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Inside This Issue
EVERY AUGUST UNTIL A CURE: THE ALS ICE BUCKET CHALLENGE RETURNS FOR 2015 By Greg Hill The ALS Association Texas Chapter
Aging Americans fight Diabetes See pg. 8
INDEX Legal Health..................pg.3 Mental Health...............pg.4 Healthy Heart................pg.5 Framework..................pg.13
TIRR Memorial Herman Nations Top Rehabilitation Hospitals See pg. 9
Promising to renew their challenge every August until there is a cure, the two ALS patients who co-founded the ALS Ice Bucket Challenge in 2014, Pat Quinn and Pete Frates, made good on that promise when they kicked off the 2015 ALS Ice Bucket Challenge on July 31 in Boston. For Texans, however, the official kick off took place at Houston’s Minute Maid Park on August 2 as the Houston Astros Houston Astros Participating in ALS Ice Bucket Challenge enthusiastically took the challenge. “Last year gave the ALS community prolonging a person’s life by only 2-3 of the responsibility in fighting a disease like ALS and in stewarding hope for the first time in a long time,” months. said Quinn, who was diagnosed For the beleaguered warriors on the unexpected windfall from the Ice with ALS two years ago. “But we still the front lines of this disease, last Bucket Challenge. “For people with need the public’s help to keep the year’s global ALS Ice Bucket Challenge ALS, time is of the essence, and a momentum going. We intend to do phenomenon was a godsend, raising cure cannot come quickly enough,” the ALS Ice Bucket Challenge every nearly $220 million for ALS research says Hockensmith. “And yet we are August until we find a cure.” Amyotrophic lateral sclerosis (ALS), also known as motor neuron disease (MND), is a progressive neurodegenerative disease that leads to paralysis due to the death of motor neurons in the spinal cord and brain. There is no known cure for the disease. On average, people live only 3-5 years once diagnosed, and there is just one drug approved to treat ALS,
and patient care. Of that, roughly half was directed to The ALS Association.
obligated to be strategic and thoughtful in how we expend resources. We Tanner Hockensmith, Executive must maintain the rigorousness with Director of The ALS Association of which we assess research opportunities see ALS Ice Bucket Challenge page 20 Texas, acknowledges the enormity
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Legal Health
State Legislatures Address “Surprise Bills” from Out-of-Network Providers BY: CHARLES C. DUNHAM, IV EPSTEIN BECKER GREEN
emergency health care services.
The essence of managed care is the ability to require that health care services be rendered by a physician or provider which is a contracted participant with the managed care organization (MCO). These MCOs require enrollees to State legislatures across the country receive treatment only from physicians have been responding to public and providers in the network, even if complaints related to “surprise bills” their primary care physician or specialist for non-emergency health care services has been excluded or terminated from not covered in whole or in part by participating in the network. the individual’s health plan. This One of the underlying causes is common when the individual is of these “surprise bills” is MCOs unaware that the physician or provider shrinking the provider networks is not a contracted participant in their to control and reduce costs. For health plan’s provider network (referred example, in 2013, UnitedHealthcare to as either an “out-of-network” or terminated more than 2,200 physicians’ “non-participating” provider). In most participation agreements under its U.S. jurisdictions, there is no explicit Medicare Advantage plan network in statutory prohibition on balance billing, the state of Connecticut. While the as most state statutory schemes prohibit majority of states have enacted laws balance billing by contracted providers, to prohibit wrongful termination of a but do not typically regulate the activities physician’s participation agreement, of non-participating providers balance such as retaliation for certain protected billing an enrollee unless in relation to conduct, there is sometimes no similar
protection against the non-renewal of a participation agreement. This past legislative session, the Texas legislature passed an Act amending the statutory protections afforded to physicians and providers participating in certain managed care plans to prohibit wrongful termination or non-renewal of participation agreement based solely on informing the patient of, or the patient using, an out-of-network physician or provider for health care services. The cause and effect of reducing the number of physicians and
providers in these types of health plan networks is an increase in out-of-pocket expenses for patients to continue treatment with an existing primary care physician or specialist who is deemed a non-participating provider. In response, several states have adopted legislation to improve transparency, which they believe can solve many out– of–network issues, such as mandated non-participation notices and cost disclosures if a physician refers a patient to an out-of-network physician or see Legal Health page 20
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Mental Health
Addiction without the Drama By Marilyn Freimuth, PhD Director and Professor, Clinical Psychology Doctoral Program Fielding Graduate University
Wile eyed starlettes, hair ascew, are pulled over for drunk driving. Talented actors and musicians tragically die from overdose. Even when making fun of addiction, as in Dave Chappelle’s portrayal of Rick James crawling across the floor interspersed with film of the real James cooing, “Cocaine is a hell of a drug,” we are reminded that addictions are obvious. Outrageous behavior is so strongly associated with addiction that a radio host accused of racist comments was praised for not pulling the “I’m addicted card” to defend his inappropriate actions. I brought images like these with me when, as a newly minted PhD clinical psychologist, I opened my practice. I knew addictions were a common mental health concern affecting up to
25% of the population. Yet, no one matching the previous descriptions came to my office. Instead, I treated people with anxiety, depression, and interpersonal problems. Liz was typical in this regard. A divorced mother and professional, she sought my help for unshakable sad feelings and worry that divorce had adversely affected her children. Within six months her presenting problems resolved. Happy with the outcome but not wanting to say “good-bye,” Liz suggested, “Let’s take a break.” This break ended eight months later when she left this message: “I need to see you. I think I have a drinking problem.” Back in my office, Liz explained that throughout her marriage she drank a glass of wine most evenings. After divorcing, her drinking increased. During therapy, she drank two or three glasses most evenings. While she considered this “normal,” safe drinking for women involves no more than five ounces of wine daily (just a little more than half
