Houston Medical Times

Serving Harris, Galveston, Brazoria and Fort Bend Counties

HOUSTON

September Issue 2015

Inside This Issue

UTHEALTH AND MEMORIAL HERMANN CELEBRATE THE LIFE OF RENOWNED SURGEON JAMES H. “RED” DUKE, JR., M.D. James H. “Red” Duke, Jr., M.D., renowned surgeon, medical educator and Texas icon, passed away today surrounded by family and friends. He was age 86.

National Study Analyzes Medical Malpractice Allegations against Orthopedist See pg. 10

INDEX Legal Health..................pg.3 Mental Health...............pg.4 Healthy Heart................pg.5 Oncology Research......pg.6 Age Well Live Well..........pg.8 The Framework............pg.12 Nutrition Corner...........pg.18

Brian Dean Named CEO of Memorial HermanTexas Medical Center See pg. 18

Duke, the John B. Holmes Professor of Clinical Sciences at The University of Texas Health Science Center at Houston (UTHealth), was a dedicated physician known for his extraordinary patient care and efforts to train medical students and surgeons, and educate the public about health issues.

“Dr. Duke was a true pioneer – a talented and tireless surgeon, a dedicated and inspiring educator, and a friend and mentor to everyone he met. He never sought to be a leader, but became one naturally through his brilliance, compassion, patience and selflessness,” said Giuseppe N. Colasurdo, M.D., president of UTHealth and dean of UTHealth Medical School. “He was a constant presence at our university and we will miss his guidance, his wit and, most importantly, his example. From all of us at The University of Texas Health Science Center at Houston – thank you Dr. Red Duke.”

As one of UTHealth’s first faculty members at its Medical School, Duke established the trauma service at the primary teaching hospital now called

James H. “Red” Duke, Jr., M.D.

Memorial Hermann-Texas Medical Center. In 1976, he was instrumental in developing Life Flight®, the state’s first lifesaving air ambulance service.

For almost four decades, he served as medical director of Life Flight, a signature program of Memorial Hermann Texas Trauma Institute.

“Dr. Duke was one of our country’s great doctors. He was a friend, a colleague, and a role model and mentor to a generation of doctors who benefited immensely from his guidance. I, along with everyone at Memorial Hermann, will forever miss Dr. Duke. As we collectively grieve, we also want to extend our sincere gratitude for his relentless and unprecedented dedication and impact on medicine, education and the medical community,” said Dan Wolterman, president and CEO, Memorial Hermann Health System.

A founding member of the American Trauma Society, Duke spent much of his medical career developing an infrastructure to provide better care for injured patients while also focusing on programs to prevent injuries. He

played a critical role in the development of the EMS and trauma system in the state of Texas. His tireless pursuits also resulted in serious consideration for the position of U.S. Surgeon General in 1989.

As a result of the nationally syndicated television news program, Texas Health Reports, which educated millions about topics ranging from kidney stones to injury prevention to proper nutrition, he became one of the most recognized personalities in his field.

His trademark bottle-brush mustache, military issued wire-rimmed glasses, Texas twang and colorful stories accented with cowboy hat and folksy humor made Duke a one-of-a-kind folk hero with the personality of an old-fashioned country doctor and the extraordinary talent of modern-day surgeon.

When the father of four wasn’t with his family, in the operating room, at his patients’ bedside or starring on a television program, he was an ardent conservationist, serving see James H. “Red” Duke page 19

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Page 3

Legal Health

The Clock’s Running Fast: The First Decision Interpreting “Identification” Under the FCA’s “60-Day Rule” for Government Overpayments is Here the moment when an overpayment is conclusively ascertained.” This case is the first of its kind, and will be perceived as a significant victory by government enforcers and qui tam relators who will use it as precedent.

However, the vagueness of the FCA

By George B. Breen and Daniel C. overpayment provision should be Fundakowski the subject of future appeals and EPSTEIN BECKER GREEN continued challenges. Nevertheless, On August 3, 2015, in United health care entities need to be aware States ex rel. Kane v. Healthfirst, Inc., of this decision and its short-term et al., the United States District Court ramifications. for the Southern District of New York The complaint alleges that, issued the first reported opinion on because of a software glitch, three New the False Claims Act’s (“FCA’s”) reverse false claim overpayment York City hospitals erroneously billed provision and determined when an the New York Medicaid program as overpayment is deemed “identified” a secondary payor after already being by a health care provider. Denying paid in full by the patients’ Medicaid a motion to dismiss, the court held managed care plan. After the State that the FCA’s statutory 60-day Comptroller inquired about the issue, clock for repaying “identified” management tasked the eventual overpayments begins ticking “when relator with investigating. Five months a provider is put on notice of a later, that employee reportedly sent potential overpayment, rather than an email to management with a

September 2015

“60-day rule” provides that any overpayment retained beyond that term becomes an “obligation” to the federal government, which can result in liability under the FCA (treble damages and civil penalties of $5,500 to $11,000 per claim).

Notwithstanding the gravity of this provision, Congress did not define the term “identified” for purposes of determining when the 60-day clock begins. That is the heart of While the FCA’s “60-day rule” the problem that providers face in is conceptually straightforward, it is complying with this statute. vague as applied. The Affordable Care The Kane court held that Act (“ACA”) contains a provision “identification” of an overpayment that imposes liability on any provider occurs—and the 60-day clock that receives an overpayment from begins—when a health care provider Medicare or Medicaid and fails is “put on notice” of a potential to repay the overpayment within government overpayment rather than 60 days of the “date on which the when an overpayment is conclusively overpayment was identified.” This see Legal Health page 20

spreadsheet of more than 900 claims from the three hospitals (totaling over $1 million) that the employee claimed were subject to the glitch. Over the next two years, the hospitals refunded the overpayments in full. However, the relator and intervening governments alleged that the hospitals violated the FCA by taking two years – rather than the mandated 60 days – to repay the overpayments.

