2013-Jan/Feb - SSV Medicine by Sierra Sacramento Valley Medical Society

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MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

January/February 2013

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EDITOR’S MESSAGE What Docs Do Best

Who Said That?

Nathan Hitzeman, MD

Memorable Physical Exam Findings

SSVMS Member Elected CMA President

Aileen Wetzel, Executive Director

The Quest for the Perfect Heart Valve

SSVMS 2013 Committees

Paul Kelly, MD

2012 HOD Provides Ammunition for CMA Staff

2013 Education Series

Richard N. Gray, Jr., MD

Dependent on Opiates and Pregnant: Now What?

First Rain

John McCarthy, MD

John Loofbourow, MD

What is it?

New Year’s Resolutions

Ann Gerhardt, MD

SSVMS Election Results

History of Gastrointestinal Endoscopy

Board Briefs

George Meyer, MD

Meet the Applicants

Classified Ads

All articles are copyrighted for publication in this magazine and on the Society’s website. Contact the medical society for permission to reprint.

Visit Our Medical History Museum 5380 Elvas Ave. Sacramento Open free to the public 9 am–4 pm M–F, except holidays.

SSV Medicine is online at www.ssvms.org/Publications/SSVMedicine.aspx The cover image for this issue shows the latest evolution of heart valves that has occurred over the past 60 years. Pictured is the Edwards SAPIEN aortic valve, introduced into the aortic annulus via a catheter in the groin or trans-apically through a small intercostal incision. The picture shows the valve ready for deployment as if it were in the aortic annulus. This valve is used in selected patients who otherwise would have to forgo traditional surgery as too high (greater than eight percent) an operative risk. The SAPIEN aortic valve is approved for use in 10 Northern California hospitals, including three in Sacramento County. This valve comes in two sizes, 23 and 26mm (the diameter of the valve when installed) and has been used in approximately 30 patients each at Sutter Memorial, UC Davis and Mercy with excellent results. The cost is $30,000.00 for the valve. Dr. Paul Kelly’s article on page 18, “The Quest for the Perfect Heart Valve,” outlines the important contributions of cardiologists and thoracic surgeons in Sacramento.

We welcome articles from our readers by email, facsimile or mail to the Editorial Committee at the address below. Authors will be able to review articles before publication. Letters may be published in a future issue; send emails to e.LetterSSV Medicine@gmail. com or to the author.

January/February 2013

Volume 64/Number 1 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org

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MEDICINE Sierra Sacramento Valley Medicine, the official journal of the Sierra Sacramento Valley Medical Society, is a forum for discussion and debate of news, official policy and diverse opinions about professional practice issues and ideas, as well as information about members’ personal interests. 2013 Officers & Board of Directors David Herbert, MD President Jose Arevalo, MD, President-Elect Alicia Abels, MD, Immediate Past President District 1 Robert Kahle, MD District 2 Ann Gerhardt, MD Lorenzo Rossaro, MD Christian Serdahl, MD District 3 Bhaskara Reddy, MD District 4 Russell Jacoby, MD

District 5 Paul Akins, MD John Belko, MD Jason Bynum, MD Steven Kelly-Reif, MD Kristen Robinson, MD District 6 Tom Ormiston, MD

2013 CMA Delegation Delegates District 1 Robert Kahle, MD District 2 Lydia Wytrzes, MD District 3 Katherine Gillogley, MD District 4 Earl Washburn, MD District 5 Elisabeth Mathew, MD District 6 Marcia Gollober, MD At-Large Alicia Abels, MD Jose Arevalo, MD Richard Gray, MD David Herbert, MD Richard Jones, MD Charles McDonnell, MD Janet O’Brien, MD Anthony Russell, MD Kuldip Sandhu, MD Boone Seto, MD

District 1 Reinhart Hilzinger, MD District 2 Margaret Parsons, MD District 3 Ruenell Adams, MD District 4 Russell Jacoby, MD District 5 Robert Madrigal, MD District 6 Karen Hopp, MD At-Large Jason Bynum, MD John Belko, MD Jeffrey Cragun, MD Maynard Johnston, MD Olivia Kasirye, MD Rajan Merchant, MD Richard Pan, MD, Assemblyman Vacant Vacant Vacant

CMA Trustees 11th District Barbara Arnold, MD Douglas Brosnan, MD Solo/Small Group Practice Forum Lee Snook, MD CMA President Paul Phinney, MD CMA President-Elect Richard Thorp, MD AMA Delegation Barbara Arnold, MD, Delegate Richard Thorp, MD, Alternate Editorial Committee Nate Hitzeman, MD, Editor/Chair Ann Gerhardt, MD, Vice Chair John Belko, MD George Meyer, MD Sean Deane, MD John Ostrich, MD Sandra Hand, MD Gerald Rogan, MD Albert Kahane, MD Chris Swanson, MD Robert LaPerriere, MD Lee Welter, MD John Loofbourow, MD Gilbert Wright, MD John McCarthy, MD Adam Dougherty, MS III Executive Director Managing Editor Webmaster Graphic Design

Aileen Wetzel Nan Nichols Crussell Melissa Darling Planet Kelly

Our Hours Are Changing, But Not Our Commitment. For over 30 years, the physicians at The Doctors Center have always been available to assist you throughout the year. We’re not competing for your patients’ business – we’re here to help you meet the demands of those unscheduled appointments and patient emergencies – 12 hours a day, 7 days a week. When your schedule becomes impossible to meet, send those patients requiring basic medical attention to us. We treat acute minor illness and injury cases including flu, eye injuries, lacerations, fractures, sore throats and pneumonia. We take care of your patients’ immediate needs and refer them back to you for on-going care. Prior to November 1, The Doctors Center is open from 8 a.m. to 10 p.m. Lab tests, x-rays and ECG’s are performed on site to allow immediate diagnosis. No appointment is ever needed. We accept assignment for Medicare and are providers for multiple HMO’s and PPO’s.

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JOANNE BERKOWITZ, M.D. Board certified in Internal Medicine and Emergency Medicine DONALD S. BLYTHE, M.D. Board certified in Emergency Medicine ANITA H. BORROWDALE, M.D. Board certified in Emergency Medicine KIMETTE M. MARTA, M.D. Board certified in Family Medicine

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Advertising rates and information sent upon request. Acceptance of advertising in Sierra Sacramento Valley Medicine in no way constitutes approval or endorsement by the Sierra Sacramento Valley Medical Society of products or services advertised. Sierra Sacramento Valley Medicine and the Sierra Sacramento Valley Medical Society reserve the right to reject any advertising. Opinions expressed by authors are their own, and not necessarily those of Sierra Sacramento Valley Medicine or the Sierra Sacramento Valley Medical Society. Sierra Sacramento Valley Medicine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. Not responsible for unsolicited manuscripts. ©2012 Sierra Sacramento Valley Medical Society Sierra Sacramento Valley Medicine (ISSN 0886 2826) is published bi-monthly by the Sierra Sacramento Valley Medical Society, 5380 Elvas Ave., Sacramento, CA 95819. Subscriptions are $26.00 per year. Periodicals postage paid at Sacramento, CA and additional mailing offices. Correspondence should be addressed to Sierra Sacramento Valley Medicine, 5380 Elvas Ave., Sacramento, CA 95819-2396. Telephone (916) 452-2671. Postmaster: Send address changes to Sierra Sacramento Valley Medicine, 5380 Elvas Ave., Sacramento, CA 95819-2396.

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Editor’s Message

What Docs Do Best By Nathan Hitzeman, MD THIS ISSUE HIGHLIGHTS the wonderful “pickups” and discoveries made by our members in their medical practices. This is juxtaposed with the incredible technological advances represented on our cover. Physicians have a unique and privileged view into the workings of the human body and mind. Until the last few centuries, physicians’ tools included the basic senses such as listening, observation, smell, touch, and sometimes taste. Despite a great expansion of our diagnostic tools, I often marvel at how appreciative patients are for a thorough physical exam, or a remark by us on a physical finding that ended up being of some significance. Imagine your respect for the mechanic who hears a telltale rattle and informs you of exactly which belt is going out on your car. Or the fisherman who takes you out to deep sea fish and somehow finds the school of fish in what looks to you like a monotony of glistening ripples. The old school pizza maker who spins the dough with ease and knows just when to stop. There is a sixth sense that comes to us, too, in medicine nurtured by experience, thoughtfulness and curiosity. When many in our craft refer to the “art of medicine,” I believe that they are speaking to this investigative and intuitive nature. Think of how much you can tell about a patient with that first eye contact, the grip of their handshake, the tone of their voice, their facial expression, their dress and level of hygiene. Is that a slight facial droop? Was that alcohol I smelled on their breath? Do I perceive a postural tremor? As you share pleasantries or listen to the first few sentences of their story, how quickly you can pick up on despair or elation, hope or hopelessness, fear or strength, deference or manipulation, expectations and beliefs. There are always clues. Do they shift uncomfortably

as they discuss their back pain? What do I think of the depth and cadence of this smoker’s breathing as he talks about his recent vacation? Did this lady’s shoulders just tense up as her husband spoke over her? Did little Andrew just give me an allergic salute? You move on to feel the sandpaper texture of their keratoses, palpate the regularity of their pulse, assess the crepitis in their joints. A moment’s touch may determine whether you scan that concerning mass or dismiss it as fibrocystic breast tissue. Was there a nodule on the prostate? Was that uterus a bit larger than expected on this lady with irregular periods? We look in orifices, nooks and crannies, cracks and crevices. Sometimes we are surprised by smells and fluids and discolorations that alert us to some urgency. We may find an old gang tattoo that opens up a new conversation. Sometimes we find things we do not want to find, like the green frothy discharge on a married woman who saw me hoping she was pregnant, and then found out she only had trichomoniasis. The findings are not always easy to deal with, and there are some stones I wish, at times, were left unturned, but it is our job to examine, and examine well. It is what we do best. It is our art. It is the essence of being a good physician. hitzemn@sutterhealth.org

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

Annual Meeting Photos Due to our earlier publication schedule, photos from the Sierra Sacramento Valley Medical Society and Alliance Annual Awards and Installation Dinner that have in the past been published in our January/February issue, will now appear in our March/ April issue instead. The meeting this year is slated for 6:00 PM January 17, 2013 at the Hyatt Regency Hotel in Sacramento.

January/February 2013

Executive Director’s Message

SSVMS Member Elected CMA President By Aileen Wetzel, Executive Director SACRAMENTO PEDIATRICIAN and Sierra Sacramento Valley Medical Society (SSVMS) member, Paul R. Phinney, MD, was installed as the 145th President of the California Medical Association (CMA) during CMA’s Annual House of Delegates gathering held in Sacramento October 13-15. Dr. Phinney is a pediatrician at Kaiser Permanente and has been a member of SSVMS since 1988. He has served in leadership roles, including President of SSVMS, CMA Presidentelect, and Chair of the CMA Board of Trustees, and he previously served on the CMA Council

on Legislation and the CMA Political Action Committee (CALPAC) Board of Directors. Addressing the group of nearly 1,000 physicians, residents, medical students and others, Dr. Phinney challenged his colleagues to lead change rather than succumb to the “default future.”

At left, Paul Phinney, MD. At right, Suzanne Phinney shares in the celebration. CMA photos by David Flatter.