a cup) or seven such drinks a week. Liz amount exceeding safe levels). even exceeded safe drinking for men: My most salient reaction to Liz’s two drinks a day and no more than 14 story was surprise. Her competent drinks per week. functioning, thoughtfulness, and even During our therapy “break,” Liz’s her age were inconsistent with my wine consumption grew until she beliefs about what an alcoholic looked routinely finished a bottle between and acted like. I realized that despite dinner and bedtime. She saw no knowing better (I knew anyone can be adverse effects and did not consider an alcoholic), I had succumbed to the drinking a problem until she had a dramatic images in the media and and wake up call—literally. She did not hear was blind to the more subtle ways in her young son crying in the middle of which an addiction can present. the night from stomach pain until he Thus began my research projects came into her room to rouse her. This with Fielding Graduate University event greatly concerned Liz and she clinical psychology doctoral students. immediately decided to cut back on We searched for the subtle signs drinking. Despite being a disciplined of addiction. Liz’s case contained woman, she was unable to meet her many examples. She came to therapy self-defined limit of two glasses (still an see Mental Health page 21
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Healthy Heart
Back to School Health: Tips and Tricks to Keep Our Kids Eating Healthy, Inside and Outside of the Classroom By Michelle Mason Director of Communications Gulf Coast Division of the American Heart Association
The United States is in the midst of a full-blown obesity epidemic that has disproportionately affected our children. According to the American Heart Association (AHA), one-third of our children are overweight, leading to staggering health consequences such as hypertension. Nearly 31.8 percent or roughly 23.9 million U.S. children ages 2-19, are overweight or obese and it is projected that 42 percent of the country will be obese by 2030, up from about one-third today. America is estimated to spend $14.3 billion annually to treat obese children. The need to create and continue federally funded programs to address childhood obesity is enormous. That’s why the
AHA believes schools and parents play a vital role in developing healthy eating habits with our children. Here are three ways you can help prevent childhood obesity just in time for the new school year. Pack Healthier Snack Options in Your Kids Lunch Boxes. Schools have made a lot of progress when it comes to serving nutritious, heart-healthy meals. However, healthy eating is a family affair. Packing healthier food options in our kid’s lunch boxes is the first step towards fighting childhood obesity. Did you know that kids are now eating 12 percent more fruit and throwing away less of the entrees and vegetables? Staying away from foods high in sodium and calories is a great rule of thumb when you are at the grocery store. Make sure to look for foods with low sodium and calories, as well as those packages with the AHA Heart-Check symbol.
Substituting foods high in sugar with yogurt and nuts, or peanut butter is a great way to give your kids a healthy snack that their taste buds will love. Remember to stay away from granola bars high in sugar, and opt for heart-healthy snacks like carrot or avocado slices. If your kids are struggling to enjoy their new, healthy treats, incorporate creative and fun games into lunch time eating. Simply leaving a fun game along with a note in their lunch box is a great way to get your kids excited about eating their education and promotion are snacks, especially if an after school successful in preventing and reducing obesity, especially with low-income prize is waiting for them! students who are disproportionally Educate Your Kids on Nutrition. affected by the childhood obesity Most kids don’t understand the epidemic. Children who participate in importance of healthy eating if they the National School Lunch Program haven’t been introduced to it. Studies eat greater amounts of healthy foods, reveal that most kids believe eating get more essential vitamins and processed food is just as good as eating minerals, drink fewer sugar-sweetened an apple or a banana. A healthy eating beverages, and have an overall better environment helps improve children’s’ quality diet. physical well-being, enhances learning A great way to get kids interested and minimizes behavior problems. in learning what is healthy and The earlier they learn to understand what isn’t is by incorporating visual the importance of healthy-eating, educational elements. Jacqueline Caver, the earlier they will begin to make a Physical Education Specialist at healthy-eating options at school. Turner Elementary school in Pasadena Comprehensive nutrition see Healthy Heart page 21
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Tumor microenvironment: Would this not be a Janus Bifrons of our time? By: Jorge Augusto Borin Scutti, PhD Houston Medical Times
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Why is it so hard to make a global cancer vaccine? Why cancer vaccines are hard to target and how to handle them to reach a targeted immune response? How do cancer vaccines stimulate the immune system to fight against cancer? In order to understand these issues we need to take a closer at how immune system and cancer microenvironment works. The immune system can recognize and destroy tumor cells in a process called cancer
and, through production and secretion of stimulatory growth factors. This collection of cells and molecules together compose the tumor microenvironment. We know that microenvironment plays a major role during the initiation and development of tumor progression. During tumor development monocytes and macrophages are actively recruited into tumors where they change the tumor microenvironment to accelerate tumor progression. Several researchers had been showed that distinct microenvironments where tumor-associated macrophages (TAM) promote cancer cell motility, angiogenesis and metastasis. In addition, there is strong evidence that a regulatory T cell populations (Treg) can migrate into tumors and suppress adequate anti-tumor responses in the tumor
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immunosurveillance. After a century of scientific controversy, the notion that the immune system contributes to cancer development is experiencing a new resurgence - cancer might be seen as a failure of immune surveillance. Recent evidences suggest that the mechanism of tolerance that commonly exist to avoid autoimmune disease may also preclude the development of an proper anti tumor response and tumors themselves have the capability to antagonize the development of effective immune response against their antigens. Thus, the major challenge has been to develop strategies to breaking this tolerance. Advances in our discerning of antigen presentation and tolerance have conduct to some promising strategies. Tumor cells are not just a provincial mass of proliferating abnormal cells, but they are defined as a heterogeneous and structurally complex tissue. These cells can recruit a diversity of cell types, including endothelial cells, fibroblasts and immune cells,
