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EDITOR'S LETTER

FOR MY DAD I OWE SOME OF MY FAVORITE MEMORIES TO THOSE DOCTORS.

WELCOME TO SONOMA HEALTH MAGAZINE, a new publication focused on the health and well-being of our county’s residents. Our goal is to educate, illuminate and entertain with evidence-based and actionable information that connects cause and effect in a direct way, encourages you to learn more and raises pertinent questions to discuss with your doctors. An esteemed Medical Advisory Board, made up of local experts and specialists from the county’s major medical groups and beyond, have vetted all articles for medical accuracy. In addition, more than half of the articles in this issue have been written by local physicians. Their expertise is invaluable in addressing such topics as advances in cardiac health, dementia diagnosis and care, digestive health and more. Starting a magazine from scratch is always a learning experience, and Sonoma Health has been no different. Meeting and conferring with medical professionals, researching and fact checking such a wide range of topics — it’s all been mind-opening. But one story in this issue holds a special place for me. Here’s why: In November 1996, my father was diagnosed with an aggressive form of prostate cancer (just like his father, uncle and grandfather before him). He was advised to put his affairs in order and given less than a year to say his good-byes. Instead of taking that news as a fait accompli, he enrolled in every clinical trial he could. Every single one benefitted him in some way. When he passed away earlier this year, he was surrounded by the love of my mother and their five children (including me). In the more than 20 bonus years we all had with Dad, he welcomed daughters- and sons-in-law and 14 grandchildren — none of whom he would have met if that early prognosis had come to pass.

SONOMA HEALTH

Beginning on page 48, writer Jean Saylor Doppenberg takes an in-depth look at the role of clinical trials here in Sonoma County. Some of the same doctors and facilities that conducted trails my dad was part of. I owe some of my favorite memories to those doctors (introducing my children to Grandpa, holiday dinners, long conversations and shared jokes). Our article makes the case, quite compellingly, that cutting-edge research is being conducted right here in Sonoma County. You owe it to yourself (or someone you love) to learn more. It takes hard work and dedication to bring a project like this to fruition. In addition to our medical board and the behind-the-scenes team at Sonoma Media Investments, I’d like to extend a heartfelt thanks to Wendy Young, Susan Gumucio and Rachel Pandolfi at Sonoma Mendocino Lake Medical Association (SMLMA), whose support, encouragement, resources and ideas were key to making this magazine happen. When we started this project six months ago, our aim was to introduce new ideas and concepts, explain treatments, showcase technological and medical advancements, and guide Sonoma County residents to self-advocate for their health by asking the right questions. How did we do? Please send your feedback to Editor@SonomaHealthMag.com. Stay healthy, Sonoma County!

ALEXANDRA RUSSELL EDITOR-IN-CHIEF

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Contents SONOM A HE ALTH 2022

EDITOR’S LETTER ALEXANDRA RUSSELL

80 MEDICAL ADVISORY BOARD

SELF CARE

COMMUNITY HEALTH

MEDICAL ADVANCES

11 WRINKLE RELIEF OPTIONS TATIANA LONGORIA, RN; AND JEFFREY SUGARMAN, M.D.

37 UNDERSTANDING MEDICARE PLANS

55 THE LATEST ON MIGRAINE ALLAN L. BERNSTEIN, M.D.

13 FROM THE INSIDE OUT A. MICHAEL LUSTBERG, M.D.

Understanding your gut microbiome can lead to better overall health.

18 FILLING IN THE GAPS ELLEN SEELEY

Proper use of dietary supplements can bolster your body’s resilience.

22 TRUSTED THIRD-PARTY CERTIFIERS 24 REMEMBER WHEN ALLAN L. BERNSTEIN, M.D.

When does forgetfulness become dangerous?

28 HOLDING HANDS BRIEN A. SEELEY, M.D.

Book Review of Caring for Your Friend with Dementia

38 ONE FOR ALL JULIE FADDA

Community health centers have far-reaching benefits for us all.

44 IN THE AIR DRS. MARIA PETRICK AND JULINE CARABALLO

The bounty of the county can trigger environmental allergies

48 RISK & REWARD JEAN DOPPENBERG

Cutting-edge clinical trials in Sonoma County can benefit current patients — and future generations.

53 WHAT TO ASK

Before you agree to participate in a clinical trial, it’s vital to understand exactly what you’re signing up for.

56 THE BEAT GOES ON SANJAY DHAR, M.D.

In spite of unforeseen obstacles, the field of clinical cardiology has seen numerous advances.

60 KNOW YOUR NUMBERS MATT VILLANO

Wearable medical technology is here and improving lives. What comes next?

When does forgetfulness become dangerous?

P. 24

65 A VIEW FROM THE INSIDE GARY GREEN, M.D.

An infectious disease physician’s COVID-19 journey in Sonoma County.

RESOURCES 72 OPEN CLINICAL TRIALS 78 TRIALS FACILITIES 78 COMMUNITY CLINICS

30 IN VINO VERITAS RACHEL FRIEDMAN, M.D.

Finding the truth — and health — in wine

Why You Get Seasonal Allergies PAGE 44

Wearable health technology is here. PAGE 60 SONOMA HEALTH

World-class cancer care, without the hassles

21-0759_AD_CC_SonomaHealth_Mag_Print_18.25x11.125_v4.indd All Pages SonomaHealth_2021.indd 8

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The UC Davis Comprehensive Cancer Center is recognized as one of the nation’s most elite. And we’re ready to serve you when you need us. UC Davis Health is the proud home of the UC Davis Comprehensive Cancer Center, the only center in inland Northern California — and one of just 51 nationwide — to hold “comprehensive” designation from the National Cancer Institute. Treatment at NCI-designated cancer centers is associated with improved outcomes for many people with cancer. And “comprehensive” designation means patients get access to leading-edge treatments, early access to clinical trials, and the benefit of collaboration between cancer physicians and researchers — here at UC Davis, across the University of California system, and beyond. We’re honored to offer Northern California access to life-changing care that’s among the best in the world — without the traffic, expense and stressors of congested urban areas. Excellence ■

A complete range of adult and pediatric specialties covering more than 20 types of cancer, from adrenal cortical to thyroid

■

Clinicians routinely handle the most difficult cases, and have extensive expertise with uncommon cancers

■

Comprehensive, multidisciplinary care for all stages of breast and prostate cancer

■

A unique oncology program specific to the care of pediatric, adolescent and young adult cancer patients

Access to leading-edge care, such as robotic surgery technologies, targeted treatments and theranostics

■

Experts from a variety of disciplines often convene tumor boards to analyze options

■

Advanced testing capabilities such as the UC Davis-developed EXPLORER – the world’s first combined research and clinical total-body PET scanner, which can provide images of the entire body in seconds

■

Part of the world’s largest cancer research organization, the UC Cancer Consortium, drawing on the collective expertise of the entire UC Health system.

Innovation ■

More than 200 active clinical trials at any one time, including our region’s only Phase 1 trials

■

Hundreds of scientists and staff engaged in research, with more than $100 million in annual funding

■

A member of the National Comprehensive Cancer Network (NCCN®), a nonprofit alliance of 31 leading centers that helps create national clinical practice guidelines

Convenience ■

Telehealth and video visits available

■

Easy hotel access for overnight and extended stays (including one on the UC Davis Health Sacramento campus)

Convenient online tools to help stay connected with your care from anywhere

■

A wide range of support services to promote healing and help our patients and families throughout their cancer experiences

For more information, visit cancer.ucdavis.edu.

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A Public Health Journey of Partnership Brings Promise to a Tough-to-Tackle Issue: Quitting Tobacco There’s no argument, one of the toughest drugs to quit is nicotine. The frequency and way in which people use tobacco, along with the social aspects and ingrained patterns of use all combine to make it very difficult to kick. Most who smoke, about 70%, say they want to quit, but it takes many attempts, and there’s a notoriously low success rate. Fortunately, there is now more support to treat nicotine addiction in Sonoma County. A recent collaboration between the Health Department’s Impact Sonoma Tobacco-Nicotine Prevention Program, Redwood Community Health Coalition and CA Quits resulted in the funding of four Sonoma County health centers who each made meaningful improvements to their operations. Alliance Medical Center, Jewish Community Free Clinic, Petaluma Health Center, and Sonoma County Indian Health Project, are better poised to help patients quit tobacco for good. These health centers are increasing screenings for vaping and smoking (including teens), and following that up with proactive referrals to cessation resources. These strategies, when done consistently, result in more quit attempts and more patients who can call themselves former smokers.

“We believe in connecting people. That’s why our project focuses on connecting each patient to the tobacco cessation counselors who can help them to succeed. Because no one should face quitting alone.” Rachel Joseph, FNP, MPH Petaluma Health Center Are you looking to quit? Contact your healthcare provider or reach out to Impact Sonoma for free resources to quit. Are you a healthcare provider and want to support your patients to quit? Contact Impact Sonoma for resources including materials, trainings, and technical assistance. Contact Impact Sonoma for resources:

Tobacco’s Damage to Health Persists The devastating health effects of tobacco are immense and real in Sonoma County. Our youth are vaping at unprecedented rates, thus starting a lifelong habit that contributes to future poor health. Shown below are some of the many negative health impacts of tobacco-related illnesses on our community.

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SELFCARE

G U T H E A LT H • D I E TA R Y S U P P L E M E N T S • D E M E N T I A • B O O K R E V I E W • W I N E

WRINKLE RELIEF OPTIONS

BY TATIANA LONGORIA, RN; AND JEFFREY SUGARMAN, M.D.

HEALTHY SKIN IS BEAUTIFUL SKIN, but despite our best care and protection efforts, age and environment can sometimes take a toll. Wrinkles, one of the most obvious signs of aging, develop as skin becomes thinner and less elastic over time. While some regard wrinkles as a sign of wisdom, most of us consider them unattractive. When you want to reduce their appearance, there are some great tools available in cosmetic dermatology. Tretinoin is a prescription retinoid (a vitamin A derivative) that works to soften superficial skin lines. ecause its effects are modest, it won’t erase deep wrinkles. ut using this cream can help improve the appearance of surface wrinkles (fine lines). It can also increase sun sensitivity, so it’s important to employ effective sun protection (at least SP 0) daily.

Common treatment areas for botox include crow’s feet and frown lines.

Botox is an injectable neurotoxin that, when applied in the correct dilution, softens muscle contractions, resulting in reduction of the depth of a wrinkle. Common treatment areas for botox include crow’s feet and frown lines. Re-treatment is necessary every 3 to 4 months. Other injectable fillers, such as hyaluronic acid, are also commonly used to help replace volume loss, correct wrinkles and create a more youthful appearance. Re-treatment is necessary anywhere from every 6 to 2 months depending on the procedure. Resurfacing lasers can improve skin’s overall texture by removing its outer layers, building collagen, thereby improving fine lines and wrinkles while, at the same time, evening out skin tone. Numbing the skin is necessary before treatment. Some of these lasers require “down time” for recovery. If you’re interested in learning more, seek the counsel of a dermatologist. About the authors: Tatiana Longoria is a cosmetic nurse and Jeffrey Sugarman is a dermatologist and the medical director at Redwood Family Dermatology in Santa Rosa and Ukiah.

S O N O M A H E A LT H

The Pediatric Colorectal Center

at Shriners Hospitals for Children — Northern California

Advanced Pediatric Colorectal and Motility Care Shriners Hospitals for Children — Northern California is a California Children’s Services designated Special Care Center for colorectal and urology care. Our Pediatric Colorectal Center brings together specialists to evaluate, diagnose and solve colorectal health issues, including: » Anorectal malformations (imperforate anus)

» Encopresis

» Pseudo-obstruction

» Fecal incontinence

» Rectal prolapse

» Hirschsprung disease

» Rectal trauma

» Idiopathic constipation

» Spina bifida

» Chronic constipation

» Megacolon

» VATER/VACTERL association

» Cloaca/cloacal anomaly

» Neurogenic bladder

» Cloacal extrophy

» Neurogenic bowel

» Bladder extrophy » Caudal regression syndrome/ sacral agenesis

To learn more visit, https://bit.ly/3hclCX5. To refer a patient:

SonomaHealth_2021.indd 12

Call: 916-453-2191

Fax: 916-453-2394

Email: referrals.ncal@shrinenet.org

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F R O M

T H E

INSIDE

O U T

Understanding your gut microbiome can lead to better overall health. BY A . MICHAEL LUSTBERG , M .D.

THOUSANDS OF YEARS AGO, ancient cultures took advantage of the process of fermentation to preserve food and enhance taste. In the 1800s, Dr. Louis Pasteur’s research showed that the growth of microorganisms was responsible for spoiling beverages such as milk. From this observation, he developed pasteurization, the process of gently heating certain foods and beverages to destroy harmful bacteria. In the early 1900s, Bulgarian physician Dr. Stamen Grigorov noted that the consumption of fermented foods, such as yogurt, seemed to be associated with longevity; his work led to the discovery of the bacteria Lactobacillus. But it wasn’t until the early 2000s that science truly turned its attention to the human gut microbiome. “Microbiome” refers to the numerous microorganisms (including bacteria and fungi) that populate the small intestine and colon,

known together as the gastrointestinal tract (GIT) or gut. The typical adult small intestine, nearly 1 feet in length, contains finger-like projections called villi, which increase surface area and help absorb nutrients. This is also where fermentation occurs, which results in gas and bloating. The colon, which is typically three to four feet long, absorbs the remaining water, calcium and potassium from the small intestine. The gut microbiome can promote a healthy intestinal lining and can affect food digestion, drug metabolism and immunologic processes (such as expelling germs and battling disease).

BALANCE IS KEY

Intestinal dysbiosis — a persistent imbalance of the gut’s normal ora or bacteria is likely responsible at least in part for insulin resistance which, in turn, results in elevated

blood sugar levels. This is mediated by a gut hormone called glucagon-like peptide (GLP1). GLP is released in response to food intake and helps regulate appetite, especially after eating. It also helps enhance the production of insulin. When the gut bacteria are out of balance, the production of GLP may be reduced. ytokines, which are pro-in ammatory substances secreted by white blood cells, are also secreted in higher amounts when the gut is out of balance. These changes can lead to a whole host of health issues, including weight gain (particularly around the waist), elevated blood sugar levels and abnormal cholesterol or triglyceride levels. Heart disease, stroke, diabetes and fatty liver can result. Increased in ammation can also lead to autoimmune conditions such as rheumatoid arthritis, Crohn’s disease or ulcerative colitis.

SONOMA HEALTH

Irritable bowel syndrome (IBS) can be caused by a condition called small intestinal bacterial overgrowth (SIBO), an alteration in intestinal bacteria. SIBO can occur after food poisoning or a viral illness, for example, and leads to more harmful intestinal bacteria, which produce excess noxious gases, such as methane and hydrogen, that can result in bloating and malodorous gas or diarrhea. lostridium di cile infection, or diff (CDF), is usually caused by antibiotics killing the good bacteria in the gut, which can leave the immune system in the gut altered and susceptible to the overgrowth of harmful bacteria. CDF can result in serious diarrhea, dehydration, bleeding, weight loss — even (rarely) death. While there are certain antibiotics that can be used to treat CDF, about one-quarter of the time the infection comes back after treatment. People of advanced age and those with a compromised immune system are more susceptible to this infection. Research on coronary artery disease has shown an increase of unhealthy intestinal bacteria in patients. These harmful bacteria produce an elevation in an endotoxin called nitric oxide (NO) after the consumption of red meat and saturated fats. NO is then absorbed through the intestine and into the bloodstream. The Mediterranean diet may reduce the risk of cardiovascular disease by decreasing bacteria that produce NO and other pro-in ammatory substances that get absorbed into the body.

RESEARCH ON CORONARY ARTERY DISEASE HAS SHOWN AN INCREASE OF UNHEALTHY INTESTINAL BACTERIA IN PATIENTS. 14

SONOMA HEALTH

THE GUT AND WEIGHT

Intestinal bacteria consist of several thousand different species. n individual’s genetic makeup and metabolic profile in uence how these bacteria interact with the gut. The role of intestinal bacteria and diet is complex, but weight loss appears to help regulate intestinal bacteria by driving down unhealthy bacteria that result in gut in ammation. Weight loss also helps repopulate the gut with healthy bacteria, resulting in a healthier intestinal lining, which then results in higher GLP levels and less cytokine production and endotoxemia (unhealthy substances produced by the intestinal lining that cause disease throughout the body).

Healthy gut has been associated with lean body type. This may occur, in part, by reversing in ammation and increasing GLP, which then results in less insulin resistance and decreases appetite. For example, normal weight individuals appear to contain more Bacteroides species bacteria in their gut. A healthy and balanced diet is key to maintaining a healthy and balanced gut microbiome. Western diet, which typically includes more processed foods, fats and sugars, encourages elevated blood sugar levels and gut in ammation resulting in an increased risk for metabolic related diseases. Healthy eating plans, such as the Dietary Approaches to Stop Hypertension

YO U A R E WH AT YO U E AT Olive oil is the main source of added fat. Fish, seafood, dairy, and poultry are included in moderation. Red meat and sweets are eaten only occasionally. The main benefit of a Mediterranean diet is that it contains relatively few energy-dense foods, such as processed carbohydrates and sugars, and it contains healthy fats, such as omega-3 fatty acids. The Mediterranean diet results in a reduction in MEDITERRANEAN DIET cardiovascular risk and imprioritizes plant-based foods, provement in overall health. such as whole grains, vegetables, legumes, fruits, nuts, WESTERN DIET is genseeds, and herbs and spices. erally characterized by DASH DIET (Dietary Approaches to Stop Hypertension) is designed to help treat or prevent high blood pressure. Studies have shown the DASH diet can lower blood pressure in as soon as two weeks. It can also lower LDL or bad cholesterol. DASH diet is high in vegetables, fruits and whole grains. It includes moderate amounts of fish, poultry and mixed nuts.

high intakes of red meat, processed meat, pre-packaged foods, butter, candy and sweets, fried foods, conventionally raised animal products, high-fat dairy products, eggs, refined grains, potatoes, corn (and high-fructose corn syrup) and high-sugar drinks, along with low intakes of fruits, vegetables, whole grains, pasture-raised animal products, fish, nuts and seeds. Some studies indicate a Western diet could impair the immune system in the gut in ways that could increase risk of infection and inflammatory bowel disease.

GU T H E A LT H

DEFINITIONS PROBIOTICS are microorganisms that are intended to have health benefits when consumed or applied to the body. They can be found in yogurt and other fermented foods, dietary supplements and some beauty products. PREBIOTICS are nutrient carbohydrates and act like food to help the healthy bacteria grow. ANTIBIOTICS are medicines (such as penicillin or its derivatives) that inhibit the growth of or destroy microorganisms. Antibiotics are prescribed for the treatment of a bacterial infection; they are not effective against viruses.

(DASH) diet and the Mediterranean diet, which emphasize eating vegetables, fruits, whole grains and lean proteins that contain healthy fats and tend to limit sugar, processed carbohydrates, salt and saturated and trans fats. (For more information, see “You Are What You at page 1 .)

KNOW WHAT YOU NEED

There are certain gastrointestinal conditions for which probiotics are used as a prescribed treatment. However, at this time, due to a large variation in how scientific studies have been performed, few specific recommendations are available. Other studies have examined prebiotics, which are derived from food nutrient substances, to help promote the growth of healthy gut bacteria. (For more about probiotics and prebiotics, see Definitions, above). Common symptoms of gastrointestinal distress are gas passage and bloating. Intestinal gas may be produced by either decreased digestion of carbohydrates or excess production of noxious gases. Decreases in intestinal digestive enzymes occur naturally with time (examples include lactose or fructose intolerance). This results in bacterial fermentation, which causes bloating

and odorless gas. These conditions can be diagnosed with a breath test ordered by your health care provider. SIBO can also be diagnosed with a breath test that measures the production of foul-smelling gases caused by the condition. Administration of an antibiotic called rifaximin can help bring the intestinal bacteria into the proper balance. Herbal medications may help as well. ifidobacterium and other probiotics appear to help prevent the recurrence of the symptoms. A novel study published by Nature magazine in September 201 found that mice that had their gut bacteria transplanted from other mice developed the weight of their donors (“Bacteria from Lean Cage-mates Help Mice Stay Slim”). The authors of the study were able to demonstrate an association between gut microbiota and a physical feature such as lean or obese body type. ecal microbiota transplant gives the purified stool from one individual or individuals to another person either through an endoscopy or capsule. Fortunately, fecal microbiota transplant restores the healthy bacteria in the gut and, most of the time, is able to treat people who have not responded to initial or recurrent courses of antibiotics in response to

CDF. Hospitals now routinely start probiotics any time antibiotics are given to prevent CDF. As always, see your health care provider if you’re experiencing chronic diarrhea, rectal bleeding or rapid and unexplained weight loss. Stool or blood tests may be the first step in diagnosis, as could a referral for colonoscopy or endoscopy.

BETTER DAYS AHEAD

The future of medicine is more personalized care, wherein specific treatment will be tailored to the individual needs of a patient based on their bacterial and genetic makeup. Currently, there are several commercial labs that perform a whole gut stool analysis of bacteria and inammatory markers that can be ordered by your health care provider. There is also ongoing research studying specific types of bacteria and how they interact with the gut in specific disease states. With proper medical supervision, healthy intestinal bacteria can be supplemented or altered through diet and probiotics to improve the GIT and overall health. About the author: Dr. A. Michael Lustberg is a fellow in the American Gastroenterological Association. He practices gastroenterology at Sutter Medical Group of the Redwoods.

SONOMA HEALTH

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FILLING IN THE GAPS

SONOMA HEALTH

Proper use of dietary supplements can bolster your body’s resilience. BY ELLEN SEELE Y

WHEN PANICKING OVER A LOOMING health threat such as the COVID-19 pandemic, we may in-

stinctively grab all the vitamin C, D3, zinc, and elderberry at our corner pharmacy to feel some sense of protection. But such knee-jerk actions highlight some integral questions about the proper role of dietary supplements in our health regimens. re they necessary? Helpful? ffective? Safe? It’s time to confront some inconvenient truths We can’t out-supplement unhealthy lifestyles, nor is it wise to use proximity and price as the primary determinants of our supplement choices. undamentally, it’s better to first attend to our nutrition, sleep hygiene, movement, stress management, time outdoors and social connection. Once our lifestyle ducks are in a row, we can consider what benefit dietary supplements might offer.

A SELF-REGULATED INDUSTRY

Several large health institutions, as well as many doctors, hold the opinion that supplementation isn’t necessary if we eat a healthy diet. n October 2021 article in the Journal of Family Medicine analyzes data from a number of research studies and finds, here is limited evidence supporting clinically significant benefit from supplementation in healthy patients with well-balanced diets.” This makes sense at face value, but it overlooks certain factors, including soil-nutrient depletion from industrial agriculture; the prevalence of processed, nutrient-poor food in many of our diets; our declining nutrient-absorption capacity as we age; any drug-induced nutrient depletion; and the impact of other environmental inputs on our nutrient status. Stress, for example, causes us to burn through many nutrients at an accelerated rate. Therefore, supplementation may sometimes be indicated. An uninformed and haphazard approach, however, can cause anything from profound healing to great harm. Such is the range of outcomes we can expect from a largely self-regulated industry. The 1994 Dietary Supplement Health and Education Act (DSHEA) ruled that, rather than undergoing review and regulation by the U.S. Food and Drug Administration (FDA), vitamin and supplement companies are responsible for the safety, purity and accurate labeling of their own products. That means, aside from avoiding actual medical claims (including using verbiage such as “treat,” “prevent,” “heal” or “cure”) and sticking to “structure/function” claims (such as “supports healthy blood sugar levels,” for example), supplement companies are free to formulate and market products pretty much as they please. While supplement companies must ensure that any marketing claims they make are backed by su cient evidence so as to not be false or misleading, such evidence doesn’t require D verification. Says Santa Rosabased neurologist Dr. Allan L. Bernstein, who

has conducted clinical trials of B vitamins, “Due to cost and confounding variables, it’s hard to find double-blind, randomized, controlled clinical trials being conducted on most supplements.” Given this uncertainty, how do we proceed as consumers? Ideally, we select supplements under the supervision of a qualified medical practitioner. If this isn’t feasible, we can search the National Center for Biotechnology Information’s PubMed database (pubmed. ncbi.nlm.nih.gov) for meta-analyses that validate the benefits of certain supplements. We can then look for evidence of third-party certifications that will lend confidence when choosing from that supplement category (see rusted hird-Party ertifiers, page 22).

VITAMIN AND SUPPLEMENT COMPANIES ARE RESPONSIBLE FOR THE SAFETY, PURITY AND ACCURATE LABELING OF THEIR OWN PRODUCTS. METABOLIZING SUPPLEMENTS

Vitamins can be either water-soluble or fat-soluble, which means that our bodies absorb and store them in two different ways easy absorption in water, with excess amounts removed by our kidneys and a lower storage capacity

(necessitating frequent replenishment); or, alternatively, dissolution in fat, breakdown via bile, and accumulation in our skeletal muscle, liver, and fat tissue, giving our bodies a reservoir from which to draw over time. Vitamins and minerals are critical for good health, yet research shows that many of us fall short on certain types. A National Health and Nutrition Examination Study (NHANES), which assessed 16,444 individuals, found multiple, widespread micronutrient deficits. ortunately, not all deficiencies reach a dangerous level. According to “Micronutrient Inadequacies in the S Population, a 201 overview article by the Linus Pauling Institute at Oregon State University that examined the NHANES data, “Micronutrient inadequacies defined as nutrient intake less than the estimated average requirement — are common in the United States and other developed countries. Such inadequacies may occur when micronutrient intake is above the level associated with deficiency but below dietary intake recommendations.” Clearly, many of us have work to do to achieve nutrient su ciency. Doing so with food is optimal, but the aforementioned factors may necessitate supplementation. Fortunately, scientific literature and clinical practice have both yielded promising evidence for a wide variety of micronutrients and herbal compounds. Some of the most promising, in terms of the health concerns they help address, are detailed below.

