton & Company. Kindle Edition.

David Alex Schulz, CHP is a community member of the BCMS Publications Committee.

The Study of Life, Revisited

By Winona Gbedey

I wanted to say something profoundly beautiful and philosophical about my experiences during quarantine, but when I sat down to write this, all I could think about was my cat.

She died in the spring of 2017, a few hours before my organic chemistry final. As I racked my brain, searching for the answers to complicated scientific principles that still elude me, my beloved pet of twelve years lay lifeless at the foot of our stairs. My parents told me what had happened when I returned home. It was quick, they said, unexpected, shocking. It was too much, so they didn’t want me to dwell on it while I was taking my exams. Grief, I soon discovered, could be all-consuming.

Reconciling my last memories of Tiger with the knowledge that she was gone was difficult. Sometimes it still is. Unlike my family, I didn’t see her wither away over a course of three days. I never got that time to flip the switch, to think maybe this is the end. To me, Tiger is still the vivacious little thing who loved to curl up next to me and vibrate my body with the force of her purr. Except she isn’t here anymore. I imagine this is what it’s like for most people who lose someone unexpectedly: disbelief and grief that indefinitely sticks to you like super glue.

Because of the pandemic, I find myself thinking about how fickle life is constantly—how it unexpectedly vanishes into the night while the rest of the world sleeps. After many hours in more quarantine-induced existential crises than I can remember, I’ve come to the conclusion that life is so fleeting because it is ruled by biology. Biology demands that all living things expire eventually, no matter how much they are loved. Despite the place I had carved in my heart for her, it was Tiger’s time to go. Biology didn’t care.

I am fortunate that when I think of death, I think of my cat. My family, my friends, they are all still with me—something I am even more grateful for now, as SARS-CoV-2 continuously sweeps across the country, claiming lives like the Grim Reaper. When I turn on the television or tap my news app, I am inundated by stories of families saying their goodbyes through an iPad screen while their loved one lays unconscious, alone, entangled in a mess of tubes and cords. Their stories remind me that I am one of the lucky few who does not yet know the pain of losing someone. And then, all of a sudden, I begin thinking about my cat.

I cannot pretend that losing a beloved pet is the same as losing a beloved person. But I can say this: Tiger’s death still hurts because she was loved. In a strange turn of events, the pandemic has taught me that all grief is valid because all grief comes from a place of love. The way others describe their pain mirrors the way I speak of mine; in those moments, we are the same, mourning the loss of someone we loved.

When biology claims another piece of my soul, Tiger’s death will not ache any less than it does now. The parts of me that I gave to her may not be as large as the ones I give my parents, my brother, my best friends or my future partner, but she has a part of my heart nonetheless. One day I will know what it is like to lose someone. But for now, I think of my cat.

Winona Gbedey is a medical student at the Long School of Medicine, UT Health San Antonio, Class of 2023.

Artistic Expression in Medicine

By Maggie Carroll, MD

Top: Hand

Bottom: Right Chest and Arm

Artwork created by Maggie Carroll, MD, Long School of Medicine, UT Health San Antonio, Class of 2021.

Impacting Recurrence in Non-Muscle Invasive Bladder Cancer

Announcement by University of Texas Health Science Center San Antonio

Bladder image from White Light Cystoscopy

Same Image from Blue Light Cystoscopy with /Cysview

In the United States, more than 720,000 people are living with bladder cancer, and an estimated 83,730 people will be diagnosed this year.1 Mays Cancer Center at UT Health San Antonio is now offering Blue Light Cystoscopy with Cysview® for improved detection and management of non-muscle invasive bladder cancer (NMIBC), including carcinoma in situ (CIS) in an outpatient setting.

“Treatment of bladder cancer requires careful, meticulous detail and adherence to surveillance regimens,” said Dr. Robert Svatek, Urologic Oncologist at Mays Cancer Center and Chair of Urology at UT Health San Antonio. “It requires diligence in the administration of proper standardized therapy, but treatment regimens must also be individualized.”

Cystoscopy is the gold standard diagnostic tool for bladder cancer. Historically, this has been conducted using white light cystoscopy; however, some tumors may escape detection under white light alone.2,3 To increase detection and decrease recurrence for patients suffering from bladder cancer, Blue Light Cystoscopy with Cysview is employed.