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microenvironment, thus contributing to the prosperity and growth of human tumors. Reasons for limited immune response against tumor cells include immune regulation mediated by cancer cells and immune cells profile on microenvironment. Cancer vaccines are strategies that belong to a class of substances defined as biological response modifiers. The potential use of cancer vaccines is to restore the immune system of patients in attempt to stimulate it to reject and destroy tumors. Furthermore, there are some strategies to modulate the microenvironment - targeting regulatory cells, blocking differentiation or recruitment, blocking immunosuppressive enzymes, regulatory cell depletion, re-programming immunosuppressive cells, modifying the chemokine and cytokine profile are some examples. The attractively of new strategies for cancer vaccines is driven by probability of antigen, immune response see Tumor Microenvironment page 21
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Aging Americans fight diabetes differently
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years to come. And luckily for them, treating type 2 diabetes in older adults America is growing older and tends to be less rigorous than it is for wider. At the same time baby boomers younger people. (the population born between 1946 Serious complications of type 2 and 1964) are celebrating their diabetes typically develop over decades. 65thbirthdays, obesity rates in the So while younger diabetes patients United States are skyrocketing. work hard to prevent them, for older Seventy-five percent of Americans are patients with fewer years left, aggressive currently living beyond the age of 65, treatment (using medications to keep which is great news. But more than glucose levels between 90 and 120 one-third of them (35.4 percent) are mg/dL) might cause more harm in the obese. short term than it may prevent. As the age and weight of the “As we age, our organs don’t population increases, so does the function as well, so we become more prevalence of type 2 diabetes. Nearly 27 susceptible not only to diabetes but to percent of older adults have diabetes, other chronic diseases,” said Castro. compared with about 14 percent of So for older adults who have several
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chronic conditions and medications to treat each of them, controlling blood “As we age, the combination of sugar can be complicated business people’s failing organ systems due to where there’s no room for error. age, diets high in sugars and fats, and What’s more, aggressive treatment familial risk for diabetes all come to of diabetes in older adults can lead to a point where patients start having hypoglycemia, or extremely low blood the symptoms and signs of diabetes sugar. For older adults, this condition at an older age,” says Juan F. Castro, might be more dangerous than a high M.D., medical director of the diabetes blood sugar reading. education program at the Texas A&M “When someone becomes Health Science Center Coastal Bend hypoglycemic, they get light headed, Health Education Center (CBHEC) in which can make them fall,” said Corpus Christi, Texas. Manuel Guajardo, registered nurse For these patients, a diagnosis and certified diabetes educator with of diabetes often seems like a death the Texas A&M CBHEC diabetes sentence. But people over 60 who have education program. “Falling can lead see Aging Americans page 22 diabetes can maintain quality of life for medicaltimesnews.com
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TIRR Memorial Hermann Moves Up the Rankings of Nation’s Top Rehabilitation Hospitals TIRR Memorial Hermann is the best rehabilitation hospital in Texas and the second best in the United States, according to U.S. News & World Report’s Best Hospital rankings for 2015-2016. TIRR Memorial Hermann’s ascend to the No. 2 spot marks the 26th consecutive year TIRR Memorial Hermann has been included in the rankings. “This acknowledgment is a testament to our long-term legacy of leading medical rehabilitation, research, education and providing excellent care,” says Carl Josehart, Sr. Vice President, CEO, TIRR Memorial Hermann. “It also demonstrates the continued innovation and dedication
walk through the door they’ll receive only the highest level of care and compassion.” U.S. News evaluated hospitals in 16 adult specialties and ranked the top 50 in most of the specialties. Less than 3 percent of the nearly 5,000 hospitals that were analyzed for Best Hospitals 2015-16 were nationally ranked in even one specialty.
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of our affiliated physicians and staff to advance the field of rehabilitation.” TIRR Memorial Hermann was founded in 1959 as one of the country’s first rehabilitation hospitals. It has since grown to a 134-bed hospital located in the world renowned Texas Medical Center in Houston. In addition to providing the very highest level of rehabilitation services to patients, TIRR Memorial Hermann is also a leader in cutting-edge research to treat people with a range of disabilities and complex conditions such as brain and spinal cord injury, stroke, multiple trauma, amputation and neurodegenerative diseases. “We’re so proud of the staff at TIRR Memorial Hermann and the consistent recognition they receive for providing patients with the best rehabilitative care possible,” says Dan Wolterman, President and CEO, Memorial Hermann Health System. “Patients and their families come to our rehabilitation hospital from around the world because they know when they August 2015
best has much to be proud of.”
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Memorial Hermann-Texas Medical Center was also listed in the U.S. News rankings in the specialty areas of gynecology, nephrology and urology.
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U.S. News publishes Best Hospitals to help guide patients who need a high level of care because they face particularly difficult surgery, a challenging condition or extra risk because of age or multiple health problems. Objective measures such as patient survival and safety data, adequacy of nurse staffing and other data largely determined the rankings in most specialties. The specialty rankings and data were produced for U.S. News by RTI International, a leading research organization based in Research Triangle Park, N.C. U.S. News used the same data, as well as the new Best Hospitals for Common Care ratings, first published in May, to produce the state and metro rankings.
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Music to a patient’s ears: when surgeons listen to their preferred music, their stitches are better and faster A new study from The University of Texas Medical Branch at Galveston shows that when plastic surgeons listen to music they prefer, their surgical technique and efficiency when closing incisions is improved. The study is currently available in the Aesthetic Surgery Journal.
chief plastic surgery resident. “This effect was reduced by randomly assigning the residents to music first or no music first groups.” The average repair completion time for all residents was 7 percent shorter when their preferred music was playing. This effect was magnified as the experience of the surgeon grew. Playing their preferred music led to a 10 percent reduction of repair time for senior residents as compared to an 8 percent time reduction seen in the junior residents.