THE Bs AND METHYLATION

he vitamins ( 1, 2, , , 6, , 9 and 12) are enzyme cofactors (that is, key ingredients) in many neurological, endocrine and metabolic processes. These eight essential nutrients work synergistically, but they also carry out their own unique functions. Among the most crucial jobs facilitated by the Bs is methylation, a critical biochemical process that occurs billions of times per second and in every one of our cells. It produces, regulates and helps transport vital hormones, such as cortisol and melatonin, and neurotransmitters, including serotonin, dopamine, adrenaline, and norepinephrine. As such, it helps regulate our stress response, our brain chemistry, our immune function, and our capacity to detoxify. It is the biological “switch” that turns genes on and off. Folate (B9) is perhaps the most important methyl donor; methylation is almost entirely dependent upon it. Bernstein notes, “In preg-

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nant women, folate has been shown to prevent neural-tube defects in infants.” According to the U.S. National Institutes of Health (www. ncbi.nlm.nih.gov), folate deficiency is also frequently found in people with depression. 12 is another key methyl donor. It supports the brain, nerves, energy levels and red blood cell production. Deficiency (which is common in vegans, the elderly and individuals with malabsorption) can lead to fatigue, pernicious anemia, vascular disease, stroke, autoimmune conditions and dementia. Without su cient 12 to convert folate into -methyltetrahydrofolate (which creates the universal methyl groups SAMe and methionine), methylation can’t proceed. Vitamin B6 (pyridoxine) is another methylation-helper with a bevy of benefits. Says Bernstein, “I’ve researched B6 for patients with carpal tunnel syndrome and had good outcomes. It also helps many women with their PMS symptoms. Plus, it’s an important co-factor in the production of serotonin, one of the chief neurotransmitters regulating our mood and digestion.” Pyridoxine works for most individuals, but those with liver problems should take the pyridoxal-5-phosphate (P-5-P) form, which the liver won’t need to convert. itamin 2 (ribo avin) also assists with methylation; its greater claim to fame, though, is helping with migraines. Bernstein notes that 2 mg of 2 can help, but the successful clinical studies used a ton 00 mg. We really don’t know what’s optimal.” One huge caveat: Two common variants in the methylenetetrahydrofolate reductase gene (MTHFR) — which are estimated to occur in more than one-third of the U.S. population — significantly compromise methylation ability, leading to greater risk of high homocysteine (a neurotoxic amino acid), as well as other problems, such as migraines and miscarriages. If a blood test indicates the presence of one or both MTHFR variants, or high homocysteine, it’s important to supplement with the most bioavailable (aka activated) forms of the Bs: folate from methylfolate (or L-5methylfolate), and 12 from methylcobalamin.

VITAMINS C, D, AND K2

Vitamin C is a major antioxidant and important cofactor for many immune, endocrine and metabolic functions. Deficiency is surprisingly widespread, and supplementation is quite safe (with excess indicated by loose stools and, possibly, kidney stones). It is best absorbed from

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whole-food sources (including citrus fruits), in liposomal form, or at least with citrus bio avonoids included (look for these terms on the label). Vitamin D is a fat-soluble vitamin critical for proper immune function, bone metabolism, mood regulation and metabolic and cardiovascular function, due to its synergistic action with other nutrients and hormones. Many of us are deficient in it, so testing and supplementation can be transformative. Santa Rosa-based naturopath Dr. Elizabeth Large says, “Every single person I test for 2 -hydroxy vitamin D is in the 20s or even the 10s nanograms per milliliter, ng/mL]. I like to see people in the functional range of 0 to 0 ng mL. It’s surprising how low people are. Deficiency has also been seen to worsen COVID outcomes and is closely associated with autoimmune conditions.

VITAMINS AND MINERALS ARE CRITICAL FOR GOOD HEALTH, YET RESEARCH SHOWS THAT MANY OF US FALL SHORT ON CERTAIN TYPES. itamin 2 is essential for bone metabolism as well, channeling calcium deposition appropriately without 2, calcium and D will default toward arterial calcification (and possible cardiovascular problems) and formation of kidney stones. 2 also regulates blood clotting. Unfortunately, tests for itamin 2 are not yet easily available, so speak with your physician if you’re experiencing heavy bleeding or poor clotting of injuries, nosebleeds, easy bruising, slow healing of injuries and/or easily fractured bones.

VITAL MINERALS

Magnesium is responsible for catalyzing close to 00 enzyme reactions in the body, yet 6 percent of us fall short of recommended levels. This vital mineral facilitates the reaction in our mitochondria (our cells’ energy factories) which produces ATP (adenosine triphosphate, our energy currency). It also enables bone synthesis, gene expression, muscle relaxation, insulin sensitivity and the parasympathetic response (rest-and-digest mode). In particular, magnesium converts vitamin D into its active form so that it can help calcium absorption. The most absorbable magnesium supplements are chelated, or bound, to one or more amino acids that help ferry them across the intestinal membrane into the bloodstream. Magnesium citrate is popular for its laxative effect, while magnesium glycinate and magnesium l-threonate help primarily for relaxation and, according to Bernstein, prevention of migraine. Magnesium malate has shown utility for muscular conditions like fibromyalgia. inc deficiency is rampant ( percent of Americans fall short of optimal levels), yet this mineral is crucial for supporting immune function, digestion and metabolic health. It also aids collagen synthesis, assists in mood regulation and cognitive processes, and enables taste and smell. Like magnesium, zinc is best absorbed when chelated to an amino acid. Iron deficiency is also widespread, leading to anemia, decreased work capacity, and impaired immune and endocrine function. Vegetarians and vegans may obtain quantities equaling those in omnivores’ diets but still end up deficient, since non-heme iron (from plant foods) is much less absorbable than heme iron (from meat, fish and poultry). alcium also can impede iron absorption. Supplements can be constipating, so look for food-based or, specifically, GI-friendly varieties that include vitamin C, which enhances absorption.

SUPPORT ESSENTIAL FUNCTIONS

The omega-3 fatty acids EPA and DHA play vital roles in neurological, cognitive, cardiovascular and metabolic health. They also can’t be made by our bodies but must be obtained from ingesting fish or algae. Our ideal omega 6-to-omega 3 ratio, essential for managing in ammation, falls between 1 1 and 1. Yet many of us range as high as 2 1. he prevalence of omega-6s in cheap industrial seed oils — and, therefore, the restaurant and packaged-food industries — means many of

NUTRITIONAL SUPPLEMENTS

us must work extra-hard to compensate with more P and DH but the effects on our in ammation, cell membranes, moods and metabolisms are worth it. Glutathione is our body’s master antioxidant; one molecule of it is used in every single detox reaction. ollowing the wildfires of recent years, Dr. Shiroko Sokitch, a functional M.D. based in Santa Rosa, has prescribed glutathione to many patients with smoke-related health challenges. In addition to fighting free-radical damage, glutathione helps our bodies detoxify certain carcinogens, heavy metals and harmful chemicals. oenzyme -10 has demonstrated effectiveness in supporting proper mitochondrial function (ATP synthesis), thereby helping fuel every single bodily process. Statin drugs, typically prescribed to lower cholesterol, deplete o- 10. ssuming you have the go-ahead from your physician, it’s best taken in its active form, ubiquinol, which is more easily absorbed by the body.

it encounters and can reduce the absorption of nutrients, other supplements and medications. Curcumin, the phytochemical in turmeric root, has proven a powerful tool in fighting pain, in ammation, joint deterioration, cognitive decline and immune dysfunction. It is, however, di cult to absorb unless combined with black pepper or ingested in its essential-oil form. Sokitch says, “I prescribe turmeric to many of my patients, but it has to be a therapeutic dose...which is hard to find on store shelves.” Just because herbs and vitamins are natural doesn’t mean we should take them casually; consult your practitioner for guidance. Bernstein and Sokitch both urge caution with any herbs sourced from China or India, which are often contaminated with heavy metals and other toxins. Says Sokitch, “I only prescribe traditional Chinese medicine remedies made in the United States, which are third-party tested.”

HERBAL CONSIDERATIONS

GETTING IT JUST RIGHT

St. ohn’s Wort, -H P, and L-tryptophan can negatively interact with other serotonin-related substances, both herbal and pharmaceutical. Activated charcoal, often used for digestive complaints or in detox protocols, binds powerfully to any substance

he benefits of most nutrients form a bell curve, meaning deficiency is problematic, but so is excess. The “Goldilocks zone” for many nutrients is still unknown, cautions Bernstein: We have no idea what the optimal level is. here is, however, significant evidence sug-

gesting toxicity is possible not only with fat-soluble vitamins and minerals but water-soluble vitamins and herbs as well. ernstein recounts that, Women who experienced PMS relief with vitamin B6 got numb legs and feet when their intake rose too high.” Excessive folic acid, if improperly metabolized (as with MTHFR polymorphisms), can lead to cardiovascular disease and cancer risk. Vitamin D toxicity can result in hypercalcemia and arterial calcification, and vitamin A in excess can cause headache, bone pain and liver damage. Even herbs require cautious use, ideally under practitioner oversight. Herbs used for infection and microbial balance, like oregano oil, are easily overused. Says Dr. Guillermo Ruiz, an Arizona-based physician who practices naturopathic endocrinology specializing in metabolic optimization, We need to use specific doses, in specific time periods. Otherwise, these herbs can create dysbiosis an imbalance in the gut microbiome . here are people who have been using allicin found in garlic] or oregano oil for months or years, for example, and in them we see a loss of homeostatic bacteria, dysbiosis, and symptoms similar to those of an actual infection.” In the developed world, serious vitamin deficiency syndromes are rare, thanks to sufficiently balanced diets and availability of fortified foods. However, if you’re experiencing symptoms such as severe fatigue, neurological dysfunction, sensory deficits or other significant red ags, deficiency may be a factor. Your doctor can request blood tests for many nutrients (such as D3) and indicators of nutrient status (including ferritin, for iron), as well as for genetic markers like MTHFR. Once you know your levels, you can supplement in a targeted way. Supplements aren’t always the answer, but they can be tremendously helpful if used judiciously and under the guidance of a qualified medical practitioner. The key is to “supplement” a healthy lifestyle, so your body’s systems can rebalance themselves. About the author: Born and raised in Sonoma County, Ellen Seeley earned a master’s degree in community development from UC Davis. Today, she is a freelance writer and copy editor for health and lifestyle publications as well as working in the wellness department at Oliver’s Market.

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[Photo courtesy NSF International]

NUTRITIONAL SUPPLEMENTS

TRUSTED THIRD-PART Y CERTIFIERS

Independent, third-party testing is crucial for determining the trustworthiness of a dietary supplement. Today, there are many independent organizations that conduct third-party testing of products for purity, potency, safety and accuracy of marketing. CERTIFIED ORGANIC SUPPLEMENTS WILL BEAR ONE OF SEVERAL CERTIFYING AGENCIES’ L ABELS. SOME OF THE TOP OPTIONS ARE:

California Certified Organic Farmers (CCOF) is a United States Department of Agricultureaccredited organic certifying agency and trade association, located in Santa Cruz, Calif. Formed in 1973, CCOF was the first organic certification entity in the United States. Through The National Organic Program, the USDA ensures that food and supplements are produced using agricultural production practices that foster resource cycling, promote ecological balance, maintain and improve soil and water quality, minimize the use of synthetic materials, and conserve biodiversity. “Organic” means 95% organic ingredients; “Made with organic___” means at least 70% organic ingredients; and specific organic ingredient listings will indicate the organic components in the Supplement Facts section. Oregon Tilth Certified Organic (OTCO), formed in 1974, shares the most innovative methods for sustainable food production through a combination of partnerships and technical assistance. It also works with the National Organic Standards Board and Accredited Certifiers Association to push for rigorous and sensible changes that maintain the integrity of organic products.

IN ADDITION TO THESE ORGANIC OVERSEERS, THERE ARE A NUMBER OF OTHER TRUSTED TESTING ORGANIZATIONS AND CERTIFIERS, INCLUDING:

Current Good Manufacturing Practice (CGMP) is the Food and Drug Administration’s main regulatory standard for ensuring human pharmaceutical quality. It verifies that products are consistently produced and controlled according to quality standards. It is designed to minimize the risks involved in any pharmaceutical production that cannot be eliminated through testing the final product.

The Non-GMO Project seal gives shoppers the assurance that a product has completed a comprehensive third-party verification for compliance with the Non-GMO Project Standard. Testing finished products is not a reliably accurate measure of GMO presence. Therefore, the Non-GMO Project Standard requires testing of individual ingredients or precursors, not finished products.

ConsumerLab.com, LLC (CL) is the leading provider of independent test results and information to help consumers and healthcare professionals identify the best-quality health and nutrition products. CL lets companies of all sizes have the quality of their products tested for potential inclusion in its list of Approved Quality products.

NSF International tests and certifies products to the requirements outlined in NSF/ANSI 173 – the American National Standard for Dietary Supplements. Products that earn this NSF certification must be produced in a manufacturing facility that is inspected twice annually to comply with Good Manufacturing Practices. Then the product is tested and the label’s claims are verified. Finally, NSF tests the product to make sure there are no harmful levels of specific contaminants or fraudulent ingredients.

ISURA is Canada’s only independent, notfor-profit natural health supplement and food product verification and certification organization. ISURA serves as an analytical competence center for the analysis of natural health products, raw food, and supplement materials at all stages of processing. Labdoor is an independent company that tests supplements to find out whether products contain what they claim and if they have any harmful ingredients or contaminants. It then grades and ranks those products, generates reports, and publishes that information for free so consumers can confidently buy the best supplements for their health.

SCIENTIFIC LITERATURE AND CLINICAL PRACTICE HAVE BOTH YIELDED PROMISING EVIDENCE FOR A WIDE VARIETY OF MICRONUTRIENTS AND HERBAL COMPOUNDS 22

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NSF Certified for Sport supplements must meet the requirements of the Contents Certified standard plus products are tested on a lot-by-lot basis for more than 280 athletic-banned substances. Products that earn this certification are the cleanest products on the market based on those testing and certification requirements. The designation helps athletes, dieticians, coaches, and consumers around the world make safer decisions when choosing sports supplements. US Pharmacopoeia (USP) is an independent, scientific nonprofit organization focused on building trust in the supply of safe, quality medicines. Through rigorous science and the public quality standards they set, USP helps protect patient safety and improve the health of people around the world.

When did Primrose open? Opening in 1997, Primrose was the first memory care specific facility in Sonoma County. Over the years we’ve been fortunate enough to retain our core staff. The continuity of staff and the quality of care we provide is an indispensable component of a safe and secure home for our residents.

Is there one thing families should know in advance? Adult children should talk with their parents, no matter how hard the conversation, about how they want to live if they develop dementia. Preparing for the journey is the single best thing I can tell people. The legal process, the emotional process: these need to be talked about.

What sets Primrose apart from other assisted living facilities? Our memory loss programs incorporate the latest research findings, including aromatherapy, touch therapy, music and pets. We have 3½ acres, so our residents can experience the feeling of freedom in a safe, secure setting. We are often successful with challenging clients, We strive for fewer medications and offer a facility that’s life affirming and outdoor-oriented in as homelike a situation as possible.

What’s important to know when dealing with dementia patients? Remember those affected with dementia, no matter how impaired they are, are still wonderful people and have something to contribute. We’ve learned enormously from our clients. What is your Day Club? We offer daytime care for people with Alzheimer’s and related dementias. This social program includes fun activities, snacks and meals. The Day Club gives people a chance to experience Primrose firsthand and provides caregivers with helpful time off during the day.

www.primrosealz.com | 707-578-8360 Day Club • Respite • Residential • Support Group Lic # 496803764-1 Family Owned and Operated

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REMEMBER WHEN

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When does forgetfulness become dangerous? BY ALL AN L . BERNSTEIN, M .D. AT S OM E P O I NT, WE ’ V E A LL WA LKE D I NTO A RO OM O N LY TO FO RG E T WH Y WE D I D.

We’ve forgotten birthdays, misspelled names, and gotten turned around while driving. Some of us will laugh off these instances; others will claim “Senior moment!” and move on. But when should you worry that such occurrences are a sign of something bigger?

Memory is based on a series of actions within the brain that include input, sorting, storage and retrieval. Input is an essential component in creating memories, since if information is never received, it effectively doesn’t exist in the brain’s memory system. Difficulty hearing may create gaps in memory: A conversation can’t have been forgotten if it was never entered into the memory system due to a hearing loss. Similarly, decreased vision, loss of taste or smell, and loss of touch may limit the information getting into the memory system. Not paying attention also impairs input, regardless of how well the other sensory modalities are functioning. We’ve all had a teacher go on about a topic we weren’t interested in: If asked about it later, it’s a blank in our memory.

THE MEMORY BANK

Sorting the information in our memory bank is a skill that improves with age. Young people retain large amounts of extraneous material, possibly because they have more “storage” space. As we get older, we get more selective in what is important to keep in the system. Storage of memory has both short-term and long-term components. A critical part of creating long-term memory is sleep. Poor sleep, such as occurs with sleep apnea or insomnia, can prevent new memory material from being properly stored. We may have pulled “all-nighters” during our school years to get through an exam the next day, successfully passing the test. However, a large amount of that material may be missing when we try to recall it a week later, having not “slept on it.” Another essential aspect of storage is having intact connections in the brain. Damage from trauma and strokes may limit both storage space and the ability to connect the various parts of the brain where information is retained. Retrieval — or, more accurately, the slowing of retrieval — is what we notice with aging. Information used frequently is rapidly available, while less used material may take a little longer. A “noun delay” is common, with the right word arriving too late to fit in the conversation. This is normal.

CAUSES OF DEMENTIA

Dementia is the gradual loss of the ability to create new memories and to retrieve old ones. It is accompanied by di culty in speech, judgement, orientation to time and location, loss of previously acquired skills, loss of the ability to perform chores that were normally routine, and di culty recognizing common objects and people. There are multiple causes of dementia, some preventable, some treatable, as well as some that still need more study. The key to meaningful intervention is to recognize that dementia is present in an individual, and start to look for causes. In the past, getting old equaled becoming “senile” i.e., demented. Since we all know cognitively intact people in their 0s, 90s and 100s, it’s time to reconsider that concept. Dementia has decreased overall due to actively treating high blood pressure and smoking cessation, thereby minimizing stroke-related dementia. We have also become better at recognizing the effect of toxins in the environment that can cause dementia, limiting exposure to lead and mercury, for example. Today, we actively monitor people for abnormalities in their thyroid function and vitamin 12 status, potentially reversing memory loss associated with these conditions. reating a sleep disorder may significantly improve memory in many people. Depression, if unrecognized, may produce a dementia-like

condition, since it is associated with lack of interest in current activities and therefore not paying attention to new material inputs. Medications, both prescription and over the counter (OTC), may contribute significantly to memory problems. ommon OTC medications to aid in sleep often contain diphenhydramine (Benadryl), which, when taken for long periods of time, may impair memory. Even medications prescribed for anxiety or sleep, if taken for a prolonged period, start to interfere with memory. Most of these offenders should be prescribed for a few weeks or months, but end up being used for years, which is when the problems start to surface. Repeated head trauma, known as chronic traumatic encephalopathy (CTE) has become more recently recognized in football players, boxers, wrestlers and soccer players (among others) as a potential cause of dementia. In the United States, the age of starting to play tackle football seems to be a marker for developing CTE, with boys who start playing before puberty being at the highest risk. Starting later, such as high school or college, seems less risky — though it’s still not safe. A previously unrecognized risk factor for dementia is related to gum and tooth disease. Fragments of mouth bacteria can often be found in the brains of people with dementia. This suggests some level of infection or

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DEMENTIA

in ammation, starting in the mouth, may be triggering the cascade of events leading to dementia or even Alzheimer’s disease.

ALZHEIMER’S DISEASE

he first symptom of lzheimer’s disease is often forgetting recent events, though lapses in judgement, getting lost in familiar places, or inability to do common (though more complex) tasks, such as cooking, may be the first presentation. In many cases, it is the diagnosis that remains when all of the other possible causes are eliminated. It is a specific type of dementia, first described by psychiatrist and neuropathologist lois lzheimer in 1906. His patient was a young woman whose ailment was associated with a specific set of findings in her brain: deposits of a protein known as beta amyloid and associated protein strands from broken nerve fibers called neurofibrillary tangles, or tau. Recent advances in diagnostic testing let us determine the level of amyloid and tau in the brain using a radioactive tracer. We can also monitor these same chemicals in spinal uid, using a lumbar puncture procedure. Given the lack of an effective treatment of this progressively degenerative condition, these tests are rarely used outside of research settings. What these tests are showing, however, is that amyloid may start to build up in the brain 10 to 20 years before any symptoms of lzheimer’s disease appear. au may appear two to five years before symptoms occur. The condition is highly prevalent in countries with aging populations, it is more common in women, and the incidence increases with age. There is also a genetic risk, which can be evaluated by a test for the APOE marker. Apolipoprotein E, or APOE, is a protein involved in the metabolism of fats in the body of mammals. The three most common, though slightly different versions (alleles) of the PO gene are e2, e and e . ccording to the U.S. National Library of Medicine (medlineplus.gov), people who inherit one copy of the APOE e4 allele have an increased chance of developing Alzheimer’s; those who inherit two copies of the allele are at even greater risk. The APOE e4 allele may also be associated with an earlier onset of memory loss and other symptoms, when compared to individuals with Alzheimer’s disease who do not have this allele. It is not known how the APOE e4 allele is related to the risk of Alzheimer’s disease.

However, researchers have found that this allele is associated with an increased number of protein clumps, called amyloid plaques, in the brain tissue of affected people. buildup of amyloid plaques may lead to the death of nerve cells (neurons) and the progressive signs and symptoms of this disorder. It is important to note that people with the APOE e4 allele inherit an increased risk of developing Alzheimer’s disease, not the disease itself. Not all people with Alzheimer’s have the APOE e4 allele, and not all people who have this allele will develop the disease. hose with an PO 2 allele have a lower risk of Alzheimer’s disease.

RESEARCH IS BEING PURSUED WORLDWIDE TO BOTH PREVENT ALZHEIMER’S AND TO STOP THE DISEASE’S PROGRESSION ONCE IT APPEARS. ONGOING RESEARCH

Research is being pursued worldwide to both prevent Alzheimer’s and to stop the disease’s progression once it appears. There is currently no way to repair damaged brains, so prevention is the ideal goal. The most recent drugs in the news are monoclonal antibodies designed to remove amyloid from the brain in the hope this will prevent further damage related to the disease. However, in spite of a huge amount of publicity, they have not reversed any damage and have not stopped progression — only slowed it slightly — in limited studies. These medications are given intravenously, monthly, without a clear stopping point. There are associated risks, including brain swelling and bleeding into the brain, that commonly occur. Other areas of research include diabetes-related medications that

change how glucose is used in the brain, antiin ammatory medications that can get into the brain, magnetic stimulation to activate injured parts of the brain to stop further damage, and pills that may prevent the formation of amyloid before it reaches the brain. A major drawback to all of these studies is that they are starting with brains that are already injured. The degree of injury may be mild to moderate, but they’re nevertheless damaged beyond repair. Since we have the ability to identify risk factors, such as a positive genetic marker and amyloid and tau deposits in the brain, before any symptoms appear, that would seem to be an ideal time to start a prevention study. The problem, of course, is that this type of study would take many years and would be extremely expensive. No single organization, government or industry, has proposed taking on this type of project.

PLAN FOR THE FUTURE

The current best plan for improving memory, preventing mental decline and treating early symptoms still rests with behavior modification, making it a life-long project. Physical activity, social engagement, diets low in saturated fats, not smoking, minimizing alcohol intake and continuing education have all been shown to delay onset of dementia. Being aware of toxins in the environment and reducing exposure as much as possible should also be a goal. General health maintenance such as blood pressure control, diabetes control and dental care are further contributors to preserving memory. Go over your medication list, including OTC medications that are often not on your medical record, with your health care provider annually. You may be able to reduce medications that are no longer needed. Medical breakthroughs are still on the horizon, so be leery of “magic cures” for failing memory. And, admitting to a strong bias: No one should take up boxing — at any age. About the author: A native of Brooklyn, Allan Bernstein attended college and medical school in upstate New York, trained in Internal Medicine in Los Angeles and Neurology in Boston. He was Professor of Clinical Neurology at UC Davis College of Medicine and Chief of Neurology at Kaiser in Santa Rosa. An author of more than 40 publications in medical journals and textbook chapters, Bernstein is currently Professor of Clinical Medicine at UCSF and actively involved in research in the field of memory loss and Alzheimer’s disease.

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HOLDING HANDS

Book Review of Caring for Your Friend with Dementia B Y B R I E N A . S E E L E Y, M . D .

THE ESSENCE OF DEMENTIA CARE IS MAINTAINING CONNECTION WITH THE PERSON WHO IS SUFFERING MEMORY LOSS.