“Although it is not a replacement for biopsy, Blue Light Cystoscopy with Cysview is an enhanced cystoscopy that helps us identify lesions that may not be visible using white light cystoscopy alone,” said Dr. Svatek. “This advanced approach helps us elevate our diagnostic capabilities and provide a higher standard of care for our patients.”

During a standard cystoscopy procedure, the bladder is examined using white light. During a Blue Light Cystoscopy with Cysview, both white and blue light are used. Cysview makes tumor cells glow bright pink in blue light, but it is not a dye. It is a hexyl-ester of aminolevulinic acid that results in an increased volume of porphyrins in cells. Unhealthy cells do not process out the porphyrins as quickly as healthy cells; the resulting accumulation creates a pink glow in blue light.

Cysview® (hexaminolevulinate HCl) is an FDAapproved optical imaging agent indicated for use in the cystoscopic detection of NMIBC including CIS among patients suspected or known to have lesion(s) based on a prior cystoscopy or undergoing surveillance cystoscopy for carcinoma of the bladder. Cysview is instilled in the patient’s bladder at least one hour before the procedure and used with the KARL STORZ Photodynamic Diagnostic system to perform Blue Light Cystoscopy as an adjunct to White Light Cystoscopy.4

“Expertise in the management of advanced bladder cancer requires proper timing and coordination of multiple treatment modalities available to treat the disease including surgery, radiation therapy and chemotherapy.” To that end, Dr. Svatek has developed a collaborative care pathway that provides exceptional precision in the pre-operative and post-operative management of patients with bladder cancer.

References:

1. National Cancer Institute. SEER Stat Facts: Bladder Cancer 2017. https://seer.cancer.gov/statfacts/html/ urinb.html. Accessed January 25, 2019. 2. Hermann GG, Mogensen K, Carlsson S, Marcussen N,

Duun S. Fluorescence-Guided Transurethral Resection of

Bladder Tumours Reduces Bladder Tumour Recurrence

Due to Less Residual Tumour Tissue in Ta/T1 Patients:

A Randomized Two-Centre Study. BJU Int. 2011;108(8b):E297-E303. 3. Daneshmand S et al. Efficacy and safety of blue light flexible cystoscopy with Hexaminolevulinate (HAL) in the surveillance of bladder cancer: A phase III, comparative, multi-center study. J Urol. 2017 Dec 2. 4. Cysview [prescribing information]. 2018:1-14. Chang SS,

Boorjian SA, Chou R, et al. Diagnosis and Treatment of

Non-Muscle Invasive Bladder Cancer: AUA/SUO Guideline. J Urol. 2016;196(4):1021-1029.

Mays Cancer Center is the first and only center in the region to offer Blue Light Cystoscopy with Cysview® in an outpatient setting for improved detection and management of non-muscle invasive bladder cancer.

Congratulations to our Medical Student Scholars!

For decades, the BCMS Alliance has rewarded excellence in allied health fields in Bexar County. This year, the 104-year-old organization began a new medical student scholarship program, presenting awards to two exceptional students, one at each of Bexar County’s medical schools. BCMS Alliance funds were matched by the TMAF Medical Student Scholarship and Grant Trust Fund of Dr. Roberto J. and Agniela (Annie) M. Bayardo and the TMAF Hispanic Medical Student Scholarship Trust Fund of Dr. Roberto J. and Agniela (Annie) M. Bayardo.

VICTORIA FAHY BCMS Alliance Hispanic Medical Student Scholarship UIW School of Osteopathic Medicine | Class of 2023

A graduate of Mary Hardin-Baylor with a BS degree in Cell Biology, Victoria was presented the coveted Loyalty Cup for exemplifying the ideals, traditions and spirit of the University. During medical school, Victoria has served others through community immunization drives, leadership roles with the Student Government Association and Academy of Pediatrics and as peer mentor as an Office of Admissions learner ambassador. “I want to thank the Bexar County Medical Society Alliance for selecting me for the inaugural BCMS Alliance Hispanic Medical Student Scholarship. With this gift, I will be able to continue to pursue my passion for both medicine and outreach within our local community. I would also like to thank the donors for investing in not only my future, but also other medical students within the Bexar County area. I am truly honored to receive this award and I will strive to enact positive change within our community. As a Latina and first-generation graduate student, I hope to inspire other students like me to pursue their dreams and passions.” RYAN WEALTHER BCMS Alliance Medical Student Scholarship UT Health San Antonio Long School of Medicine | Class of 2022