From classical to rock, music can be heard in operating rooms across the world. Although previous studies have shown that listening to music during operations can lower the stress levels of surgeons, there is limited information on the effects of music on technical “Spending less time in the performance while completing a operating room can translate into surgical task, such as closing incisions. Stitching prowess and speed is especially significant cost reductions, particularly when incision closure is a large portion important for plastic surgeons.
Fifteen plastic surgery residents were asked to close incisions with layered stitches on pigs' feet obtained at a local food market – pigs’ feet are widely accepted as similar to human skin. The residents were not informed of the purpose of the study. They were asked to do their best and to notify the researchers when they completed a closure. The day after the first incision closing exercise, the residents were asked to do another repair using identical technique with the music either being turned on or off, in opposition to the first closure. They were not told that the researchers were comparing times or that the results would be graded until the study was completed.
of the procedure, such as in a tummy tuck,” said Lies. “Longer duration under general anesthesia is also linked with increased risk of adverse events for the patient.” The quality of the work was judged by plastic surgeons who did not know whose work they were analyzing or other conditions of the study. The judges’ ratings confirmed an overall improvement in repair quality while music was played, regardless of whether the resident did the repair with their music first or second.
“Our study confirmed that listening to the surgeon's preferred music improves efficiency and quality of wound closure, which may translate to health care cost savings and better “We recognized that our subjects patient outcomes,” said author Dr. could potentially improve on the second Andrew Zhang, UTMB assistant repair simply as the result of repetition,” professor of surgery in the division of said author Dr. Shelby Lies, the UTMB plastic and reconstructive surgery. medicaltimesnews.com
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Hereditary colorectal cancers, caused by inherited gene mutations, are relatively rare for most patients. However, researchers at The University of Texas MD Anderson Cancer Center have discovered a particularly high prevalence of hereditary cancers among those diagnosed with the disease before the age of 35. They suggest that these patients should undergo genetic counseling to determine if their families may be at an elevated risk. Approximately five percent of all colorectal cancer (CRC) cases are caused by hereditary syndromes, such as Lynch syndrome and familial adenomatous polyposis (FAP). Among patients with early-onset CRC, generally defined as a diagnosis before age 50, the incidence of hereditary CRC tends to be higher. However, the prevalence in adolescents and younger adults has not been well characterized.
“We were very surprised to find that 35 percent of that population of patients had a genetic disease,” says Vilar-Sanchez, “although we hypothesized the proportion would be higher in this age group relative to the general population.” According to the American Cancer Society, colorectal cancer (CRC) is the third most common cancer among men and women in the U.S., with over 90,000 new cases expected this year. Approximately 90 percent of those cases will be diagnosed in patients older than 50.
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“Based on our findings, patients under the age of 35 need to be evaluated by a genetic counselor. Period,” says Vilar-Sanchez. “The translation of that information extends well beyond the patient, as there are tremendous benefits from being able to share genetic risk with their parents, siblings and many other family members.” Genetic findings important for families In the general population, the risk of being diagnosed with CRC in one’s lifetime is five percent. People with Lynch
The current study, published in the Journal of Clinical Oncology, focused on patients diagnosed at age 35 or younger to better characterize the extent of hereditary CRC in this underrepresented age group. The research team, led by Eduardo Vilar-Sanchez, M.D., Ph.D, assistant professor, Clinical Cancer Prevention, reviewed data from 193 patients diagnosed with CRC in this age rage that were evaluated by genetic counseling at MD Anderson between 2009 and 2013. This study represents the largest reported cohort of CRC patients diagnosed in this age range in the U.S.
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genetic risk to family members, explains Vilar-Sanchez.
Patients diagnosed with CRC at age 35 or younger therefore represent an extreme end of the spectrum, accounting for less than 1.5 percent of all cases. This population faces unique challenges related to disease aggressiveness, the impact of treatments on fertility and potential
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Eduardo Vilar-Sanchez, M.D., Ph.D.
syndrome, on the other hand, have a lifetime risk of 50-80 percent. Those with FAP have a 100 percent chance of developing cancer if no preventive measures are taken. Genetic testing in family members will identify those with high-risk mutations and allow them to take proper preventive actions, such as behavioral modification to reduce other environmental risk factors. There’s also the potential for them to participate in earlier screening, increased surveillance, prophylactic surgeries and chemoprevention studies, explains Vilar-Sanchez. A limitation of this study was the lack of uniform genetic testing across all patients. Previously, genetic counselors tested a small number of see Colorectal Cancer page 22 August 2015
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Framework
Pearland Mayor Gets Up Close Look at Memorial Hermann Pearland Hospital Construction Memorial Hermann will open its 14th hospital in Pearland next year. Recently, Pearland Mayor, Tom Reid, was taken inside to get a closer look at construction of Memorial Hermann Pearland Hospital. Merrill Stanley, director of operations, Texas Milestone Project Management, and the lead project manager for the construction project at Memorial Herman Pearland showed Mayor Reid around the 40-acre medical campus already home to the Pearland Convenient Care Center.
patient-centered care,” says Asprec. “Bringing access to growing communities like Pearland remains a core mission for the System.”
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Mayor Reid has watched the hospital go up from the very start and says he feels a sense of pride seeing the growth in Pearland. “The hospital is very impressive,” said Mayor Reid. “Pearland is becoming a medically oriented community and it’s always good to have the top players, like Memorial Hermann, in your community.”