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“We owe it to the public and to our profession to be leaders in health care reform – to create a better future that we help invent,” he said to the crowd. “We live in turbulent and uncertain times that very likely will produce the most rapid changes in the delivery of health care that the nation has seen in decades, and I look forward to tackling those challenges head-on in my term as president.“ Speaking to his goals for the next year, Dr. Phinney acknowledged the next generation of students entering medicine. “Mentorship deserves our attention, and will be an area of my focus over the next year,” he said. “A healthy future requires up-front investment.” Supporting Dr. Phinney’s goal of encouraging physiciansin-training to become involved in organized medicine and to help shape the future of medicine in California, the CMA House of Delegates and the SSVMS Board of Directors voted to eliminate membership dues for residents and fellows, beginning with the 2013 membership year. Residents and fellows can apply for their free membership at www.ssvms. org/Membership/JoinNow/ResidentApplication.aspx. Dr. Phinney’s complete address to the delegates can be watched on CMA’s YouTube channel, www.youtube.com/cmaphysicians. Congratulations to Dr. Phinney! awetzel@ssvms.org

SSVMS 2013 Committees Below are appointments by the Board of Directors for this year:

CHILD AND ADOLESCENT HEALTH SERVICES Reappointments: Drs. Mary Jess Wilson, Chair; Marcia Britton-Gray, Jason Bynum, Christine Fernando, Maynard Johnston, Robert Meagher, and Patricia Samuelson New Appointment: Dr. Anthony Russell EDITORIAL Reappointments: Drs. Nathan Hitzeman, Editor/Chair; Ann Gerhardt, Vice Chair; Sandra Hand, Albert Kahane, Robert LaPerriere, John Loofbourow, John McCarthy, George Meyer, John Ostrich, Gerald Rogan and Gilbert Wright, Adam Dougherty, MS III and Nan Crussell, Managing Editor New Appointments: Drs. Sean Deane, John Belko, Chris Swanson, and Lee Welter EMERGENCY CARE Reappointments: Drs. J. Douglas Kirk, Chair; John Wood, Vice Chair; David Berman, Michael Carl, Troy Falck, Hernando Garzon, Peter Hull, Kendrick Johnson, Vinh Le, Harold Renollet, R. Steve Tharratt, Marc Walter, Lee Welter, and David Wisner New Appointment: Dr. Seth Thomas HISTORICAL Reappointments: Drs. Robert LaPerriere, Chair, Malcolm Ettin, Christine Fernando, Francine Gallawa, James Hamill, Sandra Hand, Gabor Hertz, Julian Holt, Jack Ostrich, Kent Perryman, F. James Rybka and Irma West New Appointment: Dr. Gail Pirie JUDICIAL Reappointments: Drs. Joanne Berkowitz, Barbara Hays, and Boone Seto New Appointments: Drs. Ralph Koldinger and Anthony Russell MEDICAL REVIEW AND ADVISORY Reappointments: Drs. Howard Slyter, Chair; Joanne Berkowitz, Vice Chair; Alicia Abels, Denny Anspach, Jose

Arevalo, Richard Axelrod, Mark Chang, Satya Chatterjee, George Chiu, Jose Cueto, Douglas Enoch, Ronald Foltz, Kenneth Furukawa, Richard Gray, Kern Guppy, Ruth Haskins, Edward Hearn, Reinhardt Hilzinger, Stephen Hiuga, Donald Hopkins, Maynard Johnston, Marvin Kamras, Thomas Kaniff, Abdul Khaleq, Michael Klein, Charles Kuehner, Mylon Marshall, George Meyer, Gail Pirie, Kristen Robinson, Linda Schaffer, James Sehr, Boone Seto, and Gerald Simon New Appointments: Drs. Gregory Blair, Peter Carruth, Scarlet La Rue, Elisabeth Mathew, Conrad Pappas, Charles Perry, and Humberto Temporini PROFESSIONAL CONDUCT AND ETHICS Reappointments: Drs. Joanne Berkowitz, Chair, Frank Apgar, Mark Chang, George Chiu, Douglas Enoch, Malcolm Ettin, Jon Finkler, Richard Gray, James Hamill, Barbara Hays, Edward Hearn, Richard Jones, John Kasch, Paul Kelly, Ralph Koldinger, Charles Kuehner, Harold Renollet, Linda Schaffer, and James Sehr PUBLIC AND ENVIRONMENTAL HEALTH Reappointments: Drs. Donald Lyman, Chair; Regan Asher, Clinton Collins, Anthony DeRiggi, Christine Fernando, Albert Kahane, Olivia Kasirye, Robert LaPerriere, Stephen McCurdy, Robert Meagher and Richard Sun New Appointments: Drs. Ruenell Adams, Denette Dengler, Caroline Peck, and Anthony Russell SCHOLARSHIP AND AWARDS Reappointments: Drs. Margaret Parsons, Chair, Ruenell Adams, Ray Fitch, Francine Gallawa, Charles Hammel, Paul Kelly, Mark Levy, Travis Miller, Jack Ostrich and Patricia Samuelson New Appointments: Drs. Sean Deane, James Sehr and Chris Swanson WELLNESS COMMITTEE Reappointments: Drs. Michael Parr, Chair, Lee Snook, and Captane Thomson

January/February 2013

2012 HOD Provides Ammunition for CMA Staff By Richard N. Gray, Jr., MD

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

THE 2012 CMA HOUSE OF DELEGATES (HOD) again provided an amazing forum in which consensus was developed on multiple subjects. Missing this year were the hotlycontested, button-pushing, dramatic issues that have sometimes marked the proceedings. However, that does not lessen the importance of the policy that was given to the CMA staff to use as they represent California physicians and patients to the state legislature, officials, and others. That most of the more liberal policies have already been introduced left little to surprise this more conservative writer. Regardless, though we have yet to cross that ethical line in the sand to support physician-assisted suicide, we did officially recognize that denying civil marriage contributes to poorer health outcomes for gay and lesbian individuals, couples and their families. The reference committee initially removed this wording from the resolution on “health care quality for same sex households,” to avoid this social issue, but it was reintroduced on the floor of the house and approved by the majority of delegates. Other policies enacted by the HOD this year included the following: • Since we have already requested the decriminalization of marijuana use, we now asked that CMA request that the California Governor petition the federal government to reschedule marijuana to facilitate medical research. • That CMA support efforts to increase the number of schools that voluntarily make epinephrine auto-injectors available for treatment of anaphylactic reaction.

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• That CMA support a comprehensive approach to increasing awareness of and education on traumatic brain injury among those participating in at-risk sports, including activity-appropriate warnings and classroom curricula. • Here is one that walked the careful line between either supporting or requesting repeal of the Affordable Care Act: That CMA supports amending the Affordable Care Act to address issues of concern to the practice of medicine. • That CMA seek the right of patients to collect from Medicare for covered services provided by unenrolled or disenrolled physicians. • That CMA add medical students, residents and fellows to the member search function on the CMA members-only section of the CMA website. • That CMA support physicians in disputes with health care entities regarding the timely delivery of medically-necessary care to patients where no broader overriding patient and physician interests exist (e.g., MICRA); and that CMA oppose the infringement of the administrative policies of health care entities upon a physician’s reasonable medical judgment. • That CMA support physician-led, evidence-based, efforts to improve appropriate utilization of medical services; and that CMA educate member physicians, hospitals, health care leaders and patients about the need for physician-led, evidence-based, efforts to improve appropriate utilization of medical services. • That CMA support federal legislation that makes tactics delaying conversion of

medications to generic status, also known as “pay for delay,” illegal in the United States. • That CMA condemn financial incentives to pharmacists for pursuing prescription changes; and that CMA consider legislation to make it illegal for pharmacists to receive financial incentives to substitute a physician’s prescription. • That CMA advocate vigorously against the inappropriate escalation and incidence of physician prosecutions under criminal statutes. • That CMA support legislation requiring all California professional liability carriers to continue to provide free tail liability coverage to retired physicians who elect to provide patient care to non-profit community and similar indigent care clinics, so long as any such care carries with it adequate professional liability coverage. • That CMA support implementation by hospitals of emergency department “full capacity” protocols. • That CMA eliminate mandatory dues and assessments for medical student, resident, and fellow active members and request component medical societies to take similar action to eliminate local dues. And last, but not least: • That CMA support that medical procedures may be performed by non-physicians only when the individual practitioners have the requisite training and experience and there is appropriate physician supervision. It may seem unnecessary to take positions on some of these issues, which seem only obvious, but our society has yet to level the playing field, requiring physicians to fight uphill battles against pharmaceutical companies, insurers, and regulators. Hopefully, this policy will help our lobbyists fight some of these battles for us. rgraymd@comcast.net

First Rain By John Loofbourow, MD Rooftop rain wakes me from dreams. A thirsty land is suckled by the storm. An open window inhales sweet breath of Winter snow and silver Summer streams. I rush to save sun faded cushions that fear the stain of dank black mold, and return again to indoor light, chilled by October’s sudden cold. Our little dog peers out from her lair, moves only her eyes in pet disdain of ill-timed forays into cold wet air so long before dawn’s duties call. And the voice of Time denies us sleep: “We come; we go; like everything we know. We dreaming dreamers dream a universe, a multiverse, among the galaxies that blow in and out of time and place and space. “We’re conjoined twins, you and I. Born hungry, dumb, and torpid. We learn and grow and become, but never see the years run by.” What are we now, old man? “Each instant is forever at our birth; Then years shrink and fade like proven truth, and now we dream at the edge of eternity.” “Nonsense!” I retort, “Enough! Sleep, old liar; be still!” Again my little dog barks outraged that I talk while no one speaks to me. Silly looking, but complex and wise, She turns away with a poodle sigh, Head down, with tight closed eyes, Shuts out the noise of rain, and time, and humankind. john@loofbourow.com

January/February 2013

New Year’s Resolutions Those with words like “more” or “less” are easier to achieve!

By Ann Gerhardt, MD

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

NEW YEAR’S RESOLUTIONS get a bad rap. They mostly assure that whatever was resolved is guaranteed to not happen. As the most egregious example, each November and December millions of Americans vow to lose their extra weight after January 1, to justify the two-month binge. Come January 1, good intentions pick a diet and plan exercise. By February, failure and remorse prevail. I think the only food-related resolution I ever made was to eat less whipped cream. That became easy many years later when I tested positive for dairy allergy and its elimination produced my very first blood count with normal eosinophils. My exercise-related resolutions usually consisted of setting completely unattainable race times, so I know the agony of self-flagellation over an unmet resolution. Round about age 45, I had an epiphany. If resolutions contained a word like “more” or “less,” they would be easier to achieve. All I would have to do to be on track with a resolution would be to do the resolution one more (or less) time. For example, “I will swear less.” (I’m still working on that one. There’s nothing that says a resolution has a one-year expiration date.) Here are some other resolutions I’ve tried: I will smile more; flashing unjustified, random, subtle or wide smiles at people I do and don’t know. 1) Some recipients might wonder if their make-up is on wrong or what the joke is. 2) Most people smile back. 3) Mostly, this resolution makes me feel better.

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I will write more pen-to-paper thank-you notes (not the email kind). 1) Maurice Gloster, MD, was so surprised at my thank you note for his help with a transplant patient protocol, that he wrote one back, to thank me for the thank you. 2) It supports the stationery companies. 3) Mostly, I carry a lot of guilt, and thank you notes alleviate some of it. I will pay my bills late less often. 1) This became much easier when, after years of medical training and being a broke, single mom, I finally started to make some money. 2) When my son left for college and I had more time, it became even more attainable. 3) Mostly, this resolution reduces stress. I will treat my patients more like the way I would want to be treated (The Golden Patient Rule). 1) This one started in the middle of medical school in response to bad experiences: The ER nurse who wouldn’t give me the epi injection for an allergic reaction because my blood pressure was high, as saliva dripped from my mouth, I could no longer talk, and the stridor and wheeze were audible across the room. The hospital janitor who barged into my bathroom to empty the trash as I sponge-bathed my very-pregnant, naked torso. The world-renowned pediatrician who failed to do any lab tests on my newborn, failure-to-thrive son, because he “knew” that my returning to the research lab and classes two weeks after the birth was the cause. Upon hospital admission, the intern

made the diagnosis of adrenal insufficiency, saving my son from a hyperkalemic (K+ of 8.4 meq/l) death. 2) This one gets reinforced, either when I screw up and miss making a diagnosis or fail to respond to my patient’s emotional needs, or when a physician doesn’t follow the rule with me (remember the raccoonworm-in-the-eye story in the Jan-Feb 2010 issue of SSV Medicine?) 3) Mostly, my patients like this resolution. I will eat more vegetables. 1) This one became imperative when, as a Clinical Nutrition Fellow, I had to practice what I preach. 2) I learned quickly that the corollary is to wash spinach and sprouts well, to prevent gastroenteritis. 3) Mostly, I’m hoping this resolution will keep me healthy.