MY WIFE ANNIE AND I WALK hand-in-hand

around Spring Lake nearly every Saturday morning. Along the trail, we count how many other couples are holding hands. Our most-ever was the day we counted six. We wish there were more, for holding hands can be remarkably helpful — not only for setting a mutual pace, but for balance, safety, and instant signaling of directional intent, alerts, engagement and affection. Holding hands confers a steady reassurance and connectedness. ccordingly, I found it fitting that a photo image of hand-holding adorns the cover of Dr. Jo Ann Rosenfeld’s new, self-published book, Caring for Your Friend with Dementia (available through Amazon and other book sellers). Rosenfeld emphasizes that the essence of dementia care is maintaining connection with the person who is suffering memory loss. Connection is what keeps a patient’s mind meaningfully engaged while also fulfilling the caregiver’s role of keeping them feeling safe and protected. he first chapter begins with the author’s grim declaration that, “There is no prevention,

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postponement, or detection of early dementia…. No medicines or treatments can alter the disease, although symptoms can be affected.” She follows that stark assessment with an assurance that a person’s quality of life during the inexorable worsening of his or her dementia can be substantially eased by keeping them socially engaged, active and mindful. Such relief derives from neural plasticity and the “use it or lose it principle a rmed by modern neuroscience. Studies into the treatment and care of those with dementia are ongoing, including recent findings by L Psychiatry Professor Helen Lavretsky, M.D., that suggest cognitive improvement can be linked to yoga and chanting mantras to music. Also, the persistence of the sense of hearing in otherwise unresponsive patients in the final hours of their life offers hope that music and the voices of loved ones can also provide comfort to those with advanced dementia. This research, and other similar studies, are worth seeking out, as the more knowledge you have available when facing this

unrelenting disease, the better prepared you’ll be for unexpected challenges. For her part, Rosenfeld focuses on the basic, day-to-day reality of caring for someone with dementia, including concerns such as safety, appropriate care settings, diet, nutrition, supplements, ethics, caregiver support, living wills, end-of-life care and dealing with agitated patients. She offers understanding and forgiveness for caregiver burnout and advises how to avoid it. She also touches on the comfort of daily rituals as a way to maintain vital connection. The author describes the extremes of patient incapacitation in a way that compels addressing the tough questions of do-notresuscitate and death with dignity. As she describes the several studies that examine correlations of dementia with certain bad health habits, a likely take-away for readers will be that they rededicate themselves to the healthy lifestyle habits their physicians have been recommending. A Lake County family practitioner, Rosenfeld displays a deep and thorough knowledge of the practical aspects of dementia and the caregiving challenges it entails. Her book serves as a primer, reference and editorial on the subject. Written mainly for use by family, friends and caregivers facing this situation for the first time, the book will nonetheless also be useful to nurses, medical assistants and physicians. About the author: Brien Seeley, M.D. (brienseeley@ gmail.com), is a board-certified ophthalmologist in Santa Rosa and member of the Editorial Board of the Sonoma County Medical Association. His areas of interest include neuroscience, biologic evolution, aeronautics and baseball.

“Dr. Guy” is board certified and has been practicing county since “Dr. Guy”inisSonoma board certified and has

1999. He has a concierge been practicing in Sonomainternal county medicine since practice in the town of Sonoma where the 1999. He has a concierge internal medicine focus is on you, the patient – providing the practice in the town of Sonoma where the best inisquality and can oftenthe be focus on you, theservice. patient He – providing seen riding his bike around town with his best in quality and service. He can often be wife twohis daughters. seenand riding bike around town with his wife and two daughters.

What is the background of “Dr. Guy” and how long has practicing? of “Dr. Guy” and how long Whatheisbeen the background

Do I assume my results are good if I don’t hear back from the office? Do I assume my results are good if I don’t hear back

College of CA. He then went to Creighton School of “Dr. Guy” grew up in the Bay Area and went to St. Mary’s Medicine in Omaha, NE. and moved on to his internship and College of CA. He then went to Creighton School of residency in Internal Medicine at Providence St. Vincent’s Medicine in Omaha, NE. and moved on to his internship and Medical Center in Portland, OR. He has been practicing residency in Internal Medicine at Providence St. Vincent’s medicine in Sonoma County since 1999. The majority of his Medical Center in Portland, OR. He has been practicing career was spent caring for ill patients at Memorial Hospital. medicine in Sonoma County since 1999. The majority of his In January 2017 he opened his “concierge practice” in career was spent caring for ill patients at Memorial Hospital. Sonoma and it has become a destination for excellence In January 2017 he opened his “concierge practice” in in medical care. He is Board Certified and was voted by Sonoma and it has become a destination for excellence his peers as a top physician in his specialty two years in a in medical care. He is Board Certified and was voted by row. Call to inquire about becoming a patient. He accepts his peers as a top physician in his specialty two years in a Medicare and most PPO plans. row. Call to inquire about becoming a patient. He accepts Medicare plans.to seeing “Dr. Guy” as What areand themost key PPO benefits

news.” Our office staff calls every patient with every lab, We do NOT ascribe to the old adage, “no news is good X-ray and other test result and develops the appropriate news.” Our office staff calls every patient with every lab, next step based on those results. Our approach decreases X-ray and other test result and develops the appropriate the chance for errors and delayed diagnoses and ultimately next step based on those results. Our approach decreases leads to a higher quality of care. the chance for errors and delayed diagnoses and ultimately leads to a higher care. How does yourquality officeofmaintain financial

has he been “Dr. Guy” grew practicing? up in the Bay Area and went to St. Mary’s

your Whatconcierge are the keydoctor? benefits to seeing “Dr. Guy” as your concierge doctor? “Dr. Guy” is a board certified Internal Medicine doctor with

less than 300 patients allowing him and his staff to provide “Dr. Guy” is a board certified Internal Medicine doctor with the highest level of service. No wait times, longer scheduled less than 300 patients allowing him and his staff to provide appointments with your doctor, same day office visits during the highest level of service. No wait times, longer scheduled office hours when you are ill and 24/7 accessibility to “Dr appointments with your doctor, same day office visits during Guy”. He has the experience and relationships that allow office hours when you are ill and 24/7 accessibility to “Dr him to to be the ultimate facilitator and advocate for you in Guy”. He has the experience and relationships that allow this complex healthcare system. him to to be the ultimate facilitator and advocate for you in this complex healthcare What can you expectsystem. when you come to visit

from office? We dothe NOT ascribe to the old adage, “no news is good

sustainability seeing “one-tenth” How does yourwhen office maintain financialof the usual patients an internist has to see? sustainability when seeing “one-tenth” of the usual

patients anpay internist hasmembership to see? fee which helps Our patients an annual support our practice. This added revenue stream allows us Our patients pay an annual membership fee which helps to see a tenth of the usual patients and therefore we see support our practice. This added revenue stream allows us eight patients a day on average – this allows us to fulfill the to see a tenth of the usual patients and therefore we see promises we make to you as a patient which include some of eight patients a day on average – this allows us to fulfill the the following: a thorough annual physical, patient advocacy, promises we make to you as a patient which include some of no wait times, longer scheduled appointments, same day the following: a thorough annual physical, patient advocacy, office visits during the week when you are ill, facilitating your no wait times, longer scheduled appointments, same day care and advocating for you throughout all aspects of your office visits during the week when you are ill, facilitating your care including – insurance companies, pharmacies, urgent care and advocating for you throughout all aspects of your care clinics, emergency departments, hospitalizations, care including – insurance companies, pharmacies, urgent referrals to consultants and top quality medical centers. care clinics, emergency departments, hospitalizations, referrals to consultants and top quality medical centers.

“Dr. WhatGuy?” can you expect when you come to visit “Dr. Guy?” Easy parking just steps away from the office on the ground

floor, a warm welcome by professional staff, to be offered a Easy parking just steps away from the office on the ground drink or snack, no wait, see Dr. Guy every office visit instead floor, a warm welcome by professional staff, to be offered a of a less highly trained professional, nearly unlimited time drink or snack, no wait, see Dr. Guy every office visit instead with your physician who has time to listen, address all your of a less highly trained professional, nearly unlimited time questions and develop a personalized care plan with you. with your physician who has time to listen, address all your questions and develop a personalized care plan with you. Guy Delorefice MD | 370 Perkins St, Sonoma, CA 95476 (707) 938-1255 | staff@drguysonoma.com | drguysonoma.com Guy Delorefice MD | 370 Perkins St, Sonoma, CA 95476 (707) 938-1255 | staff@drguysonoma.com | drguysonoma.com

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SONOMA HEALTH

I N V I N O V E R I TA S Finding the truth — and health — in wine

ANCIENT ROMAN PHILOSOPHER PLINY THE ELDER FAMOUSLY SAID,

“I N V I N O V E R I TA S .” TRANSLATION: “ IN WIN

H R

s a Wine ountry family physician who has studied food as medicine for almost two decades, and as someone who married a winemaker (with whom I ran a small winery for a few years), I have a lot to say about wine and health. With Pliny in mind, here’s the truth. It’s not all rosy — or even rosé — but it’s not all bad, either. B Y R AC H E L F R I E D M A N , M . D .

DEFINING MODERATION

Most people probably know that excessive alcohol intake of any kind can lead to liver disease, accidents and behavioral problems. What you may not know is that increasing your wine or alcohol consumption even slightly past the so-called “moderate amount” increases rates of heart disease and high blood pressure, heart failure and arrhythmias, as well as increasing the risk of breast, prostate and colorectal cancer. Now for the even worse news What you think of as moderate is probably too much. According to the most recent Dietary Guidelines for Americans (www.dietaryguidelines.gov), for those who choose to drink alcohol and are able to do so, the safest daily limit is up to one drink for women and one to two drinks for men. In the context of wine, one serving is equivalent to a standard five-ounce glass. ven drinking modestly over this recommended amount may dramatically increase risks of the conditions mentioned above. nd binge drinking (defined as more than four servings of alcohol in one day) seems to increase breast cancer risk independent of total alcohol intake. A recent meta-analysis found a dose-dependent increase in breast cancer risk with increased intake of wine (or any alcohol). According to breastcancer.org, “Alcohol can increase levels of estrogen and other hormones associated with hormone-receptor-positive breast cancer. Alcohol also may increase breast cancer risk by damaging DNA in cells.” Interestingly, there are also studies indicating more dietary folate (vitamin B9, found in leafy greens, beans and whole grains) may alleviate these risks, highlighting the interplay between diet and other lifestyle habits in moderating health and disease. Fortunately, while there are certainly some people who should avoid alcohol altogether, for most healthy adults, a glass of wine with a meal a few times per week — or a fun weekend afternoon of wine tasting with friends — can certainly be part of a healthy lifestyle. Continued on page 34

SONOMA HEALTH

37 th Annua Physician Awards

Celebrating service to the practice of medicine and our community

very year since , the SONOMA COUNTY MEDICAL ASSOCIATION has recognized and honored exemplary service and contributions of Sonoma County physicians and local healthcare professionals. Please join SCMA in congratulating and thanking our  award recipients. OUTSTANDING SERVICE TO THE COMMUNITY

OUTSTANDING CONTRIBUTION TO SCMA

The SCMA COVID-19 Vaccine Clinic Physician Volunteers

David Gorchoff, MD, FAAFP, MPH

HIV & Family Medicine Physician / MCHC Lakeside Clinic, Ukiah

To honor his distinguished 33-year career in clinical leadership roles, including tenure as chief of staff for Community Hospital and Sutter Medical Center of Santa Rosa; service as the first medical director of West County Health Centers and Redwood Community Health Coalition; and primary care practice with special interest in HIV/AIDS.

With gratitude to the dedicated SCMA member physicians, who donated countless hours volunteering at our COVID-19 mass vaccine site as well as various pop-up community clinics at local businesses, events and homeless shelters from January to August 2021. (Please see next page.)

RECOGNITION OF ACHIEVEMENT

OUTSTANDING SERVICE TO THE COMMUNITY

Wendy Young

Brian Prystowsky, MD

Executive Director / Sonoma County Medical Association

Pediatrician / Sutter Health

In recognition of his being an indomitable champion for COVID-19 vaccine advocacy and community education; the force behind the “I’m In” vaccination campaign; and unrelenting organization of vaccination events and creation of multi-media vehicles to reach patients, physicians, and underserved populations.

OUTSTANDING CONTRIBUTION TO LOCAL MEDICINE

In acknowledgement of her exceptional leadership and monumental, innovative efforts organizing and then managing SMCA’s COVID-19 vaccine clinic for eight months; recruiting physician volunteers to administer life-saving vaccinations; and always going above and beyond in service to medicine and community.

PRACTICE MANAGER OF THE YEAR

Carolyn Dam, PharmD

Gary Green, MD, FIDSA

Pharmacy Services Manager / Sutter Santa Rosa Regional Hospital

Medical Director of Quality, Infection Prevention, Antibiotic Stewardship / Sutter Health

With appreciation for his identification of the first cases of COVID-19 in Sonoma County; persistent advocacy and collaboration with Public Health and the CDC; co-authoring articles on the early pandemic for MMWR and NEJM; and providing crucial education about the virus to clinicians and the public.

In recognition of her tireless work to ensure efficient processes for Sutter’s COVID-19 vaccination program and clinic; playing a critical role in developing anticoagulation guidelines and workflows for COVID patients; and instrumental work in acquiring IV Remdesivir for use in Sonoma County.

SCMA extends its deep appreciation and gratitude to our 2021 Award sponsors and partners. SPONSORS

 P R E S E N T I N G M E D I A PA RT N E R S  www.scma.org • scma@scma.org • 707-525-4375

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SCMA COVID- Vaccine Clinic

Physician Volunteers

he story of SCMA’s COVID- vaccine clinic is one of innovation and service to community, a response to the pandemic crisis that would have never been possible without our physician volunteers. A dedicated group of physicians, including the SCMA members listed below, served continuously from January to August , helping to administer more than , vaccine doses.

Dr. Olson with clinic sign.

Community members register at SCMA’s Grace Pavilion clinic.

During California’s initial “tier system,” in partnership with the County Health Department, SCMA averaged  appointments per day at Grace Pavilion in the Santa Rosa Fairgrounds. Later, we teamed up with Santa Rosa Community Health and expanded vaccination efforts to underserved populations and pop-up locations throughout the county. SCMA’s VACCINE CLINIC was the only clinic in Sonoma County to be led by volunteer physicians and managed by SCMA staff. As a mission-focused, nonprofit organization, SCMA is deeply honored to have been entrusted with this critical, life-saving work. With heartfelt gratitude, we thank and recognize our SCMA clinic physician volunteers.

SCMA COVID19 CLINIC PHYSICIAN VOLUNTEERS

SINE

Robert Anderson, MD Kate Black, MD Peter Bretan, MD Patrick Caskey, MD Jean Cool, MD Tom Cory, MD Kevin Costello, MD Martha Cueto-Salas, MD Leland Davis, MD Nancy Doyle, MD

RTNE

Gail Dubinsky, MD Mark Fahey, MD John Freedman, MD Garima Hoffman, MD Madeline Huber, MD James Hunt, MD Gary Johanson, MD Stacey Kerr, MD Dan Lightfoot, MD Harold Mancusi-Ungaro, MD

Rachel Mayorga, MD Felicity McNichol, MD Ketan Mehta, MD John Mihalik, MD Steve Olson, MD Ligaya Park, DO Brian Prystowsky, MD David Quenelle, MD John Renfree, MD Daniel Rich, MD

Loie Sauer, MD Maury Schulkin, MD Robert Schulman, MD John Schafer, MD Swati Singh, MD David Smith, MD Jim Stone, MD Dale Westrom, MD Thomas Yatteau, MD

A special note of appreciation to SCMA’s Business Partners, who support SCMA activities and the medical community throughout the year: NORCAL Group, Cooperative of American Physicians, BF Berry & Fitzinger, Ehrlicher Styles Real Estate Group, Exchange Bank, Operation Access, Russell Van Sistine CFP®, and Sudha Schlesinger, Real Estate Advisor. For information about SCMA membership, our Business Partnership program, or sponsorship opportunities, please call --.

www.scma.org • scma@scma.org • 707-525-4375

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5 HEALTH TIPS FOR WINE DRINKERS

• STAY WELL HYDRATED by drinking

primarily water between meals and throughout the day. Drink an extra glass of water before or after every serving of caffeine or alcohol.

• STRETCH AND MOVE YOUR BODY. If

you sit most of the day, ensure proper ergonomics and set a timer to stand up every hour. The best exercise is the one you will actually do — a brisk walk with a friend, a bike ride, swim, exercise class, etc. Even dancing to the radio for three minutes has mental and physical health benefits.

• EAT A MOSTLY PLANT-BASED, MOSTLY WHOLE FOODS DIET. Plant-based

foods include vegetables, fruits, beans, nuts and whole grains. Whole foods are any food in natural form, without additional processing and additives. Choose foods with shorter ingredient lists and no added sugar. The increased risks of alcohol consumption may be mitigated, in part, by diets rich in folic acid. There are countless delicious plant-based wine pairings, for example, Cabernet Sauvignon and dark chocolate, Sauvignon Blanc with a crisp, bright salad, or Pinot Noir and mushroom dishes. • GET GOOD SLEEP. Disrupted or insufficient sleep can lead to anxiety, heart palpitations, high blood pressure, pre-diabetes and weight gain. If you’re using wine or alcohol to get to sleep, talk to your doctor about other options. The alcohol may be preventing restorative slumber. • ADD MORE TO YOUR STRESS TOOLKIT. Drinking a glass of wine at

the end of a long day is one way to relax — but it’s not the only way. Go for a walk, call a friend, write down what’s on your mind. Be honest with yourself — and your doctor — about whether you may be using wine to deny or self-medicate a more serious mental health condition such as anxiety or depression. Your primary care provider can help.

SONOMA HEALTH

BETTER OFF RED

You may have heard that drinking wine can actually be healthful, and it does seem that way — if you stick to the guidelines. Light to moderate alcohol intake (as described in the Dietary Guidelines) has been shown, time and time again in large population studies, to reduce risks of premature disease and death from cardiovascular disease. INTERH R , a large study that followed 2 ,000 people across 2 countries, found that regular light alcohol intake was associated with fewer heart attacks in all genders and age groups. Furthermore, epidemiologic studies suggest that benefits seem to be slightly greater when red wine is the alcohol of choice. Clinical trials have additionally found that moderate red wine intake may help prevent type 2 diabetes (though it’s important to note more than that amount hastens progression of the disease). Several clinical trials have shown that, when people with type 2 diabetes drink red wine with dinner, it improves their glycemic control, reducing the spike in blood sugar often experienced after meals. Other potential benefits of light-to-moderate wine intake include increases in HDL (high-density lipoprotein, the “good” cholesterol) and reductions in in ammation and in ammatory markers, among other things. Some of the health benefits of alcohol intake appear to be irrespective of alcohol type, and derive from molecular properties of the ethanol (alcohol) itself. That said, red wine seems to confer something more. There are several theories about what substances in red wine provide that extra healthy oomph. One possible contributor is

FOR MOST HEALTHY ADULTS, A GLASS OF WINE WITH A MEAL A FEW TIMES PER WEEK CAN CERTAINLY BE PART OF A HEALTHY LIFESTYLE. resveratrol, a polyphenol (micronutrient) found primarily in the skins of fruits such as grapes, blueberries and raspberries. Making grapes into wine concentrates the resveratrol and, since red wine grapes are fermented with their skins, red wines (especially Pinot Noir) contain the highest quantities of resveratrol. Resveratrol may be responsible for lowering in ammatory markers, increasing the HDL, regulating heart rhythm and, maybe, even supporting some anti-cancer effects. lthough preliminary studies in animals and humans suggest benefits of increased resveratrol intake, studies of resveratrol supplementation have not yet yielded results su cient to warrant encouraging people to go out and buy concentrated resveratrol capsules. A glass of red wine a few times a week is probably a better route.

MORE BENEFICIAL EVIDENCE

he benefits of a plant-based diet are well established at this point (see You re What You Eat,” page 14). One reason is that such diets are rich in antioxidants like quercetin, a avonoid found in onions, apples, grapes and berries, among other foods. Also a major avonoid constituent of red wine, quercetin is thought to provide health benefits through cell signaling pathways and antioxidant effects. uercetin may help reduce blood pressure in people with hypertension, and emerging evidence suggests a possible role for quercetin in protection against neurodegenerative ailments such as Alzheimer’s disease. As with resveratrol and many naturally occurring substances, proof is still lacking that popping a pill of the supplement is the answer. Rather, the best prescription is to eat a healthy, balanced diet containing these polyphenols. Will drinking wine help you live longer? It might. But longevity is determined not just by what you drink, but also by the rest of your health habits. With that in mind, here are three additional ways to leverage wine for longevity based on the available evidence about scientifically proven factors that enhance joy, health and well-being.

SERENITY AND CELEBRATION

Mindfulness is the art and practice of living in the present moment — focusing on your thoughts, feelings or bodily sensations in a nonjudgmental way. While mindfulness has roots in many ancient medicinal and spiritual systems from around the world, recent studies have demonstrated its potential to reduce risks of heart disease, improve overall mental and physical health, and even increase telomere length on our DNA, an important marker of longevity. A formal wine tasting is a beautifully structured lesson in mindful consumption, an opportunity to slow down and fully engage our senses while turning down the volume on the incessant chatter in our brains. Instead of gulping down wine for its alcohol content, take advantage of its power to generate a sense of calm and well-being; savor each sip as a microcosm of sensory delights. Research has shown that taking time to feel gratitude can rewire our brains to be happier. Here in Sonoma County, every

WILL DRINKING WINE HELP YOU LIVE LONGER? IT MIGHT. bottle of locally produced wine is a unique time capsule of a particular year’s sun, rain, soil, avors, and caretaking and for that we can be grateful. As a family doctor in Sonoma County, I’m fortunate to care for patients who contribute to every stage of the winemaking process: winemakers, winery owners, cellar staff, vineyard staff and farm workers, tasting room employees, bottlers, even the farmers and chefs who produce the food pairings. Each one plays a role, and deserves our gratitude when we delight in a favorite local wine. Taking the time to feel this gratitude can release the neurotransmitters that generate feelings of happiness and well-being. The COVID pandemic was a reminder of how critically important human connection is to our mental health. Humans have evolved to live in families and communities, and to derive pleasure and health from our social connections. Studies show loneliness is a risk factor for premature death, while its counterpart, having rich and meaningful social networks, can increase longevity. Wine can mark the special moments and experiences in our lives, facilitating the social connections and positive memories that increase our health. By combining mindfulness, gratitude and connection, we can pair wine with foods (such as antioxidant-rich dark chocolate) to enhance the avors of both, and associate wine with ritual and celebration, creating sacredness and special memories that enrich the joy and happiness in our lives. hat is, we can find health in wine if we focus on quality over quantity, savoring the avors and special moments of our lives with the people we love.

Rachel Friedman, M.D., is a family medicine physician at Kaiser Permanente Santa Rosa.

DEFINITIONS

ANTIOXIDANTS are substances that can prevent or slow damage to cells caused by free radicals (see below). The sources of antioxidants can be natural or artificial. Three of the major antioxidant vitamins are betacarotene, vitamin C and vitamin E. You’ll find them in colorful fruits and vegetables, especially those with purple, blue, red, orange and yellow hues. Source: www.medicalnewstoday. com FREE RADICALS are unstable molecules that the body produces as a reaction to environmental stress and other pressures. They can damage cell membranes, tamper with DNA and even cause cell death. Source: www. medicalnewstoday.com QUERCETIN belongs to a group of plant pigments called flavonoids that give many fruits, flowers and vegetables their colors. Flavonoids, such as quercetin, are antioxidants. Source: www.mountsinai.org RESVERATROL is an antioxidantlike compound found in red wine, berries and peanuts. In preclinical studies, resveratrol has been shown to possess numerous biological activities, which could possibly be applied to the prevention and/or treatment of cancer, cardiovascular disease, and neurodegenerative diseases. Source: lpi.oregonstate.edu A TELOMERE is the protective end of a chromosome that protects the chromosome from damage. Each time a cell divides, the telomeres become shorter. Eventually, the telomeres become so short that the cell can no longer divide. Source: www.genome.gov

SONOMA HEALTH

Start your New Year today!

Relieve Your Chronic Condition No drugs. No surgery. Introducing the

Exclusively in use at O’Connor Chiropractic, this next generation laser therapy increases circulation while ionized oxygen is being emitted at the same time. This unique trait accelerates the rate of healing for a variety of chronic conditions. Repairs are faster, results last longer, and for many conditions could completely alleviate symptoms. Conditions the GenesisOne Laser could help include all manner of chronic, painful conditions such as: • Sciatica • Frozen Shoulder • Carpal Tunnel,

• Tendonitis (many forms) • Neuropathy • Plantar Faciitis / Achilles’ tendonitis

Other chronic inflammatory conditions that could benefit from GenesisOne therapy • Asthma • Scars / Anti-Aging / Wrinkle reduction • Lymphedema • Inflamed prostates • Post Covid lung symptoms • Fat reduction, and more Start the New Year today by taking care of yourself with GenesisOne Laser Therapy. Contact us for your personalized, in-person consultation.

O’Connor Chiropractic Phone: 707-778-1145 5 Keller Street., Petaluma, CA www.dockathy.com

Dr. Kathy O’Connor. DC 27 years in practice | Palmer graduate

Patient testimonials I got very sick with a two-week long virus that made it very difficult to breathe. Traditional medicine told me they could do nothing for me. The laser treatments improved my energy, and by Day 2, I was full of energy and busy living my life. The focal point in Dr. O’Connor’s practice is to bring wellness and well-being into the community. She is continually exploring new, effective ways to help her clients with a wide variety of problems. Sharon G., retired nurse I sustained a fairly debilitating concussion and was severely limited by my brain fog, fatigue and dull headaches. 24 hours following the first, I was a new person! My headaches disappeared, and so did my brain fog and fatigue. It was transformative and allowed me to get back to work and my daily exercise routine. When the symptoms reappeared about six weeks later, a final laser treatment took care of the symptoms once again. Kelly K., sales director I have Type II Diabetes and I was experiencing some vision loss. I went to see my ophthalmologist who diagnosed me with Cotton Wool spots, Capillary Occlusion and Red (Roth) Spots on the Retinas. After a total of 9 sessions, over a five month period, at my next ophthalmologist visit, all 3 of my issues were resolved. I believe it was due to this laser therapy since I administered no other treatments. Michael O., quality assurance manager My husband, Don, was diagnosed with Lewy Body Dementia. My husband is Stage One and after 5 laser treatments I saw a difference is his alertness, speech flow and memory, and is walking smoother. Although this disease cannot be cured, we believe the treatment has helped slow the process. One year later, testing shows him still at Stage One and passing tests he failed one year ago. It gives us great hope for the future. Patti P., retired business owner More testimonials on www.dockathy.com

Disclaimer: For the above-mentioned degenerative conditions and all conditions, we are not treating/curing anything. The treatment can reduce and/or eliminate symptomatology to a level where a better life, potentially symptom-free can be achieved. Some conditions are eliminated, and some require periodic maintenance therapy. All patient conditions and their situations are different and so everyone’s requirements for use of therapy varies. To maintain a symptom-free life patients may need to alter their diet or lifestyle to prevent reoccurrence.