Pearland remains the fastest-growing community in the Greater Houston area, the second in Texas and 15th overall in the U.S. The population in Pearland has more than doubled since 2011 with more than 100,000 residents and forecasted growth of nearly 50,000 additional residents by 2040 – underscoring the demand Mayor Reid was joined on for closer-to-home access to quality his tour by Kyle Price, Sr. Vice medical care. President, CEO, Memorial Memorial Hermann Pearland Hermann Southeast Hospital and is expected to add approximately Erin Asprec, Regional President, 450 jobs to the local economy. Memorial Hermann. “We look Memorial Hermann Pearland is forward to offering Pearland located at 16100 South Freeway on some of the region’s top medical the southbound side of Highway experts along with high quality, 288 near FM 518. August 2015
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Houston Methodist Hospital, MD Anderson Cancer Center teams perform first multi-organ transplant that includes skull and scalp Surgical teams from Houston Methodist Hospital and The University of Texas MD Anderson Cancer Center successfully transplanted, for the first time, a scalp and skull while performing kidney and pancreas transplants. Surgeons at Houston Methodist Hospital & MD Anderson Cancer Center performed the world's first skull & scalp transplant. James Boysen, a 55-year-old software developer from Austin, Texas, is the first patient to receive the simultaneous craniofacial tissue transplant together with solid organ transplants.
surgery, including specialized reconstructive plastic surgeons from MD Anderson and Houston Methodist Hospital and a team of transplant surgeons, a neurosurgeon and an anesthesiologist, nurses and others from Houston Methodist. LifeGift played an integral role in the planning and preparation as well, never before facilitating the procurement of a scalp and skull for transplant.
"This has been a long journey, and I am so grateful to all the doctors who performed my transplants," Boysen said. "I’m amazed at how great I feel and am forever grateful that I have another chance to get back to doing the things I love and be with the people I love." The 15-hour surgery, which was conceptualized nearly four years ago, was performed at Houston Methodist Hospital by a team led by MD Anderson’s Jesse C. Selber, M.D., and Houston Methodist’s A. Osama Gaber, M.D., on Friday, May 22, about 20 hours after LifeGift alerted the team to the availability of the organs. Today Boysen will be discharged from Houston Methodist Hospital. He will remain in Houston at Nora’s Home for three weeks of coordinated follow-up care from both institutions. More than 50 health care professionals per formed, assisted with or supported the
transplant all these tissues from When Selber and Boysen one patient, and Jim’s patience, first met, the scalp and skull courage and enthusiasm for the wound were preventing idea were vital." doctors from performing the "This was a very complex second solid-organ transplant. surgery because we had to Likewise, his critical kidney and transplant the tissues utilizing pancreas functions, together microsurgery," said Michael with his immunosuppression Klebuc, M.D., the surgeon who medications, were complicating led the Houston Methodist scalp reconstruction. Hospital Plastic Surgery Team. But while his wound, "Imagine connecting blood vessels 1/16 of an inch under medication and transplanted a microscope with tiny stitches organ failure created a clinical about half the diameter of a Catch-22, they would also be human hair being done with part of the solution that led to tools that one would use to make the triple transplant. a fine Swiss watch." "When I first met Jim, I In 2006, Boysen had been made the connection between diagnosed with leiomyosarcoma, him needing a new kidney and pancreas and the ongoing anti-rejection medication to support them, and receiving a full scalp and skull transplant at the same time that would be protected by those same medications," said Selber. "This was a truly unique clinical situation that created the opportunity to perform this complex transplant."
Left is Dr. Jesse Selber with MD Anderson and on the right is Dr. Michael Klebuc with Houston Methodist Hospital.
"While it was incredibly exciting to bring together two of the Texas Medical Center’s leading institutions to collaborate and leverage their expertise for this first-ever transplant, the most meaningful result is what the successful surgery will mean for Jim," said Selber, associate professor of Plastic and Reconstructive Surgery at MD Anderson, the clinical team co-leader and the originator of the idea to transplant the scalp and skull during the same surgery to transplant the other organs. "This was an ideal clinical situation that allowed us to
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a rare cancer of the smooth muscle, on his scalp. Successfully treated with chemotherapy and radiation, he was left with a large, deep wound on his head that included the scalp and the full thickness of his skull down to his brain. In addition to the wound, which would require a major reconstructive undertaking, Boysen’s kidney and pancreas, which were first transplanted in 1992, were failing. Diagnosed with diabetes at age 5, Boysen’s declining condition over the years prompted the original double-organ transplant.
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"With the Houston Methodist transplant resources, we had the perfect opportunity to help Mr. Boysen," said Gaber, director of the Houston Methodist J.C. Walter Jr. Transplant Center and the surgeon who performed the kidney and pancreas transplants and led the Houston Methodist team who cared for Boysen. "I was pleased that, despite the difficult nature of the procedure, the donor and recipient surgeries worked flawlessly. The two surgeries spanned over 24 hours and required multiple Houston Methodist Hospital and MD Anderson physicians and Houston Methodist nursing teams to complete. Our nurses and transplant coordinators fell in love with Jim and were excited to see him do so well." August 2015
Houston Medical Times
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Page 16
Harris Health System Achieves “Most Wired” for Fifth Consecutive Year For the fifth year in a row, Harris Health System earned the “Most Wired” recognition in the 17th annual survey and benchmarking study conducted by the American Hospital Association’s Health Forum and the College of Healthcare Information Management Executives. This year, Harris Health joins two other healthcare systems in greater Houston and 15 others in Texas to be recognized as Most Wired. “Harris Health is a leader in using technology to improve both the quality of care and the patient care experience, and this recognition proves it,” says Tim Tindle, executive vice president and chief information officer, Harris Health System. “Clinicians and staff can access a patient’s complete medical
Tim Tindle, executive vice president and chief information officer, Harris Health System.
training users and answering technical calls so clinicians can always focus on patient care,” Tindle adds. This year's Most Wired use the benefits of a patient portal to get
record, including imaging, anytime and anywhere in our system. This allows our medical staff to use the all-inclusive record to provide patients the most appropriate treatment and optimal outcomes.”