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Houston Medical Times

Mental Health

Surge in heroin use tied to prescription opioid abuse, according to CDC

By Leslie Waghorn Texas A&M Health Science Center Heroin use has increased a staggering 63 percent over the last 10 years according to the Centers for Disease Control and Prevention (CDC). That increase, according to the agency, is closely tied to the growing abuse of prescription opioids such as oxycodone (Percocet), hydrocodone (Vicodin) and codeine. An alarming 45 percent of Americans addicted to heroin are also addicted to prescription opioids.

To combat both the heroin and prescription opioid epidemic the Obama administration announced a new $13.4 million program to curb access to both.

The program will target illegal trafficking of the drugs in areas that have been particularly hard hit by the epidemic, including Appalachia, New York, New Jersey, Philadelphia, Washington, D.C. and Baltimore.

Before moving to street-level trafficking, many prescription opioid addicts first try to obtain the drugs through pharmacies. Bree Watzak, PharmD, of the Texas A&M Health Science Center Irma Lerma Rangel College of Pharmacy, says easy access to prescription opioids is

largely behind this surge in use. Watzak says that prescription opioids appeal to addicts in a way that street drugs don’t.

“If someone becomes addicted,” she says, “they can walk into a safe, clean store and use their insurance to purchase them, unlike street drugs.”

The CDC’s Vital Signs report also supports Watzak’s claims, finding both prescription opioid and heroin addiction is growing significantly among the affluent and people with private insurance, two groups that historically have had relatively low rates of abuse. According to the CDC, people in these groups tend to move on to heroin only after being cut off from prescription opioids. Watzak echoes the CDC’s findings. “We see that people tend to move on to street drugs after they’ve lost access to prescription opioids. It’s a progression,” she says.

Watzak notes that most states have a prescription drug monitoring database that allows doctors and pharmacists to see if an individual is going to multiple doctors or pharmacies seeking prescriptions. “The law says we have a corresponding responsibility to make sure that medications are used for legitimate medical purposes,” says Watzak.

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“Pharmacists are trained to recognize red flags and if we have concerns we can call the physician and ask them if they’re aware of the red flags.”

Most people who become addicted to prescription opioids don’t intend to use them for recreational purposes, according to Watzak. “People typically use prescription opioids because they’ve been prescribed them by a physician for a legitimate reason, but then they like the way the drugs make them feel.” Watzak says prescription opioid addicts use a variety of methods to access the drugs, including exaggerating or inventing symptoms, doctor and pharmacy shopping, and forgery.

Watzak says when a pharmacist suspects a patient is addicted to prescription opioids, they’re advised to stage a mini-intervention with the patient and recommend treatment options. “I’ve never had to do it,” she says, “but I’ve heard from colleagues who have and they’ve said they don’t go well. The patient typically doesn’t want to hear it at the time, but once they’re clean they remember that a pharmacist tried to help them.”

Recovery for prescription opioid and heroin addicts can be particularly fraught.

According to Dr. Tom Frieden, director of the CDC, the connection between prescription opioid abuse and heroin use is directly related to other public health issues, including the increasing rate of

An alarming 45 percent of Americans addicted to heroin are also addicted to prescription opioids.

HIV infections and car accidents. This is particularly troubling as these issues put the patient at an increased likelihood of needing a legitimate prescription for opioids to aid in the recovery from a planned procedure or accident.

“If we know the patient has a history of addiction we can prescribe drugs in a different class, or only use the minimal dose,” says Watzak, but she stresses it’s up to patients to disclose their addiction to their provider.

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Page 5

Healthy Heart

A Healthy Family Starts At Home And It Starts With You! The American Heart Association’s Life is Why Family Health Challenge™ slated to return September 2015 By: American Heart Association

The American Heart Association wants families to feel they can, and are fully equipped to, make healthy choices in the home and within their everyday activities – without throwing schedules completely off or leaving wallets empty.

Today, about one in three American kids is considered overweight or obese. To help raise awareness and make parents and caregivers more conscious of their lifestyle choices during Childhood Obesity Awareness Month, the Life is Why Family Health Challenge™ will help them take the “controls” back, leaving them feeling empowered to make small moderations in their lifestyle that will lead to bigger, heart-healthy changes down the road.

Learn how to increase your fruit and veggie consumption on a budget. Make shopping a fun and easy activity for you and your kids. ∙

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Broken down into four themed sodium aware…if you dare! weeks, the challenge is offered by the ∙ Week 4 – “My Movement is American Heart Association on its Why” – AHA recommends Facebook page, listed as an event, and kids get at least 60 minutes of encourages parents and caregivers, to moderate-to-vigorous-intensity take the challenge online, with the help aerobic activity every day. Make of free tools and resources provided physical activity fun, simple and to them throughout the week in the memorable with your family. forum. This online group also allows Quick activities that easily parents and caregivers to act as supports integrate into your daily life – to one another during the challenge and no matter your schedule. participate in peer-to-peer conversations as they share their successes and address “The Life is Why Family Health areas they feel they may be lacking.