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COMMUNITY HEALTH COMMUNIT Y CLINICS • SE A SONAL ALLERGIES • CLINIC AL TRIAL S

UNDERSTANDING MEDICARE PLANS

MEDICARE SUPPLEMENT PLANS ARE CONFUSING. Sorting through options for

parts A, B and D — or choosing to enroll in part C — takes time and mental energy, two things most of us have in short supply. Help is here. ounded in 199 , alifornia Health dvocates ( H ) is the leading Medicare advocacy and education nonprofit in alifornia. hrough its Health Insurance ounseling dvocacy Program (HI P) it offers free, one-on-one Medicare counseling. Trained volunteer counselors answer questions to help you understand Medicare rights and benefits, including Medicare supplemental insurance (Medigap policies) and Medicare Advantage plans. They do not sell, recommend or endorse any insurance product, agent, insurance company or health plan. Rather, they explain in detail, using comparative charts, how

Trained HICAP volunteer counselors can answer questions to help you understand medicare rights and benefits.

to evaluate your needs and find a plan that fits. The CHA website provides Medicare information organized by topic, with English and Spanish podcasts available in several sections. HICAP also provides free educational presentations on Medicare and related topics. These include how to appeal denials of coverage, employee and retiree coverage, and long-term care insurance. Legal help and representation at Medicare appeals or administrative hearings is also available. In addition to personal counseling and education, HICAP advocates with federal and state legislators on behalf of Medicare beneficiaries and their families. It also conducts public policy research to support improved rights and protections, and frequently partners with other statewide and national organizations to promote policies that positively impact Medicare. Although CHA supports HICAP through its membership program, training, technical assistance and educational materials, they are separate programs. HICAP is run through the California Department on Aging, which also manages its 1- 000222 hotline. cahealthadvocates.org/hicap/

S O N O M A H E A LT H

Community health centers typically provide outpatient care, including check-ups, vaccinations, and treating common injuries and illnesses. [Photo courtesy of Santa Rosa Community Health]

SONOMA HEALTH

MORE THAN MEETS THE EYE Community health centers have far-reaching benefits for us all. B Y J U L I E FA D DA

COMMUNITY HEALTH CLINICS ARE ONLY FOR POOR PEOPLE. That’s the perception, anyway. And it is, in large part, true: Clinics are a literal lifeline for people with no social safety net. But clinics also serve those who are between insurance coverage due to a move or job change; teens and young adults, including full-time students, with no employer or familial insurance plan; children and spouses of working people whose employer premiums, deductibles and co-pays make family coverage prohibitive; and those who need help beyond what many companies or retirement packages provide (also known as the underinsured). What’s more, clinics provide education and career opportunities, as well as access to services beyond health care, such as transportation, housing assistance and disaster preparedness — something all Sonoma County residents are, sadly, familiar with.

COMMUNITY PARTNERSHIP In the past, when someone needed medical care but had no (or limited) insurance coverage, they often ended up in county emergency rooms, which was — and is — a costly and ine cient way to provide service for conditions that aren’t true emergencies. The last decade has seen an explosion of walk-in and urgent care clinics, which are meant to siphon less critical cases away from Rs by offering same-day, after hours and weekend availability for less-serious maladies. Of course, upon arriving at one of these types of facilities, you’re still asked to provide insurance information. When someone without health insurance seeks medical aid at a county emergency room or urgent care center, their visit triggers a well-delineated series of interventions.

Regardless of income level or immigration status, sick or injured persons will be treated (or referred to an appropriate provider if the matter can wait) and interviewed to determine eligibility for state and federal aid. Thanks to federal passage of the Patient Protection and ffordable are ct ( ) in 201 , most people who need assistance with medical expenses can receive it; an expansion of state-funded Medi-Cal and the open exchange marketplace Covered California dramatically changed the state’s health care landscape. (For more about these options, see Definitions, page ) In Sonoma County, a network of nine community health care organizations (some that reach beyond our borders) provide thousands of residents with quality medical care and preventive, dental, vision and mental

health services. In addition to five large clinic groups, there are at least four smaller or standalone care clinics run by various religious, social or community groups. All together, there are more than different sites throughout the county where one can find care. ach health center organization is independently owned and operated, but they all work within the system to provide — and be reimbursed for — the care they give. ACA CHANGED THINGS Partnership HealthPlan of California (PHC) is a nonprofit, community-based health care organization that contracts with the state to ensure those covered by Medi-Cal have access to high-quality, comprehensive, cost-effective care. Serving 14 Northern California counties, including Sonoma, PHC’s mission

SONOMA HEALTH

WE FOCUS ON UNDERSTANDING SOCIAL DETERMINANTS OF HEALTH, AND WE PROVIDE FULL-SPECTRUM FAMILY MEDICINE. — DR. NURIT LICHT, PETALUMA, ROHNERT PARK, AND COASTAL HEALTH CENTERS

is to help its members, and the communities it serves, be healthy. In 2011, Dr. Marshall Kubota joined as a regional medical director. “I chose this position because the organization endeavors to use public funds in the best way possible — to keep people and communities healthy,” he says. Originally from Fresno, Calif., Dr. Kubota attended UCLA then St. Louis University School of Medicine. After residency, he began medical practice at Russian River Health enter in Guerneville. When the ACA passed, community health centers saw an in ux of new patients. t PH , we were overjoyed,” says Kubota, “because we knew there was a large population of uninsured people not getting active and preventive care.” In just a short time, he says, “Our patient population quickly rose by one-third.” With expanded eligibility came an in ux of patients, agrees Dr. Nurit Licht, chief medical o cer at Petaluma, Rohnert Park, and Coastal Health Centers (in Point Reyes and Bolinas). When the passed, the number of clinic patients skyrocketed, she says. So many people had avoided even routine health care due to fear of costs. The ACA took that fear away. It was incredible to intake the new patients and watch their health improve. Community health improved as a result.”

SONOMA HEALTH

While health centers may have varying levels of specialty care capacity and coordinate a broad range of health care services for their patient population, they typically provide outpatient care, including check-ups, vaccinations and treating common injuries and illnesses (colds and u, digestive issues and the like). General patient care is largely determined by location and accessibility. But when someone comes into a health center with a serious medical condition — for example, cancer or organ failure — the center will contract with PHC, which holds separate contracts with specialists and hospitals. For patients with private insurance, health centers use the specialty network contracted with each insurance to direct referrals for patients. For patients without insurance, “It’s a challenge and a scramble,” admits Alvaro Fuentes, interim CEO at Redwood Community Health Coalition (RCHC, headquartered in Petaluma and serving patients in Sonoma, Napa, Marin and Yolo counties). “Health centers use internal specialists when they can, telehealth specialists if available, and e-consults if they’re available, to leverage their relationships and contracts with specialists to refer patients for in-person specialty care.”

A HOLISTIC APPROACH

The idea behind holistic health care is that each patient receives everything he or she might need to be healthy, which often goes beyond medical services. We have counselors onsite who help people get insurance, and we help patients obtain food through CalFresh,” says Licht, a Dartmouth graduate who came to Petaluma in 200 expressly to work in a federally qualified health care center (FQHC) setting to embrace collaboration and advocate for systemic change in health care. We focus on understanding social determinants of health, and we provide full-spectrum family medicine, she continues. We provide behavioral health, dental, vision and nutrition care. We have established schoolbased health centers and a medical clinic in the homeless shelter. We also see patients in the hospital and at skilled nursing facilities. It’s a broad range of what people need.” Says Naomi Fuchs, CEO of Santa Rosa Community Health Centers (SRCHC), “A holistic approach centers around any given patient’s personal health goals. SR H began with one location in 1996. When uchs came on board in 2000, there were employees. Today, there are eight locations and more than 00 employees serving upward of 0,000 patients annually.

C OM MU N I T Y H E A LT H C E N T E R S

SRCHC began with one location in 1996. Today, there are eight locations and more than 500 employees serving upward of 40,000 patients annually. With a background in anthropology, I find the interface between culture and healing very important. My desire is to transform health care so everyone can access it,” adds uchs. We provide comprehensive care medical, dental, mental health and specialty services including case management. “It’s about social justice and health equity,” she adds. We do a lot of advocacy and outreach to make health care more accessible to people who’ve been historically left out — regardless of education, income or language barriers.” RCHC’s Fuentes has been working within the nonprofit sector since he was in his early 20s. I sought to make a difference first by wanting to become a police o cer, he says. “I later met a mentor, who told me I could make much more of an impact working with nonprofits. “I got a job at AltaMed Health Services Corporation in Los Angeles as a grant writer, where I learned about community health centers. I came to the Community Clinic Consortium of Contra Costa and Solano ounties in 200 . I blinked, and it’s been 1 years. Yet it always feels fresh,” he adds. Fuentes was brought in as interim O at R H in une 2021 to guide the organization during its transition between CEOs. The two organizations have since discussed a merger plan to create a consortium that would cover six Bay Area counties, including Sonoma County. There’s been a positive reaction within

MY DESIRE IS TO TRANSFORM HEALTH CARE SO EVERYONE CAN ACCESS IT.

— NAOMI FUCHS (ABOVE), SANTA ROSA COMMUNITY HEALTH CENTERS

the organizations, with lots of excitement surrounding the possibilities. “Even though we’d be a larger organization, there’s 100 percent commitment to deepening local relationships,” he says.

COVID-19 AND NATURAL DISASTERS

Most everyone’s least-favorite subject these days is O ID-19. We’re all tired of hearing about it, dealing with ever-changing mandates, and not being able to visit our loved ones, especially if they’re in a highrisk category. Community health centers are there to help. “COVID brought a lot of people to us for testing. We worked with the county and other partners to fill gaps and develop a safety net. It was very heartening to see,” says Licht. “Then we focused on vaccinations and new challenges with the Delta variant. There will be a lot of twists down the pandemic road, but a lot of new patients have turned to us over the past year.”

“COVID has been the major disruptor of health care in my lifetime,” says Kubota. It caused tremendous upheaval. O ces were closed, hospitalization rates increased. Nursing homes and long-term care facilities were stressed.” “Every year, we have to retool how we do things because of fires, evacuations, oods and now the pandemic,” adds Fuchs. “After the 201 fires, we launched a communitywide collaborative, called Sonoma County Resilience, and trained more than 200 people to be facilitators in mind/body medicine, with wonderful results. It’s an eight-day intensive training course, then the students go into the community to address and create awareness and understanding of how trauma affects people. “Nobody was prepared for COVID,” says Fuentes, who also partners with statewide organizations and other health consortiums throughout California. “Now, almost two years into it, people are able to admit that. We realized right away that we’d play a key role in mitigating pandemic challenges. We leveraged local relationships with public health departments to provide personal protective equipment PP and accurate information. We had to protect front-line workers, first with PP and then with vaccination distribution. “At the end of the day, it should be clear to everyone that community health centers are playing a vital role in ensuring the vaccine gets to patients and communities served.”

NEW IDEAS AND GOALS

One positive that’s come out of the pandemic is greater access to telemedicine. While remote diagnosis and treatment has long been important to outlying communities, it hasn’t always been the case for those closer to in-person help. Prior to the pandemic, insurance companies resisted telehealth visits, requiring in-house appointments instead. But that all changed last year. When COVID hit, we shifted to 0 percent telehealth visits in 10 days, says uchs. Now it’s about 0 percent. “The pandemic opened the door for telemedicine, agrees Licht. We’ve had real success with it regarding chronic disease management, prenatal education and behavioral health. Patients like being able to stay home.”

SONOMA HEALTH

Geriatric care is also on the radar. We’re working with UCSF and the Institute for Healthcare Improvement on a model of health care for elders, says Licht. We’re always looking for new ways to provide highquality services. Eliminating barriers is the key to success.” We’re about to launch our three-year strategic plan,” adds Fuchs. “Part of it addresses the needs of older adults, a growing population in the area. We’re also looking to expand mental health services, chronic disease management, team-based care, telehealth and more.” At PHC, transportation services were added a few years ago for people without means to get to medical appointments. We provided more than 00,000 non-emergency transports in 2019, says ubota (the organization’s region extends to the Oregon border). PHC has also provided support in the form of grants for medical and other housing programs. “Hospital-style beds are important for the acutely ill,” he says. But for many who are recovering from illness or injury, 2 -hour medical surveillance isn’t necessary. “These programs allow more open beds in hospitals, while patients receive the rehabilitative care they need at a separate facility.”

FACING CHALLENGES

One of the biggest challenges faced by community health clinics is maintaining a strong workforce. While clinics cannot compete with large hospitals regarding salaries, they can attract employees by providing a positive, family-like work environment. “During the last several years, we’ve been focusing on teaching and training people onsite, says Licht. We have nurse practitioner and physician assistant residency programs that are growing. We also have post doctorate programs and are starting a pediatric dental residency. We also train dental assistants as well as medical assistants and nursing externs. We find that, when they train with us, they want to stay.” Providing job training and employment opportunities is just another way clinics support the larger community. We offer a positive work culture and excellent benefits, says uchs. We have lots of opportunities and a strong growth ladder for people who work here. For example, one person who started here in high school as a volunteer ended up becoming our associate director of nursing.”

SONOMA HEALTH

Congressional Representative Jard Huffman (dark jacket) visits a North Bay health center during the pandemic. [Photo courtesy RCHC] here have been mass resignations in the healthcare sector] because people are burnt out,” says Fuentes. “Community health centers aren’t immune to that. There’s a tremendous amount of pressure on all healthcare workers, which COVID has increased. We have local training programs to build up the pipeline and ensure the workforce re ects the communities served.” Another challenge is long-term sustainability. “Fiscal sustainability is a very important thing to factor into organization planning,” says Fuentes. “The federal government, over the last 18 months, has provided three rounds of COVID relief funding, which has been key to keeping health centers running and able to provide key health services during the pandemic. “Added support from community foundations has likewise been essential during this challenging time,” he continues. “Community Health enters receive significant funding from the federal government, through

reimbursement from Medi-Cal, which is administered by the State of California, some private insurance, as well as nonprofit community foundations and private donations from community members.”

OVERCOMING BARRIERS

Community health centers help our entire community, not just those patients directly served. They’re a trusted information, education, career, and (of course) health resource that extends into everyone’s lives. With luck, hard work and perseverance, this valuable resource will continue for generations to come. Find a complete list of Sonoma County community health centers on page 78. About the author: Julie Fadda is a freelance writer and former magazine editor based in Sonoma County.

THIS ORGANIZATION ENDEAVORS TO USE PUBLIC FUNDS IN THE BEST WAY POSSIBLE — TO KEEP PEOPLE AND COMMUNITIES HEALTHY. —DR. MARSHALL KUBOTA, PARTNERSHIP HEALTH PLAN OF CALIFORNIA

C OM MU N I T Y H E A LT H C E N T E R S

DEFINITIONS CALAIM is a state-funded program that provides safe discharge housing for patients to stay and finish home medical therapies. CALFRESH , federally known as the

Supplemental Nutrition Assistance Program (SNAP), issues monthly electronic benefits that can be used to buy most foods at many markets and food stores. The CalFresh Program helps to improve the health and well-being of qualified households and individuals by providing them a means to meet their nutritional needs. CALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES (DHCS) is

the backbone of California’s healthcare safety net, funding healthcare services for about 13 million Medi-Cal beneficiaries, including low-income families, children, pregnant women, seniors and persons with disabilities. COVERED CALIFORNIA is the state’s

health insurance marketplace, established under the federal Patient Protection and Affordable Care Act. The exchange lets eligible individuals and small businesses purchase private health insurance coverage at federally subsidized rates. FQHC is a reimbursement designation

from the Bureau of Primary Health Care and the Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services. An FQHC provides care to underserved areas of population, provides a sliding fee scale, and comprehensive services (either onsite or with a thirdparty provider) including transportation services, hospital and specialty care. Each FQHC must have an ongoing quality assurance program and a governing board of directors.

CENTER FOR MEDICAID AND CHIP SERVICES (CMCS), is one of six centers

within the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). CMCS serves as the focal point for all the national program policies and operations for three important, state-based health coverage programs, which, together, provide an important foundation for maintaining the health of our nation: • MEDICAID provides health coverage to low-income people and is one of the largest payers for health care in the United States. • The CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP) provides federal matching funds to states to provide health coverage to children in families with incomes too high to qualify for Medicaid, but who can’t afford private coverage. • The BASIC HEALTH PROGRAM (BHP) gives states an option to provide affordable coverage and better continuity of care for people whose income fluctuates above and below Medicaid and CHIP eligibility levels. MEDI-CAL is California’s Medicaid health care program. This program pays for a variety of medical services for children and adults with limited income and resources. Medi-Cal is supported by federal and state taxes. MEDICARE is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with EndStage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).

(Photos courtesy Santa Rosa Community Health and Redwood Community Health Coalition) SONOMA HEALTH

IN T H E

A I R

The bounty of the county can trigger environmental allergies

BY DR. M ARIA PETRICK AND DR. JULINE ( JULIE) CARABALLO

IN 1875, HORTICULTURIST LUTHER BURBANK REFERRED TO SONOMA COUNTY AS “THE CHOSEN SPOT OF ALL THIS EARTH.” Why? ecause virtually everything grows here. If, like many Sonoma County residents, you experience sneezing, nasal congestion and itchy and watery eyes at certain times of the year, it’s possible that you have what’s commonly known as environmental allergies, also known as “hay fever.”

SONOMA HEALTH

YOU MAY THINK POLLEN IS CAUSING YOUR SUFFERING, BUT OTHER SUBSTANCES MAY BE INVOLVED.

others have reactions to multiple allergens because they have many more types of IgE antibodies. It’s not yet fully understood why some substances trigger allergies and others do not, nor why some people have severe allergic reactions while others are barely bothered. There are several types of allergic disease. pproximately 0 million mericans suffer from some form or another, and the number is increasing. If you have a food allergy, your immune system overreacts to a particular protein found in that food. Symptoms can occur when coming in contact with even a tiny amount of the food. The most common triggers are the proteins in cow’s milk, eggs, peanuts, wheat, soy, fish, shellfish and tree nuts. People can also be allergic to insect stings, which means their immune system overreacts to venom of insects like bees, yellow jackets, hornets and wasps. With environmental allergies, the immune system overreacts to allergens such as dust mites, pollens, pet dander and molds, which is where this article will focus.

PROBLEMS WITH POLLEN

ALLERGIC REACTIONS

Your immune system controls how your body defends itself. Allergies occur when your immune system identifies an allergen a usually harmless foreign substance, such as pollen or pet dander — as a dangerous intruder. It tries to fight and expel it, which leads to an eruption of symptoms. Your immune system overreacts by producing antibodies called immunoglobulin E (IgE). These antibodies travel to cells that release chemicals including histamine, causing an allergic reaction. This reaction usually causes symptoms in the nose, lungs, throat, sinuses, ears, lining of the stomach or on the skin. ach type of Ig has specific radar for a specific allergen. hat’s why some people are only allergic to cat dander (they only have the Ig antibodies specific to cat dander), while

In Sonoma County, pollens are seasonal. Tree pollination begins earliest in the year, followed by grass pollination in spring and summer, and weed pollination in late summer and fall. While the timing and severity of an allergy season varies across the county, certain climate factors can also in uence how severe allergic symptoms will be. Tree, grass and weed pollens thrive during cool nights and warm days. Pollen levels tend to peak in the morning hours. Rain washes pollen away, but pollen counts can soar after rainfall. On a day with no wind, airborne allergens are grounded. When the day is windy and warm, pollen counts surge. Moving to another climate to avoid allergies is usually not successful, as allergens are virtually everywhere. As we’ve seen with the drought and increasing temperatures in our area, changes in climate can impact pollen seasons by both increasing the amount of pollen produced and extending the duration of each pollen season, therefore worsening cumulative symptoms in allergy sufferers. Climate change will potentially lead to shifts in precipitation patterns, warmer seasonal air temperatures, and more carbon dioxide (CO2) in the atmosphere. hese changes can affect when the pollen season starts and ends and

how long it lasts each year, how much pollen plants create and how much is in the air, as well as how much pollen we are exposed to. All of these factors will increase our risk of experiencing allergy symptoms.

OTHER ALLERGY TRIGGERS

You may think pollen is causing your suffering, but other substances may be involved. Molds are tiny fungi whose spores oat through the air. Molds grow quickly in heat and high humidity, and they can be found virtually everywhere — indoors and outdoors. We all breathe in mold spores every day, but in some people, mold inhalation can trigger symptoms such as sneezing, itchy, watery eyes, runny nose and nasal congestion or itchy nose, mouth and lips, shortness of breath and/or cough. There are hundreds of types of molds, but not all of them are responsible for causing allergy symptoms. The most common allergycausing molds include alternaria, aspergillus, cladosporium and cladosporium. The proteins found in a pet’s dander, skin akes, saliva and urine also trigger allergic symptoms. Pet hair or fur can also collect pollen, mold spores and other outdoor allergens. Contrary to popular opinion, there are no truly “hypoallergenic breeds” of dogs or cats. llergic dander in cats and dogs is not affected by length of hair or fur, nor by the amount of shedding. Regular grooming can keep allergens to a minimum. Dust mite allergens are a common trigger of allergy and asthma symptoms. While they can be found throughout the house, these microscopic creatures thrive in warm, humid environments such as bedding, upholstered furniture and carpeting. The best defense here is frequent vacuuming and keeping your bedding clean; you may also want to invest in dust mite covers for your mattresses and pillows. Sometimes symptoms can also be triggered by non-allergic factors, such as irritants in the air, including smoke, scents such as perfume and personal care products, change in air temperature, change in air humidity and pollution.

DIAGNOSIS AND TREATMENT

board-certified allergist can help identify specific allergic triggers and help make a plan for better symptom management. It’s important to know whether your symptoms are triggered by allergens or irritants, as

SONOMA HEALTH

EN V IRONM EN TA L A LLERGIE S

During intradermal testing, a small amount of the possible allergen is injected under the skin using a thin needle. Allergy symptoms might occur during the test. The most common symptoms are itching and swelling. In rare cases, a more serious reaction can occur, so skin testing should always be done by a specialist. Blood tests may be ordered in specific situations however, it takes a few days to get the results, and depending on the test, there can be false positives. As of today, there is no reliable and standardized home test to Dr. Maria Petrick and Dr. Juline (Julie) Caraballo of FamilyCare Allergy & Asthma diagnose environmental allergies. Allergists do not recommend any home-administered tests for this purpose. treatment might differ depending on the Allergists are specially trained to diagnose cause. Adults and children of any age can be and treat allergies. They work with patients tested for allergies. Your allergist may want to to develop a plan that helps avoid allergens do skin testing, blood testing or both. and manage symptoms. If it’s not possible Skin testing is the preferred method for to completely avoid an allergen, there are medically trained allergists. Performed at the things you can do to decrease your symptoms. allergist’s o ce, it’s usually the most accurate Common treatments include oral medications test and also offers fast results (about 1 to 20 such as antihistamines, nasal sprays and allergy minutes). There are two types of skin tests: a immunotherapy. prick (or scratch) test and an intradermal test. Immunotherapy is a preventive treatment During prick testing, a tiny drop of a possible for allergies. It involves gradually increasing allergen — such as grass pollen — is pricked a patient’s exposure to doses of an allergen. or scratched into the skin. If the results of These phased increases of the allergen cause prick tests are negative, they may be followed the immune system to become less sensitive to by intradermal tests, which give allergists more the substance, which reduces allergic symptoms details about what’s causing specific symptoms.

HOW DOES WILDFIRE SMOKE AFFECT ALLERGY SYMPTOMS? Smoke is a well-known trigger of allergic symptoms, including burning eyes, nose, and throat; watery eyes; runny nose and nasal congestion; and coughing and shortness of breath. Your body may produce extra phlegm in response to inhaling smoke. These symptoms are, in part, your body’s attempt to protect itself from smoke and other harmful particles in the air. Air quality has become a top concern for Sonoma County residents, as we’ve increasingly been exposed to wildfire smoke in the past few years. For people with environmental allergies, wildfire smoke exposure can worsen symptoms, sometimes to the point of debilitation. 46

SONOMA HEALTH

If you can smell smoke, it’s best to stay inside. If you must go outside, the Centers for Disease Control and Prevention (CDC) advises not relying on dust masks or cloth masks for protection. The cloth masks many people are using as a safeguard from COVID-19 will not protect you from smoke. An N95 mask offers some protection by filtering out fine particles in the smoke. When fitted and worn correctly, an N95 mask filters out 95 percent of particles larger than 0.3 microns, meaning they’re very efficient in keeping out the typically 2.5-micron particles in wildfire smoke.

when the allergen is encountered in the future. It builds immunity similar to the way a vaccine introduces a weakened version of something to generate preemptive antibodies. There are two types of immunotherapies: subcutaneous (“allergy shots”) and sublingual (under the tongue). Subcutaneous immunotherapy is the more commonly used and more effective. It’s the only treatment available that changes the immune system, making it possible to prevent the development of new allergies and asthma. Sublingual immunotherapy is an alternate way to treat allergies without injections. Currently, the only FDA-approved sublingual therapy is tablets. Allergy drops currently are not FDA-approved in the United States.