patients actively involved in their health and healthcare. For instance, 89 percent of Most Wired offer access to a patient portal through a mobile application. Other key According to the survey, hospitals findings include: are taking more aggressive privacy ∙ 67 percent of Most Wired and security measures to protect and offer the ability to incorporate safeguard patient data. Top growth areas in security among this year’s patient-generated data. Most Wired include privacy audit ∙ 63 pe rc e n t offer systems, provisioning systems, data self-management tools for loss prevention, single sign-on and identity management. chronic conditions. “Our entire information ∙ 60 pe rc e n t offer technology staff responds to the patient-specific education in needs of our clinical teams by multiple languages. operating servers, building networks, medicaltimesnews.com
August 2015
Houston Medical Times
Page 17
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New UTMB study uncovers how common white fat can be turned into energy-burning brown fat in humans
model of severe and prolonged stress where adrenaline-release is massively increased for several weeks following the injury. The researchers used this “stress model” to study their hypothesis that, similar to animal models, human Researchers from The University rate while also lowering blood glucose white fat can also turn into brown of Texas Medical Branch at Galveston levels. In this study the researchers fat. The authors enrolled 72 patients have discovered, for the first time in show that white fat in humans can also that had sustained severe burns over humans, that the widely reviled energy turn into a form resembling brown fat. approximately 50 percent of their storing white fat can be turned into an energy burning brown fat that uses up excess calories. These findings were published in the August 4th edition of Cell Metabolism. Given today’s global obesity and metabolic syndrome epidemic, the ability to burn calories without altering physical activity levels would be of great therapeutic value. Increasing energy expenditure by the browning of white fat holds much promise for the treatment of complications associated with obesity and sedentary lifestyle. Previous studies by the UTMB group and others have shown that people have brown fat, albeit in small amounts and that when ‘switched on’ this brown fat can increase metabolic
following the injury. The metabolism of the fat samples, the makeup of the fat cells and the patients’ resting metabolic rates were measured. Brown fat cells are unique from white fat in terms of their genes, structure and function. Brown fat cells are smaller than white fat cells, have higher numbers of mitochondria – the combustion engines of the cell and express a protein called UCP1, or uncoupling protein 1. Adrenaline turns on UCP1, which makes mitochondria burn calories without making any chemical energy - just heat. The researchers found in burn patients that there was a gradual shift in molecular and functional characteristics of white fat to a more brown fat phenotype over time, suggesting progressive browning of white fat in response to a burn injury.
“Our study provides proof of concept that browning of white fat is possible in humans. The next step is to identify the mechanisms underpinning However, for this to happen it requires bodies. Nineteen healthy people served this effect and then to develop drugs severe and prolonged adrenaline-releas- as a comparison group. Samples of that mimic the burn-induced effect,” ing stress. white fat were taken from the burned said lead author Labros Sidossis, Burn trauma represents a unique patients at different time points UTMB professor of internal medicine.
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ALS Ice Bucket Challenge Continued from page 1
while also ensuring resources remain available to help improve quality of life for those currently living with the disease.” Hockensmith concedes it’s a challenging balance to maintain given what’s at stake. While there has been no shortage of public commentary about how the money should be spent, The ALS Association has announced how it intends to devote the money (see spending info graphic). The organization has directed the bulk of the money, $67 million, towards research efforts, working to ensure the most promising projects are funded to accelerate the search for treatments and a cure, with projects focused on five key areas: biomarker discovery, gene discovery, disease model development, clinical studies and drug development. To that end, the organization will increase its annual funding through various research award opportunities and fund four collaborative global research initiatives: ∙∙ Project MinE — global sequencing effort to identify new genes linked to sporadic and familial ALS ∙∙ The Neuro Collaborative — Three research labs working together to find effective treatments ∙∙ The New York Genome Center — repository for ALS genome sequencing data that
increases number of genetic samples scientists can study •ALS ACT — joint project aimed at expediting clinical trials and searching for biomarkers as indicators of disease The organization has also directed $23 million to provide more support to people living with the disease, and increase access to multi-disciplinary care at ALS Association Certified Treatment Centers of Excellence. This includes: ∙∙ Doubling grants to ALS Association Certified Treatment Centers of Excellence, which offer state-of-the-art multi-disciplinary care and provide a home for clinical trials to find treatments for the disease. This includes increased funding for Certified Treatments Centers in both Houston and San Antonio, and first time funding for a third clinic in Austin currently going through the credentialing process.. ∙∙ Offering grants to ALS Association chapters to help improve patient access to care in unserved or underserved communities. This includes resources to extend the Texas Chapter’s reach into far west Texas, the Texas Panhandle and South Plains areas.