This year: I will reduce the size of the piles in my house (elimination is probably impossible). 1) After years of saving unread journals, it’s time to de-pile and read mail and journals as they arrive. 2) Sifting through the old journals yields discoveries that have helped current patients, sort of like deciding to read Harrison’s Textbook of Internal Medicine (that resolution won’t happen any time soon). 3) Mostly, this resolution makes my husband happy. Resolutions are best when they fit our own foibles and frailties, so if you are perfect, you have no reason to resolve anything. But I suspect that you are human, and hope that you are honest. Change is good. Since absolutes are rarely attainable, in my opinion resolutions become more so by adding words like “more” and “less.” algerhardt@sbcglobal.net

January/February 2013

History of Gastrointestinal Endoscopy By George Meyer, MD, FACP, MACG

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

ALTHOUGH RUDOLPH SCHINDLER is credited with developing the first semiflexible gastroscope in 1932, with instrument-maker George Wolf, there were many earlier advances that led to this outcome, all of which occurred in Europe. In 1806, in Germany, Philipp Bozzini developed a light conducting system with mirrors and a candle that allowed him to look into orifices. In 1853, Antonin Desormeaux improved the light source with a kerosene lamp. In 1868, Adolph Kussmaul is credited with the first rigid esophagoscopy, apparently in a sword swallower, using this kerosene lamp apparatus. In 1879, Max Nitze used a cystoscope using a platinum lamp light source to inspect the rectum. In the late 19th century, Johannes von Mikulicz-Radecki was considered the first person to be able to examine the stomach, apparently being able to identify gastric malignancies, as well as the pylorus. Schindler’s gastroscope had a semiflexible distal end that could be angulated up to 34 degrees allowing for easier introduction into the stomach. In the early 20th century, the glass industry was making progress in light transmission through glass fibers. Heinrich Lamm was the first to show this in 1924, apparently sharing this information with Schindler. Further developments led to putting multiple fibers together and learning how to prevent the light from moving between fibers. Basil Hirschowitz and his group, in particular Lawrence Curtiss, developed the first fully flexible fiberoptic endoscope in 1957. The American Cystoscope Company (ACMI)

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developed an upper endoscope whose directions could be managed with a handle, while the Olympus Optical Company developed an endoscope with two dials, one for up and down, and one for right and left. Each scope transmitted light down one set of bundles and received the images from another. There was a channel for the passage of air and water, and another allowing passage of instruments to brush, biopsy, snare, and to guide certain maneuvers such as removing polyps or foreign bodies. The ACMI handle was too cumbersome to use, and other instrument companies developed endoscopes with twin dials instead. Most U.S. endoscope users chose the twin dial scopes, while the U.S. military was forced to buy American – using the ACMI equipment until they dropped out of the competition. More recently, the glass fibers have been replaced by microchips at the tip of the endoscope, allowing endoscopists to have HD pictures of their procedures transmitted through a television receiver. The incidence of gastric cancer was quite high in Japan in the 1950s, so the Olympus Optical Company developed a “gastrocamera” in 1952, which, when placed into the stomach, could take multiple pictures. Relatively untrained personnel could insert the camera, take a series of photographs, and have the photos developed and reviewed by a gastroenterologist. Patients with suspicious photographs would be invited back for full endoscopy and biopsy, as indicated. The first use of endoscopy in Japan is said to have occurred after Professor Kondo personally purchased a Hirschowitz endoscope

in 1960. But by 1963, Japanese endoscope makers had been able to build a fiberoptic endoscope and added the biopsy channel. Since that time, Japanese endoscope makers have led the industry. Several endoscopists were reporting their experience with colonoscopy as early as 1971 or 1972, with Wolff, Shinya and Waye reporting from the U.S., while Williams was busy in the U.K., and Niwa and his colleagues were pioneering colonoscopy in Japan. Originally this procedure was often attempted with two physicians, one pushing and one guiding the scope with the controls, often under fluoroscopy; however, now it is a one-person procedure and usually requires less than 30 minutes. Advances have been made in preparing the patients for their colonoscopy. The preferred preparation is a split dose (half the evening before and half the morning of the procedure) of a polyethylene glycol electrolyte solution for a total of four Liters. One brand is “Go-Lytely” – perhaps an understatement. Endoscopic retrograde cholangiopancreatography (ERCP) was first described in 1970, but the quality of the images was poor. Later that year, Oi, from Japan, wowed the audience at the World Congress of Gastroenterology when he showed his achievements in the biliary and pancreatic ducts. Many gastroenterologists around the world began to perform these procedures, Zimmon in New York, also Geenen in Wisconsin and

Vennes in Minnesota. A mother/daughter scope has been developed that allows the endoscopist to push a small fiberoptic scope through the operating channel of the endoscope to allow direct visualization of the biliary and pancreatic ducts, allowing direct brushing and biopsies of the ductal epithelium. More recently, the enteroscope has been developed that allows direct visualization of the small bowel, either from above, or, if the distal ileum is the desired location, through the rectum. Earlier scopes would allow the endoscopist to examine the proximal small bowel only. Recent developments have placed first two balloons, and later, a single balloon at the end of the long scopes to assist the endoscopist in passing the scope through the length of the bowel. A new “gastrocamera” has recently been developed. This capsule, the size of a large medication capsule, contains a camera that takes multiple photographs per second with a battery life of approximately seven hours. During this time, the pill progresses down the GI tract, usually photographing the whole small bowel. It was first used to help gastroenterologists detect occult bleeding in the small bowel to help guide therapy. Now it has been used to find abnormal mucosal changes in such disorders as inflammatory bowel disease. Software has been developed to help the doctor reading the study to more quickly evaluate the seven-hour study.

Several examples of endoscopic tools are on display at the SSV Museum of Medical History.

geowmeyer1@earthlink.net Reference “Gastroenterological Endoscopy,” Meinhard Classen, et al, Editors, 2010 Thieme Medical Publishers

January/February 2013

Who Said That? Each quote below is ascribed to one of the listed writers. Match the author’s name with the quotes. Hint: an asterisk* identifies the author as a physician.

* Anton Chekhov

* John Keats

* John Donne

* William Osler

* Oliver Wendell Holmes

Mark Twain

* Somerset Maugham

* Nicolai Copernicus

* Rabelais

Benjamin Franklin

* Michael Crichton

Karl Marx

Ralph Waldo Emerson

* Paracelsus

1. “The fist duty of a physician is to teach the masses not to take medicine.” 2. “A chief event of life is the day in which we have encountered a mind that startled us.” 3. “Man is a noisome bacillus whom Our Heavenly Father created because he was disappointed in the monkey.” 4. “I observe the physician with the same diligence as the disease.” 5. “What I call a good patient is one who, having found a good physician, sticks to him till he dies.” 6. “Beware of the young doctor, and the old barber.” 7. “Doctors are just the same as lawyers; the only difference is that lawyers merely rob you, whereas doctors rob you and kill you, too.” 8. “Near the sun is the center of the universe.” 9. “Any nation that thinks more of its ease and comfort than its freedom will soon lose its freedom; and the ironical thing about it is that it will lose its ease and comfort too.” 10. “The human body is vapor materialized by sunshine mixed with the life of the stars.” 11. “Science without conscience is the death of the soul.” 12. “Philosophy will clip an angel’s wings.” 13. “The work of science has nothing whatever to do with consensus. Consensus is the business of politics.” 14. “The production of too many useless things results in too many useless people.”

ANSWERS: 1. *William Osler; 2. Ralph Waldo Emerson; 3. Mark Twain; 4. *John Donne; 5. *Oliver Wendell Holmes; 6. Benjamin Franklin; 7. *Anton Chekhov; 8. *Nicolai Copernicus; 9. *Somerset Maugham; 10. *Paracelsus; 11. *Rabelais; 12. *John Keats; 13. *Michael Crichton; 14. Karl Marx

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Memorable Physical Exam Findings BACKGROUND: There has been recent concern about technology replacing the basic physical examination and laying on of hands. Before advanced scans and diagnostics, Sir William Osler once said, “The whole art of medicine is in observation.” Stanford School of Medicine and writer/internist Dr. Abraham Verghese have published on the web teaching videos for 25 key physical exam techniques at http:// stanfordmedicine25.stanford.edu. We asked our members to share with us their most memorable (and perhaps unexpected) physical examination findings, whether it be a fungating mass, trench foot, infestation, some kind of “megaly,” conjoined twins, or little green men! I was called to see a patient in the ED with hypotension. On exam, his whole body was vibrating − he had an aorto-caval fistula. He did well with surgery. −Jack Kashtan, MD

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

My most memorable physical finding was many summers ago on a very nice lady who presented for evaluation of a foreign body sensation laterally in her right eye. She had been outdoors on her patio the afternoon before and felt something fly into her right eye. When I examined her, I found several, very small, fly larvae crawling on her conjunctiva! Needless to say, she was very happy to have them extricated, which completely resolved her foreign body sensation. −Thomas Kidwell, MD When I was a fairly new plastic surgeon in the area, I was called to the ER at American River Hospital to see a lady who had been brought in by ambulance. Her husband had called them because she had been in the bathroom sitting on the toilet for about three

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days and he could not get her up! The nurses were smiling and smirking when I got there, and led me to her. Upon going behind the curtain, I observed the patient lying on her stomach under a sheet. Further examination demonstrated an elderly woman with a toilet seat firmly attached to her buttocks! Her skin had ulcerated through from the pressure of sitting there for the three days and the seat was firmly fused to her subcutaneous tissue. The ambulance crew had to remove the toilet seat to allow for them to get her into the ambulance, because it was too painful for her when they tried to pick her up. It took several trips to the OR to get her healed and home again. The first procedure was to remove the toilet seat under general anesthesia and to debride the “horseshoe-shaped” wound, and then many more trips for grafting and skin flaps. I shall never forget this dear lady and her husband. −Jon Finkler, MD I had a recent discussion with a nurse who works the ED at UCD. She described to me two surprise findings in severely obese patients in the ED. Both had large pannuses [large rolls of fat]; in one the pannus was hiding a Hostess Twinkie with fungal growth in the Twinkie (she was hiding it from her husband and forgot it was there); the other revealed a TV remote underneath the pannus :) −George Meyer, MD I was examining a somewhat heavyset woman for a job as a nursing home care attendant, and her uterus was at the level of the umbilicus. I inquired if she was pregnant and she said, “No.” A pregnancy test said otherwise, and when I asked her if she had felt movement, she told me, “Yeah, but I just didn’t think

nothin’ of it.” −Joanne Berkowitz, MD Myopia following Hyperbaric Chamber Oxygen Therapy. Fortunately, this is usually temporary. −Philip Levy, MD I was a resident. A 30-something blue collar guy came in to the ED and said he couldn’t walk straight. It was the first really positive Rhomberg I had seen. I was pretty sure he was faking it. He wasn’t; brain metastasis from lung cancer. I will always remember that walk, always. −Thomas Atkins, MD Last patient of the day, a Friday. Young woman concerned about some problems with balance. Otherwise a history of excellent health. Examining the head, I noticed a faint nystagmus (rapid twitching back and forth of the eyes). The real surprise was when she opened her mouth. There was a rhythmic beating (relaxation and contraction of the soft palate). Never saw before or since. Later learned some refer to it as a palatine seizure. The cause turned out to be an arteriovenous malformation (AVM) in the midbrain. Lesion was not surgically correctable nor did it seem to change with radiation. She went on to have a productive life. Despite risk of rupture of the AVM, she had a child. Balance was always an issue, but I believe she is still alive, with soft palate still beating. −Eugene Ogrod, II, MD As a ski patrol member and instructor in Outdoor Emergency Care a few years ago, I was teaching the signs and symptoms of a basal skull fracture. On a half day at Homewood, I was about to leave the mountain, when the family of a missing snowboarder informed us he was still missing. I responded to our terrain park and found a young snowboarder sitting upside down in a tree well next to a jump. He stated his name, that he was at Sugar Bowl, and did not know what the day was or what happened (oriented to name only). His examination was totally unremarkable except for a frothy pink exudate from his nose and his disorientation. I correctly diagnosed a basal

skull fracture, ordered helicopter evacuation to Renown Neurosurgery and he, indeed, was found to have epidural bleeding and had two sets of burr holes. He fully recovered. −James Margolis, MD I had a female patient in her late 60s, recently widowed, who was due for an annual health maintenance exam. She told me she didn’t want it. I told her she ought to have it done. She noted she already had a hysterectomy, so didn’t need one. I told her we didn’t need to do a PAP smear, but ought to do the pelvic. She agreed to come in. The speculum exam was unremarkable, but the bimanual exam was different from anything I had ever noted before: Between my fingers and my hand was a strange, ballotable, doughnutshaped, soft mass. I asked her to go empty her bladder; maybe I was being confused. She did, and returned, and I tried again. That strange thing was still there. It turned out to be a leiomyosarcoma of the small intestine. It was a freak find, but I’m so glad I found it. It was resectable, and she was able to live several more years before metastatic lung cancer took her. − Richard N. Gray, Jr., MD

It was a freak find, but I’m so glad I found it.