Prior to graduating summa cum laude from Drake University with a BS degree in Biochemistry, Cell and Molecular Biology and a BA in Chemistry, Ryan earned his nurse aide certification working as a CNA to hone his clinical skills. Heavily involved in research, his recent studies focus on palliative care, COVID-19 prevalence and vaccine hesitancy. A leader, peer mentor and student physician advocate for medicine on the national, state and local level, Ryan is also committed to serving others, especially at-risk communities. “I am very grateful to accept the inaugural BCMS Alliance Medical Student Scholarship. As a medical student advocate, I strive to serve my community and use my voice to advocate for patients in San Antonio, the state of Texas and across the nation. As the newly elected Chair of the TMA Medical Student Section, I look forward to increasing medical student advocacy throughout the state of Texas over the upcoming year. This award is especially meaningful to me because its financial support will allow me to continue pursuing my passions and endeavors, including conducting research, attending advocacy events and participating in away rotations as I apply to dermatology programs. Thanks again to the BCMS Alliance and to the TMA Foundation for supporting me in my endeavors and helping me achieve my goals.”

Please ask your practice manager to use the Physicians Purchasing Directory as a reference when services or products are needed.

ACCOUNTING FIRMS

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ACCOUNTING SOFTWARE

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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” Norton Rose Fulbright (HHH Gold Sponsor) Norton Rose Fulbright is a global law firm. We provide the world’s preeminent corporations and financial institutions with a full business law service. We deliver over 150 lawyers in the US focused on the life sciences and healthcare sector. Mario Barrera Employment & Labor 210 270 7125 mario.barrera@nortonrosefulbright.com Charles Deacon Life Sciences and Healthcare 210 270 7133 charlie.deacon@nortonrosefulbright.com Katherine Tapley Real Estate 210 270 7191 katherine.tapley@nortonrosefulbright.com www.nortonrosefulbright.com “In 2016, we received a Tier 1 national ranking for healthcare law according to US News & World Report and Best Lawyers”

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

BankMD (HHH Gold Sponsor) Our Mission is your Success. We are the ONLY Physician-Focused Bank in the Country Moses Luevano, President 512.547.6065 mdl@bankmd.com Chris McCorkle Director of Healthcare Banking 210.253.0550 cm@bankmd.com www.BankMD.com “Specialized, Simple, Reliable”

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

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FINANCIAL ADVISOR

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. Jeffrey Allison 210-268-1530 jallison@aspectwealth.com www.aspectwealth.com “Get what you deserve … maximize your Social Security benefit!”

Regions Bank (HHH Gold Sponsor) Regions Financial Corporation is a member of the S&P 500 Index and is one of the nation’s largest full-service providers of consumer and commercial banking, wealth management and mortgage products and services. Mary P. Mahlie Vice President Wealth Advisor (512)787.2488 Mary.Mahlie@Regions.com Blake M. Pullin Vice President - Mortgage Banking Regions Mortgage NMLS#1031149 (512)766.LOAN(5626) blake.pullin@regions.com Fred R. Kelley Business Banking Relationship Manager (210)385.9326 Fred.Kelley@Regions.com www.Regions.com

HEALTHCARE BANKING

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 Danette Castaneda Business Banking Specialist 512.797.5129 Danette.castaneda@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 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 & treat human disease. Our patented nitric oxide delivery platform includes drug therapies for COVID 19, heart disease, Pulmonary hypertension & topical wound care. info@NitricOxideInnovations.com (512) 773-9097 www.NitricOxideInnovations.com

HOSPITALS/ HEALTHCARE FACILITIES

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) Created and endorsed by the Texas Medical Association (TMA), the TMA Insurance Trust helps physicians, their families and their employees get the insurance coverage they need. Wendell England 512-370-1746 wengland@tmait.org James Prescott 512-370-1776 jprescott@tmait.org www.tmait.org “We offer BCMS members a free insurance portfolio review.”

