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www.sfms.org mArCH/APrIL 2006San FranciSco Medicine��San FranciSco MedicinemArCH/APrIL 2006 www.sfms.org

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�San FranciSco MedicinemArCH/APrIL 2006 www.sfms.org�San FranciSco MedicinemArCH/APrIL 2006 www.sfms.org

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�San FranciSco MedicinemArCH/APrIL 2006 www.sfms.org www.sfms.org mArCH/APrIL 2006San FranciSco Medicine��San FranciSco MedicinemArCH/APrIL 2006 www.sfms.org

conTenTS

San FranciSco Medicine March/april �006 Vol. 79, #�

Hands and High Technology: Minimally invasive Surgery

FEATURE ARTICLES

�� Is Coronary Bypass Surgery Obsolete in the Era of Drug-Eluting Stents? PeterHui,MD,FACC,FSCAI

�6 Interventional Neuroradiology: Less Invasive Approaches For The Treatment Of Complex Cerebrovascular Diseases & Stroke RandallT.Higashida,MD

�9 Non-Surgical Techniques and Modalities for Skin Rejuvenation GaetanoZanelli,MD

�� Screening for Abdominal Aortic Aneurism with Ultrasound can Save Lives GretchenAWGooding,MD

�� Phoenix Rising: And the Big Bird is Looking Through a Laparoscope LeonardShlain,MD

�5 The Past, Present, and Future of Laparoscopic Colectomy 2006 LaurenceF.Yee,MDandMichaelE.Abel,MD

MEMBER SERVICES

4 On Your Behalf

�� Report from the San Francisco Department of Public Health: A Successful Community Hepatitis B Screening and Vaccination Program JanetZola,MPH,EricSue,BA

MONTHLY COLUMNS

7 Executive Memo MaryLouLicwinko,JDMHSA

9 President’s Message GordonFung,MD

��Editorial MikeDenney,MD,PhD

�8 Hospital News

OF INTEREST

6 Letter to the Editor: DavidSmith,MD

�8The San Francisco Earthquake 1906: Quick Action Saved Countless Lives NancyThompson,MD

�0Surgeons Volunteer Locally through Operation Access: HaileDebas,MDand PaulB.Hofmann,Dr.PH

��Removing Bad Money from Good Medicine: Time for Some Bitter Pills: GeorgeSusens,MDand SteveHeilig,MPH

�4SFMS Annual Dinner Report

�7Report Links Environmental and Occupational Exposures to Cancers: RichardClapp,DSc,MPH,and MollyJacobs,MPH

Editorial and Advertising Offices

1003AO’Reilly

SanFrancisco,CA94129

Phone:415.561.0850ext.261

Fax:415.561.0833

Email:[email protected]

Web:www.sfms.org

Subscriptions:

$45peryear;$5perissue

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Printing:

SundancePress

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on YoUr BeHaLF

ediToriaLSan Francisco Medicine continues to Publish:

TheEditorialBoardofSanFranciscoMagazinehasbeenworkingdiligently tomaintaincontinuityofourpublicationaftertheabrupt lossofourpreviousManagingEditor.Becauseof the timedelayscausedbymovingintothenewSFMSoffices,thevacancywhilesearchingforanewManag-ingEditor,andtheresultantdisruptionofthenecessaryflowof thepublishingpro-cess,wehavefounditchallengingtokeepthepressesrolling.Wehavethusfounditnecessary-temporarily-tocombineafewissuesthisSpringratherthanhavingoneeachmonth.

Asaresultofthededicatedeffortsofmembers likeGretchenGooding,NancyThomson, Steve Walsh, Gordon Fung,EricaGoode,andmanyothers,andwithSteveHeiliggracefullyandskillfullystep-ping into thebreach,youare receivingaMarch/April issue aboutnewminimallyinvasiveprocedureswhichwe thinkyouwillfindhighlyinterestingandinformative.WewillthenhaveaMay/Juneissuewithathemeofdiversityandmedicine.

Ourhighly competentnewManag-ingEditor,AmandaDenz, starts thefirstofApril.So,wehavetakenadeepbreath,hunkereddowntowork,andexpecttore-turntonormalschedulesoon.Ourwebsite,www.sfms.org,isalsostillaworkinprogress.ThoseseekingtoaccessthearchivesofthisjournalbuthaveproblemsdoingsoshouldcontactSFMSheadquartersforassistance,asthecontentsdatingto1996remainonthesite.Ourthanksgoouttoallmembersforyourpatienceandsupport.