Early in my gynecology training, I was asked to examine a two-year old female who had a bloody vaginal discharge after every weekend visitation she had with her mother’s ex-husband and his new girlfriend. The mother was concerned about possible abuse. The child was very cooperative, after a dose of chloral hydrate, sitting frog-legged in front of Mom on my exam table. She readily permitted my tiniest speculum for an exam. From the top of her narrow vagina, I extracted a triangular, foam make-up sponge (the kind only used by Dad’s new gal.) Mom said, “What the heck? How did that get in there???” Patient replied, in her tiny high-pitched baby voice, “I hid that in there, Mom.” Problem solved. No further charges of abuse. −Ruth Haskins, MD As a general internist, I did over 3,000 flexible sigmoidocopies and saw a wide variety

January/February 2013

…I was making my way uneventfully up the descending colon when suddenly I was confronted by something looking at back at me.

of abnormalities, but nothing prepared me for the following. During a routine screening flexible sigmoidoscopy, I was making my way uneventfully up the descending colon when suddenly I was confronted by something looking at back at me. The creature swam up to the lens and I nearly dropped the scope! The lens magnifies things so as the critter came up the lens, it looked huge. I thought it might be the Loch Ness Monster. Then it quickly turned around and began heading toward the splenic flexure. For a moment, I was absolutely spellbound and mesmerized by the incredibly beautiful, sinuous and elegant movement it displayed as it swam over the rugae. Then it disappeared from sight. I stopped, waited a moment, and did a circumduction motion when suddenly the creature re-appeared from within a diverticulum where it had attempted to hide. It resumed its proximal escape route, and now I was determined to catch it. The chase was on! I followed the creature to the splenic flexure and finally, with only a few cm of scope left, I caught it with the suction and withdrew the scope with the creature captured. I sent it off to the lab and confirmed that is was enterobius vermicularis, the “pinworm.” I had the very rare opportunity to observe the parasite in vivo, something most gastroenterologists have never seen. Even more exciting, I directly observed its incredibly beautiful motion as it swam away from me. You simply have to see it to believe it. −Michael Patmas, MD About 1976, a 40-ish Asian male patient came to me for an establishing full exam. He was found to be in excellent health, a little neurotic, and a daily exerciser. He was seen yearly for a full exam, at his request. In the early 1980s, I found hepatomegaly (four cm below the costal margin) and splenomegaly (two cm below the costal margin). A CT of the abdomen read out as “carcinoma” of liver and spleen. I scheduled myself to do his liver biopsy, but I remained hesitant because he felt well and his liver, now grossly enlarged, was warm to very warm by

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palpation. Two days before his scheduled liver biopsy, I asked another radiologist to review the CT scan and it came back as “hepatic and splenic hemangioma.” LFT’s were normal. A liver biopsy would likely have killed him. When I left practice in 1994, he remained fit now with his liver below his umbilicus. (The initial CT reading was referred for peer review). −Robert Forster, MD The most memorable physical finding in my experience was the case of a former Kings’ basketball player. Shortly after leaving the basketball arena, he was broadsided by a car speeding through a stop sign. He was in his open car without a seat belt and was thrown 100 feet into a drainage ditch. When brought into the UC Davis Emergency room, he was in severe respiratory distress and was intubated and positive pressure ventilation instituted. He immediately blew up like a literal Michelin man. This led to the recognition that he had a bronchial rupture, and he was taken to the OR where a complete severance of his left main stem bronchus was repaired. He had numerous other injuries including broken ribs and a damaged shoulder, but he made an uneventful recovery and was able to play pro basketball for another year or two before retiring. −Bill Blaisdell, MD Provocative test with a can of Coke. A 55-year-old male came into the ED complaining of syncope. He felt fine now. His exam and cardiac monitoring was normal. I asked what he was doing when he passed out. He said he was drinking a Coke. So I went to the vending machine and bought him a Coke. Shortly after he drank it, he went into V-tach for a few seconds. I called the cardiologist. Cath findings showed 99 percent narrowing of a coronary artery, which was treated. The incremental cost of the diagnostic test, a can of Coke, was fifty cents. Here is one more. A 35-year-old male presented with a paronychia of the thumbnail to my urgent care one evening. Over the past five days, he had been treated elsewhere twice, first with Augmentin, followed in two days by

removal of the side of the nail and a change to Keflex. He stated his thumb was no better. Exam showed redness, swelling, and tenderness over the medial left thumb distal phalanx without signs suggesting a felon. No red streaks or abnormal epitrochlear node. No history of diabetes. I diagnosed “compromized host” and sent him to the lab for a stat CBC. The CBC showed about 60,000 white count with 80 percent blasts. He was immediately referred to a hematologist/oncologist. −Gerald N. Rogan, MD There are many that were unusual, like the black retinal spots of CMV in a transplant patient, but the one that saved a patient’s life was the new, loud blowing murmur, unlike any I had ever heard before. The man had come in to the hospital sick, and suddenly developed tachycardia, shortness of breath and a high lactate level. The Rapid Response Team was starting the sepsis protocol by the time the doctor (me) was called. We did an emergency ECHO, which demonstrated a large, flapping hole in his interventricular septum. At the same time, the underlying MI had boosted the troponin to astronomical levels. He was emergently taken to the OR, which saved his life. Needless to say, the sepsis protocol was stopped. −Ann Gerhardt, MD

a laparotomy for a benign problem. She had no health problems, except heavy smoking. The surgery went well, and she was discharged home on the third post-op day. I had her return to the office at seven days rather than the usual 14 days, due to my concern with her lung function. During that exam, she reported that she had no problems at all. To auscultation, her lungs were clear. Since she was in the office, I decided to check her incision. To my horror, she had a large greenish black flat shiny patch surrounded by erythema and induration. During the time that it took to call the hospital and a general surgeon, and to admit her directly to the OR − less than an hour − that patch had nearly doubled in size. Fortunately she did well. My first and only (so far) case of necrotizing fasciitis. It wasn’t until after that second surgery that she mentioned the strange fact that multiple family members had severe infections after minor injuries; she didn’t consider that significant family history... −Barbara Hays, MD

I saw a young lady who had recently returned from Jamaica with a pruritic rash on her ankle. When I found a red, raised, serpiginous track on her ankle, I called a dermatologist colleague asking him to see my patient with cutaneous larva migrans. His response was something like, “I really doubt it, but I’ll be happy to see her. Send her over to my office.” I was gratified when he called me later that day to confirm my diagnosis. −Mark Blum, MD A young woman in her 30s needed

January/February 2013

The Quest for the Perfect Heart Valve By Paul Kelly, MD, FACS

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

“OPEN HEART” SURGERY BEGAN dramatically on May 6, 1953 when Dr. John Gibbon used his new experimental heart-lung machine to divert blood around a beating and temporarily empty human heart. He quickly repaired a large atrial septal defect and the operation was successful! This signal event was the result of over 30 years of painstaking experiments conducted by Dr. Gibbon and his wife, nurse Mary Gibbon, at the University of Pennsylvania. Within weeks, several other university hospitals throughout the U.S. had developed their own “open heart” programs as the method had been carefully described in research journals for many years. Quickly, Dr. Gibbon’s vision, courage and determination resulted in an international tidal wave of heart surgery that changed the way heart disease was treated forever. Your 12-ounce heart pumps 2,000 gallons of blood through 60,000 miles of blood vessels to 75 trillion cells each day! The valves in our heart keep that blood going in one direction only, and this results in frequent pathology. Early experiments to find valve substitutes refined the following qualities necessary for successful valve replacement: • Biocompatibility • Low valvular gradient • Low thrombogenicity • Durability The first years of open heart surgery had a steep learning curve for both surgeons and their courageous patients. Many of these early surgeries were to modify or correct aortic and mitral valve disease, trying to open narrowed valves or reinforce dilated and leaky valves.

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In a brief time, it was apparent that fixing or repairing diseased aortic or mitral valves was not succeeding. Despite the wealth of knowledge known about valvular heart disease, there was no artificial valve that could function in this early environment. An international effort began to design and build prosthetic heart valves, combining the specialties of engineering, metallurgy, plastics, polymers and inventive surgeons. By the end of the 1950s, there were several commerciallyavailable aortic and mitral valves − most successfully, the Starr-Edwards valves. One of the first successful cardiac valves was designed at the University of Oregon by Dr. Albert Starr and a retired engineer, Lowell Edwards. Mr. Edwards had approached Dr. Starr to help design an “artificial heart.” Dr. Starr suggested that he start first with the design of an aortic valve. Their collaboration resulted in one of the great success stories of our time − the Edwards Lifesciences Laboratories, and Dr. Starr’s professional career as an innovator in cardiac surgery. These early encouraging reports of valve replacement sparked an immediate interest in valve replacement for some of the sickest patients on the planet. Dr. Edward Smeloff’s career in heart surgery began with his training at the University of Pittsburg at the dawn of open heart surgery. Following thoracic surgery training, he was drafted into the Air Force. After discharge, he moved with his family to Sacramento where he pioneered open heart surgery in Northern California. He began by creating in the basement of Sutter Memorial Hospital an animal experimentation lab to train a team of

nurses and doctors, and he initiated the first open heart surgery in Northern California on September 24, 1959. That was 53 years ago.

The ball cage valve era 1964-2012 Back in Sacramento, Dr. Smeloff was quick to use the new Starr valves, and he detected some problems with them – namely thrombus formation on the valve struts, some strut weld fractures, and unacceptably-high gradients in the smaller valve sizes. Dr. Smeloff recruited two bioengineers at California State University, Sacramento, Boris Kaufmann and Trevor Davies, to design and produce the “Smeloff valve” that was manufactured and distributed by Cutter Laboratories. The new Smeloff valve had some significant changes. The cage was milled out of a solid block of titanium (no welds). The cage was open at both ends, minimizing thrombus formation. The ball or “poppet” was seated equatorially in the valve orifice to maximize blood flow with lower orifice gradients. The Smeloff valve had excellent professional and commercial success and has been used in over 200,000 patients throughout the world. There are numerous reports of Smeloff valves lasting over 40 years in vivo. The royalties on the valve were directed to the support and maintenance of the Sutter Memorial Research Lab which continues today to provide experimental surgery facilities for a host of new innovative techniques. However, by the 1970s, the less pleasant aspects of mechanical valves became apparent – noise, thromboembolism, valve gradient, accelerated valve wear or malfunction plus the need for anticoagulation. This led to the design and implementation of disk valves made of pyrolytic carbon.

The tilting disk era – pyrolytic carbon – 1965 In the past 60 years, over 70 types of mechanical and tissue valves have been deployed with varying acceptance, largely based on their safety, reliability and thromboembolism rate. The tilting disk valves all have one thing in common today; they are made from pyrolytic

carbon. This material is pure carbon with a molecular structure similar to diamond. (Its previous utilization had been to clad uranium 235 fuel rods for storage.) Somewhat

January/February 2013

Above is the Smeloff Valve; below is the Starr Edwards Valve.

Above is the Kay-Shiley Valve.

serendipitously, it was found that pyrolytic carbon could be coated with benzylkonium and heparin to provide an anti-thrombogenic surface for this type of valve. A fortuitous partnership between surgeon, Jerome Kay of USC, and engineer Donald Shiley provided the nexus for the first disk valve first used clinically in 1965. Progression of design changes followed, all using pyrolytic carbon. The Carbomedics and St. Jude valves emerged which use much of the same technology. Today, only six mechanical valves remain in clinical use: Starr Edwardâ&#x20AC;&#x2122;s ball valve, the Omni Science, Omnicarbon and Medtronic-Hall tilting disc valves, and the St. Jude and Carbomedic bileaflet valves. All six of these valves are on exhibit at the SSVMS Museum of Medical History.

Cardioplegia and air embolism As more complicated valve replacement and longer operating times were required, the myocardium was relatively unprotected and severe ischemic injury and heart failure became obstacles to extended surgery within the arrested heart. The use of cold (topical ice and cold coronary perfusion) was an early solution. The addition of steroids, Xylocaine, K

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(potassium) and other drugs resulted in a large number of partially-successful methods of heart preservation, and most depended on keeping the myocardium cold (50F). The topic of cardioplegia was center stage at national meetings where CV surgeons discussed multiple solutions for heart protection while the aorta was clamped. By the late 80s, cardioplegia had become reasonably standardized and today it is a routine addition to many types of heart surgery requiring the heart to be arrested. From the very start of heart surgery, and responsible for many deaths, was the unrecognized displacement of blood with ambient air on the left side of the heart while working in the left atrium or ventricle. Initially, it was confusing to remove air from places where it could not be seen or recognized. Much of the time, the air was sequestered in the pulmonary veins where it was difficult to remove without moving the patient on the operating table. Now, much time is spent avoiding letting air into the left heart circulation, and routine air-removing maneuvers are carried out to evacuate any air left behind before the aortic cross clamp is removed and the heart begins to eject blood. Both of these early challenges to successful extended surgery in the heart have been solved so that the length of an operation is less of a determinant of morbidity.