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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 continued on page 42

Visit us at www.bcms.org 41

for our insureds. ProAssurance Group is A.M. Best A+ (Superior). Delano McGregor Senior Market Manager 800.282.6242 ext 367343 DelanoMcGregor@ProAssurance.com www.ProAssurance.com/Texas

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. Clayton Brown - Regional Sales Director 210-693-8025 clayton.brown@upnfiber.com David Bones – Account Director 210 788-9515 david.bones@upnfiber.com Jim Dorman – Account Director 210 428-1206 jim.dorman@upnfiber.com www.uniteprivatenetworks.com “UPN is very proud of our 98% customer retention rate”

MEDICAL BILLING AND COLLECTIONS SERVICES

PCS Revenue Cycle Management (HHH Gold Sponsor) We are a HIPAA compliant fullservice medical billing company specializing in medical billing, credentialing, and consulting to physicians and mid-level providers in private practice. Deion Whorton Sr. CEO/Founder 210-937-4089 inquiries@pcsrcm.com www.pcsrcm.com “We help physician streamline and maximize their reimbursement by 30%.”

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 & Radiation Physics, Inc. (HHH Gold Sponsor) Medical physics and radiation safety support covering all of South Texas for over 40 years. Diagnostic imaging, radiation therapy, nuclear medicine and shielding design. Licensed, Board Certified, Experienced and Friendly! Alicia Smith, Administrator 210-227-1460 asmith@marpinc.com David Lloyd Goff, President 210-227-1460 dgoff@marpinc.com www.marpinc.com Keeping our clients safe and informed since 1979.

MEDICAL SUPPLIES AND EQUIPMENT

CSI Health (HHH Gold Sponsor) CSI Health is a telehealth technology company providing customized solutions to healthcare professionals, assisted-living facilities, and more. CSI was founded in 1978, it was one of the first companies to move medical testing information from self-service kiosks into the cloud. Brad Bowen President, CEO 210-434-2713 brad@computerizedscreening.com Katherine Biggs McDonald Brand Development Manager 210-434-2713 katherine@computerizedscreening.com Bobby Langenbahn National Sales Manager 210-363-1513 bobby@computerizedscreening.com www.csihealth.net Extend the Reach of Healthcare. Elevate the Level of Remote Care. Enhance the Patient Experience.

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.”

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”

PRACTICE SUPPORT SERVICES

Medical & Radiation Physics, Inc. (HHH Gold Sponsor) Medical physics and radiation safety support covering all of South Texas for over 40 years. Diagnostic imaging, radiation therapy, nuclear medicine and shielding design. Licensed, Board Certified, Experienced and Friendly! Alicia Smith, Administrator 210-227-1460 asmith@marpinc.com David Lloyd Goff, President 210-227-1460 dgoff@marpinc.com www.marpinc.com Keeping our clients safe and informed since 1979.

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! President, Kevin Barber 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 Group Managers (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. Tom Tidwell, President info4@samgma.org www.samgma.org

REAL ESTATE SERVICES COMMERCIAL

CARR Healthcare (HH Silver Sponsor) CARR is a leading provider of commercial real estate for tenants and buyers. Our team of healthcare real estate experts assist with start-ups, renewals, , relocations, additional offices, purchases and practice transitions. Brad Wilson Agent 201-573-6146 Brad.Wilson@carr.us Jeremy Burroughs Agent 405.410.8923 Jeremy.Burroughs@carr.us www.carr.us “Maximize Your Profitability Through Real Estate”

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”

The Oaks Center (HH Silver Sponsor) Now available High visibility medical office space ample free parking. BCMS physician 2 months base rent-free corner of Fredericksburg Road and Wurzbach Road adjacent to the Medical Center. Gay Ryan Property Manager 210-559-3013 glarproperties@gmail.com www.loopnet.com/Listing/84348498-Fredericksburg-Rd-SanAntonio-TX/18152745/

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.”