∙∙ Supporting the ALS Untangled initiative to help fund the review of non-traditional treatments for ALS. ∙∙ Improving education materials for people newly diagnosed and those who continue to manage the disease. Texans with ALS are seeing tangible benefits from the success of last year’s Ice Bucket Challenge. The ALS Association of Texas has initiated a general grants program through which people with ALS and their families can receive grants to retrofit their homes to accommodate their changing mobility needs as the disease progresses, help cover expenses for transportation to and from ALS clinics, help pay for respite care, and assist with some minor medical equipment purchases. Additionally, the Texas Chapter has been able to hire an additional Case Manager to cover the growing caseload of newly diagnosed patients, particularly in north Texas, and expand its equipment loan closets inventories from which it can provide patients with electric wheelchairs and communications devices. Reflective of the wishes of the founders of the Ice Bucket Challenge and their families that all ALS related organizations benefit from the increased awareness and resources and work collaboratively whenever possible, a new dedicated website – www.al-
sicebucketchallenge.org – has been launched to inform people about ALS and the ALS Ice Bucket Challenge, and to make it easier for them to donate to The ALS Association or one of 14 other ALS organizations. This represents the largest coordinated effort of ALS nonprofits to date, and many of the organizations hope to work more closely together not only on awareness and fundraising activities such as the ALS Ice Bucket Challenge, but also on providing crucial patient services and accelerating ALS research. “The ALS Ice Bucket Challenge embodies all that is great about the people of Texas,” says Hockensmith. “It’s about fun, family and friends, and helping our fellow Texans who are in the fight of their life. Nobody can predict when the turning point in this fight will come, but it’s imperative that we all commit ourselves to supporting this campaign until that day does finally arrive.” IMPORTANT LINKS w w w. a l s t e x a s . o r g http://www.alsa.org/fight-als/icebucket-challenge-spending.html http://www.alsa.org/ fight-als/ibc-progress.html http://www.alsa.org/ fight-als/ibc-instr uctions.html www.ALSIceBucketChallenge.org
Legal Health
Continued from page 3 provider. Moreover, several states have established a dispute resolution process for patients to contest the amount of “surprise bills” in certain instances. Since 2009, Texas has mandated a non-participation notice and right of mediation process, which are limited to non-emergency services provided in a hospital by an out-of-network “facility-based physician” (defined as a radiologist, an anesthesiologist, a pathologist, an emergency department physician, or a neonatologist). ∙∙ The right to mediation provision is applicable if the facility-based physician balance bills an amount in excess of $1,000 (after all copayments, deductibles, and coinsurance,
including the amount unpaid by the administrator or insurer). The statute requires that the billing physician provide notice of the patient’s right to mediation with the invoice and participate in the mediation if requested by patient. ∙∙ The disclosure provision requires an out-of-network, facility-based physician to notify the patient prior to providing any service or supply, except in the case of any emergency, that (i) the physician does not have a contract with the patient’s health plan; (ii) the projected out-of-pocket costs; and (iii) the patient’s responsibility
in the health insurance industry to market lower premiums by deferring costs on the backend through a higher coinsurance, deductible or copayment amount. In the end, the negative result of this trend is that patients will not be able to cover the high out-of-pocket This past legislative session, an Act costs, and the physicians and providers was passed amending the statutory right will need to address how to deal with to mediation by reducing the minimum increased collection activities and amount to $500 and expanding the loss of revenue due to unpaid patient definition of a “facility-based physician” services. To what extent the physicians to include an assistant surgeon. The and providers need to make good statute will be effective September 1, faith efforts to collect the coinsurance, 2015. deductible or copayment amounts owed The implementation of the Health by the patient is a topic of significant Insurance Marketplace (or State debate and litigation in the context Exchanges) under the Affordable Care of out-of-network services and the law Act is reflective of another recent trend differs on a state-by-state basis. for such costs. The statute removes the right to mediation if the patient provides written acknowledgement of such disclosure and the amount billed is less than or equal to the projected amount.
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Houston Medical Times
Mental Health
Continued from page 4 warning signs so that treatment can occur sooner and be more effective. Again, Liz was an example. Loss of control over substance use (i.e., using more than intended, can’t stop or cut back despite good intentions) is an early warning sign that appears well before any dramatic adverse consequences portrayed in the media. This work is summarized in two books: Hidden Addiction and Addicted? Recognizing Destructive Behavior Before It’s too From what we learned, my students Late. As for Liz, who was in the early and I developed a continuum view of addictions to identify addiction’s early stage of addiction (loss of control but with classic signs of depression --self doubt, sadness, sleep probems—and I immediately concluded that this was the problem. Lesson one was to remember that substance use problems come disguised as psychological ones. Alcohol, which at first promotes sleep, ultimately disrupts it. As a nervous system depressant, alcohol initially relieves stress but can leave a person feeling lack luster and low, like depression.
no major adverse effects), she had the choice to stop drinking or drink within safe limits. Either way, treatment starts with 6 months of no alcohol. Liz accomplished this goal with the help of therapy. Now, it was Liz’s turn for surprise; without alcohol she discovered a new self who was more content and better attuned to others’s needs. Relationships with her children and work improved. To this day, she continues not to drink.
substance and behavioral addictions in their early stages. This novel approach limits the enormous costs of addictions and makes for more effective treatment. Her addiction study group at Fielding has yielded
addictions in their early stages. This novel approach limits the enormous costs of addictions and makes for more effective treatment. Her addiction study group at Fielding Dr. Marilyn Freimuth is the author has yielded numerous publications and of two books that provide a ground presentations with clinical psychology breaking approach to recognizing doctoral students.
Healthy Heart
Continued from page 5 Independent School District, said she In December 2010, President showed her students how much sugar Obama signed the bipartisan Healthy, was in one can of soda by showing Hunger-Free Kids Act (HHFKA), them the equivalent with sugar cubes. which empowered the U.S. “[My] students were blown away Department of Agriculture (USDA) by the amount of sugar they found in to update the national nutrition beverages they drink just about every standards for school meals and establish nutrition standards for other day,” Caver said. “They could not foods sold in schools throughout the believe it.” school day. It is because of this, more Caver uses Facebook as a tool to get than 93 percent of schools are meeting the parents of her students interested the updated nutrition standards for the in promoting healthy living at home. school lunch program – a threshold By issuing Facebook challenges, Caver that they must meet to receive an extra has found that parents are eager to six cents reimbursement. introduce healthier eating options But there is still a lot of work to during each meal. be done in order to reduce childhood “If parents tag me with a picture obesity. Schools need to be part of the of their family or the student drinking solution by establishing a foundation water, being active, eating fruits and for a lifetime of healthy behaviors. veggies, than I give them special tickets One way schools and parents can at the beginning of the school year to do this is by providing healthy meals participate in a before school open and nutrition education to promote a gym,” Caver said. healthy food environment. Research Healthy-Eating Initiatives on the Local and National Level.