The tissue valve era â&#x20AC;&#x201C; homograft, heterograft and xenografts Mechanical valves had some unacceptable qualities, such as noise and thrombogenicity. This prompted investigation of tissue valve alternatives. The aortic valve with its tri-leaflet valve configuration is the most easily-replicated valve. Many early efforts were masterful surgical achievements of excising the diseased aortic valve and then carefully sewing a cadaver human homograft into the vacant space in the aortic root, or using a cuff of aortic root with the contiguous aortic valve. The procedure had severe limitations that included precise sizing of the valve, availability of several different sizes in reserve, and manpower to do all the extensive harvesting,

preparation, preservation and insertion of the valve. An early solution involved harvesting human cadaver aortic valves, sewing them onto a Dacron/metal stent and preserving them. The subject of preservation, both to reduce antigenicity and to sterilize, resulted in the use of gluteraldehyde as the most ideal substance to achieve both these goals. The decade from 1965-1975 saw various types of tissue valve replacements, many times in the face of active bacterial endocarditis. The results of these trials resulted in the use of gluteraldehyde-treated bovine and porcine pericardium, tailored carefully and mounted with technical skill on frames of Dacron wrapped and attached to a sewing ring. This allowed satisfactory variability in sizes, inventory storage and a familiar technique to facilitate insertion of the mounted pericardial tri-leaflet valve in a variety of clinical situations and valve positions. For example, this valve could be used equally well in the tricuspid, pulmonary, mitral or aortic positions, as well as combined with tubular grafts. A large number of cardiac surgery centers now perform uncomplicated mitral and aortic valve replacement with mortalities of two percent or less, with acceptable prosthesis durability and minimal risk of thromboembolism. These last two challenges in valve surgery remain without a finite solution. Perhaps the most urgent is the development of an oral, longterm anticoagulant that is safer and more easily monitored than Coumadin.

crimped or mounted on a balloon catheter. It is passed via the femoral artery and aorta to and across the diseased aortic valve. There the new valve is expanded, dilating the diseased aortic valve while fixing the new valve in place. More recently, the FDA has approved a catheter that delivers this valve through the apex of the heart through a small intercostal incision. This method is used in patients whose aorta and Iliac arteries are too small or too diseased

Above, is a pericardial heterograft. Below is the Direct Flow Medical Transcatheter Aortic Valve System.

The TAVR era? Riding on the coattails of experienced cardiologists, cardiac surgeons and innovative bioengineers, the concept was developed of a collapsible aortic valve that could be introduced into the aortic root via a slender catheter. The SIMR lab at Sutter Memorial Hospital participated in some of the early research and continues work in this innovative arena. To date, the only FDA-approved TAVR valve is the Edwards SAPIEN aortic valve. This valve is made of bovine pericardium, and folded inside a large stent. The valve is

January/February 2013

Above is the Direct Flow Medical Transcatheter Aortic Valve and below, the Edwards SAPIEN aortic valve.

to accommodate the large femoral delivery sheath. This year, about 30 SAPIEN aortic valves have been implanted with overall excellent results at each of the three Sacramento Heart Surgery Centers: Sutter Memorial, Mercy and UC Davis. It is a testament to the quality of cardiac care in Sacramento that three of the six centers in all of Northern California are in Sacramento. The indications to date are either inoperable or high-risk surgical candidates. However, ongoing research into better delivery devices, as well as ways to lower the risk

of procedural stroke, are likely to move that needle in the future. Technology, innovative engineering and skilled surgical teams have made dramatic changes in the quality and duration of life for patients with cardiac valvular disease. However, the quest for the “perfect” heart valve remains elusive with incomplete solutions for durability and thromboembolism. Sixty years after it all began in Dr. Gibbon’s research laboratory, millions of heart surgeries have been performed with dramatic changes in the way cardiac disease is treated throughout the world. Today, there is increasing pressure and ability to perform many heart surgeries such as coronary bypass and some valve replacement without the use of the heart lung machine. It has been a privilege to live through this remarkable period of change and innovation in health care delivery for patients with valvular heart disease. Mother Nature and evolution have provided a standard for engineers and surgeons that is difficult to emulate, but achievable. nocwatch@sbcglobal.net Additional reference: Animation of the SAPIEN valve insertion www.edwards.com/ products/transcathetervalve/pages/thvcategory.aspx?Homebanner

EDITOR’S NOTE: Permission to use the heart valve image on this issue’s cover came from Edwards Lifesciences LLC, Irvine, CA. Additionally, Edwards SAPIEN, SAPIEN, RF3, RetroFlex, RetroFlex II and RetroFlex 3 are trademarks of Edwards Lifesciences Corporation.

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Dependent on Opiates and Pregnant: Now What? Methadone Treatment for the Fetus?

By John McCarthy, MD

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

OPIATE WITHDRAWAL AFTER BIRTH is a scenario becoming more and more common, as reflected by the tripling of newborn babies being treated for neonatal abstinence syndrome (NAS) in NICUs around the country. This likely underestimates the true numbers of pregnant women using opiates when they conceive. Locally, we have seen a significant rise in the number of women presenting to our methadone pregnancy program, the majority of who are using prescription opiates. Last February, a Sacramento Bee article addressed the rise in neonates with opiate withdrawal, focusing on the experience at Sutter Memorial. This is all part of the larger picture of dramatic increases in opiate use among adolescents and young adults. I’ve deliberately used the term “dependence” to emphasize the physiological state that complicates the pregnancy, whether this occurred in the context of chronic pain management or illicit drug use. In both cases, we have the same dilemma: opiate withdrawal is a threat to the pregnancy. In the first trimester, withdrawal can cause miscarriage. In the second and third trimesters, it risks the health of the fetus which also becomes dependent. The reality of fetal dependence is not universally recognized; however, after a point in fetal development when sufficient numbers of opiate receptors have developed, fetal dependence occurs pari passu with maternal dependence, and the fetus can have an intrauterine abstinence syndrome.

Sierra Sacramento Valley Medicine

Maternal withdrawal causes uterine cramping and restriction of placental blood flow. Fetal withdrawal causes hyperactivity and increased oxygen needs. The combination is potentially deadly. In the era before methadone treatment, the death rate from fetal and neonatal opiate withdrawal was 10 percent. Autopsies showed fetal strokes. The morbidity in fetuses experiencing non-fatal repeated hypoxic episodes is truly unknown. Our clinical tools for identifying fetal withdrawal are quite inadequate, unless the fetus is in extremis. Hence, most fetal withdrawal goes undetected. Every time the mother goes into withdrawal from running out of opiates, we can presume the fetus has withdrawal also, which leads to a disturbing thought... It is likely that many of the neonates, who seem to have especially severe neonatal abstinence, are suffering not just from simple opiate withdrawal, but from the consequences of accumulated fetal stress and brain trauma from repeated cycles of maternal opiate withdrawal, and/or consequences of polydrug exposure, e.g. alcohol, nicotine, stimulants. We just can’t diagnose those earlier events, although treatment tries to limit or prevent them. So, what are we to do with the pregnant and opiate-dependent mother? For over 40 years, the treatment of choice has been methadone maintenance. But why continue maternal/fetal dependence? If you try to slowly withdraw the mothers, they usually relapse to opiate abuse because they can’t tolerate the withdrawal

symptoms (including uterine cramping). So we have little choice, and it is fortunate we have methadone maintenance. But can’t methadone cause withdrawal too? Well, methadone is usually prescribed in a therapeutically-controlled environment, and it has a long half-life. Severe withdrawal from short-acting opioids is more risky, and this is what methadone treatment is trying to eliminate. When and if the newborn has withdrawal after birth, it is better to have this occur in the hospital where the neonatologists can treat it, rather than in the womb where we don’t know what is really happening. The neonatal withdrawal in neonates exposed to methadone treatment is extremely variable. Studies report rates ranging from 13-94 percent, but the majority of studies report rates well over 50 percent. Again, attributing neonatal abstinence syndrome to methadone is an over simplification of the effects of drugs and drug withdrawal on fetal development. But NAS is usually very manageable. In the past, all neonates who had the potential for withdrawal were transferred to NICUs. This made sense when heroin was the drug the mother was on, and when the baby was born in acute withdrawal. The length of action of methadone eliminates any emergency and gives the mother time with the baby. We now have good evidence that maternal rooming in with the newborn, with encouragement of nursing and frequent skin-to-skin contact, reduces NAS. The mother is a better modulator of neonatal symptoms than morphine. NICUs are important for other complications or unusually severe NAS, but the NICU environment is far too stimulating for babies who need reduced stimulation. And babies in NICUs go through a “maternal” abstinence syndrome by separation from their mothers. Perhaps one could achieve significant cost savings by allowing these mothers to stay with their babies until discharge. Canada is already doing this with good success. Locally, Sutter Memorial policies are heading in this direction.

I have been fortunate to have excellent collaboration between our Bi-Valley pregnancy program, the obstetricians at Capitol OB-GYN and at Camellia Women’s Health who see the majority of our pregnant women. Sutter Memorial Labor and Delivery and neonatal nurses have been gracious in coming to our pregnancy group and helping our mothers prepare for their birth experience while minimizing the fears of being judged for being on methadone. It is a sign of progress that treatment for opiate addiction with methadone is broadly supported throughout our local healthcare system. Pregnancy is the most powerful motivator for recovery from drug abuse. Almost all of our mothers are in recovery when they deliver. Almost all stay in recovery after delivery and are good mothers. The majority (currently 70 percent) of babies born to our mothers have withdrawal so mild that no treatment beyond the mother’s close presence is needed. This is in spite of, at times, the need for very high methadone doses (200-300 mg in some cases) needed to counter the increased metabolism of methadone that complicates attempts to minimize maternal/fetal withdrawal. So what do we need in the future? We need more research into the area of fetal withdrawal. We know it can be dangerous, but our tools for detecting it are inadequate. We need insurance companies to recognize that allowing a mother to stay in the hospital with a baby having NAS will reduce costs of NICUs and result in a better allocation of resources, as well as improve bonding. We need far more informed discussion with women of childbearing age of the consequences of conceiving while dependent on opiates prescribed for pain. We need more informed physician referrals to methadone treatment for consultation on management of opiate dependence during pregnancy. And we need better education of our youth about opiate addiction and more efforts toward prevention and treatment of this problem.

Pregnancy is the most powerful motivator for recovery from drug abuse. Almost all of our mothers are in recovery when they deliver.

jmccarthy@bivalley.com

January/February 2013

What is it?

Sierra Sacramento Valley Medicine

If you thought “a sewing machine,” you’re wrong. This is a suppository maker. A suppository − a readily meltable cone shaped solid − is used to introduce medication into the body through the rectum, vagina or urethra. The term is derived from Latin: “to place beneath or to put under.” Our Museum of Medical History has a variety of small molds for making suppositories, but this unique instrument was brought in as a donation during Museum Day this past February. It came from the estate of Eugene L. Rogers, Sr. who was a pharmacist at Grey’s Pharmacy (an early Sacramento pharmacy circa 1914, but in business until at least 1960) and was donated by Dan and Lisa Little. Are you a physician who is near retirement or who has retired? Our museum gladly accepts donations of medical artifacts and equipment. Usable items not appropriate for the museum will be sent overseas to one of several developing hospitals where there is a great need. Contact Dr. Bob LaPerriere, xtbob@surewest.net.

SSVMS Election Results 2013 Board of Directors President: David Herbert, MD President-Elect: Jose Arevalo, MD Immediate Past President: Alicia Abels, MD District 1, North: Robert Kahle, MD District 2, Central: Ann Gerhardt, MD, Lorenzo Rossaro, MD, Christian Serdahl, MD District 3, South: Bhaskara Reddy, MD District 4, El Dorado County: Russell Jacoby, MD District 5, Permanente Medical Group: Paul Akins, MD, John Belko, MD, Jason Bynum, MD, Steve Kelly-Reif, MD, Kristen Robinson, MD District 6, Yolo County: Tom Ormiston, MD

2013 CMA Delegation District 1, North: Robert Kahle, MD, Delegate; Reinhardt Hilzinger, MD, Alternate District 2, Central: Lydia Wytrzes, MD, Delegate; Margaret Parsons, MD, Alternate District 3, South: Katherine Gillogley, MD, Delegate; Ruenell Adams, MD, Alternate District 4, El Dorado County: Earl Washburn, MD, Delegate; Russell Jacoby, MD, Alternate District 5, Permanente Medical Group: Elisabeth Mathew, MD, Delegate; Robert Madrigal, MD, Alternate District 6, Yolo County: Marcia Gollober, MD, Delegate; Karen Hopp, MD, Alternate At-Large Office #7: Jose Arevalo, MD, Delegate; MD, John Belko, MD, Alternate At-Large Office #8: David Herbert, MD, Delegate; Olivia Kasirye, MD Alternate At-Large Office #9: Anthony Russell, MD, Delegate; Alternate (Vacant) At-Large Office #10: Alicia Abels, MD, Delegate; Maynard Johnston, MD, Alternate At-Large Office #11: Boone Seto, MD, Delegate; Richard Pan, MD, Alternate At-Large Office #12: Kuldip Sandhu, MD, Delegate; Rajan Merchant, MD, Alternate At-Large Office #13: Charles McDonnell, MD, Delegate; Jason Bynum, MD, Alternate At-Large Office #14: Richard Jones, MD, Delegate; Jeffrey Cragun, MD, Alternate At-Large Office #15: Richard Gray, MD, Delegate; Alternate (Vacant) At-Large Office #16: Janet Oâ&#x20AC;&#x2122;Brien, MD, Delegate; Alternate (Vacant)