TELEHEALTH TECHNOLOGY

Join our Circle of Friends Program

The sooner you start, the sooner you can engage with our 5700 plus membership in Bexar and all contiguous counties. For questions regarding Circle of Friends Sponsorship, please contact: Development Director, August Trevino august.trevino@bcms.org or 210-301-4366

2022 Ford F-150 Lightning EV

By Stephen Schutz, MD

Ford recently unveiled the coming-in-2022 all-electric F-150 Lightning pickup truck, and it was, as they say, kind of a big deal. It looks a lot like the current F-150—which we’ll get to in a minute— but with numerous futuristic styling touches, particularly in the lighting department.

Interestingly, Ford is positioning the Lightning as a tough pickup for commercial fleet buyers first, presumably thinking that if those demanding customers can be won over, then retail customers should be relatively easy to satisfy.

It makes sense. On the one hand, commercial buyers put many more miles on their trucks and are much harder on them than everyday owners—think hauling stacks of drywall to 12 different job sites in one day—but on the other, if Ford can make them happy, then people who use their trucks for more mundane activities like Costco runs will likely be satisfied too.

As with most things in life, easy to say, hard to do.

Anyway, the Lightning includes some highly innovative features such as the ability to use its battery pack as a power source in case of a power outage in your house, and a huge lockable “frunk” storage space located under the hood in the place where the engine used to be.

Base F-150 Lightnings are expected to start at around $40,000, but no other details about pricing have been provided. It’s reasonable to expect all the trim levels we’ve become accustomed to with internal combustion engine (ICE) F-150s (XLT, Lariat, Platinum and the like), but with an extra cost for the electric versions. And it’s easy to predict that average transaction prices will be much higher than $40,000.

I have neither driven nor seen an F-150 Lightning, but I did spend a week with a gasoline powered version of what Automotive News calls Ford’s, “crown jewel.” It was a pleasant experience, as you’d expect, given the fact that the ICE F-150 has been the best-selling vehicle in the U.S. for more than four decades.

My test vehicle came with the loaded Limited trim and had a V8 engine, which used to be ubiquitous and is now quite unusual (most F-150s today come with the more efficient and torquier 3.5L EcoBoost V6).

Driving the F-150 Limited reminded me that some versions of this truck are almost Lexus-like from inside the cabin. The ride is comfortable, noise is limited, passenger space is generous, even in the back seat and most materials are soft and very attractive. Nevertheless, this is a Ford and not a Lexus, so many buttons and knobs (and a few surfaces) are more reflective of a base model $40,000 truck than a $80,000 luxury vehicle (an F-150 Limited lists for about that much money, FYI).

While driving an F-150 around town and (especially) on the interstate is invariably pleasant, and it’s always nice to have room to put almost anything, this is not a perfect vehicle. Parking one can be difficult, and fuel economy is generally disappointing (16 MPG City/22 MPG Highway for the V8 and 18 City/23 Highway for the 3.5L EcoBoost V6).

By the way, only my favorite engine, the 3.0L turbo-diesel V6, gets respectable fuel mileage: 20 MPG City/27 Highway.

Interestingly, the most recent F-150—updated just last fall—includes some retro styling touches that harken back to the 1970s, particularly the egg crate grilles found on most trim levels. The overall design is of course completely modern, but it’s surprising to see an icon like the F-150 tip its hat to a decade marked by automotive designs that are not remembered fondly. Vehicles from that decade are derisively called “malaise era” cars, as then-new emissions regulations and back-to-back oil embargoes rocked the industry, resulting in underpowered and ugly products.

The F-150 can be configured in an almost infinite number of ways, but BCMS members will likely be drawn to the higher-end models with four doors, especially the Platinum and King Ranch versions. While those two trim levels have much in common, they use different styling elements and interior materials to appeal to more urban and rural buyers, respectively. The Limited sits above those trim levels at the very top of the F-150 food chain.

For the next year or so until it actually launches, the all-electric F150 Lightning will be the darling of automotive publications across the country, but for the time being, the less cool ICE F-150 remains a pickup you can count on. It can tow, haul and get you to the hospital in any weather condition. Plus, it does so with a level of comfort and luxury that surpasses what even some expensive cars can provide. It’s easy to see why it’s so popular.

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.