ENJOY YOUR SURROUNDINGS

From beaches to redwood forests, open space to state and regional parks and vineyards to orchards, Sonoma County is rich with natural beauty and opportunities for outdoor activities. If you feel curtailed from enjoying all this place has to offer due to allergy symptoms, seek the counsel of an allergist who understands the land where we live. About the authors: Dr Maria Petrick, MD FAAAA FACAAI and Dr. Juline (Julie) Caraballo, MD FACAAI, are Board Certified Allergists/Clinical Immunologists practicing at FamilyCare Allergy and Asthma (with offices in Santa Rosa, Petaluma, and San Rafael).

THERE IS NO RELIABLE AND STANDARDIZED HOME TEST TO DIAGNOSE ENVIRONMENTAL ALLERGIES.

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Expert care. Every patient, every time. UNDERSTANDING ALLERGIC ASTHMA

Asthma is a chronic disease that inflames the airways. This means that people with asthma generally have inflammation that is long lasting and needs managing. An asthma episode, also called an asthma flare-up or asthma attack, can happen at any time. Mild symptoms may only last a few minutes while more severe asthma symptoms can last hours or days.

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More than 25 million people in the United States have asthma, and allergic asthma is the most common type, affecting around 60 percent of people with asthma. Both allergic and non-allergic asthma have the same symptoms, such as shortness of breath and wheezing. Having allergic asthma means allergens trigger your asthma symptoms. Allergens cause an allergic reaction because your immune system thinks they are harmful. Your immune system responds by releasing a substance called immunoglobulin E (or IgE). Too much IgE can trigger inflammation (swelling) of the airways in your lungs. This can make it harder for you to breathe and can trigger an asthma attack. Although we cannot cure asthma, we can control it. Everyone’s asthma is different, so you and your doctor need to create an asthma treatment plan just for you. This plan will include an Asthma Action Plan that will have information about your asthma triggers and instructions for taking your prescribed medicines. Source: Asthma and Allergy Foundation of America, www.aafa.org

SonomaHealth_2021.indd 47

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12/8/21 5:51 PM

RISK &

REWARD

Cutting-edge clinical trials in Sonoma County can benefit current patients — and future generations. B Y J E A N S AY L O R D O P P E N B E R G

WHEN A PHYSICIAN PRESCRIBES A MEDICINE OR TREATMENT in response to illness, there’s a level of trust that patients need to exercise: trust in the doctor’s knowledge and training trust in the e cacy of the drug or intervention to do what’s intended. s medical and scientific knowledge continues to deepen, new (and improved versions of) medicines will be developed for all manner of ailments. But before a drug can be introduced for public use, it must undergo a lengthy and detailed testing and review process. ver wonder about those miles of fine print that accompany prescription drug advertisements in magazines? These drugs, which went through long and robust clinical trials processes, have been approved by the .S. ood and Drug dministration ( D ) for widespread use by patients, who might benefit from taking them for their various disorders and diseases.

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Through the course of these studies, all possible side effects and risks have been well documented, and it’s the legal responsibility of the developing pharmaceutical or medical device company to make potential patients aware of risks as well as benefits. ( or the course of this article, we will focus on medication trials.) It takes a village of willing patient candidates to try out these medications before the D clears them, to make certain they are safe and effective. No wonder drug comes to market for a physician to prescribe without first being extensively monitored in clinical trials with real patients, who, in many cases, have little to lose and much to gain by taking part in the studies.

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STAYING LOCAL

Historically, pharmaceutical companies went to institutions such as teaching and university hospitals to conduct their clinical trials, but that shifted many years ago. Appliedclinicaltrialsonline.com, a clinical trials management resource, points to changes in health care funding and the broadening of available experts in the private sector for the shift: “Study conduct costs and overheads at hospitals often exceed comparable private practice costs. Research indicates 0 percent of all investigator payments go to physicians working in private practice. Few doctors conduct clinical trials in teaching hospitals alone. The large majority do all their clinical trial work in private practice settings. Slightly more than one in 10 works at both teaching hospitals and private practice.” According to Dr. Stephen Halpern, a cardiologist who runs clinical trials through North Bay Clinical Research in Santa Rosa, “Physicians in private practice with both academic interest and expertise with proper vetting tend to have faster start-up times for trial site initiation as opposed to academic institutions, that might have slower start-up times since decisions about study protocol acceptance must pass through a lengthier board approval process.” Facilities in Sonoma County and across Northern California now routinely conduct and/or participate in national and global medical research studies.

THE PHASES OF CLINICAL TRIALS

Newly created drug compounds go through a multi-phase clinical trial process on their way to becoming approved by the FDA. Preclinical trials involve testing on laboratory bench cell lines (cell cultures developed from a single cell and therefore consisting of cells with a uniform genetic makeup) and animal studies to determine potential e cacy and toxicity. If results look promising, the developing pharmaceutical company submits an application to the FDA for an “investigational new drug,” or IND, prior to initiating clinical testing in humans. Once the FDA approves the IND submission (which delineates a step-by-step process of study design, endpoints to be evaluated, inclusion and exclusion criteria, and how the study will be monitored with regard to recorded data and safety), the trial proceeds through several phases. North

SONOMA HEALTH

I ENJOY HAVING ACCESS TO INVESTIGATIONAL DRUGS THAT SHOW PROMISE TO TREAT THE DISEASES I TAKE CARE OF. — DR. STEPHEN HALPERN, NORTH BAY CLINICAL RESEARCH

Bay Clinical Research outlines the typical sequence of study: • Phase I clinical trials are conducted at one or a small number of sites, in a limited number of people, who are either healthy or who have the disease in question, to determine safety and dosage. These trials usually last several months. • Phase II trials are typically conducted at 10 to 20 sites, evaluating several hundred people who have the disease to be studied, to assess e cacy and potential side effects. ewer than 0 percent of Phase II trials progress to Phase III, either due to unexpected side effects occurring in Phase II trials (that were deemed too significant to let a drug progress to Phase III) or data that showed the new drug lacked e cacy compared to already available treatment options. • Phase III trials often use several hundred investigative sites and thousands of patients to assess the treatment benefit and study any longer-term side effects. Rarely, patients can be randomized into a Phase III trial after participating in a Phase II trial; however, one of the usual exclusion criteria is no prior exposure to the study drug. Theoretically, if a Phase II patient was on placebo and that information was available at the time of randomization for the phase III trial (which is rarely the case) that patient could be randomized. But this is not a common occurrence.

If a Phase III trial demonstrates e cacy, the pharmaceutical company can apply to the FDA to let the new drug be marketed to and prescribed by physicians. During this process, the sponsor usually will conduct a Phase IV clinical trial that evaluates post marketing safety to identify potential side effects in a real world setting serious adverse events are unusual at this point.

RANDOMIZED BUT NOT HARMFUL

Phase II and III trials usually are randomized controlled clinical trials (RCCT) that employ a “comparator” (either a placebo or a medication already known to treat the disease as a baseline constant), so clinicians can compare results of a new drug against a known outcome. These are typically “double-blinded studies,” meaning neither the patients nor the investigators know which participants are receiving the trial drug. “The randomization scheme depends on the trial, but the most common ratio of study drug to comparator is one-to-one, indicating that 0 percent of the participants will get the trial drug,” says Halpern. “In some trials, there may be a three-in-four chance of getting the trial drug, but one-to-one is most common.” ccording to W P linical (a specialist services company that works with sponsors to help patients and physicians gain early access to medicines when no other treatment options are available), the reason most often cited for using a comparator drug rather

CLINICAL TRIALS

PEOPLE SOMETIMES HAVE THE MISPERCEPTION THEY HAVE TO GO TO A BIG INSTITUTION OUT OF THE AREA TO ENTER A TRIAL, BUT THAT’S JUST NOT NECESSARY. — KIMBERLY YOUNG, PROVIDENCE MEDICAL FOUNDATION

Providence Medical Foundation’s clinical trials team: Tracy Foster, Sam Hansen, Kayla Cordes, Camille Shaffer, Kimberly Young, Jan Nielsen, Lauren Weber, Melissa Phillips, Charity Behrend, Jenni Tolentino, Teresa Lund, Peg Jennings-Shaw, Cathy Hollister [Photo by Guy Foster] than a placebo drug is an ethical one. From the website: “Many subjects involved in a clinical trial are suffering from life-threatening diseases and have enrolled in the trial in order to gain access to what could be a life-saving treatment. It would, therefore, be unethical to give some of these subjects no treatment at all. Using a comparator drug means that these subjects are at least receiving a treatment that is known to be effective and beneficial. This is true even if the trial isn’t addressing a life-threatening condition. “Depending on the type of therapy we are investigating and the protocol approved by the FDA, we may have a trial assessing a novel therapy to a current standard treatment — or, if no current standard is available, the comparison could be to a placebo,” says Dr. Jason Bacharach, clinical research medical director at North Bay Eye Associates in Petaluma, which conducts numerous clinical trials relating to eye health.

We only consider placebo-based studies after consultation with the patient regarding risk assessment.” Bacharach says it’s not uncommon for eye conditions that require drop therapy to require alternate treatment options when an initial treatment is either ineffective or not tolerated. We are always assessing the risk-to-benefit ratio before we consider inviting a patient into a clinical trial. The trials are important, yes, but the patient is more important.” Patients in trials are monitored very carefully throughout. This includes ongoing communication with a patient’s other health care providers. Explains Halpern, “Treating physicians of these patients are updated periodically about their progress in the trial, but are encouraged to not make therapeutic changes to the patient’s regular medications that could impact or undermine the trial’s integrity. This

might include making no changes to a cholesterol medication profile for a patient enrolled in a trial investigating a new cholesterol medication, for example.”

EXPECTED OUTCOMES

Depending on the drug being studied — and the disease it’s intended to treat — the data collected during a trial and the expected outcomes can vary widely. “During a clinical trial, we collect lots of data on the patient, such as laboratory values and tumor images,” says Kimberly Young, director of clinical trials with Providence Medical Group in Santa Rosa. “But when they end the trial, we still follow their progress, because there can be a long benefit after taking a trial drug.” Unlike many other experimental treatments, clinical trials for cancer drugs are not only for when no other treatment is available.

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UNDERSTANDING TERMS

TRIAL DRUGS AREN’T ALWAYS AN END-OF-THE-LINE SCENARIO ANYMORE.

OS This refers to overall survival, or how long someone lives after starting on a treatment.

— DR. SARA KECK, PROVIDENCE MEDICAL GROUP

PFS Progression-free survival measures how long someone is on a treatment before their disease resurges. DFS Disease-free survival is the length of time after primary treatment ends, and the patient survives without any signs or symptoms of that disease. In a clinical trial, measuring DFS is one way to see how well a new treatment works. Also called relapse-free survival (RFS). CR Complete response to treatment is the term used for the absence of all detectable illness after treatment is complete. Complete response doesn’t necessarily mean a patient is cured, but it is the best result that can be reported. It means there is no remaining evidence of disease. ORR Overall response rate is defined as the proportion of patients who have a partial or complete response to therapy; it does not include stable disease and is a direct measure of drug efficacy. OPEN LABEL Sometimes trials are conducted in an open-label fashion, meaning study participants and researchers both know which treatment the patient is receiving. Open-label trials can be used to compare treatments or gather additional information about the long-term effects in the intended patient population. Open label trials are sometimes referred to as “nonmasked” or “unblinded.”

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“A [cancer] patient could enter a trial right after being diagnosed. A physician might bring it up as an option for the patient’s very first treatment, so it’s not always an endof-the-line scenario anymore, says Dr. Sara eck, Medical Director linical rials of Providence Medical Group (she also sees patients in her ancer Survivorship practice). In the field of cardiology, says Halpern, the D has become focused on outcome studies. He explains he D continues to be interested in drug e cacy, such as the ability of a trial drug to lower a person’s cholesterol, for example, but is more interested in whether the trial drug has the benefit of reducing a patient’s likelihood of heart attack or prolonging life. hese types of trials can last two to five years and focus on long-term effects of treatment. (To understand some of the common trials-related acronyms, see “Understanding Terms,” left.)

SEEING THE BENEFIT

rom a physician’s perspective, says Halpern, clinical trials can be a great way to get a promising new medication to patients prior to its release, especially those who are not responding to the existing drugs available to them. or me personally, I enjoy having access to investigational drugs that show promise to treat the diseases I take care of. hat’s the main reason I continue to do it. One of the secondary benefits of clinical trials, in most cases, is that it defrays significant out-of-pocket expenses for the patients who participate. Generally, there is no cost to patients who participate in clinical trials, so if diagnostic testing and blood work are required for monitoring the effects of a trial drug, for example, the sponsoring

pharmaceutical companies cover those expenses. ut we don’t encourage people to be in a study for that reason, says acharach. “We evaluate many novel options that might not be on conventional formularies or even available commercially in the nited States. We encourage [patients] to be in a study because we offer some of the most cuttingedge therapies and best opportunities available on the planet. You can get access to the newest possible treatments right here at Providence; we have put some of the first patients in the world into important clinical trials, says Young. “People sometimes have the misperception they have to go to a big institution out of the area to enter a trial, but that’s just not necessary. ottom line here’s excellent, highquality research going on in our community. And taking part in trials is good for a patient and for the next generation. ven if a new drug doesn’t help the patient in the trial, it likely will help that patient’s children and grandchildren. (For a list of questions to help you make an informed decision on whether to participate in a clinical trial, see “What to Ask,” page 53.) A list of open clinical trials in Sonoma County can be found starting on page 72.

About the author: Jean Saylor Doppenberg is a lifelong journalist who has written extensively about health-related topics.

CLINICAL TRIALS

W H AT T O A S K

Before you agree to participate in a clinical trial, it’s vital to understand exactly what you’re signing up for. “It can be a shared discussion between the patient and their treating physician, who may be the one to recommend the study,” says Dr. Sara Keck of Providence Medical Group in Santa Rosa, which conducts numerous clinical trials, mostly with cancer patients. “Often, patients have come to a point in their care where there are no longer any conventional treatment options, so they start looking for a clinical trial.” When speaking with your doctor about participating in a trial, consider taking a family member or friend along for support and for help in asking questions or recording answers. Plan ahead what to ask, but don’t hesitate to ask any new questions you think of while you’re there. Write down your questions in advance to make sure you remember to ask them all, and take careful notes so you can review the conversation again later. Ask about recording what’s said (even if you write down answers), or record the conversation yourself; most smartphones have a built-in recording app. Here’s a list of questions that can help you make an informed decision: THE STUDY

• How long will the study last? When does it start and end? • What is the purpose of the study? • What “phase” is this trial? • Why do researchers think the approach may be effective? Why might it not be effective? Has it been tested before? • Who will fund the study? • Who has reviewed and approved the study? • How are study results and safety of participants being checked? • What will my responsibilities be if I participate? • Who will pay for my participation? POSSIBLE RISKS AND BENEFITS

• What are my possible short-term benefits? • What are my possible long-term benefits? • What are my short-term risks, such as side effects? • What are my possible long-term risks? • What other options do people with my disease have? • How do the possible risks and benefits of this trial compare with those options? PARTICIPATION AND CARE

• What kinds of therapies, procedures, and/ or tests will I have during the trial? • How will the medicine, medical device, or test be given to me?

• Will they hurt, and if so, for how long? • Can I drop out of the trial if I become too uncomfortable? • How will it be determined which interventions I receive (for example, by chance)? • Will I be able to take my regular medications while participating in the clinical trial? • Where will I have my medical care? • Who will be in charge of my care? • Who will know which intervention I receive during the trial? Will I know? Will members of the research team know? • How often will I have to visit the hospital or clinic? Will hospitalization be required? • If I benefit from the intervention, will I be allowed to continue receiving it after the trial ends? PERSONAL ISSUES

• How could being in this study affect my daily life? • Can I talk to other people in the study? • Will I be reimbursed for other expenses? • Will results of the study be provided to me? • What are my options if I am injured during the study? • What type of long-term follow-up care is part of this trial? • How is my privacy protected throughout the study?

COST ISSUES

• Will I have to pay for any part of the trial, such as tests or the study drug? If so, what will the charges likely be? • Will there be any travel or child care costs that I need to consider while I am in the trial? • What is my health insurance likely to cover? Will the drug company pay my insurance co-pay? • What if the investigational drug or device makes my illness worse, or causes another medical issue in me? Will my insurance cover it? Or does the sponsor company? • Does the sponsor company or other insurance offer coverage for my family in the event that I die in the trial? Will my life insurance still cover me? • Who can help answer any questions from my insurance company or health plan? Sources: Meridian Clinical Research (www.mcrmed. com); National Institute for Mental Health (www.nimh.nih.gov); ClinicalTrials.gov

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MEDICAL ADVANCES H E A R T H E A LT H • W E A R A B L E T E C H N O L O G Y • C O V I D -1 9 U P D AT E

THE LATEST ON MIGRAINE

BY ALL AN L . BERNSTEIN, M .D.

MIGRAINE IS THE MOST PREVALENT NEUROLOGIC CONDITION IN THE U.S.

It’s also the one that gets the least notice. Since it’s not a fatal condition — or one that leads to long hospitalizations — it tends to be dismissed as “just a headache,” in spite of producing severe pain, nausea, light sensitivity, sound sensitivity and fatigue. Migraine affects 20 percent of adult women, 10 percent of adult men and 10 percent of children. It’s most common between the ages of 16 and 6, thus having a major impact on school and work for a significant portion of the population. Since there is no animal model, or genetic or laboratory marker for migraine, research in the field has been frustratingly slow.

Migraine is most common between the ages of 16 and 46, thus having a major impact on school and work for a significant portion of the population.

he first migraine-specific medication, dihydroergotamine (DHE), was developed in the 19 0s. he next breakthrough came in the 19 0s with the development of the triptan medications such as sumatriptan (now sold under a variety of prescription names, including Imitrex). Botox for migraine relief was introduced in the 1990s but, due to cost and the need for 20 to 2 injections every three months, it has not become a mainstay of treatment. The most recent medical advance arrived in the last two years with the observation that a specific chemical in the brain, calcitonin gene related peptide (CGRP), plays a major role in the physiology of migraine events. Multiple pharmaceutical companies have developed medications that block the effect of GRP in the brain, either via pill or injection, as a treatment for acute attacks and, potentially, as a means of preventing onset. Other areas under investigation include nerve stimulators, psychedelic medications and various cannabis extracts, though these studies are so far inconclusive. If you suffer from frequent, severe headaches, you should discuss it with your primary care provider to get the proper diagnosis and plan for treatment.

S O N O M A H E A LT H

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Despite the challenges of a global pandemic and of significant limitations in clinical research (due to reduced voluntary patient participation), the past 18 months have been invaluable in the fields of cardiology research and new product development. Global challenges have included learning how to care for COVID-19 patients experiencing acute cardiac emergencies, and relying on remote webcam evaluations to make critical decisions in order to keep ourselves safe. Doctors had to develop and practice new protocols for managing acute cardiac decompensation (aka heart failure) in COVID patient populations of varying ages, due to heart inflammation or to a heart attack resulting from clotting abnormalities. Lifesaving care for these patients was delivered while wearing several layers of personal protective gear to protect physicians and health care professionals from contracting COVID themselves. In most cases, persistence, dedication and perseverance saved lives, although there were still a large number of deaths due to COVID infection. Despite these unique circumstances, there have been significant advances in preventive cardiology and in nonsurgical treatment of chronic cardiac diseases.

T H E B E AT G O E S O N In spite of unforeseen obstacles, the field of clinical cardiology has seen numerous advances. B Y S A N J AY D H A R , M . D .

NON-STATIN DEVELOPMENTS

Patients with high cholesterol and associated cardiovascular disease are usually treated with escalating doses of statins (a group of medicines that can help reduce the level of low-density lipoprotein LDL cholesterol in the blood), in addition to recommended lifestyle changes, to achieve certain therapeutic goals. bout to 10 percent of patients, however, can’t tolerate statins due to side effects, most commonly muscle aches and pains. Until recently, there weren’t many alternatives, but now patients have choices outside of statins. Non-statin drugs, such as evolocumab and alirocumab, have dramatically helped

reduce cholesterol levels to numbers that were not previously possible. These drugs inhibit PCSK9 (proprotein convertase subtilisin-kexin type 9), a protein that’s made in the liver. Research has proven that people with high levels of PCSK9 tend to have high cholesterol throughout their lives and develop heart disease early. People with low levels of PCSK9 tend to have low cholesterol and a lower risk of heart disease. This research has led to the successful development of PCSK9 inhibitors to lower cholesterol. Another non-statin drug, bempedoic acid, blocks an enzyme in the liver called ATP (adenosine triphosphate citrate lyase), which is involved in making cholesterol. Like

statins, it also blocks a pathway in production of cholesterol in the liver, but without any statin-related side effects. Other medications showing promise include over-the-counter omega-3 fatty acid supplements. The U.S. Food and Drug Administration (FDA) recently approved a highly purified omega- supplement which helps lower cholesterol and triglyceride levels and also shows a reduction in overall cardiovascular related morbidity and mortality. (See rusted hird-Party ertifiers, page 22 to learn about wisely choosing O supplements.) Recently, there’s been a resurgence in using the drug colchicine, which is typically

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THERE HAVE BEEN IMPORTANT NEW DEVELOPMENTS IN TREATING COMPLEX, RESISTANT CORONARY BLOCKAGES.

lar to the technique used to break up kidney stones. SW uses low-energy, high-voltage, high-frequency electromagnetic ultrasonic pulses to disrupt rigid calcium deposits in coronary arteries, facilitating implantation of coronary stents. Advances in coronary stents include a new generation of drug-eluting stents (DES) that are coated with a slow-release medication to help prevent blood clots from forming within them. These include stents with ultrathin struts (support framework), making their placement easier even in challenging situations. What’s more, they are nano-coated with new biodegradable polymers that target drug delivery to reduce narrowing (restenosis) and scar formation within the stent. These developments have reduced the time requirement for subsequent and prolonged use of blood thinning medications.

HEART VALVE PROBLEMS

used to treat gout, to reduce in ammation caused by acute and chronic coronary artery disease. Previously, colchicine was used to reduce in ammation in patients with pericarditis (in ammation of the heart covering, or pericardium). However, recent studies have shown it to improve survival rates in patients with chronic coronary disease who are already receiving lipid-lowering and antithrombotic therapy such as aspirin.

TREATING CORONARY BLOCKAGES

There have also been important new developments in treating complex, resistant coronary blockages. For example, infrared spectroscopic imaging of coronary arteries — using light with a longer wavelength and lower frequency than visible light — enables early detection of unstable plaques (fatty deposits that collect on arterial walls, causing clogs and damage). Once detected, plaques can be targeted for aggressive primary and sec-

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ondary preventive therapies to limit plaque rupture and subsequent heart attacks. Intravascular ultrasound (IVUS) is a catheter-based diagnostic detection procedure that uses sound waves to produce an internal image of the coronary artery. IVUS can quantify the percentage of arterial narrowing and give insight into the nature of the plaque. Another catheter-based detection device is the instantaneous wave-free ratio (iFR), used to evaluate whether a blockage is causing limitation of blood ow in coronary arteries. It is also used to help guide deployment of balloons and stents in coronary arteries; a stent is a tiny mesh tube that’s inserted into an artery, then expanded using a balloon and fixed in place to help keep the artery open. Once detected, the newest technique available for managing resistant blockages is cardiac shock wave therapy ( SW ), simi-

Advances in managing structural valvular heart disease, both congenital and developed over time, have allowed for percutaneous treatment rather than open heart surgery. Initial success in managing diseased aortic valves (TAVI), has led to the proliferation of new devices in the management of diseases affecting the mitral, tricuspid and pulmonic valves. Because of these advances, it’s conceivable that, in the near future, few patients will have to undergo open heart surgery for heart valve replacement. These gains in treating advanced heart valve conditions have resulted from active and effective collaboration between biomedical engineers and physicians. Advances in alloy technology and nanotechnology have also helped make great strides in this field.

MORE THERAPEUTIC ADVANCES

Hypertension a icts almost every race and ethnicity with long-term catastrophic consequences. A huge assortment of blood pressure medications is available to manage the problem, but some patients are simply resistant to drugs and therapy. Management of drug-resistant or di cult-to-treat hypertension using a minimally invasive procedure called renal denervation strategies (RDN) has been studied for a while and is now ready for prime time. RDN uses radiofrequency ablation to burn the nerves in the kidney’s blood vessels. This process causes a reduction in the nerve ac-

CA R D I AC H E A LT H

SIGNIFICANT ADVANCES IN OUTCOME BENEFITS, THERAPEUTIC TECHNIQUES, AND DEVICE INNOVATIONS AND INVENTIONS HAVE RESULTED IN SIGNIFICANT dition — as seen in sudden cardiac deaths in young athletes — didn’t have a therapeutic IMPROVEMENT IN CARDIAC CARE. option until now. Mavacamten, a new drug

on the market, reduces heart muscle contractility, which directly reduces the stress within the heart and, hence, prevents catastrophic complications.

DEVELOPING TREATMENTS

tivity around the kidneys, which indirectly decreases blood pressure. Advances in cardiac electrophysiology (a test performed to assess the heart’s electrical system or activity) have focused on ablation to treat atrial fibrillation at a much earlier stage of the disease, rather than waiting until an arrhythmia has become unmanageable and resistant to all cardiac suppressive medications. Arrhythmia detection and management has also become easier with advances in cardiac equipment, which can reduce the time a patient has to be under anesthesia for the procedure. Other advances include stroke risk prevention in patients with arrhythmias who can’t take blood thinners. This is achieved by deploying a tiny device that plugs the left atrial appendage (an extraneous yet naturally occurring protrusion in the upper left part of the heart), which is notorious for clot formation. These devices are implanted percutaneously, meaning the procedure does not require open heart surgery.