The SFMS Board of directors invites all members to:The SFMS Open HouseCome see our new headquarters in thePresidioFriday,April283-6PMHorsd’ouvresandrefreshments1003AO’ReillyAvenueBetweenGorgasandTorneyAvenuesinthePresidio,SanFrancisco

A sampling of activities and actions of interest to SFMS members.

RSVPtoCarolNolanat561-0850,[email protected]

Medicine and Patients ScoreMajor Victory at Supreme court

InJanuarytheUnitedStatesSupremeCourtruledinfavorofpatientsandphysi-cians in the longstandingcaseGonzales(originally Ashcroft) vs. Oregon. TheUnitedStatesAttorneyGeneral(s)hadsought tooverturnOregon’s legalizationof“assistedsuicide”byradicallychangingthe regulationand scrutinyofprescribedmedications.While theSFMSdoesnottakeaformalpositionontheassisteddyingissue(duetotheverydividedopinionsofourmemberson the topic),wedidagreewithexpertswho felt that theAshcroft/Gonzalesproposalwouldlikelyaddtothelongstandingconcernsofphysiciansabout“overuse”ofpainmedicationsinparticular.TheSFMStookanopposingpositiontotheproposal,convincedtheCMAtodolike-wise,andjoinedina“FriendoftheCourt”brief alongwithmanynationally-knownpain specialistsandhealthpolicyfigures.Thecasetookyearstowinditswaytofinalresolution,butoneattorney in the caseremarked that the supportofmainstreammedical organizations such as ours was“invaluable”intheoutcome.

cMa coalition Stops 5 Percent Medi-cal rate cut

ThegovernorsignedaCMA-sponsoredbill(SB912)thateliminatesthe5percentMedi-CalratecutthattookeffectJanuary1.

Thecut—theresultofalawsignedin2003byGovernorDavis—wasscheduledtostartJanuary1,2004,andsunsetJanuary1,2007.In2003theCMAwonafederalcourtinjunctionblockingthecut,butthatinjunc-tionwasoverturnedinAugust2005.

CMAandabroadcoalitionofpatientand provider organizations immediatelysoughtemergencylegislationtostopthecutandprotectaccesstocareforthe3millionpoor,children,elderly,anddisabledwhorelyonMedi-Calfortheirhealthcare.Thebill

MarcH/aPriL �006Volume 79, number �

Editor Mike Denney, MD, PhDManaging Editor Amanda DenzCover Artist Alex Rothwell

Editorial BoardChairman Mike DenneyObituarist Nancy ThomsonStephen Askin Wade Aubry Toni Brayer Corey Maas Jaqueline Dolev Jerome Fishgold Alan Greenwald Erica Goode Gretchen Gooding Samuel Kao Thomas Lee Arthur Lyons Rita Melkonian Kenneth MayburyJudith Mates Ricki Pollycove Jordan Shlain Leonard Shlain David Smith Kathleen Unger Leo van der Reis Stephen Walsh Shieva Khayam-Bashi

SFMS oFFicErSPresident Gordon L. FungPresident-Elect Stephen E. FollansbeeSecretary Charles J. WibbelsmanTreasurer Stephen H. FugaroEditor Mike DenneyImmediate Past President Alan G. Greenwald

SFMS Executive StaffExecutive Director Mary Lou Licwinko, JD, MHSADirector of Public Health & Education Steve L. Heilig, MPHDirector of Administration Posi LyonDirector of Membership Therese Porter

Board of directorsTerm: Jan 2006-Dec 2008Mei-Ling E. Fong, MDThomas H. Lee, MDCarolyn D. Mar, MDRodman S. Rogers, MDJohn B. Sikorski, MDPeter W. Sullivan, MDJohn I. Umekubo, MD

Term: Jan 2005-Dec 2007Gary L. Chan, MDGeorge A. Fouras, MDJeffrey Newman, MDThomas J. Peitz, MDJohn W. Pierce, MDDaniel M. Raybin, MDMichael H. Siu, MD

Term: Jan 2004-Dec 2006Richard L. Caplin, MDLucy S. Crain, MDJane M. Hightower, MDBrian J. Lewis, MDMichael Rokeach, MDJordan Shlain, MDAlan M. Teitelbaum, MD

CMA Trustee Robert J. MargolinAMA RepresentativesH. Hugh Vincent, DelegateJudith L. Mates, Alternate DelegateJudith L. Mates, AMA’s Women Physicians Congress Governing Committee

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passedunanimously inbothhousesof thelegislature,andwassignedbythegovernorwithin24hours.