January/February 2013

Board Briefs November 13, 2012 The Board: Received an update regarding the Sierra Sacramento Valley Medical Society (SSVMS) and Community Service, Education and Research Fund (CSERF) investments from Patty Estopinal, Director, Robert W. Baird & Company. Approved recommended changes to the investment policies for the Sierra Sacramento Valley Medical Society funds, Community Service, Education and Research Fund and the Society’s Employee Money Purchase Pension Plan. Approved the Third Quarter 2012 SSVMS and CSERF Financial Statements and Investment Reports. Approved the SSVMS and CSERF 2012 YearEnd Projections and 2013 Proposed Budget. Approved the following recommendations from the Scholarship and Awards Committee to for the 2012 annual awards: Marion Leff, MD, Golden Stethoscope Award; Christopher Gresens, MD, Medical Honor Award; Sister Clare Marie Dalton, Medical Community Service Award. The recipients will be honored at the January 17, 2013 SSVMS and Alliance Annual Awards and Installation of Officers dinner at the Hyatt Regency Hotel, 6:00 pm. Serving as the BloodSource Member, approved the 2013 BloodSource Officers and Board of Directors. Approved the Membership Report: For Active Membership — Olana Aberra, MD; Brett L. Adams, MD; Javaid Akhter, MD; Kaj Anderson, MD; Jonathan H. Aron, MD; Pramjeet Atwal, MD; Ben Balough, MD; Benugopal Bellum, MD; Melissa Bergstrom, MD; Kristin Bicocca, MD; Richard Blohm, MD; Evan Bloom, MD; Susan Boone, MD; Manpreet Brar, MD; John Brawley, MD; Bruce Burns, MD;

Sierra Sacramento Valley Medicine

Malrubio Cabrera, MD; Trevor S. Cadogan, MD; Christine A. Castro, DO; Chung-Yin Stanley Chang, MD; Abhinav Chandra, MD; Ashish Chawla, MD; Sabrina Chen, MD; Nelson Chiang, MD; Jennifer Choe, MD; Norman Chow, MD; Gary Chu, MD; Mary Chu-Yee, MD; Jeremy Cooke, MD; Lisa M. Cosens, MD; Nicholas Currlin, MD; Kalani K. Cullison, MD; Daren Danielson, MD; Laura Darling, MD; Dinh-Hai N. Dao, MD; Glenn Daubert, MD; Kimberly Davis, MD; Lawrence Davis, MD; Kamalbir Dhaliwal, MD; Kapil Dhingra, MD; Susan Diez, MD; Cristian Dinescu, MD; Dorothy Do, MD; Thuy D. Do, DO; Kevin Doley, MD; Andrew Elms, MD; Farhad Farzanegan, MD; Wayne Fenton, MD; Stephen Fisher, MD; Brian Fitch, MD; Sarah L. Fletcher, MD; Fatima FloresAbutin, MD; Theodore Foondos, MD; Gary Fox, MD; Edward Fuchs, MD; Carrie Gardner, MD; Deepika Goshike, MD; Gary Grinberg, MD; Eli R. Groppo, MD; Brian Gunter, MD; Arpana Gupta, MD; Elmer E. Gurmai, MD; Mrudula K. Guthikonda, MD; Naduvathusery J. Jacob, MD; Brian J. Jian, MD; Domingo A. Hallare, MD; Jeff M. Hamman, MD; Elizabeth M. Hammel, MD; Emily A. Hannon, MD; Lynne R. Harris, MD; Wesley K. Hashimoto, MD; Sonya S. Heitmann, MD; Lam H. Hoang, MD; Amy A. Hung, MD; Luong T. Huynh, MD; Nancy M. Inforzato, MD; Brian A. Jan, MD; Jafer M. Jeelani, MD; Anne K. Johnstone, MD; Kristi F. Jones, MD; Jae H. Jun, MD; Alexander M. Kane, MD; Yewondwossen B. Kassa, MD; Kirk D. Keene, MD; Karuna Kem, DO; Gerald J. Khachi, MD; Gregory J. Klinke, MD; David Kollhoff, MD; Kristopher E. Kordana, MD; Gudrun Kungys, MD; Yuen (Vivian) W. Kwan, MD; Vincent Lee, MD; Hengli (Henry) Lin, MD; Helen L. Liu, MD; Eleanor F-Y Lo, MD; Jason A. London, MD; Michael J. Lovely, MD; Dave C. Lu, MD; Saradha Mahesh, MD; Jeremy D. Martinez, MD;

Maria J. MBA Wright, MD; Jamie E. McInturff, MD; Scott D. Meier, MD; Aimee Moulin, MD; James T. Ngo, DO; Patrick M. Overfield, DO; Anna R. Pinlac-Sanchez, DO; Rutt Ratanasen, MD; Daniel Shibru, MD; Bryan D. Smith, MD; Aisha Taylor, MD; Jeanne Taylor, DO; Long Tran, DO; Michael Vance, MD; Mathew Walker, MD: Stacey Wallach, MD; Nathan Watkins, MD: Randall S. Winslow, DO; Curtis Witcher, MD; Shagulta Yasmeen, MD. For Resident Membership — Jared D. Ament, MD; Ivan Anderson, MD; Steven R. Chan, MD; Melanie Chang, MD, Shannon Chin, MD; Lisa Chu, MD; John Coburn, MD; Erin Cotton, MD; Jessica Curti, MD; Brandon Doskocil, MD; Allison Freeman, MD; Matthew Gibson, MD; Alexandra Hunt, MD; Sadiah Iqbal, MD; Deborah Kim, MD; Janice Kim, MD; Peter Knudsen, MD; Yelena Lapan, DO; Michael Lasker, MD; Irene Lee-Klass, MD; Christina Millhouse, MD; John Posten, DO; Colin Randau,

MD; Jennifer Rizzo, MD; Johan B. Roberts, MD; Christie Romo, MD; Sijie Shen, MD; Jennifer L. Sullivan, MD; Don N. Udall, MD. For Reinstatement to Active Membership — Jeffrey Cragun, MD; Stacy S. Hull, MD; Richard C. Lynton, MD. For A Change in Membership Status from Active to Active 65/20 — Gail Pirie, MD. For Retired Membership — Jack G. Bruner, MD; Deepak D.R. Chabra, MD; George Chiu, MD; Denette J. Dengler, MD; Paul Gottlieb, MD; Sandra Hand, MD; Norman Label, MD; George Meyer, MD; Robert Midgley, MD; Douglas R. Schuch, MD; Chun K. Yang, MD. For Resignation — Robert T. Barrett, MD; Elizabeth A. Chase, MD, Sandy S-Y Cho, MD; Octav C. Constantinescu, MD; Trissy M. Chun, MD; Sean Doherty, MD; Saba Hussain, MD; Aloysius V. Llaguno, MD; Rupina Mann, MD; Stanely Roe, MD; Richard S. Stayner, MD; Lisa Swensson, MD.

Your care makes all the difference. Roberta Reid, BloodSource employee, head-trauma survivor and grateful platelet recipient.

www.bloodsource.org

not-for-profit since 1948

For every patient, like Roberta, who gratefully receives the gift of blood — and another day to be with family and friends — there are countless medical professionals whose care and support make all the difference. Thank you for the care you give to every man, woman and child whose life depends on the precious gift of blood. Yes, you do save lives.

January/February 2013

December 10, 2012 The Board: Received the Annual BloodSource Report from Michael Fuller, Chief Executive Officer. Serving as the BloodSource Member, approved the following 2013 BloodSource Officers and Board of Directors: Harry Lawrence, DDS, President; Sherri Kirk, Esq., Vice President; Paul Rosenberg, MD, Secretary/Treasurer; Jim Schraith, Member at-large; Keith McBride, Esq., Immediate Past President; Director, Esther Aw, Chris Ann Bachtel, Mark Carter, MD, George Chiu, MD, Angelo de Mattos, MD, Keith Doram, MD, Michael Lucien, MD, Travis Miller, MD, Anthony Russell, MD, Larry Salinas, MD. Received an update regarding the Medical Review & Advisory Committee from Howard Slyter, MD, Chair. Approved the 2013 Committee Appointments. Approved the Membership Report: For Active Membership — Michael Chan, MD; Hui Min Cheong, MD; Robert C. Duncan, DO; Julia B. Golden, DO; Janice A. GranzellaRogers, MD; Catherine J. Ho, DO; Spencer J. Kwong, MD; Kathryn E. Lang, MD; Joyce C. Leary, MD; Andrew K. Lee, MD; Bryan K. Lee,

MD; Maya D. Leggett, MD; Liang Liang, MD; Matthew J. Lutch, MD; Rekha Mamidi, MD; Lisa M. Meneses, MD; Peter H. Miles, MD; David J. Moitoza, MD; Juan P. Moreno, MD; Yi Y. Myint, MD; Vicki E. Nagano, MD; Brandy A. Nagle, MD; Charlotte Newcomb, MD; Jasmine B. Nguyen, MD; Long Nguyen, MD; Tan M. Nguyen, MD; Steven R. Offerman, MD; Masaru H. Oshita, MD; Edward C. Patriquin, MD; Tan H. Pham, MD; Mihaela Pirau, MD; Donna A. Poplawski, MD; Sarah J. Preiss-Farzanegan, MD; Gregory J. Rabin, MD; Sujatha Ramkumar, MD; Wilfredo R. Ramos, MD; Milin M. Ratanasen, MD; Kristen T. Rathbun, MD; Vijay S. Rathore, MD; Karimereddy J. Reddy, MD; Jeff D. Rodgerson, MD; Mukesh K. Sahu, MD; Miguel A. Sanchez, MD; Teresa Sandoval-Phillips, MD; Joel R. Schaffer, MD; Michael G. Schlieman, MD; Minajoy T. Sebastian, MD; Matthew J. Sena, MD; Steven L. Seto, MD; Akshat D. Shah, MD; Shahin Shahbazi, MD; Jennifer M. Sheppard, MD; Gertrude Shiu, MD; Shashi Shravana, MD; John M. Shrum, MD; Marjan Siadat, MD; Reza Sianati, MD; Rodger A. Siemens, MD; Jashan D. Singh, MD. For Resident Membership — Kelly Albin, MD; Katherine Belsky, MD; Crystal Blankenship, MD; Drystin Granger, DO; Erica Heiman, MD; Brian Holoyda, MD; Hollis Hopkins, MD; Sterling Humphrey, MD; Stefani T. Kappel, MD; Andrew Last, MD; Robert Levy, MD; Vanessa McGowan, MD; Christina Ortega, MD; David Posner, MD; Matthew Reed, MD; Naomi Ross, MD; Rebecca Sonu, MD; Kris Srinivasan, MD; Toby Steele, MD; Robert Stephens, MD: John Taylor, MD; Jason Young, MD. For Reinstatement to Active Membership — Mark D. Levine, MD For Retired Membership — Gerardo Lamiel, MD; Donald Lyman, MD; Glennah Trochet, MD For Resignation — Stephen N. Fisher, MD (moved to Pittsburgh, PA)

One can only wonder what these pills were intended for!

Sierra Sacramento Valley Medicine

Meet the Applicants The following applications have been received by the Sierra Sacramento Valley Medical Society. Information pertinent to consideration of any applicant for membership should be communicated to the Society. —Robert A. Kahle, MD, Secretary.