BATTLING HEART FAILURE

New therapies have also been introduced for managing patients with heart failure. Heart failure has a significant negative socio-economic impact in our society. It’s

projected that 0 percent of cardiac diseaserelated expenses (reaching 0 billion per year domestically) are due to heart failure and associated hospitalizations. In response, there’s been a significant push to develop new strategies to help patients while, at the same time, lowering costs related to repeated hospitalizations. New medication classes to treat heart failure have shown remarkable success and continue to grow. These include sodium-glucose cotransporter 2 (SGL 2) inhibitors sotagli ozin, empagli ozin, and dapagli ozin, drugs originally designed to treat diabetes patients. Research has shown them effective in treating heart failure even for patients without diabetes. Other pharmacological advances include vericiguat, which helps relax the blood vessels and indirectly reduces stress on the heart; omecamtiv, which improves cardiac contractility and directly helps patients with poor cardiac function; and the combination sacubitril/valsartan (marketed as Entresto), which works in two complementary ways to effectively lower blood pressure. Hypertrophic cardiomyopathy is a condition in which the heart muscle becomes very thick, making it harder to pump blood. This relatively dangerous, often undetected con-

rtificial Intelligence ( I) is still in its infancy in the field of application cardiology, yet AI algorithms are already being used to automatically detect arrhythmias and send alerts to patients using wearables or smartphone-based apps that record ECG. Examples of this technology are the Apple watch and the Alivecor KardiaMobile device (see now Your Numbers, page 60, for more about AliveCor). AI will likely see its biggest steps in the coming years for pointof-care (POC) triage apps and wearable cardiac monitoring technologies. This will speed the process of getting at-risk patients examined by a cardiologist and aid in earlier detection of cardiovascular diseases. Although cardiac medical advances were lessened in 2020-2021 by the O ID pandemic, due to reduced research funding and low patient participation, adaptability, new technologies and applications allowed us to manage both cardiac complications due to COVID infection, as well as innovate therapeutic strategies in structural, coronary, cardiomyopathic and arrhythmogenic diseases. Significant advances in outcome benefits, therapeutic techniques, and device innovations and inventions have resulted in significant improvement in cardiac care. These goals were only achieved due to the dedication and hard work provided by teams of cardiologists, cardiac surgeons, bio-engineers, nano technologists and many other medical personnel. We will continue to work to provide for a better future in health care.

About the author: Dr. Sanjay Dhar is a practicing clinical cardiologist with Providence Medical Group in Santa Rosa. He is the chief of cardiovascular diseases at Santa Rosa Memorial Hospital.

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K N O W

Y O U R

NUMBERS Embr Labs’ watch-style Wave device lets the wearer regulate body temperature (warmer or cooler) regardless of their environmental surroundings. (Photo courtesy Embr Labs)

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Wearable medical technology is here and improving lives. What comes next? B Y M AT T V I L L A N O

TEN THOUSAND STEPS IS SO 2020.

A study published earlier this year in the medical journal JAMA Network Open indicates 7,000 steps per day is the new secret to good health. Researchers from across the United States participated in the study, which determined taking 7,000 steps per day during middle age can keep a person’s arteries healthy and reduce the risk of premature death by up to 70 percent. Of course, the best way to count daily step totals is with the help of a wearable device that keeps track while we go about our lives. Once the stuff of fantasy novels, wearable technologies are becoming more and more prevalent with every passing month. A 2021 report from the Consumer Technology Association predicts the market for wearable gadgets will get a boost from the overall booming consumer tech market, which is expected to generate a recordbreaking $487 billion in revenue in 2021. The report projects that shipments of connected health monitoring devices — such as smart thermometers, pulse oximeters, and blood pressure monitors — will grow to 13 million units and earn $740 million in revenue by the end of the year, an increase of 17 percent. What’s more, the total revenue of health and fitness tech will reach 1 billion, a 12 percent growth over 2020, according to the report. Looking farther into the future, other reports predict the wearable market could top $265.4 billion by 2026. A few factors are driving this growth. First, the rising popularity of connected devices and the Internet of Things (IoT, see sidebar on page 62 for more information), along with the rapid growth of a technologically literate global population, are anticipated to fuel the demand for wearable technology. Second, the rising prevalence of chronic diseases and obesity has contributed to the adoption of wearable health products, such as activity

trackers and body monitors, that provide real-time information on the user’s overall well-being. In many ways, says Kreigh Moulton, a retired cardiac electrophysiologist based in Calistoga, wearables provide the Holy Grail of medical technology: increased prevention. “Taking the lead from the medical technology industry, physicians have become increasingly better equipped to monitor the progress of certain diseases and disorders through the use of wearables. Their adoption has increased participation by patients in their disease management, which, in turn, can improve outcomes. Whether it’s on or in your body, these devices have the potential to improve one’s health.” Odd as it may seem, doctors aren’t in a position to help patients before they get sick. Medical research and development do that. Preventive measures is an entirely different matter, as it works to forestall or avert a potential problem from developing in the fi rst place.

PREVENTION FIRST

As Moulton suggests, wearables are currently being used to collect and report real-time information related to day-to-day events and physiological data, such as quality of sleep, heart rate, blood oxygen level, blood pressure, cholesterol level and calories burned (to name a few). Patients and doctors alike can leverage this information to make healthier choices overall. To this end, many smartphone and smartwatch companies are now adding blood oxygen (Sp02) sensors to their devices as standard, as well as other monitors that provide warnings when data suggests a wearer might be in poor health. Software sold with these devices also has the capability to analyze data and make suggestions about how we might improve our health.

Fitbit (which is now owned by Google) and Huami (the company goes by mazfit in North America) both make watches that include built-in thermometers to track body temperature and alert patients when their temperature rises in a way that suggests a viral infection. AliveCor, a company in Mountain View, Calif., has devised a piece of hardware (called KardiaMobile) and a related app that effectively gives patients a personal G machine in their pocket. Denver, Colo.-based BioIntelliSense has devised something called the BioButton, medical-grade technology that monitors a host of vital signs for up to 60 days at a time. Dr. James Mault, a former cardiopulmonary technician, founded the company and has boasted that these types of wearables are key steps toward a new frontier in medical technology. his is an opportunity to finally make, or help make, remote patient monitoring something that is ubiquitous — and I mean, truly ubiquitous, in the sense that the simplicity, the cost effectiveness, and the beneficial outcomes can finally be realized, Mault told an industry podcaster earlier this year. Products like Mault’s yielded benefits during the COVID-19 pandemic because they were all wearing vital-sign monitors 24/7, BioIntelliSense employees were able to return to the o ce well before workers in other industries. Another wearable that achieved widespread adoption during the pandemic: so-called smart masks that fi lter air, amplify sound and check how well people are breathing. With both technologies, patients can share data with doctors in one of two ways, via on-demand download during an appointment, or by automatic upload to the cloud. ventually the thinking is to have devices pass along information in real-time so doctors can get an up-to-the-minute sense of how their patients are doing.

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LOCAL CONNECTIONS

Wearable devices have become important parts of medical treatment programs in Sonoma County. At Kaiser Permanente Santa Rosa, Dr. Lakshmi Aggarwal evaluates whether continuous glucometers (CGMs) and insulin pumps would help her patients with Type-1 diabetes manage their condition more effectively. A CGM is a small device attached to the skin’s surface with medical grade adhesive; a small sensor wire extends under the skin from the device, monitoring the wearer’s glucose uctuations in real time and, in some cases, “talking” to an insulin pump, which can adjust the amount of insulin it delivers to prevent high or low blood sugars. CGM’s have “revolutionized” treatment for some of her patients who would have gotten themselves into life-threatening situations if not for the technology. he main benefit is with what we call hypoglycemia unawareness. This is where someone does not recognize when their blood sugar goes dangerously low,” says Aggarwal, an endocrinologist whose formal title is diabetes quality consultant. “CGMs can help people with hypoglycemia unawareness recognize a low blood sugar before it is too late. These devices can help patients avoid those serious lows. They can literally save lives.” Medtronic has developed a wearable CGM that surveils diabetes in precisely this fashion. hough the company has o ces in Santa Rosa, the lab in Northridge, Calif., developed this tool. According to Ali Dianaty, vice president of product innovation for Medtronic, the technology is part of a new diabetes

treatment dubbed the hybrid closed loop system. With this system, the technology uses real-time glucose readings and calculates a personalized amount of insulin to deliver based on your needs,” she wrote in an email. “It also autocorrects and adjusts for individual needs, so people don’t have to think as much about their diabetes. They can also be confident that, over the longterm, they have the results and data they need for healthy outcomes.”

USING THE DATA

Then there’s Carium, a Petaluma-based software company that’s received local attention in recent years for its involvement with digital health projects involving wearables. With patient permission, the projects collect input from multiple wearables on multiple patients and translate that information into actionable data that participating doctors can use to change the course of medical treatment overall. O and founder Mike Hatfield describes his company as the “omnivore” of medical and other health-related data, and says its approach is data collection and mining on a fundamentally human scale. Lots of people wear pple Watches, these devices will be able to take blood pressure readings frequently and passively throughout the day, Hatfield explains. Once you tap into that data, think about the possibilities: Most people see their doctors once or twice a year — that’s two data points. But what if you could tap the data about someone’s wellbeing every day? That’s 365 data points. hat can make a huge difference. We have thousands of people currently using Bluetooth-connected blood pressure monitors to feed measurements into Carium

WHAT IF YOU COULD TAP THE DATA ABOUT SOMEONE’S WELLBEING EVERY DAY? — MIKE HATFIELD, CARIUM

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WHAT IS IOT? The Internet of Things, or IoT, refers to the billions of physical devices around the world that are now connected to the internet, all collecting and sharing data. Connecting up all these different objects and adding sensors to them adds a level of digital intelligence [that enables them to] communicate real-time data without involving a human being. The Internet of Things is making the fabric of the world around us smarter and more responsive, merging the digital and physical universes. Source: www.zdnet.com on a daily basis. That’s what we’re unlocking.” One of Carium’s initial pilots involved working with the Petaluma Health Center One to manage and support patients with ype 2 diabetes. While the active phase of the pilot ended in 2019, some of its participants are still using the Carium app on an individual basis. The company has active engagements for hypertension management with the enter for Wellbeing and another healthcare group in Sonoma County. Hatfield expects to see wearable technologies in the form of rings and gloves in the not-too-distant future — any form factor that patients can wear naturally, effortlessly, and without intrusion has a high probability of success, he predicts. That said, there are challenges ahead for the wearable technology market. For starters, many of the bleeding-edge devices aren’t 100 percent accurate yet a problem, since lives are at stake. Kaiser’s Dr. Aggarwal notes that, in addition to their CGM, many patients are still encouraged to prick their fi nger with a lancet and administer blood drops into a glucometer to either calibrate their CGM or verify high or low readings. She adds that, to maximize benefit from a GM, one has to administer

WEARABLES

SO LONG AS DOCTORS AND/OR TECH GURUS CAN DREAM UP A NEW TECHNOLOGY, IT’S LIKELY SOMEONE WILL MAKE IT REALITY. insulin, either via injection or insulin pump, after receiving a high reading from the sensor. Bandwidth is another potential challenge, particularly since so many wearables connect to the internet. As more and more citizens begin using wearables, cities will need to lean on 5G wireless for additional bandwidth to accommodate these tra c requests. (Many reports suggest most of the nited States will have G by the end of 2022.)

WHAT’S NEXT

he future of wearables is a bit of a green field. So long as doctors and or tech gurus can dream up a new technology, it’s likely someone will make it reality. Imagine the possibilities: real-time alerts at the earliest (often undetectable or unrecognized) signs of everything from ovulation to a respiratory or asthma attack, an oncoming epileptic seizure, or even the presence of certain cancer cells in the blood. (All these options are either already available or undergoing study in anticipation of approval by the U.S. Food and Drug Administration.).) he possibilities seem infi nite, but it’s never a seamless development process. Says Moulton, “As is the case with any medical technology, widespread adoption never happens overnight and never gains real momentum until critical mass is reached. For every one product on that road to success, there are probably ten that came and went and no one ever knew.” hat said, he continues, Wearables will slowly insinuate themselves into our existence without much fanfare — as they should.” The retired cardiac electrophysiologist knows of at least one company working to bring personal wearable blood pressure cuffs to market which, when coupled with a device like the KardiaMobile, will “provide even more meaningful cardiac data.” Experts predict wearables will get smaller and lighter over time — not surprising, considering how much smaller and lighter they’ve gotten even in the last five years. Dr. lbert H. itus, professor and chair of the department of biomedical engineering at the niversity of uffalo in New York, says the challenge now is to improve the technology of consumer wearables to bridge the gap between “fun, tracking, and making exercise a game to promote wellness” toward more “medical-grade” sensing technology. “Predicting the future is a guessing game, but looking at the technology today and where it came from, it’s safe to assume wearables will have more functionality and be in forms that go beyond a watch,” Titus says. He adds that, for true wearable medical devices, the challenge is to continue to improve the sensing, reduce invasiveness, and increase connectivity with user devices (such as smartphones) to enhance usability. Fitbits and smart watches have shown us how wearable technology can help improve our health. Now it’s up to the medical and tech communities to realize and actuate the life-changing possibilities this sector offers. About the author: Matt Villano is a freelance writer and editor based in Healdsburg. Learn more about him at whalehead.com.

NON-MEDICAL WEARABLES In addition to medical applications, laypeople are leveraging wearables individually. Many local runners and cyclists use smartwatches to track daily steps, heart rate, and respirations per minute during sleep. Skip Brand, owner of Healdsburg Running Company, says these uses are recreational but important, nevertheless. “Some of this technology can really help if you’re training for a big race,” he says. Other personal health-related wearables have also made an impact in recent times, including: • Cove, a “stress canceling technology” that is worn over the ears in the same way as a headset (above). It uses vibrations applied to specific parts of the head that can, according to developers, create a clinically proven stress-reducing and sleep-enhancing effect. www.feelcove.com • Upright Go is a small wearable device that helps patients train themselves to employ healthier posture using biofeedback. It produces a small vibration when the person wearing the device is slouching. The biofeedback vibration helps users to form better overall posture behaviors and reduce the possibility of future spinal problems. www.uprightpose.com • Embr Labs’ watch-style Wave device lets the wearer regulate body temperature (warmer or cooler) regardless of their environmental surroundings. www.embrlabs.com • Wearables that take the form of clothes. The Nadi X yoga pants track and give feedback on the wearer’s posture, while Neviano connected swimsuits detect the strength of ultraviolet light and can send warnings to the wearer’s smartphone app if levels are too high. www.wearablex.com; www.spinali-design.com These are just a few of the wearable options found with a quick internet search. They aren’t even the only products in their categories, by a long shot. The truth is, we could devote 10,000 words to different wearables and still wouldn’t scratch the surface of what’s available — or what might possibly come next.

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A VIEW FROM THE INSIDE An infectious disease physician’s COVID-19 journey in Sonoma County BY GARY GREEN, M .D., FIDSA

In October 2019, China began to experience the outbreak of a novel viral respiratory illness, a new disease strain that had not been previously identified in humans. he hinese government suppressed the information for political reasons. In December 2019, however, hinese health authorities and the World Health Organization (WHO) announced discovery of a new and severe acute respiratory syndrome coronavirus 2 (S RS- o -2). he illness it caused was named O ID-19 (COronaVIrus Disease 2019). Once the world was alerted to the threat, clinical and international events happened quickly. ust days after the WHO bulletin, O ID-19 cases were reported outside of hina, and it became clear the virus was spreading internationally. In mid- anuary 2020, the first cases were identified in the nited States. On anuary 11, 2020, hina shared the virus’ sequence with the international scientific and medical communities, and work began around the globe to address the rapidly spreading health crisis. ebruary 22 report, issued in the Journal of the American Medical Association ( M ) and co-written by a representative from the hinese enter for Disease ontrol and Prevention in eijing, provided vital information on severity of the disease. ccording to the article, 1 percent of early cases could be mild, only 1 percent were asymptomatic the overall case fatality rate was 2. percent, but those over 60 years of age had nearly a 1 percent case fatality rate. his became a clinical compass for healthcare providers. ach day brought an onslaught of new information some true, some not and medical professionals were tasked with sorting through the deluge to find the facts, while at the same time fielding frantic calls and questions from patients and the public. he chaotic, rapid-fire progression felt like standing unprotected in front of an open fire hydrant.

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IN MY 25-YEAR CAREER STUDYING AND TREATING INFECTIOUS DISEASES, I HAVEN’T SEEN SO MUCH DESPERATION AND DEATH SINCE THE AIDS EPIDEMIC.

FIRST SONOMA COUNTY CASES

In late ebruary 2020, only six weeks after S RS- o -2 was sequenced, Sutter Santa Rosa Regional Medical Hospital admitted the first two O ID cases in Sonoma ounty. he patients had recently returned from a cruise to Mexico, but that epidemiological link made no sense at the time. On March 1, a 2 a.m. phone call to my personal residence from the .S. enters for Disease ontrol ( D ), asking, Where is this cruise ship now? aligned Sutter Santa Rosa closely with the alifornia Department of Public Health ( DPH), which turned the cruise ship around on its voyage to Hawaii and delayed early spread of S RS- o -2 to that location. Once O ID arrived in the nited States, it spread quickly. On March 1 , 2020 less than two weeks

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after Sonoma ounty identified its first O ID case the White House declared a state of national emergency in response to the now-classified pandemic. irst, we struggled with the loss of our elders grandparents, great aunts and uncles, beloved neighbors and friends who, ill and isolated, could only communicate by phone or tablet and never got to say goodbye in person. s variants emerged, our peers younger people, middle-aged husbands, wives, brothers and sisters were hospitalized with severe illness, struggling to breathe and to survive. Some did not. Sonoma ounty has also experienced critical cases of O IDrelated multisystem in ammatory syndrome in children. In my 2 -year career studying and treating infectious diseases, I haven’t seen so much

desperation and death since the IDS epidemic. My fellow physicians, nurses, pharmacists and other clinical staff have experienced ongoing physical, mental and emotional exhaustion for nearly two years. It’s not entirely accurate to say no one saw it coming. Most of my infectious disease colleagues were anticipating a novel in uenza pandemic sometime this century. However, fewer expected a novel coronavirus pandemic, since 200 S RS and 2012 M RS coronaviruses did not spread worldwide. ( or more on these comparative diseases, see iruses at a Glance, page 6 .)

COLLABORATION WAS KEY

he early international sharing of the S RS- o -2 sequence from hina was an absolute critical step for development of diagnostic tests, treatment considerations and vaccine planning. he ebruary JAMA publication, which delineated the first case series, became our first clinical guidepost S RS- o -2 was 10 times more dangerous than seasonal in uenza, but not as lethal as S RS, M RS or the 191 in uenza (H1N1). he intervention surrounding the cruise ship fostered collaboration with the CDC, PDH, Sonoma ounty Public Health and the Mayo linic, which paved the way for Sutter Santa Rosa Regional Hospital to

participate in international treatment trials of intravenous (I ) remdesivir and convalescent plasma (two therapies investigated as possible treatment). Sutter Santa Rosa was able to stay one step ahead of the epidemic by gathering real-time information in a grass roots D weekly meeting, which later evolved into a weekly briefi ng between the D , IDS (Infectious Disease Society of merica) and treating providers. We quickly learned I remdesivir has a modest benefit, and convalescent plasma treatment only worked if it was administered within 2 hours of infection and if the plasma had high titres (levels) of protective antibodies. Plasma treatment was soon eclipsed by monoclonal antibody cocktails such as Regeneron’s. s the pandemic hit the ast oast of the .S., our colleagues in New York ity realized and shared the survival benefit of anticoagulation treatment to prevent or treat the unique thrombosis events (blood clots that block veins or arteries) that occur with this viral infection. he nited ingdom-based R O RY trial, launched in March 2020, is the world’s largest clinical trial into treatments (www. recoverytrial.net). Many of the world’s successful interventions have stemmed from this study, and it continues to deliver meaningful data. R O RY confirmed a survival benefit to dexamethasone (the most potent steroid available). Later studies supported the survival benefit of tocilizumab and barcinitib (both potent immune suppressive treatments). Not all immune suppressive treatments are effective, however, as we recently learned with the lack of benefit from Inferferon-1 . We further learned that diabetes control (before and during hospitalization) was as potent as other measures for survival.

MOVING QUICKLY

Within a month of seeing our first O ID cases, we had an evidence-based, five-pronged treatment strategy for patients hospitalized due to O ID-19 pneumonia Supply oxygen support Stop virus replication Slow down the immune system Prevent blood clots and ontrol blood sugars.

VIRUSES AT A GLANCE

Severe acute respiratory syndrome (SARS) is a viral respiratory disease first identified at the end of February 2003 during an outbreak that emerged in China and spread to four other countries. World Health Organization coordinated the international investigation with the assistance of the Global Outbreak Alert and Response Network (GOARN) and worked closely with health authorities in affected countries to provide epidemiological, clinical and logistical support to bring the outbreak under control. Source: www.who.int Middle East Respiratory Syndrome (MERS) is a viral respiratory illness that is new to humans. It was first reported in Saudi Arabia in 2012 and has since spread to several other countries, including the United States. Most people infected with MERS-CoV develop severe respiratory illness, including fever, cough and shortness of breath. Source: www.cdc.gov H1N1 influenza A: The 1918 influenza pandemic was caused by an H1N1 virus with genes of avian origin. Although there is no universal consensus regarding where the virus originated, it spread worldwide during 1918-1919. It is estimated that about 500 million people — one-third of the world’s population — became infected with this virus. The number of deaths was estimated to be at least 50 million worldwide with about 675,000 occurring in the United States. Source: www.cdc.gov Cytomegalovirus (CMV) is a common virus for people of all ages; however, a healthy person’s immune system usually keeps the virus from causing illness. In the United States, nearly one in three children are already infected with CMV by age five. Over half of adults have been infected with CMV by age 40. Once CMV is in a person’s body, it stays there for life and can reactivate. A person can also be re-infected with a different strain (variety) of the virus. Most people with CMV infection have no symptoms and aren’t aware that they have been infected. Source: www.cdc.gov Multisystem inflammatory syndrome in children (MIS-C) is a condition where different body parts can become inflamed, including the heart, lungs, kidneys, brain, skin, eyes or gastrointestinal organs. Its cause is not yet known. However, we know that many children with MIS-C had the virus that causes COVID-19 or had been around someone with COVID . MIS-C can be serious, even deadly, but most children who were diagnosed with this condition have recovered with medical care. Source: www.cdc.gov

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Some of these treatment modalities can be aggressive and risky, but also lifesaving. We heavily weighed the risk and potential benefits for each and every patient, and carefully planned the timing of each treatment strategy. onscientiously, we followed the Hippocratic oath to Do no harm and avoided adopting unproven and unsubstantiated treatment modalities that could also prove inadvertently harmful. rom the start, our mantra has been to trust in the science. If a report or study wasn’t biologically plausible or didn’t make sense, we waited for more data and rigorous investigation. ach treatment modality and policy decision was determined by evidencebased rigorous science not by rumor, anecdote, weak science or social media speculation. We quickly learned that hydroxychloroquine, azithromycin, colchicine, ivermectin, vitamin mega doses and uvoxamine don’t work and can be toxic. We felt validated when such treatments were also discouraged by the National Institutes of Health (NIH), considered by physicians as one of our country’s most credible institutions. Recently, more hope is emerging as the first oral antiviral medication, molnupiravir, received .S. ood and Drug dministration ( D ) approval, and a new S RS- o -2 antiviral protease inhibitor is just around the corner. lthough promising, we are waiting to see if these medications offer a quantified survival benefit. s with seasonal in uenza, antiviral medication can shorten the illness duration, but a vaccine offers the most significant chance of survival.

THE VACCINE ARRIVES

In spring of 2020, the NIH started vaccine trials less than one month after hina shared the full sequence of the virus. Was that too fast ? No. It was 1 years in the making. In 200 and 200 , the NIH developed a new mRN vaccine platform (that is, a new application of science led to its development) for the original S RS coronavirus. It took 20 months to develop this new vaccine, which demonstrated safety and e cacy in healthy volunteers. ut by the time it was ready, S RS had evaporated, and we couldn’t test this promising vaccine against that illness. his new vaccine platform had also been studied as a revolutionary vaccine

for the M RS coronavirus, rabies virus and cytomegalovirus ( M ). ast forward to 2020, and the NIH took the earlier mRN S RS vaccine research, which had been studied and improved over the years, and started vaccine trials using the S RS- o -2 sequence hina had provided in anuary. We were standing on the shoulders of molecular biologists, biochemists, virologists and vaccine scientists dating back to 19 on mRN nanoparticle, liposomal and vaccine research. he White

THE VIRUS’ TRANSMISSIBILITY, VIRULENCE AND PATHOLOGY ARE CHANGING. House called the O ID-19 vaccine efforts Operation Warp Speed, which, understandably, frightened many, who questioned whether protocols had been set aside in favor of a fast introduction. ut it was really a culmination of decades of hard and laborious science. Late in 2020, data from large vaccine trials across the globe were released. he medical community hoped for at least a 0 percent vaccine e cacy for D approval (for more on the D approval process, see Risk Reward, page ) Our hopes were bolstered with percent protection with the ohnson ohnson adenovirus platform O ID vaccine and, even better, with 9 to 96 percent protection of the mRN Pfizer and Moderna vaccines. his was a home run, and serious side effects were very rare. here was no in uenza vaccine in 191 and more than 0 million people died of the disease globally. o date, we have lost .2 million to this pandemic too many, to be sure, but imagine the devastation if vaccines weren’t available. accines have made O ID a preventable disease, similar to polio, measles, mumps and rubella, among

others. hey’ve already saved millions of lives. What’s more, the nited States has the three best and safest vaccines in the world. Our science has been rigorous and cautious, unlike Russia, which released its Sputnik vaccine before trials were finished, meaning safety and e cacy data was unknown. VARIANTS EMERGE ollowing viral science, we expected this virus to make random mistakes when it replicated these errors create new forms of the virus that we call variants. he first one, originally designated as D61 G, evolved only one month after we sequenced the original virus from hina. Soon, a more contagious and virulent variant emerged from the , and we designated this as .11 or the alpha variant. Other variants emerged in South frica, razil, olombia and even the nited States. In October 2020, further random mutations in the virus created an even more contagious and harmful variant designated .1.61 or the Delta variant, which emerged from India and quickly circulated worldwide. o date, virologists have documented more than 12,000 significant mutations to this novel virus, which have created 2 new variants being tracked and monitored by the WHO and a consortium of international virology labs. learly, the virus’ transmissibility, virulence and pathology are changing. he only way to break the epidemic cycle is by lowering the asic Reproductive number (called Ro) the only way to do this is for more people worldwide to get vaccinated. he more this virus circulates and replicates, the more mutations and variants will arise. urthermore, none of the available treatments not even monoclonal antibody cocktails are as life-saving as vaccination. ven surviving O ID doesn’t offer as much immune protection (called natural immunity ) as vaccine immunity, and surviving patients are encouraged by the D and our medical society to get vaccinated. Re-infection is real and dangerous, especially for the elderly and those with significant medical problems. When countries, whether poor or wealthy, aren’t successful with high-rate vaccine programs, more virus will circulate and mutate, and more variants will emerge.