Evenwithoutthecut,Medi-Calrateshavenotkeptpacewithinflation,andper-patientMedicaidspendingbyCaliforniarankslastamongthe50states.CMAiscommittedtoworkingwiththegovernor,thelegislature,andotheradvocacygroupsonMedi-Calre-formsthatwillimproveprogramefficienciesandcontrolcosts,whilemaintainingaccess,continuity,andqualityofcareforMedi-Calpatients.

Contact:LisaFolberg,916/[email protected].

cdc advisory Panel recommends Flu Shots for children Under 5

TheCenters forDiseaseControl&Prevention’s immunizationadvisorycom-mitteerecommendedthatallchildrenunder5andover6monthsbevaccinatedagainstinfluenza,currentguidelinescallforchildren6to24monthsoldbevaccinated.

Physicians shouldalsobeaware thateffectiveJuly1, itwillbeagainstCalifor-nialawtoadministermercury-containingvaccines—includinginactivatedinfluenzavaccinefrommultidosevials—topregnantwomenandchildrenyoungerthan3yearsold.Nextfluseason,onlydosesofinfluenzavaccine fromsingle-dose syringesorvialswithtracelevelsornomercurymaybegiventothesegroups.

Contact:RobinFlagg,415/[email protected].

Physicians, Beware of Mislead-ing Medem invoices

AnumberofphysicianshavereportedtoCMAthattheyhavereceivedunsolic-itedinvoicesfromMedem,chargingthem$195 for “PracticeWebSiteand iHealthServices.”Physiciansshouldbeawarethattheseinvoicesareoffersofservice,notac-tualbills.Whiletheservicesbeingofferedarelegitimate,youdonotneedtopaythe“invoice”unlessyouactuallywanttosignupforMedem’sservices.

CMA has expressed its concern toAMA,apartownerofMedem,aboutthese

misleadingsolicitations.AMAhasassuredCMAthatitisworkingwithMedemtostopthisuntowardmarketingpractice. In themeantime,physiciansshouldinformtheirofficestaffofthisissue.

Contact:CMA’slegalinformationline,415/[email protected].

cMa Sponsors Bill to eliminate Physician Participation in execu-tions

Reacting toanattemptby stateof-ficialstohavephysicianstakeanactiveroleinexecutingMichaelMorales,aprisoneratSanQuentinStatePrison,CMAannouncedthisweek that it is sponsoringabill thatwouldeliminatephysicianinvolvementinallfutureexecutions.

“Physiciansshouldbetreatingpeople’sillnesses,notparticipating in theirexecu-tion,” saidCMACEOJackLewin,M.D.“Participationinanexecutiongoesagainstlong-standingprinciplesofprofessionalethicsandisaviolationoftheHippocraticoath:First,donoharm.”

CMAhasa longhistoryofopposingphysicianparticipationinexecutions.

Contact: CMA Media Relations,916/[email protected].

cMe offerings This is just a samplingof courses avail-able from theUCSFofficeofCME seehttps://www.cme.ucsf.edu/cme/index.aspx?Display=Date&year=Cforacompletelist.UCSFOfficeofContinuingEducationRegistrationOffice-415-476-5808Hours:7:30-4:00

CME and Pain Management and End-of-Life Care

WiththepassageofCaliforniaAssemblyBill487inOctober2001,physicianslicensedinCaliforniamustcomplete12hoursofCMEintopicsassociatedwithpainmanagementand/orend-of-lifecarebyDecember31,2006.Duetolimitedpatientinteraction,radiologistsandpathologistsareexemptfromthisrequire-ment.Thisisaone-timerequirementmeanttobecompletedbytheendof2006.