Aberra, Olana, Internal Medicine, UC Los Angeles 2002, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Adams, Brett L., Otolaryngology, Creighton University 1995, The Permanente Medical Group, 7300 Wyndham Dr, Sacramento 95823 (916) 525-6350 Agnew, Matthew L., Thoracic Surgery, University of Pittsburgh 2001, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2014 Akhter, Javaid, Family Medicine, University of Karachi, Pakistan 1990, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Albin, Kelly C., Family Medicine, UC San Diego 2011, Sutter Health Family Practice Residency Program, 1201 Alhambra Blvd., #340, Sacramento 95816 (916) 731-7866 (Resident Member) Ament, Jared D., Neurosurgery, Ben Gurion University, Columbia 2007, UCDMC, 4860 Y St #3740, Sacramento 95817 (916) 734-4300 (Resident Member) Anderson, Kaj, Emergency Medicine, UHS/The Chicago Medical School 2000, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Aron, Jonathan H., Internal Medicine, Medical College of Wisconsin 2006, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Atwal, Paramjeet K., Pulmonary/Critical Care Medicine, Russian People’s Friendship Universitsy 1997, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-4821 Balough Ben J., Otolaryngology, University of Southern California 1989, The Permanente Medical Group, 7300 Wyndham Dr, Sacramento 95823 (916) 525-6350 Belsky, Katherine C., Family Medicine, University of Michigan 2011, Sutter Health Family Practice Residency Program, 1201 Alhambra Blvd., #340, Sacramento 95816 (916) 731-7866 (Resident Member)

Blankenship, Crystal B., Family Medicine, UC Davis 2011, Sutter Health Family Practice Residency Program, 1201 Alhambra Blvd., #340, Sacramento 95816 (916) 731-7866 (Resident Member) Blohm, Richard R., Internal Medicine, George Washington University 1984, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Bloom, Evan D., Pediatrics, UC San Francisco 1982, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-6800 Brar, Manpreet S., Internal Medicine, Univ Mumbai, India 1998, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Brawley, John G., Vascular Surgery, Emory University 1994, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Burns, Bruce E., Psychiatry, Texas A & M University 1989, The Permanente Medical Group, 7300 Wyndham Dr, Sacramento 95823 (916) 525-6100 Cabrera, Malrubio, Internal Medicine, UC Davis 1999, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Cadogan, Trevor S., Emergency Medicine, Loma Linda University 2002, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Chu, Gary S., Internal Medicine, Meharry Medical College 1998, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Chu, Lisa L., Radiology, UC San Francisco 2010, UCDMC, 4860 Y St #3100, Sacramento 95817 (916) 703-2108 (Resident Member) Chu-Yee, Mary, Pediatrics, Loyola University 1993, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-6800 Coburn, John, Emergency Medicine, Rush Medical College 2012, UCDMC, 4150 V St #2100, Sacramento 95817 (916) 734-2011 (Resident Member) Cooke, Jeremy L., Emergency Medicine, Oregon Health Sciences Univ 2001, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Cosens, Lisa M., Family Medicine, University of Colorado 2000, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove 95758 (916) 478-5000 Cotton, Erin M., Family Medicine, Cornell University 2011, Sutter Health Family Practice Residency Program, 1201 Alhambra Blvd., #340, Sacramento 95816 (916) 731-7866 (Resident Member)

Chan, Steven R., (Specialty-Undecided), UC Irvine 2012, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member)

Cullison, Kalani K., Emergency Medicine, University of Virginia 2005, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Chang, Melanie, Radiology, Medical College of Wisconsin 2011, UCDMC, 4860 Y St #3100, Sacramento 95817 (916) 703-2108 (Resident Member)

Curti, Jessica M., Family Medicine, UC Davis 2011, Sutter Health Family Practice Residency Program, 1201 Alhambra Blvd., #340, Sacramento 95816 (916) 731-7866 (Resident Member)

Chawla, Ashish, Gastroenterology, University of Kansas 1997, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2000

Dao, Dinh-Hai N., Family Medicine, Medical College of Ohio 2004, The Permanente Medical Group, 10305 Promenade Parkway, Elk Grove 95757 (916) 544-6300

Chen, Sabrina MY, Pulmonary/Critical Care Medicine, UC San Francisco 2000, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Bergstrom, Melissa A., OB-GYN, Rush Medical College 1994, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2055

Chiang, Nelson KY, Internal Medicine, Tufts University 2003, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Bicocca, Kristin L., Pediatrics, Northeastern Ohio University 1993, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-6800

Chin, Shannon J., Family Medicine, UC Davis 2011, Sutter Health Family Practice Residency Program, 1201 Alhambra Blvd., #340, Sacramento 95816 (916) 731-7866 (Resident Member)

Choe, Jennifer YW, OB-GYN, Boston University 1991, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2055

Darling, Laura A., Internal Medicine, University of Michigan 1999, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Daubert, Glenn P., Emergency/Toxicology Medicine, St. George’s University 2001, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Davis, Lawrence G., Interventional Radiology, Howard University 1991, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2029

January/February 2013

Dhaliwal, Kamalbir K., OB-GYN, Ross University 2001, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove 95758 (916) 478-5300

Granger, Krystin C., DO, Anesthesiology, Touro University 1999, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member)

Holoyda, Brian J., Psychiatry, Northwestern University 2012, UCDMC, 2230 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member)

Grinberg, Gary G., General/Bariatric Surgery, Northeastern Ohio University 2002, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2014

Hopkins, Hollis M., Emergency Medicine, University of Colorado 2011, UCDMC, 4150 V St #2100, Sacramento 95817 (916) 734-2011 (Resident Member)

Groppo, Eli R., Otolaryngology, George Washington 2006, Sacramento ENT, 1111 Exposition Blvd., #700, Sacramento 95815 (916) 736-3399

Hull, Stacy S., OB/GYN, Northwestern University 1990, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove 95758 (916) 478-5300

Dinescu, Cristian L., Internal Medicine, Institute of Medicine & Pharmacy in Bucharest 1989, Woodland Clinic Medical Group, 1321 Cottonwood St #313, Woodland 95695 (530) 662-3961

Gunter, Brian A., Radiology, Loyola University 1990, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2029

Humphrey, Sterling L., General Surgery, Oregon Health Sciences 2009, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member)

Do, Dorothy H., Internal Medicine, St. Georgeâ&#x20AC;&#x2122;s University 2007, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove 95758 (916) 478-5000

Gupta, Arpana, Internal Medicine, UC Irvine 2000, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Dooley, Kevin F., Ophthalmology, Harvard Medical School 1983, The Permanente Medical Group, 7300 Wyndham Dr, Sacramento 95823 (916) 525-6400

Gurmai, Elmer E., Psychiatry, Universitatea De Medicina, Romania 1986, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2000

Dhingra, Kapil R., Emergency Medicine, Tulane University 2007, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Diez, Susan J., OB-GYN, UC Los Angeles 1982, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2055

Doskocil, Brandon J., Radiology, University of Arizona 2011, UCDMC, 4860 Y St #3100, Sacramento 95817 (916) 703-2108 (Resident Member) Elms, Andrew R., Emergency Medicine, University of North Carolina 2007, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Farzanegan, Farhad, Interventional Radiology, Albany medical College 2002, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2029 Fenton, Wayne H., Otolaryngology, UC Los Angeles 1981, The Permanente Medical Group, 7300 Wyndham Dr, Sacramento 95823 (916) 525-6350 Fitch, Brian P., Psychiatry, University of Texas 1991, The Permanente Medical Group, 7300 Wyndham Dr, Sacramento 95823 (916) 525-6100 Fletcher, Sarah L., OB-GYN, University of New Mexico 2008, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove 95758 (916) 478-5300 Flores-Abutin, Fatima C., Internal Medicine, University of Santo Tomas 2006, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Fox, Gary M., OB-GYN, University of Miami 1976, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2055 Fuchs, Edward S., Internal Medicine, Albert Einstein 1978, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Gardner, Carrie M., Pediatrics, University of Southern California 2008, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-6800 Gibson, Matthew, Family Medicine, The Ohio State University 2012, UCDMC, 4860 Y St #1600, Sacramento 95817 (916) 734-2011 (Resident Member)

Guthikonda, Mrudula K., Internal Medicine, UHS Vijayawada/Gandhi Medical College, India 2000, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Hallare, Domingo A., Orthopedic/Orthopedic Trauma Surgery, UC Davis 2002, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2030 Hamman, Jeff M., Internal Medicine, University of Illinois 2004, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove 95758 (916) 478-5000 Hammel, Elizabeth M., Pediatrics, University of Southern California 1996, The Permanente Medical Group, 10305 Promenade Parkway, Elk Grove 95757 (916) 544-6600 Hannon, Emily A., Pediatrics, University of Vermont 2004, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-6800 Harris, Lynne R., Pediatrics, UC Los Angeles 1986, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-6800 Hashimoto, Wesley K., Occupational/Internal Medicine, St. Louis University 1983, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2005 Heiman, Erica M., Internal Medicine, UC San Francisco 2012, UCDMC, 4150 V St #2100, Sacramento 95817 (916) 734-2011 (Resident Member) Heitmann, Sonya S., Internal Medicine, UC Irvine 2009, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Ho, Catherine J., Family Medicine, Touro University 2007, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove 95758 (916) 478-5000 Hoang, Lam H., Otolaryngology/Maxillofacial Surgery, Vanderbilt University 2005, The Permanente Medical Group, 7300 Wyndham Dr, Sacramento 95823 (916) 525-6350

Sierra Sacramento Valley Medicine

Hung, Amy A., Family Medicine, Medical College of Wisconsin 2008, The Permanente Medical Group, 10305 Promenade Parkway, Elk Grove 95757 (916) 544-6300 Huynh, Luong T., Family Medicine, UC Davis 2005, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove 95758 (916) 478-5100 Inforzato, Nancy M., Internal Medicine, University of Oklahoma 1987, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Iqbal, Sadiah, Family Medicine, UC Los Angeles 2012, Sutter Health Family Practice Residency Program, 1201 Alhambra Blvd., #340, Sacramento 95816 (916) 731-7866 (Resident Member) Jan, Brian A., Emergency Medicine, Tufts University 1992, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Jeelani, Jafer M., Internal Medicine, St. Georgeâ&#x20AC;&#x2122;s University 2005, The Permanente Medical Group, 10305 Promenade Parkway, Elk Grove 95757 (916) 544-6300 Johnstone, Anne K., Otolaryngology/Pediatric ENT, UC Los Angeles 1993, The Permanente Medical Group, 7300 Wyndham Dr, Sacramento 95823 (916) 525-6350 Jones, Kristi F., Cardiology, Loyola University 1995, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-4000 Jun, Jae H., Otolaryngology/Maxillofacial Surgery, The Permanente Medical Group, 7300 Wyndham Dr, Sacramento 95823 (916) 525-6350 Kane, Alexander M., Interventional Radiology, Tulane University 2003, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2029 Kassa, Yewondwossen B., Family Medicine, Military Medical Academy, Russia 1987, The Permanente Medical Group, 10305 Promenade Parkway, Elk Grove 95757 (916) 544-6300 Keene, Kirk D., Urology, Boston University 1995, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2081 Kem, Karuna, DO, Family Medicine, Ohio University 2004, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove 95758 (916) 478-5000

Khachi, Gerald J., Plastic Surgery, Natâ&#x20AC;&#x2122; University of Ireland 2000, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2045 Kim, Deborah S., Emergency Medicine, University of Illinois 2009, UCDMC, 4150 V St #2100, Sacramento 95817 (916) 734-2011 (Resident Member) Kim, Janice Y., Family Medicine, UC Davis 2010, Sutter Health Family Practice Residency Program, 1201 Alhambra Blvd., #340, Sacramento 95816 (916) 731-7866 (Resident Member) Klinke, Gregory J., Radiology/Neuroradiology, University of Texas 1992, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2029 Knudsen, Peter R., Psychiatry, UC Davis 2010, UCDMC, 2230 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member) Kollhoff, David M., Urology, University of Kansas 2006, Woodland Clinic Medical Group, 1207 Fairchild Ct, Woodland 95695 (530) 668-1631 Kordana, Kristopher E., Internal Medicine, Uniformed Services University 1995, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2029 Kungys, Gudrun, Anesthesiology, University of Wurzburg, Germany 2001, Sacramento Anesthesia Medical Group, 3939 J St #310, Sacramento 95819 (916) 733-6990 Kwan, Yuen (Vivian) W., Pulmonary/Critical Care Medicine, UC Davis 1998, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-4821 Kwong, Spencer J., Pediatrics, Hahnemann Medical College 1987, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4060 Lang, Kathryn E., Emergency Medicine, University of Connecticut 2004, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Lapan, Yelena, DO, Family Medicine, Touro University 2010, Sutter Health Family Practice Residency Program, 1201 Alhambra Blvd., #340, Sacramento 95816 (916) 731-7866 (Resident Member) Lasker, Michael V., General Surgery, University of Illinois 2009, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member) Last, Andrew S., OB-GYN, UC Davis 2010, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member) Leary, Joyce C., Endocrinology, UC San Francisco 2004, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-4644 Lee, Andrew K., Internal Medicine, UC Davis 1998, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Lee, Bryan K., Internal Medicine, UC Davis 2007, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Lee, Vincent J., Radiation Oncology, Jefferson Medical College 2001, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Lee-Klass, Irene H., Family Medicine, UC Irvine 2010, Sutter Health Family Practice Residency Program, 1201 Alhambra Blvd., #340, Sacramento 95816 (916) 731-7866 (Resident Member) Leggett, Maya D., Surgical Critical Care Surgery, Pennsylvania State University 2003, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2014 Levy, Robert E., Internal Medicine, Jefferson Medical College 2011, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member) Liang, Liang, Internal Medicine, Hua Shan Shanghai Medical University, China 1990, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Lin, Hengli (Henry), Plastic Surgery, Tufts University 2002, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2045 Liu, Helen L., Pediatrics, Drexel University 2004, The Permanente Medical Group, 10305 Promenade Parkway, Elk Grove 95757 (916) 544-6600