SONOMA HEALTH

THE UNITED STATES HAS THE THREE BEST AND SAFEST VACCINES IN THE WORLD.

his is a certainty, and the Omicron variant, which is estimated at four times more contagious than the Delta variant, is a testament to that certainty. arly evidence from South frica, which first reported discovering the Omicron variant, suggests that natural immunity from previous O ID infection may not offer much protection at all against this new strain. We may have to lean even harder on vaccination. With more contagious variants, we need more people vaccinated to break the epidemic cycle, by lowering the Ro. Nearly 99 percent of patients now hospitalized are unvaccinated, and much younger people are becoming critically ill. Some do not seem to respond as much to our treatment strategies, and either perish or are transferred to other medical facilities on chronic long-term oxygen support. his is a very dangerous time to be unvaccinated. DRIVE SAFELY hink of O ID prevention and treatment as similar to the daily risk of driving.

SONOMA HEALTH

ollowing the rules of the road is similar to your decision to wash your hands, not touch your face, wear a mask and social distance in public it keeps you and those around you safe. On the other hand, how fast and recklessly you drive and how you maintain your vehicle are equivalent to aunting recommended social distancing and mask protocols and underlying health risks. Some of the treatments we’ve discovered are similar to air bags in an automobile, which ensure many more people will survive a collision but not everyone. he incredibly safe and effective vaccines we have in the nited States (Pfi zer, Moderna, ohnson ohnson) are more fundamental and effective, like seat belts. It would be very rare for a seat belt or airbag to fail, and most of us don’t lose sleep over this infi nitesimally low risk. his is analogous to the rare risk of a serious adverse reaction to the safe O ID vaccines available in the states. We know these devices reduce the chance of death in automobile accidents by 0 to percent.

o help each of us, our families, our friends, our co-workers and our neighbors survive this pandemic, it’s wisest to get vaccinated, continue sensible public health measures and, if needed, turn to evidence-based effective treatments such as monoclonal antibodies. accination wasn’t available during the 191 in uenza pandemic, and the disease persisted globally, in deadly fashion, for four more years. ventually, this virus will become endemic hopefully more quickly than the 191 in uenza strain. In the meantime, we need to prepare for the long haul sensibly. accination is the most vital factor toward this outcome. About the author: Gary Green, M.D., FIDSA, is an infectious disease specialist who serves as Medical Director of Quality, Infection Prevention and Stewardship for Sutter Medical Group of the Redwoods and Sutter Santa Rosa Regional Hospital. He has published on COVID-19 in the Morbidity and Mortality Weekly Report published by the CDC, and on IV remdesivir use in COVID-19 in the New England Journal of Medicine.

SCMA RESPONDS TO THE PANDEMIC BY SUSAN GUMUCIO AND WENDY YOUNG The Sonoma County Medical Association (SCMA, now known as Sonoma Mendocino Lake Medical Association, or SMLMA) supports the business and practice of medicine in Sonoma, Mendocino and Lake counties. SCMA provides a multitude of advocacy, wellness and practice assistance programs to member physicians, as well as offering opportunities for community involvement and service. Never has this commitment been so needed as when COVID-19 arrived in the North ay early in 2020. Once the O ID vaccines became available, S M helped lead efforts to vaccinate county residents to protect as many as possible from this devastating disease. In partnership with the County of Sonoma, SCMA opened a O ID vaccine clinic in anuary 2021 at Grace Pavilion in the Sonoma County Fairgrounds in Santa Rosa. It later teamed with Santa Rosa Community Health, expanding services to underserved populations and providing pop-up sites throughout the area. etween anuary and ugust 2021, almost 6,000 vaccine doses were administered by SCMA volunteer physicians and medical staff. Supporting medical professionals and the community during the COVID crisis has been SCMA’s most important accomplishment of the last year. In addition to the vaccine clinic, SCMA initiated the statewide Care4Caregivers program, which provided housing and services to physicians and all medical staff exposed to the virus in the course of their essential work at hospitals and medical practices. S M also supported local efforts to create and distribute handsewn face masks to physicians, first responders, essential workers, schools and shelters in the early days when N95 masks were being recommended, but were di cult to obtain. hey also delivered desperately needed personal protective equipment (PPE) supplies to medical practices in Sonoma County. SCMA supports county public health initiatives addressing vaccine advocacy, smoking cessation, youth vaping, heart health and more. Its long-standing Health Careers Scholarship program guides local students planning a career in medicine. t community events, you may see our first-aid tent, staffed by volunteer physicians. SCMA is actively engaged during times of crisis including wildfires, oods and, now, the O ID pandemic. SCMA also provides referrals for those seeking a primary care or specialty physician in our service area. You can check our Physician inder at www.scma.org or call 0 - 2 for assistance. About the authors: Susan Gumucio is the Communications Director and Wendy Young is the Executive Director of the Sonoma-Mendocino-Lake Medical Association (SMLMA).

BETWEEN JANUARY AND AUGUST 2021, ALMOST 36,000 COVID VACCINE DOSES WERE ADMINISTERED BY SCMA VOLUNTEER PHYSICIANS AND MEDICAL STAFF. SONOMA HEALTH

RESOURCES OPEN CLINICAL TRIALS IN SONOMA COUNTY 2022 This list of open, FDA-approved clinical trials in Sonoma County is intended to increase awareness of local medical research and to benefit physicians who may wish to refer patients. Organized by condition, each listing includes basic information about who may be eligible and what medical provider is conducting the study. As this list is subject to frequent changes, please contact the individual research groups or your primary care provider for the latest information (contacts listed on page 78). Source: www.clinicaltrials.gov (Dec. 1, 2021) ALZHEIMER’S / DEMENTIA NCT05026866: A Donanemab (LY3002813) Prevention Study in Participants with Preclinical Alzheimer’s Disease (TRAILBLAZER-ALZ 3); Phase III Age: 55 years to 80 years Location: Providence Medical Foundation, Santa Rosa, Calif. and more (national)

CANCER Anal cancer NCT04444921: EA2176: Trial of Carboplatin and Pacliitaxel +/- Nivolumab in Metastatic Anal Cancer Patients; Phase III Age: 18 years and older Location: Kaiser Permanente, Santa Rosa, Calif.; Rohnert Park Cancer Center, Rohnert Park, Calif. and more (national)

Bladder cancer NCT03288545: A Study of Enfortumab Vedotin Alone or with Other Therapies for Treatment of Urothelial Cancer; Phase I, Phase II Age: 18 years and older Location: Providence Medical Foundation, Santa Rosa, Calif. and more (international)

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NCT04637594: Trying to Find the Correct Length of Treatment with Immune Checkpoint Therapy; Phase III Age: 18 years and older Location: Kaiser Permanente, Santa Rosa, Calif.; Rohnert Park Cancer Center, Rohnert Park, Calif. and more (national)

Blood cancers NCT04071457: S1803, Lenalidomide +/- Daratumumab/ rHuPh20 as Post-ASCT Maintenance for Multiple Myeloma w/MRD to Direct Therapy Duration; Phase III Age: 18 years to 75 years Location: Kaiser Permanente, Santa Rosa, Calif.; Rohnert Park Cancer Center, Rohnert Park, Calif. and more (national) NCT03150693: Inotuzumab Ozogamicin and Frontline Chemotherapy in Treating Young Adults with Newly Diagnosed B Acute Lymphoblastic Leukemia; Phase III Age: 18 years to 39 years Location: Kaiser Permanente, Santa Rosa, Calif.; Rohnert Park Cancer Center, Rohnert Park, Calif. and more (North America)

NCT03893682: A Study of CG806 in Patients with Relapsed or Refractory Chronic Lymphocytic Leukemia / Small Lymphocytic Lymphoma or Non-Hodgkin’s Lymphomas; Phase I Age: 18 years and older Location: Providence Medical Foundation, Santa Rosa, Calif. and more (national) NCT03269669: Obinutuzumab with or without Umbralisib, Lenalidomide, or Combination Chemotherapy in Treating Patients with Relapsed or Refractory Grade I-IIIa Follicular Lymphoma; Phase II Age: 18 years and older Location: Kaiser Permanente, Santa Rosa, Calif.; Sutter Pacific Medical Foundation, Santa Rosa, Calif. and more (national) NCT01896999: Brentuximab Vedotin and Nivolumab with or without Ipilimumab in Treating Patients with Relapsed or Refractory Hodgkin Lymphoma; Phase I, Phase II Age: 12 years and older Location: Kaiser Permanente, Santa Rosa, Calif.; Rohnert Park Cancer Center, Rohnert Park, Calif. and more (national)

Brain and spinal cancers NCT02179086: Dose-Escalated Photon IMRT or Proton Beam Radiation Therapy Versus Standard-Dose Radiation Therapy and Temozolomide in Treating Patients with Newly Diagnosed Glioblastoma; Phase II Age: 18 years and older Location: Rohnert Park Cancer Center, Rohnert Park, Calif. and more (North America) NCT03180268: Observation or Radiation Therapy in Treating Patients with Newly Diagnosed Grade II Meningioma That Has Been Completely Removed by Surgery; Phase III Age: 18 years and older Location: Rohnert Park Cancer Center, Rohnert Park, Calif. and more (international) NCT02523014: Vismodegib, FAK Inhibitor GSK2256098, Capivasertib, and Abemaciclib in Treating Patients with Progressive Meningiomas; Phase II Age: 18 years and older Phases: Phase 2 Location: Kaiser Permanente, Santa Rosa, Calif.; Sutter Pacific Medical Foundation, Santa Rosa, Calif. and more (national) NCT03550391: Stereotactic Radiosurgery Compared with Hippocampal-Avoidant Whole Brain Radiotherapy (HA-WBRT) Plus Memantine for 5-15 Brain Metastases; Phase III Age: 18 years and older Location: Rohnert Park Cancer Center, Rohnert Park, Calif. and more (North America)

Breast cancer NCT03328026: Combination Study of SV-BR-1-GM in Combination with INCMGA00012 and Epacadostat; Phase I, Phase II Age: 18 years and older Location: Providence Medical Foundation, Santa Rosa, Calif. and more (national) NCT01901094: Comparison of Axillary Lymph Node Dissection with Axillary Radiation for Patients with Node-Positive Breast Cancer Treated with Chemotherapy; Phase III Age: 18 years and older Location: Kaiser Permanente, Santa Rosa, Calif.; Providence Medical Foundation, Santa Rosa, Calif.; Rohnert Park Cancer Center, Rohnert Park, Calif. and more (North America) NCT02445391: Platinum Based Chemotherapy or Capecitabine in Treating Patients with Residual Triple-Negative Basal-Like Breast Cancer Following Neoadjuvant Chemotherapy; Phase III Age: 18 years and older Location: Kaiser Permanente, Santa Rosa, Calif.; Sutter Pacific Medical Foundation, Santa Rosa, Calif.; Rohnert Park Cancer Center, Rohnert Park, Calif. and more (international) NCT04457596: T-DM1 and Tucatinib Compared with T-DM1 Alone in Preventing Relapses in People with High Risk HER2Positive Breast Cancer, the CompassHER2 RD Trial; Phase III Age: 18 years and older Location: Sutter Pacific Medical Foundation, Santa Rosa, Calif. and more (national) NCT04266249: CompassHER2pCR: Decreasing Chemotherapy for Breast Cancer Patients After Pre-surgery Chemo and Targeted Therapy; Phase II Age: 18 years and older Location: Sutter Pacific Medical Foundation, Santa Rosa, Calif. and more (national)

NCT02488967: Doxorubicin Hydrochloride and Cyclophosphamide Followed by Paclitaxel with or without Carboplatin in Treating Patients with Triple-Negative Breast Cancer; Phase III Age: 18 years and older Location: Kaiser Permanente, Santa Rosa, Calif.; Sutter Pacific Medical Foundation, Santa Rosa, Calif. and more (North America) NCT04961996: A Study Evaluating the Efficacy and Safety of Adjuvant Giredestrant Compared with Physician’s Choice of Adjuvant Endocrine Monotherapy in Participants with Estrogen Receptor-Positive, HER2-Negative Early Breast Cancer (lidERA Breast Cancer); Phase III Age: 18 years and older Location: Providence Medical Foundation, Santa Rosa, Calif. and more (international) NCT03199885: Testing the Drug Atezolizumab or Placebo with Usual Therapy in First-Line HER2-Positive Metastatic Breast Cancer; Phase III Age: 18 years and older Location: Kaiser Permanente, Santa Rosa, Calif. and more (North America) NCT03488693: Regional Radiotherapy in Biomarker LowRisk Node Positive and T3N0 Breast Cancer; Phase III Age: 35 years and older Location: Rohnert Park Cancer Center, Rohnert Park, Calif. and more (North America) NCT03418961: S1501 Carvedilol in Preventing Cardiac Toxicity in Patients with Metastatic HER-2Positive Breast Cancer; Phase III Age: 18 years and older Location: Kaiser Permanente, Santa Rosa, Calif.; Rohnert Park Cancer Center, Rohnert Park, Calif. and more (international)

NCT04869943: Efficacy Evaluation of Enobosarm Monotherapy in Treatment of AR+/ER+/HER2- Metastatic Breast Cancer; Phase III Age: 18 years to 100 years Location: Providence Medical Foundation, Santa Rosa, Calif. and more (international) NCT01872975: Standard or Comprehensive Radiation Therapy in Treating Patients with EarlyStage Breast Cancer Previously Treated with Chemotherapy and Surgery Age: 18 years and older Location: Rohnert Park Cancer Center, Rohnert Park, Calif. and more (international)

Cervical cancer NCT01649089: Studying the Physical Function and Quality of Life Before and After Surgery in Patients with Stage I Cervical Cancer Age: 18 years and older Location: Sutter Pacific Medical Foundation, Santa Rosa, Calif. and more (international) NCT01101451: Radiation Therapy with or without Chemotherapy in Patients with Stage I-IIA Cervical Cancer Who Previously Underwent Surgery; Phase III Age: 18 years and older Location: Sutter Pacific Medical Foundation, Santa Rosa, Calif. and more (international) NCT02466971: Testing the Addition of a New Anti-Cancer Drug, Triapine, to the Usual Chemotherapy Treatment (Cisplatin) During Radiation Therapy for Advanced-stage Cervical and Vaginal Cancers; Phase III Age: 18 years and older Location: Kaiser Permanente, Santa Rosa, Calif.; Rohnert Park Cancer Center, Rohnert Park, Calif. and more (national)

Colon / Colorectal cancer NCT04094688: Vitamin D3 with Chemotherapy and Bevacizumab in Treating Patients with Advanced or Metastatic Colorectal Cancer; Phase III Age: 18 years and older Location: Kaiser Permanente, Santa Rosa, Calif.; Rohnert Park Cancer Center, Rohnert Park, Calif. and more (national) NCT02912559: Combination Chemotherapy with or without Atezolizumab in Treating Patients with Stage III Colon Cancer and Deficient DNA Mismatch Repair; Phase III Age: 12 years and older Location: Sutter Pacific Medical Foundation, Santa Rosa, Calif. and more (national) NCT03365882: S1613, Trastuzumab and Pertuzumab or Cetuximab and Irinotecan Hydrochloride in Treating Patients with Locally Advanced or Metastatic HER2/Neu Amplified Colorectal Cancer That Cannot Be Removed by Surgery; Phase II Age: 18 years and older Location: Sutter Pacific Medical Foundation, Santa Rosa, Calif. and more (national) NCT01349881: S0820, Adenoma and Second Primary Prevention Trial of Colorectal Neoplasms; Phase III Age: 18 years and older Location: Kaiser Permanente, Santa Rosa, Calif.; Sutter Pacific Medical Foundation, Santa Rosa, Calif. and more (national)

HPV NCT03811015: Testing Immunotherapy Versus Observation in Patients with HPV Throat Cancer; Phase II, Phase III Age: 18 years and older Location: Kaiser Permanente, Santa Rosa, Calif.; Rohnert Park Cancer Center, Rohnert Park, Calif. and more (national)

SONOMA HEALTH

Bring On Those Bright Smiles! Winter break is a great time for kids to see their dentist for a checkup Children with healthy teeth eat, speak and sleep better. All are essential to doing well in school.

Get your child ready to end the school-year strong with a healthy mouth

To find a dentist and other school readiness tips visit SmileCalifornia.org

Lung cancer NCT03793179: Testing the Timing of Pembrolizumab Alone or with Chemotherapy as First Line Treatment and Maintenance in Non-small Cell Lung Cancer; Phase III Age: 18 years and older Location: Kaiser Permanente, Santa Rosa, Calif.; Sutter Pacific Medical Foundation, Santa Rosa, Calif., Rohnert Park Cancer Center, Rohnert Park, Calif. and more (North America) NCT02201992: Crizotinib in Treating Patients with Stage IB-IIIA Non-small Cell Lung Cancer That Has Been Removed by Surgery and ALK Fusion Mutations (An ALCHEMIST Treatment Trial); Phase III Age: 18 years and older

Funded by the CDPH under Contract 17-10730

Location: Kaiser Permanente, Santa Rosa, Calif.; Sutter Pacific Medical Foundation, Santa Rosa, Calif., Rohnert Park Cancer Center, Rohnert Park, Calif. and more (national) NCT02194738: Genetic Testing in Screening Patients with Stage IB-IIIA Non-small Cell Lung Cancer That Has Been or Will Be Removed by Surgery (The ALCHEMIST Screening Trial) Age: 18 years and older Location: Kaiser Permanente, Santa Rosa, Calif.; Sutter Pacific Medical Foundation, Santa Rosa, Calif., Rohnert Park Cancer Center, Rohnert Park, Calif. and more (national)

E Everyone five years fi of age and older is now eligible

NCT03845296: Rucaparib in Treating Patients with Genomic LOH High and/or Deleterious BRCA1/2 Mutation Stage IV or Recurrent Non-small Cell Lung Cancer (A Lung-MAP Treatment Trial); Phase II Age: Child, Adult, Older Adult Location: Kaiser Permanente, Santa Rosa, Calif.; Sutter Pacific Medical Foundation, Santa Rosa, Calif.; Rohnert Park Cancer Center, Rohnert Park, Calif. and more (national) NCT04334941: Testing Maintenance Therapy for Small Cell Lung Cancer in Patients with SLFN11 Positive Biomarker; Phase II Age: 18 years and older Location: Providence Medical Foundation, Santa Rosa, Calif. and more (national) NCT03447769: Brief Title: Study of Efficacy and Safety of Canakinumab as Adjuvant Therapy in Adult Subjects with Stages AJCC/UICC v. 8 II-IIIA and IIIB (T>5cm N2) Completely Resected Non-small Cell Lung Cancer Acronym: CANOPY-A; Phase III Age: 18 years and older Location: Providence Medical Foundation, Santa Rosa, Calif. and more (international)

NCT03851445: Lung-MAP: A Master Screening Protocol for Previously-Treated Non-Small Cell Lung Cancer; Phase II, Phase III

NCT04092283: Testing the Addition of an Antibody to Standard Chemoradiation Followed by the Antibody for One Year to Standard Chemoradiation Followed by One Year of the Antibody in Patients with Unresectable Stage III NonSmall Cell Lung Cancer; Phase III

Age: 18 years and older

Location: Kaiser Permanente, Santa Rosa, Calif.; Rohnert Park Cancer Center, Rohnert Park, Calif. and more (national)

Location: Sutter Pacific Medical Foundation, Santa Rosa, Calif. and more (national)

For a list of free COVID vaccination clinics and testing sites, visit: socoemergency.org or call (707) 565-4667 for information 74

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RESOURCES

NCT04181060: Osimertinib with or without Bevacizumab as Initial Treatment for Patients with EGFR-Mutant Lung Cancer; Phase III Age: 18 years and older Location: Kaiser Permanente, Santa Rosa, Calif. and more (national) NCT04625647: Testing the Use of Targeted Treatment (AMG 510) for KRAS G12C Mutated Advanced Non-squamous Nonsmall Cell Lung Cancer (A LungMAP Treatment Trial); Phase II Age: 18 years and older Location: Sutter Pacific Medical Foundation, Santa Rosa, Calif. and more (national) NCT04380636: Study of Pembrolizumab with Concurrent Chemoradiation Therapy Followed by Pembrolizumab with or without Olaparib in Stage III Non-Small Cell Lung Cancer (NSCLC) (MK7339-012/KEYLYNK-012); Phase III Age: 18 years and older Location: Providence Medical Foundation, Santa Rosa, Calif. and more (international) NCT04262856: Study to Evaluate Monotherapy and Combination Immunotherapies in Participants with PD-L1 Positive Non-small Cell Lung Cancer; Phase II Age: 18 years and older Location: Providence Medical Foundation, Santa Rosa, Calif. and more (international)

Nasopharyngeal cancer NCT02135042: Individualized Treatment in Treating Patients with Stage II-IVB Nasopharyngeal Cancer Based on EBV DNA; Phase II, Phase III Age: 18 years and older Location: Rohnert Park Cancer Center, Rohnert Park, Calif. and more (international)

Other cancers NCT04803305: Study to Compare the Effects of Repeated Doses of an Investigational New Drug and a Placebo on Appetite in Advanced Cancer and Anorexia; Phase I Age: 18 years and older Location: Providence Medical Foundation, Santa Rosa, Calif. and more (North America) NCT03761914: Galinpepimut-S in Combination with Pembrolizumab in Patients with Selected Advanced Cancers; Phase I, Phase II Age: 18 years and older Location: St. Joseph Heritage Healthcare, Santa Rosa, Calif. and more (national)

Ovarian / Endometrial / Uterine cancers NCT04251052: A Study to Compare Two Surgical Procedures in Women with BRCA1 Mutations to Assess Reduced Risk of Ovarian Cancer Age: 35 years to 50 years Location: Kaiser Permanente, Santa Rosa, Calif.; Rohnert Park Cancer Center, Rohnert Park, Calif. and more (national) NCT02502266: Testing the Combination of Cediranib and Olaparib in Comparison to Each Drug Alone or Other Chemotherapy in Recurrent Platinum-Resistant Ovarian Cancer; Phase II, Phase III Age: 18 years and older Location: Sutter Pacific Medical Foundation, Santa Rosa, Calif. and more (national) NCT04095364: Letrozole with or without Paclitaxel and Carboplatin in Treating Patients with Stage II-IV Ovarian, Fallopian Tube, or Primary Peritoneal Cancer; Phase III Age: 18 years and older Location: Kaiser Permanente, Santa Rosa, Calif.; Providence Medical Foundation, Santa Rosa, Calif. and more (international)

NCT04739800: Comparison of Standard of Care Treatment with a Triplet Combination of Targeted Immunotherapeutic Agents for Ovarian, Endometrial and Fallopian Tube Cancers; Phase II

NCT03375320: Testing Cabozantinib in Patients with Advanced Pancreatic Neuroendocrine and Carcinoid Tumors; Phase III

Age: 18 years and older

Location: Kaiser Permanente, Santa Rosa, Calif. and more (national)

Location: Sutter Pacific Medical Foundation, Santa Rosa, Calif. and more (national) NCT03660826: Testing the Combination of Olaparib and Durvalumab, Cediranib and Durvalumab, Olaparib and Capivasertib, and Cediranib Alone in Recurrent or Refractory Endometrial Cancer Following the Earlier Phase of the Study That Tested Olaparib and Cediranib in Comparison to Cediranib Alone, and Olaparib Alone; Phase II Age: 18 years and older Location: Providence Medical Foundation, Santa Rosa, Calif.; Sutter Pacific Medical Foundation, Santa Rosa, Calif.; Providence Santa Rosa Memorial Hospital, Santa Rosa, Calif. and more (national)

Pancreatic cancer NCT02595424: Cisplatin, Carboplatin and Etoposide or Temozolomide and Capecitabine in Treating Patients with Neuroendocrine Carcinoma of the Gastrointestinal Tract or Pancreas That Is Metastatic or Cannot Be Removed by Surgery; Phase II Age: 18 years and older Location: Kaiser Permanente, Santa Rosa, Calif.; Sutter Pacific Medical Foundation, Santa Rosa, Calif. and more (national) NCT04548752: Testing the Addition of Pembrolizumab, an Immunotherapy Cancer Drug to Olaparib Alone as Therapy for Patients with Pancreatic Cancer That Has Spread with Inherited BRCA Mutations; Phase II Age: 18 years and older Location: Sutter Pacific Medical Foundation, Santa Rosa, Calif. and more (national)