Challenge™ was crafted to be simple, The week-by-week overview of the quick, and fun for families to do together. Childhood obesity is a challenge includes: sensitive subject and we tend to see that ∙ Week 1 –“My Cart is the trend starts at home, but it doesn’t Why”– The American Heart have to. Once parents realize just how Association recommends easy it is to live healthier without adding eating a variety of fruit and extra time to their schedules, it will help vegetable servings every day. see Healthy Heart page 21 September 2015

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Oncology Research

Nomad and Pioneer: From here to there- a cancer journey through the metastasis.

By: Jorge Augusto Borin Scutti, PhD Houston Medical Times

Let me start by telling you about cancer development and metastasis.

Nobody wanted to hear and physicians don't want to say, “Your cancer has metastasized”. Cancer metastases are responsible for the majority of cancer-related deaths.

Metastasis is the process were cancer cells have spread from the part of the body – the primary site (where it started) to other parts of the body and arise from a unique subpopulation of cancer cells that adapt to involve normal homeostatic mechanisms of cellular control. Why some cancer cells tends to spread to certain parts of the body? Before answering that question let's first consider how cancer cells have been lately behaving on tumor microenvironment.

As previously state cancer 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, and, through production and secretion of stimulatory growth factors. This collection of cells and molecules together compose the tumor microenvironment. We know that local microenvironment or niche plays important roles during the initiation and development of tumor progression and the communication between cancer cells and their microenvironment is critical for tumor growth.

they may suffer a form of programmed cell death called anoikis.

However metastatic cancer cells may escape from anoikis and invade other organs through 3 major pathways: lymphatic vessels, blood vessels and along surfaces on the inside of the body cavity. The mechanism by which invading cancer cells survive the anoikis process remains unknown, however, recent findings suggest that TrκB and its ligand BDNF might be involved.

Various other factors like angiogenesis and lymphangiogenesis depend on the ECM. Furthermore tumor cells produce several components, including VEGF (vascular endothelial growth factor) and proteases to regulate blood vessel formation and to break down the basement membrane to grow out respectively.

In addition to ECM components participate in cell migration, tumor inflammation, survival, proliferation and chemoattractant to immune cells. According to Dr. Charles Saxe, director of the American Cancer Society Program in Cancer Cell Biology and Metastasis “Researchers hope a better understanding of the niche can provide new strategies for inhibiting the growth of metastatic cells. If we can recreate the conditions that keep metastatic cells from growing beyond micrometastases, then even if we can not kill all of the cancer cells, maybe we can block their ability to grow and expand”.

A major component of this niche is the extracellular matrix (ECM), a complex organization of macromolecules with distinctive physical, biochemical, and biomechanical properties. Commonly cells keep close to the tissue to which they belong and ECM provides Several studies have been showed essential signals for growth or survival. that the cellular origin and intrinsic When, for some reasons some cells properties of the tumor determine not are detached from ECM, there is a only the sites of tumor dispersion but loss of normal cell interactions and see Oncology Research page 21

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The dog days of summer are upon us, and who wants to heat up the house cooking? You could use this as an excuse to barbecue every night, but what if you don’t want to do that?

Fortunately, summer provides us with a bounty of fresh fruit and vegetables that allow us to fix delicious and nutritious meals and still stay cool.

LET US ADD VALUE TO YOUR NEXT TRANSACTION.

Sonia Coyle is a Family and Consumer Science Agent with the Texas A&M AgriLife Extension service, a partner with DADS Volunteer and Community Engagement unit. She explains why summer is a great time for those who want to eat a healthy diet without turning the house into a sauna.

“The nutrients in fresh fruits and vegetables have better bioavailability than

which helps preserve its nutritional value.

Canned fruits and veggies come in third in terms of nutritional value, she said.

“Canned vegetables often include preservatives and salt,” she said. “Even fruits that are packed in their own juice often contain some sort of preservative.

That’s why frozen is the best choice if you can’t get fresh.”

In addition to fresh fruits and vegetables being tastier and more nutritious, they are often locally produced, which can make them cheaper than frozen or canned. “Lower transportation and storage costs can make them a very affordable option,” she said.

While not specific to the summer season, other recommendations for a healthy diet include: ∙∙

Make at least half of your grain products whole grain, such as brown rice, whole-wheat bread and tortillas, oatmeal and whole-grain pasta.

∙∙

Eat five servings of fruits and vegetables a day, and be sure to

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Not only are the nutrients in fresh produce easier for our bodies to use, “but fresh produce is more attractive and it tastes better.” And since experts recommend eating several servings of fruit and veggies every day, anything that makes them more fun to eat is a good thing, she said.

To maximize the nutrients available to our bodies, Coyle recommends eating fruits and veggies raw. “Some nutrients – Vitamin C, for example – can be destroyed by heat, and that’s why we should opt for raw whenever possible.”

When vegetables are cooked, Coyle recommends steaming. This method helps maximize available nutrients and has the added benefit of not heating up the house the way baking or other methods can.

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When fresh produce is not available, Coyle recommends eating frozen. Frozen produce is picked, washed and frozen,

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consume a variety of colorful vegetables, since each one has different nutrients. ∙∙

Choose low-fat or fat-free dairy products.

∙∙

Select lean cuts of meats and poultry.

∙∙

Eat protein-rich foods such as beans and fish.

∙∙

Get most of your fats from fish and nuts.

∙∙

Drink plenty of water daily to stay hydrated and to help you feel full.

∙∙

Get plenty of calcium (kale, greens and broccoli); vitamin D (wild-caught fish, liver and egg yolks); and vitamin B-12 (fish, beef and dairy products)

∙∙

Reduce sodium intake by limiting the amount of salt added to foods and avoiding consumption of processed foods.