environments might benefit by joining one that can open the door to new forces with the AHA’s Voices for possibilities and opportunities for Healthy Kids. healthier food environments in our Voices for Healthy Kids works with schools. state agencies and local school boards For more information on Voices to support efforts to sell healthier for Healthy Kids and back to school snacks and beverages in school by: lunch box recipes, visit www.heart.org
∙∙ Helping to align state or local Michelle Mason is the Director school nutrition standards of Communications for the American with updated federal standards. Heart Association Gulf Coast Division. ∙∙ Exploring ways schools can go Stephanie Phillips is currently a public beyond the federal standards, relations intern for the American such as by creating heathier Heart Association. The American fundraising standards or heart Association is the nation’s extending standards to apply oldest and largest voluntary health to after school time. organization dedicated to building ∙∙ Working with food service healthier lives free of cardiovascular providers to enhance disease and stroke. Our mission is professional standards. to build healthier lives by preventing, ∙∙ Making water a free, safe, and treating, and defeating these diseases – easily accessible option for kids America’s No. 1 and No.5 killers. We throughout the school day. fund cutting-edge research, conduct Making time to become a local lifesaving public and professional Parents eager to make a difference voice and advocate for our kid’s heart educational programs, and advocate and help establish a healthier food health can be a daunting task, but to protect public health.
Tumor Microenvironment Continued from page 6
and microenvironment discovery, product development, development cost and clinical development. In April 2010 FDA approved the first cancer treatment vaccine against metastatic prostate cancer - Provenge®. For this strategy immune cells are removed from the patients blood by leukapheresis handed over to the laboratory and designed to stimulate a class of cells called antigen-presenting August 2015
cells (APCs), more specifically dendritic cells. These cells are stimulated with an antigen that is found on prostate cancer cells -prostatic acid phosphatase (PAP) plus GM-CSF (Granulocyte-macrophage colony stimulating factor) a protein that stimulates the APCs to increasing the antigen presentation to lymphocytes – crucial step for the immune response. Biologically tumor cells are regarded as
poor stimulators of T cells. Dendritic cells are highly specialized in this function and are therefore likely to be important intermediaries in the process of stimulating T cells responses against tumors. These dendritic cells that have taken up PAP-GM-CSF stimulate T cells of the immune system to kill tumor cells that express PAP. According to American Cancer Society although the vaccine
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doesn’t cure prostate cancer, it has been shown to help extend patient’s lives by several months on average. Studies to see if this vaccine can help men with less advanced prostate cancer are now being done. As Isaac Newton once said What we know is a drop, what we don't know is an ocean.
Houston Medical Times
Aging Americans
HOUSTON
Continued from page 8
to serious injury for seniors, such as diabetes self-management. Declining broken hips and ribs.” vision makes it more difficult to read For this reason, Guajardo says prescription bottles and glucometers; achieving a certain number might not cognitive impairment affects decision be the best approach for older adults. making and retention of new In fact, some older diabetes patients information; physical decline makes might feel ill if their blood sugar it harder to shop and cook, not to mention being physical active. reaches an “ideal” level. But while these barriers may be “Most of these people have lived greater for much older adults, some with elevated blood sugar for ten, twenty, thirty years before they’re might be fully capable of doing all the diagnosed,” said Guajardo. “For them, above. that’s the norm. We don’t want to let “Each patient is different,” their blood sugar go too high, but they Guajardo said. “We have to take might be perfectly fine maintaining into account their living situations – levels that are a bit higher than the at home or in assisted living – their guideline.” mobility, transportation, number of Age also brings other barriers medications, psychosocial needs. All that can add to the complexities of of these factors change the formula.
There’s no single combination that works for everyone.” And while physical activity is crucial, patients might fear falling or unsafe neighborhoods. But health educators recommend starting by walking for a few minutes a day inside, then moving to the sidewalk or nearby track. Water fitness is a good alternative for older patients who have joint problems. To get the most out of diabetes treatment and to learn more, Castro recommends attending a diabetes self-management education (DSME) program and bringing at least one relative or close friend. A list of DSME providers is available through the American Diabetes Association.
Colorectal Cancer Instead, Vilar-Sanchez says, “Our data advocates for gene panel testing in this population.” Gene panel testing denotes the simultaneous analysis of dozens of genes known to influence CRC risk. This would allow all young patients
Published by Texas Healthcare Media Group Inc. Editor Sharon Pennington Director of Media Sales Richard W DeLaRosa Creative Director Lorenzo Morales Distribution Vincent DeLaRosa Accounting Liz Thachar Staff Writers Jorge Augusto Borin Scutti, PhD Denise Hernandez MS,RD,LD Office: 713-885-3808 Fax: 281-316-9403
Continued from page 12
genes sequentially based on family profile and tumor analysis until the culprit was identified. Therefore, not all patients in this cohort underwent identical testing, and some patients’ underlying hereditary predisposition may have been missed.
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to undergo comprehensive genetic testing, rather than a biased approach. A recent study, also published in the Journal of Clinical Oncology, found that gene panel testing for CRC was cost-effective. Vilar-Sanchez notes that gene-panel testing is now normal clinical practice at MD Anderson. Continuing efforts in cancer prevention Going forward, Vilar-Sanchez would like to focus efforts on the remaining two-thirds of patients diagnosed under age 35 without an identified genetic cause. Within this group, 28.6 percent had a family history of CRC and 51.6 percent had a family history of other cancers. Strong family disease history suggests a hereditary contribution and future research will try to identify the gene mutations responsible. In addition to genetics, early-onset CRC may be attributed to several behavioral and environmental risk factors, including diet, obesity, smoking and alcohol. These risk factors may compound minor genetic contributions or contribute to early onset in those without a genetic component. Cataloguing environmental and genetic factors that contribute to CRC are critical for physicians to identify those with an elevated disease risk and work to prevent cancer development. “The best way to cure cancer is not to get it in the first place,” says Vilar-Sanchez.
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