Age: 18 years and older

Prostate cancer NCT03678025: Standard Systemic Therapy with or without Definitive Treatment in Treating Participants with Metastatic Prostate Cancer; Phase III Age: 18 years and older Location: Kaiser Permanente, Santa Rosa, Calif.; Rohnert Park Cancer Center, Rohnert Park, Calif. and more (North America) NCT03419234: Abiraterone Acetate and Antiandrogen Therapy with or without Cabazitaxel and Prednisone in Treating Patients with Metastatic, CastrationResistant Prostate Cancer Previously Treated with Docetaxel; Phase II Age: 18 years and older Location: Kaiser Permanente, Santa Rosa, Calif.; Sutter Pacific Medical Foundation, Santa Rosa, Calif. and more (national) NCT03070886: Antiandrogen Therapy and Radiation Therapy with or without Docetaxel in Treating Patients with Prostate Cancer That Has Been Removed by Surgery; Phase II, Phase III Age: 18 years and older Location: Kaiser Permanente, Santa Rosa, Calif.; Rohnert Park Cancer Center, Rohnert Park, Calif. and more (North America) NCT04455750: A Clinical Study Evaluating the Benefit of Adding Rucaparib to Enzalutamide for Men with Metastatic Prostate Cancer That Has Become Resistant to TestosteroneDeprivation Therapy; Phase III Age: 18 years and older Location: Kaiser Permanente, Santa Rosa, Calif. and more (national)

SONOMA HEALTH

RESOURCES

NCT02975934: A Study of Rucaparib Versus Physician’s Choice of Therapy in Patients with Metastatic Castration-resistant Prostate Cancer and Homologous Recombination Gene Deficiency; Phase III Age: 18 years and older Location: Providence Medical Foundation, Santa Rosa, Calif. and more (international) NCT03367702: Stereotactic Body Radiation Therapy or Intensity-Modulated Radiation Therapy in Treating Patients with Stage IIA-B Prostate Cancer; Phase III Age: 18 years and older Location: Rohnert Park Cancer Center, Rohnert Park, Calif. and more (international)

Rare tumors / solid tumors NCT02834013: Nivolumab and Ipilimumab in Treating Patients with Rare Tumors; Phase II Age: 18 years and older Location: Kaiser Permanente, Santa Rosa, Calif.; Providence Medical Foundation, Santa Rosa, Calif.; Sutter Pacific Medical Foundation, Santa Rosa, Calif. and more (international) NCT02465060: Targeted Therapy Directed by Genetic Testing in Treating Patients with Advanced Refractory Solid Tumors, Lymphomas, or Multiple Myeloma (The MATCH Screening Trial); Phase II Age: 18 years and older Location: Kaiser Permanente, Santa Rosa, Calif.; Sutter Pacific Medical Foundation, Santa Rosa, Calif., Rohnert Park Cancer Center, Rohnert Park, Calif. and more (national)

NCT03887702: Prophylactic Antiviral Therapy in Patients with Current or Past Hepatitis B Virus Infection Receiving Anti-Cancer Therapy for Solid Tumors; Phase III Age: 18 years and older

Renal cancer

CARDIAC

NCT04195750: A Study of Belzutifan (MK-6482) Versus Everolimus in Participants with Advanced Renal Cell Carcinoma (MK-6482-005); Phase III

NCT04435626: Study to Evaluate the Efficacy and Safety of Finerenone on Morbidity & Mortality in Participants with Heart Failure and Left Ventricular Ejection Fraction Greater or Equal to 40%; Phase III

Location: Kaiser Permanente, Santa Rosa, Calif.; Rohnert Park Cancer Center, Rohnert Park, Calif. and more (international)

Age: 18 years and older

NCT03893955: A Study to Determine the Safety, Tolerability, Pharmacokinetics, and Preliminary Efficacy of ABBV-927 with ABBV-368, Budigalimab (ABBV181) and/or Chemotherapy in Participants with Locally Advanced or Metastatic Solid Tumors; Phase I

Skin cancers

Age: 18 years and older

Location: Kaiser Permanente, Santa Rosa, Calif.; Providence Medical Foundation, Santa Rosa, Calif.; Sutter Pacific Medical Foundation, Santa Rosa, Calif. and more (national)

Location: St Jude Hospital dba Providence Medical Foundation, Santa Rosa, Calif. and more (international) NCT04032704: A Study of Ladiratuzumab Vedotin in Advanced Solid Tumors; Phase II Age: 18 years and older Location: Providence Medical Foundation, Santa Rosa, Calif. and more (international) NCT03251378: A Multi-Center, Open-Label Study of Fruquintinib in Solid Tumors, Colorectal, and Breast Cancer; Phase I Age: 18 years and older Location: Providence Medical Foundation, Santa Rosa, Calif. and more (national) NCT03093116: A Study of Repotrectinib (TPX-0005) in Patients with Advanced Solid Tumors Harboring ALK, ROS1, or NTRK1-3 Rearrangements; Phase I, Phase II Age: 12 years and older Location: Providence Medical Foundation, Santa Rosa, Calif. and more (international)

Location: Providence Medical Foundation, Santa Rosa, Calif. and more (international)

NCT03698019: A Study to Compare the Administration of Pembrolizumab After Surgery Versus Administration Both Before and After Surgery for High-Risk Melanoma; Phase II Age: 18 years and older

NCT02339571: Trial of Nivolumab, Ipilimumab, and GMCSF in Patients with Advanced Melanoma; Phase II, Phase III Age: 18 years and older Location: Sutter Pacific Medical Foundation, Santa Rosa, Calif. and more (national) NCT03712605: Testing Pembrolizumab Versus Observation in Patients with Merkel Cell Carcinoma After Surgery, STAMP Study; Phase III Age: 18 years and older Location: Sutter Pacific Medical Foundation, Santa Rosa, Calif. and more (national) NCT03765918: Study of Pembrolizumab Given Prior to Surgery and in Combination with Radiotherapy Given Post-surgery for Advanced Head and Neck Squamous Cell Carcinoma (MK3475-689); Phase III Age: 18 years and older Location: Providence Medical Foundation, Santa Rosa, Calif. and more (international)

SONOMA HEALTH

Age: 40 years and older Location: NorthBay Clinical Research, Santa Rosa, Calif. and more (international)

CHRONIC PAIN NCT04096391: Post-market, Randomized, Controlled, Prospective Study Evaluating Intrathecal Pain Medication (IT) Versus Conventional Medical Management (CMM) in the Noncancer, Refractory, Chronic Pain Population Age: 22 years and older Location: Evolve Restorative Center, Santa Rosa, Calif. NCT04944459: Meditation Utilizing Signals from Electroencephalography in Chronic Pain (MUSE-PAIN) Study Age: 18 years and older Location: Pacific Research Institute, LLC, Santa Rosa, Calif. and more (national) NCT04676022: SCS as an Option for Chronic Low Back and/ or Leg Pain Instead of Surgery Age: 22 years and older Location: Summit Pain Alliance, Santa Rosa, Calif. and more (national)

EYE HEALTH NCT04734210: A Study to See How Well an Eye Drop, SURF-200 (0.02% and 0.04% Betamethasone Sodium Phosphate), Works, What Side Effects There Are, and to Compare it with Vehicle (Placebo) in Subjects Diagnosed with Dry Eye Disease and Experiencing an Episodic Flare-Up; Phase II Age: 18 years and older

Age: 18 years and older Location: North Bay Eye Associates, Petaluma, Calif. and more (national)

Location: North Bay Eye Associates, Petaluma, Calif. and more (national)

NCT05049070: Evaluate the Reliability, Validity and Safety of Subjective Mobile Refraction

NCT04810962: Efficacy and Safety of APP13007 for Treatment of Ocular Inflammation and Pain After Cataract Surgery Including a Corneal Endothelial Cell Substudy; Phase III

Location: North Bay Eye Associates, Petaluma, Calif. and more (national)

Age: 18 years and older Location: North Bay Eye Associates, Petaluma, Calif. and more (national)

Age: 18 to 39 years

NCT04899063: Evaluate the Safety and Effectiveness of the ELIOS System to Reduce Intraocular Pressure in Patients with Primary Open-Angle Glaucoma Undergoing Cataract Surgery Age: 45 years and older

NCT03697811: DE-117 Spectrum 5 Study of Primary Openangle Glaucoma and Ocular Hypertension; Phase III

Location: North Bay Eye Associates, Petaluma, Calif. and more (national)

Age: 18 years and older

NCT04899518: Evaluate the Safety and Efficacy of Two Concentrations (0.4% and 1%) of ALY688 Ophthalmic Solution in Subjects with Dry Eye Disease (OASIS-1); Phase II, Phase III

Location: North Bay Eye Associates, Petaluma, Calif. and more (national) NCT04599972: An Evaluation of the Efficacy and Safety of CSF-1 in the Temporary Correction of Presbyopia (NEAR-2); Phase III Age: 45 years to 64 years Location: Orasis Investigative Site, Petaluma, Calif. and more (national) NCT04676737: TTHX1114(NM141) in Combination with DWEK/ DSO for Patients with Fuchs’ Endothelial Dystrophy; Phase II Age: 18 years and older Location: North Bay Eye Associates, Petaluma, Calif. and more (national)

FIND WHAT MOVES YOU.

NCT04647214: ARGOS - Assess the Effectiveness and Safety of Bimatoprost Intracameral Implant (DURYSTA); Phase IV

Age: 18 years and older Location: North Bay Eye Associates, Petaluma, Calif. and more (national) NCT04599972: Evaluate the Efficacy and Safety of CSF-1 in the Temporary Correction of Presbyopia (the NEAR-2 Study: Near Eye-vision Acuity Restoration) Age: 45 to 64 years Location: North Bay Eye Associates, Petaluma, Calif. and more (national)

FIND YOUR Y.

Sonoma County Family Y At the Y, you’ll find countless opportunities to get moving and experience the joy of better health. All it takes is one first step.



Amenities for the Entire Family



Robust offering of Group Exercise Classes



Free Child Care while you workout



No Annual Fees



Financial Assistance – The Y is for everyone!



Nationwide Access to Y’s across the country

(fitness center, 2 pools, sauna, basketball) (in person & virtual)

FIND YOUR Y AT: Sonoma County Family Y 1111 College Avenue  545-9622  scfymca.org

The Y is a leading non-profit, committed to improving our community’s health.

NCT04630808: Evaluate the Safety and Efficacy of NCX 470 vs. Latanoprost 0.005% in Subjects with Open-Angle Glaucoma or Ocular Hypertension (Mont Blanc); Phase III

NCT00737399: Anxiety and Depression Levels in Cancer Patients After Self-Application of EFT (Emotional Freedom Techniques); Phase I

Age: 18 to 84 years

Location: Soul Medicine Institute, Santa Rosa, Calif.

Location: North Bay Eye Associates, Petaluma, Calif. and more (national)

MENTAL HEALTH NCT01327690: Mental Health and Post-Traumatic Stress Disorders in Veterans and Families After Group Therapies; Phase I Age: 18 years to 80 years Location: Soul Medicine Institute, Santa Rosa, Calif.

Age: 18 years to 89 years

PSORIASIS NCT04036435: Long-Term Study That Measures the Safety and Efficacy of Deucravacitinib (BMS-986165) in Participants with Psoriasis; Phase III Age: 18 years and older Location: NorthBay Clinical Research, Santa Rosa, Calif.; Synexus, Santa Rosa, Calif. and more (international)

SONOMA HEALTH

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CLINICAL TRIALS FACILITIES Evolve Restorative Center 416 Aviation Blvd. Santa Rosa, CA 95403 (844) 527-7369 evolverestorativecenter.care

NorthBay Clinical Research 4740 Hoen Ave. Santa Rosa, CA 95405 (707) 542-2783

Kaiser Permanente 401 Bicentennial Way Santa Rosa, CA 95403 kpstudysearch.kaiser.org

North Bay Eye Associates 380 Tesconi Cir. Santa Rosa, CA 95401 (707) 999-4708 northbayeye.com

Laservue Eye Center 3540 Mendocino Ave. #200 Santa Rosa, CA 95403 (707) 522-6200 laservue.com

Providence Medical Foundation 3555 Round Barn Cir. Santa Rosa, CA 95403 (707) 521-3830 stjosephhealthmedicalgroup.com

Rohnert Park Cancer Center 301 Professional Center Dr. Rohnert Park, CA 94928 (707) 584-2200 uscmc.com

Summit Pain Alliance 392 Tesconi Ct. Santa Rosa, CA 95401 (707) 623-9803 summitpainalliance.com

Soniphi 496 S Main St. Sebastopol, CA 95472 (707) 874-6061 Research@soniphi.com

Sutter Pacific Medical Foundation 30 Mark West Springs Rd. Santa Rosa, CA 95403 (707) 576-4000 sutterhealth.org/research

Soul Medicine Institute 2168 Francisco Ave. Santa Rosa, CA 95403 (707) 237 6951 dawsonchurch.com/soul-medicineinstitute

SONOMA COUNTY COMMUNITY HEALTH CENTERS ALEX ANDER VALLEY HEALTHCARE Alexander Valley Healthcare is a community health center providing comprehensive primary care and preventive health care services. Medical Clinic 6 Tarman Dr. Cloverdale, CA 95425 (707) 894-4229 Services offered: Adolescent Care, Children’s Health, Family Planning, Birth Control, Pregnancy Testing, STI Treatment, HIV Testing and Counseling, Lab Services On-site, Prenatal Care, Chronic Disease Management, Diabetes Care, Physical Exams, Women’s Health, School Sports Exams, Eye Exams Dental Clinic 100 W 3rd St. Cloverdale, CA 95425 (707) 894-4229

ALLIANCE MEDICAL CENTER More than half of Alliance Medical Center patients receive government assistance with their healthcare costs. Without us, the only access to healthcare for thousands of families would be the emergency room at the local hospital, a costly alternative for both the family and community. 78

SONOMA HEALTH

Teen Health Center 1557 Healdsburg Ave. Healdsburg, CA 95448 (707) 431-1170 Healdsburg Clinic 1381 University Ave. Healdsburg, CA 95448 (707) 433-5494 WIC 1381 University Ave. Healdsburg, CA 95448 (707) 431-0831 Windsor Clinic 8465 Old Redwood Hwy. #320 Windsor, CA 95492 (707) 433-5494 Windsor Dental 8499 Old Redwood Hwy. # 112 Windsor, CA 95492 (707) 433-5494

JEWISH COMMUNIT Y FREE CLINIC Since 2001, the Jewish Community Free Clinic (JCFC) has been providing completely free medical care to anyone in need, regardless of any discriminating factors. From our first days in a one room clubhouse to the fully equipped medical offices we occupy today,

JCFC offers services to anyone in need who finds themselves without health coverage. 50 Montgomery Dr. Santa Rosa, CA 95404 (707) 585-7780

NORTHERN CALIFORNIA CENTER FOR WELL-BEING NCWB offers education, mobilization and advocacy to help curb the effects of chronic diseases such as diabetes, arthritis, cardiovascular disease, obesity and more. 101 Brookwood Ave., Suite A Santa Rosa, CA 95404 (707)575-6043

PETALUM A HEALTH CENTER The Petaluma Health Center’s mission is to ensure access and provide high-quality, preventionfocused health care for the communities we serve. Medical Clinic 1179 N McDowell Blvd. Petaluma, CA 94954 (707) 559-7500

Mary Isaak Homeless Shelter Clinic (COTS) 900 Hopper St. Petaluma, CA, 94952 (707) 773-4305 Founded in 1988, we empower homeless families, veterans and adults to rebuild their lives and find housing. More than a shelter, we are a network of thousands of volunteers, collaborative partners and staff that work together to provide comprehensive services that end homelessness – for good. San Antonio High School Health Clinic 500 Vallejo St. Petaluma, CA 94952 (707) 559-7500 San Antonio Clinic provides primary care of adolescents throughout southern Sonoma County. Located on the San Antonio High School campus, the clinic provides services to students as well as community members. Casa Grande High School Health Clinic 333 Casa Grande Rd. Petaluma, CA 94954 (707) 559-7500 Rohnert Park Clinic 5900 State Farm Dr., 2nd Fl. Rohnert Park, CA 94928 (707) 559-7600

RESOURCES

Rohnert Park Vision Center 4625 Redwood Dr., Ste. A Rohnert Park, CA 94928 (707)559-7600 SRJC (Petaluma Campus) Student Health Services Clinic 680 Sonoma Mountain Pkwy. Petaluma, CA 94954 (707) 559-7500

SANTA ROSA COMMUNIT Y HEALTH At Santa Rosa Community Health, we believe there’s more to the story of health than access. It’s being seen for who you are and, together with our team, charting the course to a healthier you. Every day, we open our doors to care for patients in a way that honors and meets their needs. We welcome everyone with love and respect, because none of us should ever receive anything less than the best care possible. Bridge Campus 2235 Challenger Way, #109 Santa Rosa, CA 95407 (707) 303-8912 Brookwood Campus 983 Sonoma Ave. Santa Rosa, CA 95405 (707) 583-8700 Dental Campus 1110 North Dutton Ave. Santa Rosa, CA 95401 (707) 303-3395 Dutton Campus 1300 North Dutton Ave. Santa Rosa, CA 95401 (707) 396-5151 Elsie Allen High School Clinic 599 Bellevue Ave., Ste. G17 Santa Rosa, CA 95407 (707) 583-8777 Lombardi Campus 751 Lombardi Ct. Santa Rosa, CA 95407 (707) 547-2222 Pediatric Campus 711 Stony Point Rd., Ste. 17 Santa Rosa, CA 95407 (707) 578-2005 Santa Rosa Junior "College Campus Clinic 1501 Mendocino Ave. Santa Rosa, CA 95401 (707) 527-4445

Source: www.rchc.net/health-centers

Turning Point Campus (by referral only) The Turning Point mission is “Turning Lives Around by Providing Healthy Alternatives to Alcohol and other Drug Use.” We have provided thousands of people the tools and guidance to live a healthy and sober life. 440 Arrowood Dr. Santa Rosa, CA 95407 (707) 284-2950

SONOM A COUNT Y INDIAN HEALTH PROJECT Licensed by the State of California as a Community Health Center, SCHIP currently provides medical, dental, nutritional, behavioral health, pharmacy and health education services. SCIHP has expanded care to non-Indians with Medi-Cal on a limited basis. SCIHP has adopted the model Medical Home, also known as the patient centered medical home (PCMH), a team-based health care delivery model that provides comprehensive and continuous medical care to patients with the goal of obtaining maximized health outcomes. 144 Stony Point Rd. Santa Rosa, CA 95401 (707) 521-4545

SONOMA VALLEY COMMUNIT Y HEALTH CENTERS At SVCHC, we want to provide you with comprehensive care for your optimal health. Often patients only see their doctors when care is critical. However, preventive care is available and is your pathway to good health. SVCHC offers many programs, from early childhood exams, annual physicals, and cancer prevention screenings to diabetes management to ensure you have the best health, right now. 19270 Sonoma Hwy. Sonoma, CA 95476 (707) 939-6070 Hanna Boys Center Satellite Campus 17000 Arnold Dr. Sonoma, CA 95476 (707) 939-6070

ST. JOSEPH HEALTH SYSTEM SONOM A COUNT Y COMMUNIT Y HEALTH CLINICS AND PROGRAMS Dental Clinic and Mobile Dental Clinic (707) 547-2221 The mobile dental and fixed site dental clinics work to address a pressing need in our community. The clinics serve children ages 0-16, with a targeted effort on children 0-5, special needs’ patients, and prevention and education for pregnant women via our Mommy and Me program. We provide basic, preventive, emergency and comprehensive dental care with a strong focus on prevention and education. Emergency care is available to all on a first-come, firstserved basis. Mobile Health Clinic (707) 547-4612 The Mobile Health Clinic serves those who don’t have health insurance coverage. Our mission is to provide urgent and episodic care for the most vulnerable in our community, with the goal of treating patients and then referring them to a primary care medical home. House Calls (707) 547-4684 House Calls provides primary care for adults who are homebound for a variety of reasons, including chronic illness, mobility issues, mental health and cognitive disorders.

WEST COUNT Y HEALTH CENTERS West County Health Centers, Inc. is a private, nonprofit Federally Qualified Health Center, receiving Section 330 grant funding from the federal government to provide quality health services to the whole community, regardless of ability to pay. We strive to provide a medical home for patients, ensuring they experience continuity of care and have a secure place to come for all of their healthcare needs. Forestville Wellness Center (Temporary Address Change) 652 Petaluma Ave., Ste. F Sebastopol, CA 95472 (707) 887-0290 The Forestville Wellness Center’s mission is to educate, support and empower our patients to create behavioral changes in their lives with

the goal to improve their health and well-being. We believe each person’s health is a unique journey. Through collaborative and sustainable partnerships between patients, practitioners of alternative and traditional medicine, and the greater community, we strive to provide a holistic and integrative model of care. Forestville Teen Clinic 6570 1st St. Forestville, CA 95436 (707) 887-0427 Forestville Teen Clinic services include confidential family planning, STD/HIV testing and treatment, pregnancy testing, emergency contraception, free condoms, mental health counseling, peer education and comprehensive sexual health presentations. Payments accepted: Free for patients under age 25 Gravenstein Community Health Centers 652 Petaluma Ave., Ste. H Sebastopol, CA 95472 (707) 823-3166 Occidental Area Health Center 3802 Main St. Occidental, CA 95465 (707) 874-2444 Russian River Health Center 16319 3rd St. Guerneville, CA 95446 (707) 869-2849 Sebastopol Community Health & Dental Center 6800 Palm Ave., Ste. C Sebastopol, CA 95472 (707) 869-2663 Third Street House 16312 3rd St. Guerneville, CA, 95446 (707) 887-0427 West County Health Services Dental Clinic 6800 Palm Ave., Ste. C1 Sebastopol, CA 95472 (707) 869-2663 The Dental Clinic offers a comprehensive dental program with services for adults and children. RRDC accepts Medi-Cal, CMSP, Delta Dental Healthy Families and Premier Access Healthy Families. In addition, we offer a sliding scale discount program for all uninsured patients and/or for services that are not covered by the above programs. We do not accept any private dental insurance. SONOMA HEALTH

MEDICAL ADVISORY BOARD MEMBERS M AN Y TH AN KS to the Sonoma Health Medical Advisory Board

for your ideas, enthusiasm and support for this project.

CHAIR

Allan L. Bernstein, M.D. North Bay Neuroscience Institute Petaluma Health Center Healdsburg District Hospital Sonoma Specialty Hospitals (affiliate)

MEMBERS

Ty Affleck, M.D. Santa Rosa Sports & Family Medicine SPMF Marin, Sonoma HMO Network Sutter Santa Rosa Regional Hospital Providence Santa Rosa Memorial Hospital Meritage Medical Network SRJC Team Physician Juline N. Caraballo, Allergist-Clinical Immunologist FamilyCare Allergy and Asthma Santa Rosa, Petaluma, San Rafael/Marin James C. DeVore, M.D. Family Medicine Providence Medical Group Santa Rosa

Gail Dubinsky, M.D. Orthopedic Medicine Sebastopol

SONOMA HEALTH

Rachel Friedman, M.D. Family Medicine Kaiser Permanente Santa Rosa

Gary Green, M.D., FIDSA Infectious diseases Sutter Medical Group of the Redwoods Sutter Santa Rosa Regional Medical Center J. Michael Gospe, M.D. (retired) Gastroenterology Author and Director of Medical Ethics Santa Rosa Memorial Hospital Stephen Halpern, M.D. Cardiology NorthBay Clinical Research Providence Cardiology Santa Rosa Stanley Jacobs B.Sc., M.Sc., M.D., F.R.C.S. (C) The Jacobs Center for Cosmetic Surgery Healdsburg, San Francisco Santa Rosa Memorial Hospital and Sutter Health, Santa Rosa Stacey Marie Kerr, M.D. Family Medicine Freelance physician, author, educator Santa Rosa

A. Michael Lustberg, M.D. Gastroenterology Sutter Medical Group of the Redwoods Santa Rosa Kriegh Moulton, M.D. (retired) Clinical Cardiac Electrophysiology Sutter Santa Rosa Regional Hospital Prairie Heart Institute, Springfield, Ill. Maria M. Petrick, M.D., FACAAI-FAAAAI Allergist-Clinical Immunologist FamilyCare Allergy and Asthma Santa Rosa, Petaluma, San Rafael/Marin Richard E. Powers, M.D. (retired) Family Practice and Geriatrics Solo practitioner, Sebastopol Jesse Rael, M.D. Radiology Sutter Santa Rosa

Brien A. Seeley M.D. Ophthalmology Providence Health Northern California Santa Rosa

Emily Shaw, M.D. Certified Life Coach Family Physician Sutter Medical Group of the Redwoods, Santa Rosa Mark Sloan, M.D., M.P.H. Director of Pediatrics Sutter Santa Rosa Family Medicine Residency University of California, San Francisco (affiliate) Jeffrey Sugarman M.D., Ph.D. Redwood Family Dermatology University of California, San Francisco Victor W. Wong, M.D. Cosmetic and Reconstructive Surgery Kaiser Permanente Santa Rosa

All board members are also members of Sonoma County Medical Association (SCMA). Effective Jan. 1, 2022, the Sonoma County Medical Association and the Mendocino-Lake County Medical Society will merge to become the Sonoma-Mendocino-Lake Medical Association (SMLMA) — greatly expanding membership services and resources for the tri-county area. Contact SMLMA: 707-525-4375, scma@scma.org, www.scma.org

COME JOIN THE FUN AT COGIR SENIOR LIVING! At Cogir Senior Living, we realize that keeping an active mind and body is essential to a happy life. That is why we offer fun and engaging activities for every individual living in our communities. Along with 3 Chef-prepared meals, housekeeping, transportation, and independent, assisted and memory care services Cogir Senior Living has something for everyone.

Now offering onsite occupational and physical therapy through our partner ONR.

Call or stop by for a tour and see what Cogir can do for you today!

91 Napa Road Sonoma, CA 95476

4855 Snyder Lane Rohnert Park, CA 94928

111 Merrydale Road San Rafael, CA 94903

800 Oregon Street Sonoma, CA 95476

License # 496803736

License # 496803807

License # 216803735

License # 496803812

(707) 939-1500

(707) 585-7878

(415) 472-6530

(707) 996-7101 CogirSeniorLiving.com

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Sonoma Health & Wellness 2021

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