For more tips on eating healthy go to www.Texercise.com

September 2015

Houston Medical Times

Page 9

Researchers strategize to outsmart bacteria

Rice University lab identifies mutations that allow bacteria to resist antibiotics Rice University scientists are slow -- the process. The research developing strategies to keep germs appeared in the journal Molecular from evolving resistance to antibiotics Biology and Evolution. by heading them off at the pass.

Antibiotic resistance is responsible The Rice lab of biochemist for hundreds of thousands of Yousif Shamoo identified a infections acquired in American genetic mechanism that allows hospitals, according to the Centers bacteria to develop resistance for Disease Control and Prevention. while simultaneously and quickly These infections kill thousands of spreading the capability to others in patients. While progress is being a population. made to control microbes that spread "This is really a double whammy," infection, the overriding concern Shamoo said. "Our finding that these remains that drugs developed to kill bacteria become more antibiotic-resis- germs will ultimately stop working. tant while at the same time spreading their resistance more efficiently was really surprising and worrying."

The researchers hope this knowledge will help predict when and how bacterial strains are likely to develop resistance to future antibiotics and perhaps act to halt -- or at least

Kathryn Beabout, lead author of a Rice University study on antibiotic resistance

she said. "But our idea is that if we can predict how resistance is going to emerge, we can come up with Until now, the only effective strategies to use antibiotics in a more way to keep antibiotics from losing intelligent way." their potency has been to use them The lab used experimental sparingly, said Kathryn Beabout, a evolution to study a specific Rice graduate student and lead author combination of bacteria and an of the new paper. antibiotic that had not been in "The best you can do is try to common contact. The bacteria of manage when you use the antibiotic," interest was Enterococcus faecalis, found in the gastrointestinal tract.

The antibiotic was tigecycline, a highly effective but sparingly used derivative of tetracycline. The goal was to see how horizontal gene transfer – the means by which cells pass along favorable mutations – would work in the presence of the antibiotic.

It worked quite well, they found.

That was due mostly to a chunk of mutant DNA known as Tn916, a transposon that can change its see Outsmart Bacteria page 22

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National Study Analyzes Medical Malpractice Allegations Against Orthopedists

Research Indicates Patients and Physicians Must Work Together to Avoid Risks

By The Doctors Company

NOW LEASING PHASE II

A study issued today by The Doctors Company of closed malpractice claims against orthopedists underscores the joint responsibility of physicians and patients to reduce risks. The study of 1,895 claims against orthopedists that closed from 2007-2014 found that the three most common patient allegations were improper performance of surgery, improper management of the surgical patient, and diagnosis-related issues, such as failure or delay in diagnosis or wrong diagnosis. The claim of improper performance of surgery patient/family and provider, and was often made by the patient patient assessment issues, such when the outcome differed from as failure or delay in ordering the patient’s expectations. diagnostic tests. In 29 percent of the “This study of claims brought cases, patient behaviors affected the against orthopedists sheds light outcome of care, when the patient on the wide array of issues that did not follow the treatment plan may arise during surgery and or missed scheduled appointments. postoperative treatment,” said David “These findings make it B. Troxel, MD, medical director, The Doctors Company. “As the clear that healthcare teams and nation’s largest physician-owned patients need to partner to achieve medical malpractice insurer, we better outcomes,” said Ralph A. were able to analyze the collective Gambardella, MD, chairman experience of more than 2,100 and president of Kerlan-Jobe orthopedists nationwide to provide Orthopaedic Clinic in Los Angeles. unique insights that advance “While improper performance and protect the practice of good of surgery was the top patient medicine. Our hope is that as allegation, in most cases the risks orthopedists and hospital risk had been disclosed to patients managers review the findings of prior to the procedure, but the this study, they will scrutinize their patient may not have understood. systems and processes to reduce the In nearly a third of claims, patients likelihood of adverse outcomes.” did not adhere to the treatment Physicians within the specialty plan, and this behavior was more also reviewed the cases to look likely when there was inadequate beyond what the patient alleged and determine the factors that led communication. At our clinic, we to injury. In orthopedic claims, will apply the results of this study to the top five factors were technical continually find new and innovative performance, patient factors, ways to improve communication selection and management of with our patients both before and therapy, communication between after surgery.”

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MD Anderson to build new outpatient center in West Houston

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With the approval of The University of Texas System Board of Regents today, The University of Texas MD Anderson Cancer Center is one step closer to developing and building its own outpatient diagnostic and treatment center to better serve the growing communities of West Houston and beyond.

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The new center will be the first In other Board of Regents action free-standing clinical building that MD Anderson has constructed outside the today impacting MD Anderson outreach, the board approved a first-ever Texas Medical Center. clinical collaboration agreement between The center will be built on 36 MD Anderson and The University of acres of land owned by MD Anderson, Texas Medical Branch at Galveston, near the intersection of Interstate 10 and Highway 6. When it opens to which will include construction of an patients in 2018, the building will be outpatient cancer center on UTMB’s campus in League City. approximately 175,000 square feet.

“It’s great to get the green light from the Board of Regents to start work on a new facility that will give the residents of West Houston and the surrounding region even greater access to MD Anderson specialty services, care, research and diagnostics,” said Thomas Burke, M.D., executive vice president, MD Anderson Cancer Network®. “Our mission to end cancer charges us with expanding and adapting programs that best reflect and respond to the needs of our patients, and this new center demonstrates that commitment.”

There are three MD Anderson patient care facilities located in West Houston.

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surgeons for follow-up appointments and consultations. The surgeries may be performed at MD Anderson in the Texas Medical Center or at other area hospitals, but patients can see their doctors before and after their procedures closer to home. The office is about five miles from where the new center will be located.