Meneses, Lisa M., Pediatrics, UC Davis 2007, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-6800 Miles, Peter H., Cardiovascular Disease, University of Texas 1998, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-4000 Millhouse, Christina, Emergency Medicine, Uniformed Service University 2002, UCDMC, 4150 V St #2100, Sacramento 95817 (916) 734-2011 (Resident Member) Moitoza, David J., Radiology/MRI, Washington University 1983, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2029 Moreno, Juan P., Internal Medicine, UC Irvine 1996, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Myint, Yi Y., Physical Medicine & Rehabilitation/ Occupational Medicine, Institute of Medicine, Rangoon 1970, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2005 Nagano, Vicky E., Nuclear Medicine, UC San Diego 1985, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2029

Lo, Eleanor FY, Internal Medicine, UC Davis 1989, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Nagle, Brandy A., Emergency Medicine, University of Southern California 2001, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

London, Jason A., Surgical Critical Care, University of Pennsylvania 1997, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2014

Newcomb, Charlotte, Internal Medicine, UC San Francisco 1995, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Lovely, Michael J., Anesthesiology, University of Tennessee 1987, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2000

Ngo, James T., DO, Family Medicine, Touro University 2006, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Lu, Dave C., Internal Medicine, UC San Diego 2005, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Nguyen, Jasmine B., Pediatrics, UC San Francisco 2004, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-6800

Lutch, Matthew J., Otolaryngology, UC San Diego 2003, The Permanente Medical Group, 7300 Wyndham Dr, Sacramento 95823 (916) 525-6350

Nguyen, Long, Family Medicine, Oregon Health Sciences 2005, The Permanente Medical Group, 10305 Promenade Parkway, Elk Grove 95757 (916) 544-6300

Martinez, Jeremy D., Emergency Medicine, Cornell University 1999, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Nguyen, Tan M., Radiology, University of Nebraska 1999, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2029

MBAWright, Marie J., Pediatrics, Meharry Medical College 1998, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-6800

Ortega, Christina S., Internal Medicine, UTHSCSA 2011, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member)

McGowan, Vanessa, Physical Medicine & Rehabilitation, UC Davis 2010, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member)

Overfield, Patrick M., DO, Emergency Medicine, WUHS/College of Osteopathic Medicine 2006, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

McInturff, Jamie E., Dermatology/MOHS Surgery, UC Los Angeles 2006, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove 95758 (916) 478-5671

Pinlac-Sanchez, Anna, DO, Univ New England/ College of Osteopathic 2009, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove 95758 (916) 478-5000

Meier, Scott D., Pediatrics/Sports Medicine, Tulane University 2006, The Permanente Medical Group, 10305 Promenade Parkway, Elk Grove 95757 (916) 544-6600

Randau, Colin P., Radiology, UC Davis 2010, 4860 Y St #3100, Sacramento 95817 (916) 703-2108 (Resident Member)

January/February 2013

Ratanasen, Rutt M., Pediatrics, Virginia Commonwealth University 2008, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-6800

Shah, Akshat D., Physical Medicine & Rehabilitation/ Spinal Cord Injury, Ross University 2001, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2036

Reed, Matthew J., Internal Medicine, University of Utah 2010, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member)

Shahbazi, Shahin, Internal Medicine, St. Georgeâ&#x20AC;&#x2122;s University 1998, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Rizzo, Jennifer L., Ophthalmology, Boston University 2009, UCDMC, 4860 Y St #2400, Sacramento 95817 (916) 734-2011 (Resident Member)

Shen, Sijie Joy, Family Medicine, Eastern Virginia 2012, Sutter Health Family Practice Residency Program, 1201 Alhambra Blvd., #340, Sacramento 95816 (916) 731-7866 (Resident Member)

Roberts, Joan B., Family Medicine, UC San Francisco 2010, Sutter Health Family Practice Residency Program, 1201 Alhambra Blvd., #340, Sacramento 95816 (916) 731-7866 (Resident Member) Romo, Christie A., Family Medicine, Loma Linda University 2007, Sutter Health Family Practice Residency Program, 1201 Alhambra Blvd., #340, Sacramento 95816 (916) 731-7866 (Resident Member) Ross, Naomi E., Internal Medicine, Tufts University 2011, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member) Sandoval-Phillips, Teresa, Internal Medicine, UC Davis 2008, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Schaffer, Joel R., Physical Medicine & Rehabilitation, University of Minnesota 2008, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2036 Schlieman, Michael G., General Surgery/Surgical Oncology, Virginia Commonwealth University 1998, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2014 Sebastian, Minajoy T., OB/GYN, UC Davis 1994, The Permanente Medical Group, 10305 Promenade Parkway, Elk Grove 95757 (916) 544-6500 Sena, Matthew J., Surgical Critical Care/General Surgery, UC Davis 1998, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2014 Seto, Steven L., Family/Occupational Medicine, UC Irvine 1981, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2005

Sheppard, Jennifer M., OB-GYN, Medical College of Wisconsin 1992, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2055 Shibru, Daniel, Colon/Rectal Surgery, University of Illinois 2002, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2014 Shravana, Shashi, Internal Medicine, Bangalore University 1999, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Shrum, John M., Urology, UC Davis 1974, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2081

Sonu, Rebecca J., Pathology, Ross University 2009, UCDMC, 4400 V St, Sacramento 95817 (916) 734-2011 (Resident Member) Srinivasan, Kris, Family Medicine, UC Davis 2009, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member) Steele, Toby O., Otolaryngology, University of Colorado 2009, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member) Stephens, Robert F., Anesthesiology, Howard University 2010, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member) Sullivan, Jennifer L., Cardiothoracic Surgery, University of Maryland 2005, UCDMC, 2221 Stockton Blvd., #2112, Sacramento 95817 (916) 734-7255 (Resident Member) Taylor, Jeanne M., DO, Internal Medicine, Edward Via College of Osteopathic Medicine 2008, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove 95758 (916) 478-5000 Taylor, John R., Orthopedic Surgery, University of Utah 2012, UCDMC, 4860 Y St #3800, Sacramento 95817 (916) 734-2011 (Resident Member)

Siadat, Marjan, Emergency Medicine, University of Illinois 2007, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Tran, Long, DO, Radiology/Body Imaging, Ohio University 1999, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2029

Sianati, Reza, Internal Medicine, National University of Iran 1993, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Udall, Don N., Radiology, Vanderbilt University 2001, UCDMC, 4860 Y St #3100, Sacramento 95817 (916) 703-2108 (Resident Member)

Siemens, Rodger A., Internal Medicine, UC San Francisco 1996, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Walker, Matthew W., Anesthesiology, Bowman Gray 1999, Sacramento Anesthesia Medical Group, 3939 J St #310, Sacramento 95819 (916) 733-6990

Singh, Jashan D., Anesthesiology, St. Georgeâ&#x20AC;&#x2122;s University 2003, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2000 Smith, Bryan D., Urology, Loma Linda University 1999, Radiological Associates of Sacramento, 1500 Expo Parkway, Sacramento 95815 (916) 646-8471

Watkins, Nathan P., Emergency Medicine, Northeastern Ohio University 1995, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Witcher, Curtis L., Family Medicine, University of Vermont 2009, The Permanente Medical Group, 2345 Fair Oaks Blvd., Sacramento 95825 (916) 973-5000 Yasmeen, Shagufta, Internal Medicine, University of Kashmir, India 1984, The Permanente Medical Group, 1955 Cowell Blvd., Davis 95616 (530) 757-7100 Young, Jason B., General Surgery, UC Irvine 2007, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member)

PLANET

E L LY

Kelly Rackham [916] 616 6270 planetkelly@me.com www.planetkelly.com Out-of-this-world design

Sierra Sacramento Valley Medicine

AD INDEX Page Hill Physicians................................................ Inside Front Cover BloodSource............................................................................29 UC Davis....................................................................................9 Marsh.......................................................................................13 Moss Adams...................................................Inside Back Cover COMCAST......................................................Inside Back Cover NORCAL Mutual Insurance Company.........Outside Back Cover The Doctors Center...................................................................2 Tracy Zweig Associates...........................................................17

Classified Advertising

Office Space Office Space for Lease: Corner of 39th and J Street, 850 sf, fully serviced. Rent negotiable. Contact R.J. Frink, MD at (916) 801-5276 or email at rjfrink@surewest.net. Medical Office. Like new. 1,200 sf, 3 exam rooms, large waiting room, 1355 Florin at Freeport, (916) 730-4494. Share Office: Surgeon looking for another doctor or medical professional to share a brand new office on Scripps Drive, Sacramento. (916) 924-1400; (916) 718-8882. Office Space to Share: 7600 Hospital Dr. next to Methodist Hosp. of Sacramento. 2400sqft, 6 exam/procedure rooms. Ideal for FP or OB/GYN. Contact K.A. Overton MD by email kaomdinc@netzero.net or (916) 681-4434. Physician Office Space Available. Shared space. 4 patient exam rooms. Lab. Physician Office. Very nice location. Full time staff. Available January 1, 2013. Please inquire at (916) 849-1055.

PHYSICIANS FOR JUDICIAL REVIEW COMMITTEES The Institute for Medical Quality (IMQ) is seeking primary care physicians, board certified in either Family Practice or Internal Medicine, to serve on Judicial Review Committees (JRC) for the California Department of Corrections and Rehabilitation (CDCR). These review committees hear evidence regarding the quality of care provided by a CDCR physician. Interested physicians must be available to serve for 5 consecutive days, once or twice per year. Hearings will be scheduled in various geographic locations in California, most probably in Sacramento, Los Angeles, and San Diego. IMQ physicians credentialed to serve on JRC panels will be employed as Special Consultants to the State, and will be afforded civil liability protection to the same extent as any Special Consultant. Physicians will be paid on an hourly basis and reimbursed travel expenses. Please contact Leslie Anne Iacopi (liacopi@imq.org) if interested.

Membership Has Its Benefits!

SIERRA SACRAMENTO VALLEY

MEDICAL SOCIETY

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Auto/Homeowners Discounted Insurance

Mercury Insurance Group 1.888.637.2431 or www.mercuryinsurance.com/cma

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Members-only coupon code is required Go to: www.cmanet.org/memberhip-benefits or call 800.786.4262

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Epocrates discounted mobile/online products www.cmanet.org/membership-benefits

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Healthcare Information Technology (HIT) www.cmanet.org/health information Resource Center technology HIPAA Compliance Toolkit

PrivaPlan Associates, Inc. 1.877.218.707 / www.privaplan.com

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800.786.4262 or email legalinfo@cmanet.org

Magazine Subscriptions 50% off subscriptions

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Medical School Debt Management Members-only coupon required: www.cmanet.org/membership-benefits Practice Financing Reduced Loan Administration Fees

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All SSVMS Members $100,000 Automatic Policy http://www.ssvms.org/Membership/ BenefitsandServices.aspx

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January/February 2013

The Sierra Sacramento Valley Medical Society and Alliance Invite You and Your Guest to Attend the

2013 Annual Awards and Installation Dinner Thursday, January 17, 2013

6:00 p.m. Social, 6:45 p.m. Dinner, 7:30 p.m. Program Hyatt Regency Hotel, Regency Ballroom 1209 L Street, Sacramento

Installation

2013 SSVMS Officers and Board of Directors

Award Presentations Golden Stethoscope Award Marion Leff, MD

Medical Honor Award Christopher Gresens, MD

Medical Community Service Award Sister Clare Marie Dalton Dorothy Dozier Helping Hands Award Paula Cameto

Entertainment

World Renowned Guitarist and Grammy Award Nominee Richard Savino

Grammy nominated Guitarist/Lutenist Richard Savino has been a featured performer throughout the US and abroad. He is the recipient of a Diapason dâ&#x20AC;&#x2122;Or (a French Grammy), received a Grammy nomination in 2010 for his collaborative project with Ars Lyrica of Houston, for Anthony & Cleopatra, and another nomination in 2011 for Best Small Ensemble Recording: The Kingdome of Castile. He is director of El Mundo, a chamber group dedicated to the performance of sixteenth through nineteen century Latin American, Spanish and Italian chamber music. Mr. Savino recently completed a cross country tour with opera singer Joyce DiDonato and the Il Complesso Barocco orchestra that concluded with a sold-out concert at Carnegie Hall.

Dinner Price $60.00 SSVMS Members, Alliance Members & Guests $30.00 Medical Students & Residents Please RSVP by returning the enclosed card with your dinner selection and payment. Members are encouraged to consider hosting a medical student or resident. Reserved tables of 10 are available by request.

Reservation Deadline: January 14, 2013, 10:00 a.m. Special appreciation to the following for their support of this event: NORCAL Mutual Insurance Company Johnson Aizenberg Financial Strategies Group of Wells Fargo Advisors

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