The newly approved MD Anderson outpatient center is expected to open by 2018 and encompass about 135,000 square feet. It will complement UTMB’s inpatient facility on the same campus.

MD Anderson currently has a clinical care center in Bay Area (Nassau Bay) that offers a variety of medical, surgical and radiation oncology services.

It is about eight miles from the new UTMB League City campus.

As MD Anderson’s first clinical care center to open outside of the Texas Medical Center, the center in Bay Area opened in 2007 with two medical oncologists and one radiation oncologist. Today, it offers medical, surgical, radiation oncology services; chemotherapy infusion; laboratory and pharmacy services, and employs 11 physicians and 67 nurses, mid-level providers, phlebotomists, radiation technologists and support staff.

MD Anderson in Katy offers medical, surgical and radiation oncology; chemotherapy infusion; pharmacy; pain management; and nutrition services as well as other supportive care. It is located about six miles from the new center and employs about 90 physicians, mid-level In addition to MD Anderson providers, nurses, phlebotomists, regional locations in Bay Area, Katy radiation therapists and support staff. and Memorial City, there also are MD Anderson Diagnostic Imaging care centers in Sugar Land and The Center in West Houston opened one Woodlands. year ago providing a full spectrum of The first Houston area location laboratory and imaging services, on-site radiology interpretation, and breast opened about 15 years ago, offering screening. It is about one mile from the only radiation oncology services, and new center and about 30 radiologists, the outreach has grown at a steady nurses, diagnostic imaging technologists pace. Last year more than 4,000 newly and other staff support the center. diagnosed patients were treated in the MD Anderson in Memorial City is institution’s regional system, which a clinical office space that gives patients accounts for more than 15 percent of convenient access to see specialized MD Anderson’s new patient volume.

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Page 13

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Page 14

Promising Target for New Drugs Found in Pancreatic Cancer Cells

UH Researchers Aiming to Defeat One of Deadliest Cancers

by Targeting Liver X Receptors

By Lisa Merkl University of Houston

biologist Chin-Yo Lin, an assistant professor with the UH Center for Pancreatic cancer is extremely Nuclear Receptors and Cell Signaling deadly and often has a poor (CNRCS). “We examined the levels prognosis. Ranked as the fourth of LXRs in patient tumor samples deadliest cancer in the U.S. and and studied the effects of candidate poised to move up within the next drug compounds targeting LXRs on determine whether LXRs are few years, pancreatic cancer is very cultured pancreatic cancer cells.” expressed in all tumors or a specific difficult to detect in its early stages.

Liver X receptors are important subset of tumors that might be more Seldom diagnosed early and typically regulators of cholesterol, glucose sensitive to drugs targeting LXRs. spreading rapidly, the disease has no metabolism and inflammatory effective treatment once it advances. response modulation. Collaborating Another goal is to test the effects of the drugs on pancreatic tumors U n i ve r s i t y of H o u s to n with CNRCS director Dr. Jan-Åke in murine models that are very researchers are on a mission to Gustafsson, a pioneer in the similar to those found in humans. develop drugs that will allow discovery of LXRs and the Robert Ultimately, they plan to use the physicians to prolong patient survival A. Welch Professor in Biology and and, possibly, even eradicate this Biochemistry in the UH College of knowledge from these studies to Natural Sciences and Mathematics, develop better drugs to target LXRs deadliest of cancers. in pancreatic cancer, as well as other “Our research on the role of liver Lin said there is now enough types of malignancies.

X receptors, or LXRs, in pancreatic evidence to support the involvement The research team has already cancer cells points to a promising of LXRs in a variety of malignancies.

samples and is preparing to analyze more samples. Recent studies showed that chemical compounds targeting LXRs can slow the growth of tumors in murine models transplanted with human tumor cells.

“Our findings point to a class of receptors that can be precisely targeted by drug compounds and are expected to stimulate both basic and translational research on their functions and application as a drug target,” Lin said. “Long-term goals are to develop additional drug compounds and clinical testing in target and strategy in the treatment Lin and his colleagues anticipate carried out some preliminary studies human subjects, which will require of pancreatic cancer,” said cancer their ongoing studies will help of LXR expression in patient tumor see Cancer Cells page 22

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Nutrition Corner

Vitamin D: Are you getting enough?

By E. Denise Hernandez, MS, RD, LD Houston Medical Times

Vitamin D, otherwise known as the sunshine vitamin, has slowly become an issue for a lot of Americans in recent years. It is naturally present in very few foods, added to others, and available as a dietary supplement. It is referred to as the “sunshine vitamin” because it is also produced within your body when your skin is exposed to ultraviolet rays from sunlight.

Vitamin D has several vital functions. One of the most well-known functions of vitamin D is its promotion of calcium absorption in the gut and role in bone mineralization, growth, and remodeling. Without sufficient vitamin D, we know that the risk of developing rickets, osteomalacia, and osteoporosis increases.

Vitamin D plays other important roles including cell growth, neuromuscular and immune function, and reduction of inflammation.

Estimates show that 75 percent of the population is not receiving the recommended dosage. Because of its significant role in immunity, deficiencies may increase the risk of developing hypertension, heart disease, diabetes, cancer, and a variety of autoimmune conditions.

yogurt, orange juice). One tablespoon of cod liver oil contains 1,360 IU. Aim to eat fatty fish at least 2 times per week (about 4-5 ounces each time) and 2 to 3 servings of low-fat vitamin D fortified products each day. Here is a list of food sources: ∙

Fatty fish such as salmon, tuna, and mackerel are among the best sources

∙

Beef, liver, cheese and egg yolks provide small amounts

∙

Mushrooms provide some (especially if exposed to UV light)

∙

Milk (almost all US milk supply is fortified with 400 IU of vitamin D per quart); foods made from milk (cheese and ice cream) are usually not fortified.

∙

Breakfast cereals, orange juice, yogurt, margarine, and soy beverages (fortified; check labels)

If it is challenging for you to consume these foods, you may want to consider a supplement. Take into consideration that there is a toxic amount (adults: 4,000 IU). Toxicity levels mostly occur when consuming a vitamin D supplement, and is very hard to reach through foods and sun exposure. Speak to your doctor and pharmacist if taking medications, since interactions with certain steroids and The groups that are at risk of other drugs can take place. a Vitamin D inadequacy include Individuals with fair skin should breastfed infants, older adults, limited sun exposure, people with dark skin, aim for 10 to 15 minutes, and those people with inflammatory bowel with darker skin 30 minutes, of disease (or other conditions causing unprotected sun exposure to the fat malabsorption), and those who are face, arms, and hands, 2 to 3 times per week. As much as 15,000 IU can obese. be manufactured in 30 minutes in a The Recommended Dietary Allowances (RDAs) for vitamin D are fair skinned individual. If you wear sunscreen, lather it on right before as follows:

Very few foods naturally contain you leave the house. It takes about 20 vitamin D and include fatty fish, fish minutes for sunscreen to become fully oils, and fortified products (milk, effective. medicaltimesnews.com

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Brian Dean Named CEO of Memorial Hermann-Texas Medical Center Memorial Hermann Health System recently announced the promotion of Brian Dean, MPH, MBA, to Chief Executive Officer of Memorial Hermann-Texas Medical Center (TMC), effective August 23. Previously Dean served as Vice President and Chief Financial Officer of Memorial Hermann-TMC and has been serving as interim CEO since February when Craig Cordola, former CEO, was promoted to Senior Vice President and Regional President for the Central/ West Region for Memorial Hermann.

of our flagship facility.”

As CFO for Memorial Hermann-TMC, a role he has held for the past two years, Dean optimized financial outcomes and improved overall productivity for the Campus.

Under Dean’s leadership, the hospital has encouraged clinical innovation by investing in world-class programs through the medical staff, nurses, support staff and facilities. And now, Dean will steer the ongoing strategic vision and plans for the Campus as it continues to grow, renovate, expand “Brian is a strong leader who has and improve through the $650 million a great passion for people and a special Breaking New Ground project that talent for directing operations, ensuring launched in May. financial success and advancing “I am humbled and honored to the health of our community,” said Cordola. “We look forward to have this opportunity to lead such a continuing to deliver the high quality wonderful team of world-class clinicians care for which we are known to the and staff at Memorial Hermann-TMC patients and families of the Greater that, for nearly a century, has set new Houston area with Brian at the helm standards of care in Texas and across

Page 18

the nation,” said Dean. “As I assume this new role, my focus will center on building upon the incredible foundation Craig established in his many years at the TMC. Having served at a number of academic medical centers over the course of my career, I can honestly say that the qualities this Campus possesses, through our partnership with UTHealth Medical School, are remarkably unique. With a shared sense of purpose and a culture of collaboration, the team here works tirelessly every day to provide our patients and families with the best, safest and most advanced care available, and I am grateful for the opportunity to be part of such an organization.”

Brian Dean, MPH, MBA Prior to joining Memorial “Power Leaders in Health Care” in Hermann, Dean held leadership 2012, and he is currently a member roles at healthcare systems across the South, including: Jackson Health of several organizations including System in Miami, where he was the American College of Healthcare Senior Vice President of Finance and Executives. Dean earned his Bachelor also served as CEO of their Health of Health Science and Master of Public Plan; University Community Health Health in Health Administration, both in Tampa; and the University of from the University of Kentucky, and Kentucky Chandler Medical Center later received his Master of Business in Lexington. He was named one of Administration from the University of the South Florida Business Journal’s Miami.

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James H. “Red” Duke Continued from page 1

as past president of the Wild Sheep Foundation, the Boone and Crocket Club and founder of the Texas Bighorn Society, which has been successful in reintroducing bighorn sheep to West Texas.

Born in Ennis, Texas on Nov. 16, 1928, his family moved to Hillsboro, where the enterprising young Duke picked cotton, dug ditches and became the lone agent for the Saturday Evening Post and the Dallas Morning News while earning Eagle Scout rank. There he acquired his nickname, “Red,” for his curly red locks. Hunting and fishing in the surrounding countryside, he would often run across another red-head from nearby Abbott, Texas, who would become a legendary country singer and his lifelong friend, Willie Nelson.

Physicians and Surgeons in New York, where he pursued additional graduate studies in chemical engineering, biochemistry and computer sciences at Columbia University.

In 1970, he moved with his family to Jalalabad, Afghanistan to serve as a visiting professor and later chairman of surgery at Nangarhar University School of Medicine. He often said how much he loved the Afghani people and how he found it exciting and challenging to practice medicine there, without the benefits of modern imaging tools and other medical technologies.

In 1972, he returned to Texas to join the faculty of the newly created University of Texas Medical School at Houston, now part of UTHealth.

In this role, he brought Level I trauma care to Memorial Hermann Graduating from Hillsboro High and Houston and a reputation as a School, Duke attended Texas A&M compassionate surgeon, innovator and University and graduated in 1950 educator. with a Bachelor of Science degree.

Richard Andrassy, M.D., professor At A&M, he achieved school-wide and chairman of the Department of popularity and distinction as head yell Surgery at UTHealth Medical School, leader and began a tradition as the first said, "Dr. Duke was a friend, mentor Aggie to recite “The Last Corps Trip” and larger-than-life figure for thousands poem at the school’s bonfire. With of us who were fortunate to be his his undergraduate degree in hand, students, residents or colleagues. He he served for two years as an Army has passed down the wisdom that ‘the tank commander in Germany during most important part of being a doctor the Korean War before enrolling in is being a doctor.’ His hands-on care – the Southwestern Baptist Theological from applying brown sugar to wounds Seminary in Fort Worth. He received to sitting at the bedside and holding a divinity degree in 1955. the hand of his patients – would be a During seminary, a book about lost art if not for Dr. Duke.”

Albert Schweitzer, M.D., inspired His curriculum vitae, more than 70 Duke to pursue a career in academic pages long, itemizes publications, book medicine. He thought that caring for chapters, more than 600 presentations patients and conducting scientific and numerous awards including research while training the next “Surgeon of the Year” in 1988 by the generations of physicians would James F. Mitchell Foundation, the Boy be the best ways he could serve his Scouts of America’s Distinguished community.

Eagle Scout Award, and lifetime Duke earned his medical degree achievements awards from both the in 1960 at The University of Texas Houston Technology Center and the Southwestern Medical School in Governor’s EMS & Trauma Advisory Dallas. He completed his residency Council. in general surgery at Dallas’ Parkland “As a physician, Dr. Duke is Memorial Hospital, where he helped remembered for his tireless and save the life of wounded Texas Gov. steadfast dedication to his patients, as John Connally in 1963 on the day well as his personable bedside manner.

President John F. Kennedy was He was compassionate, ethical, assassinated. brilliant and humble. A colleague and Before accepting an appointment a friend to all of us, he leaves behind a at UTHealth Medical School, legacy of selfless service to his beloved Duke served on the faculty at UT community. He was a great physician, see James H. “Red” Duke page 20 Southwestern and the College of September 2015

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Page 20

James H. “Red” Duke Continued from page 19

but even more so, an extraordinary Life Flight established a worldwide call man,” said Craig Cordola, regional sign – “Red Duke” – for all Life Flight president at Memorial Hermann. communications with Air Traffic Duke’s most recent accolades Control while on Instrument Flight included knighthood of the Order Rules (IFR) flights. At its Constellation of Saint George by the U.S. Calvary Gala on Nov. 14, 2014, UTHealth and Armor Association and the Peter honored Duke for his lifetime Hathaway Capstick Hunting Heritage achievements and announced the Award, the Dallas Safari Club’s establishment of the James H. “Red” highest honor. Memorial Hermann Duke, Jr., M.D. Endowed Scholarship,

the first full-ride scholarship for students at UTHealth Medical School.

Also in 2014, Alvin Independent School District recognized Duke’s commitment to education, math, science and innovation by opening Dr. James “Red” Duke Elementary.

medical technology on the battlefield and surgical techniques supporting the medical needs of our military personnel. As a co-founder of the Texas Medical Center’s Hiring Red, White & You! initiative, he was equally dedicated to finding employment In recent years, Duke was opportunities for military veterans who especially dedicated to his ongoing wanted to transition into the civilian work with the U.S. military to enhance workforce.

Legal Health

Continued from page 3 ascertained.” Both government enforcers and relators increasingly will bring cases on this theory – arguing that “notice” and “identified” are congruent terms.

the holding to mean that once an employee internally reports any alleged overpayment, a provider is obligated, without more, to identify and return the amount described within 60 days.

The opinion’s lack of clarity calls Such an interpretation would not for vigorous defense by health care allow for a reasonable and meaningful providers undergoing scrutiny or investigation that likely could take investigation for alleged overpayments. longer than 60 days to complete.

Although the court’s categorical view It is critical to document of what it takes to be “put on notice” overpayment investigation response can be facially onerous for providers, efforts. In order to mount a defense it is patently unreasonable to interpret against a knowing violation of the

60-day rule, health care providers should document and keep detailed records of what actions were taken in response to a reported overpayment and how the investigation was handled internally at each stage. A vigorous investigative response, well documented, will help demonstrate that there is no “identification” in fact while a good-faith effort to make an ultimate determination is underway.

Health care providers can take no comfort in “prosecutorial discretion.”

The Kane court suggested that the appropriate exercise of prosecutorial discretion would be an ameliorating antidote to the apparent rigidity and “unforgiving” nature of the 60-day rule. Given the fact that government officials are under constant political pressure to attack alleged health care fraud and qui tam relators are economically motivated to bring cases, this is small consolation and worthy of little reliance. see Legal Health page 21 ©2014 Tiff’s Treats

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Page 21

Legal Health

Continued from page 20 State Medicaid regulations may complicate provider compliance with the 60-day rule. For example, Massachusetts’ Medicaid program, MassHealth, has an overpayments regulation that closely tracks the federal provision. According to that state, after identifying an overpayment, “[t]he provider should not send a check for any overpayment, unless the provider has received prior written approval from MassHealth.

Once the full overpayment has been determined, MassHealth will initiate its standard recoupment process.”

Here, a provider is instructed not to repay an overpayment until the process is initiated by MassHealth—a process that might take longer than 60 days to complete—technically running afoul of the FCA’s overpayment provision.

court’s opinion, the Centers for Medicare & Medicaid Services (“CMS”) is expected to offer additional clarity on the issue when it releases its final rule on overpayments relating to Medicare Part A and Part B providers and suppliers. CMS announced on February 17, 2015 that its final guidance can be expected in February 2016.

With the release of this long-awaited opinion, government overpayment enforcement and litigation can be expected to increase.

Indeed, on the same day that Kane was decided, the Justice Department announced a “first of its kind” $6.88 million settlement with a nursing home services provider in a similar overpayments case, and the Department has signaled its intention Although there is considerable to pursue similar cases with vigor. ambiguity and uncertainty in the

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Continued from page 5 them to maintain the changes they November 7 and celebrate the results made in September throughout 2015 from participating in the Life is Why and beyond.”

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Association This September, join the American Heart Association, and families across the country, to make a change in your life and the lives of your loved ones.

Visit www.heart.org/healthierkids to learn more about the Life is Why Family Health Challenge™ and access the free activities and templates today.

Remember, change starts at home and it starts with you as the caregiver of your home.

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Oncology Research Continued from page 6

also the severity of metastasis to vital organs. Furthermore to the above aspects of metastases certain cancer metastatic cells exhibit tissue tropism (tissue affinities) preferring to grow in certain organs. In lung cancer, for example, metastasis affects the brain, September 2015

bone, adrenal gland and liver; in the breast, prostrate and skin melanoma cancer the most common metastatic sites are bone, lungs, liver and brain.

In summary the metastatic pathway can be widely divided into three main see Oncology Research page 22

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Houston Medical Times

Oncology Research

HOUSTON

Continued from page 21

processes: invasion, intravasation and extravasation.

Peter Woolf, of the Department of Chemical Engineering at the University of Michigan, defends a holistic approach of systems biology.

“Despite considerable success of the reductionist approach, many fundamental questions in tumor

biology remain unanswered.

Particularly how a tumor cell acquires the ability to metastasize and colonize a distant site is probably the most puzzling question in cancer biology.

Perhaps a clearer appreciation of the unique clinical patterns of dissemination, the micro-environment at the metastatic site, and the temporal variables of metastases

will provide scientists with a more holistic approach to understanding metastases”. Despite some of these aspects of metastasis have just begun to be revealed new comprehension from animal models and clinical studies offer opportunities for more effective therapeutic approaches for controlling cancer metastasis.

Without tigecycline, Tn916 moves only infrequently, as about one in 120,000 bacteria transfer their resistance to another bacteria.

But in the presence of the antibiotic, Tn916 movement rose to one in 50 bacteria, due to a mutation that also causes overproduction of tetM. The resistance mechanism required the presence of two mutations, to Tn916 and to a gene that encodes the ribosomal S10 protein, both of which could be easily identified through preand post-experiment gene sequencing.

"Tetracyclines bind to the cell's ribosome and prevent it from making proteins," Beabout said.

That's definitely worrisome."

The lab allowed colonies of E. faecalis to grow rapidly in bioreactors for 19 and 24 days. The results showed the bacteria were remarkably proficient at picking up the resistance gene. "All the cells at the beginning had one copy of the transposon, and throughout the experiment they started acquiring additional copies.

The copy number of the transposon was increasing very rapidly."

In their experiments, the researchers discovered the mutations led to the production of large amounts of tetM proteins. "When you have an abundance of tetM, they're able to have an effect against tigecycline," Beabout said. "What's really interesting is that tetM is on Shamoo hopes the research a conjugative transposon (Tn916), leads to drugs that inhibit resistance which is a DNA element that's able mechanisms and preserve the to move around the genome and can effectiveness of new antibiotics. be transferred to other cells.

"Our lab does a form of "An additional effect of this tetM evolutionary reconnaissance into overexpression is that the Tn916 how bacteria will become resistant transposon moves more," she said. in the future," Shamoo said. "The "It passes from cell to cell more. So pharmaceutical industry and other we are seeing both resistance and an labs can use this information to increase in the frequency at which develop drugs to stay ahead of the resistance is able to transfer from cell pathogens." to cell and move around genomes.

Cancer Cells

Continued from page 14 several more years of research.”

the Karolinska Institute in Sweden, A number of students who assisted with the analysis, as participated in these studies, well as provided some of the drug including Ph.D. students Sridevi compounds.

Addanki and Husna Karaboga and Their research was funded recent Ph.D. graduates Nicholes by Golfers Against Cancer and a R. Candelaria, Trang Nguyen-Vu, pilot study grant from the Cancer Prasenjit Dey, Philip Jonsson, Jean Prevention and Research Institute Lin and Lakshmi Reddy Bollu. Other of Texas (CPRIT). Following the collaborators were professor William publication of some findings in the E. Fisher from the Baylor College of research journal PLOS ONE last Medicine, who provided the clinical year, Lin and Gustafsson recently samples, and researchers Knut summarized these and other Steffensen and Lise-Lotte Vedin from advances in targeting LXRs in cancer

Editor Sharon Pennington Director of Media Sales Richard W DeLaRosa

Distribution Vincent DeLaRosa

Continued from page 9

"TetM is a protein that comes in and kicks tetracyclines off and frees the ribosome, but it doesn't usually work against tigecycline. We didn't expect to see it emerge."

Published by Texas Healthcare Media Group Inc.

Creative Director Lorenzo Morales

Outsmart Bacteria position along the genome, duplicate itself and pass to other cells in a process known as parasexuality, the exchange of genetic material between cells. Tn916 carries the tetracyclineresistance gene called tetM, which has been found in many pathogens, according to the researchers.

Page 22

treatments in an invited review article for Nature Reviews Cancer, a monthly journal devoted to the review of current topics in oncology.

“Our next steps are to collect more information from patient samples and data from pre-clinical studies,” Lin said. “Based on the results, we will then move forward with clinical studies using existing compounds or partner with biotech or pharmaceutical companies to develop better drug candidates.”

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