UCSFCMEoffersanannuallivecon-ference,whichmaybefoundonourwebsite.UCSFalsooffersChallengesofManagingPainSymposium(ChaMPS)attheirPainManagementCenteratMt.Zion.TheyholdabimonthlyseminarinHerbstHall(RoomB-248) focusingonvarioustopicsofpain,andaredesignedtomeettherequirementsofAB487.Youmaycontactthemdirectlyat415.885.7272.

IfyouhavequestionsaboutthisCMErequirement,pleasecontacttheUCSFOfficeofCMEat415.476.4251.

Pain Management and End-of-Life CareSunday,June04-Monday,June05,2006SanFrancisco,FairmontHotel27thAnnualAdvancesinInfectiousDiseases:NewDirectionsforPrimaryCareWednesday,April26-Friday,April28,2006SanFrancisco,HotelNikko

Current Issues in HIV Care: Pain Manage-ment and End-of-Life Care for HIV/AIDSMonday,May15-Tuesday,May16,2006SanFrancisco,PresidioGoldenGateClub

Essentials of Women’s Health: An Inte-grated Approach to Primary Care and Office GynecologySunday, July02-Friday, July07,2006BigIsland,Hawaii,HapunaBeachPrinceHotel

dMHc’s Financial Solvency re-porting rules do not apply to individual Physicians, do apply to risk-Bearing Groups/iPas

CMAhas learned that thecurrentissueofPacifiCare’sprovidernewsletterin-cludesinaccuraciesabouttheDepartmentofManagedHealthCare’s(DMHC)financialsolvencyreportingrequirements(underSB260).Thearticle,“HowtoComplywithSB260,”erroneouslystatesthatallphysicianswithhealthplan contractsmust submitquarterlyandannualfinancial statementsand“correctiveactionplans”toDMHCandtoeachcontractinghealthplan.

CMAremindsphysiciansthatthestate’s

continued on p29

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David E. Smith, MD

LeTTer To THe ediTor

End of An EraDearColleagues:

IfeelcompelledtowritetomyfriendsandcolleaguesintheSFMS,asthemedicalsocietyhassupportedmeandtheHaightAshburyFreeClinics(HAFC)sinceourinceptionin1967.Youmayhavereadorheardrecently,intheChronicleorontelevision,thatIhaveresignedasmedicaldirectoroftheHAFC.

TheHAFCwasfoundedwiththemotto“healthcareisaright,notaprivilege”andwewerecommittedtothatvisionfor39years.Manylocalphysicianshavetrained,worked,andcontributedtousduringthoseyearsandknowthatweprovidedprimaryandothercarewithoutregardtothepatient’sabilitytopay.Duringthattime,manyofyou,andI,workedforfarlessthanwewouldanywhereelse.Westruggledattimes,butkepttruetoourvisionandsetstandardsinnewtreatments—especiallyinaddictionmedicine,clinicmodels,publications,andmore.Thoseofuswhospentmuchtimethereareproudofthis,ourchosenlife’swork.

InrecentyearstheHAFCwasvictim-izedbyembezzlement,amostdestructivedevelopment. In thepastyearwehadbeenrecovering fromthat setbackbyinstitutingamorecorporatestructureand leadership team. This was,and is, essential, but it alsoposes some risk to medicalstandards, ethics, and par-ticularly theguidingvaluesoftheHAFC.

If there is one lessonI would like to impart tomycolleagues in thiseraof“medical”foundations,letitbethatyouneverlosemedi-

calcontrolofwhereveryouchoosetopractice.InowfearthatmanyofSanFrancisco’sneediestpatientsmaysuffer.

MysinceregratitudegoesouttoeveryphysicianandthoseattheSFMSwhohavebeensupportivethroughthepast39years.Iwillremainactiveinthefieldsthathaveinspiredmethroughthesedecadesandhopetoseemanyofyouagain.

Sincerely,

DavidE.Smith,MD

Dr. David E. smith and george Harrison at Haight Clinic benefitconcert, 1974

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We Have Moved and We are Moving

eXecUTiVe MeMo

TheSanFranciscoMedicalSocietysuccessfullysolditshead-quartersin2005andmadethemovetoournewlocationinthePresidioinJanuary2006.Itwasquiteafeatdownsizing

from15,000squarefeettojustover3,000butthemovewentsur-prisinglywellthankstothehardworkoftheSFMSstaffandthecoordinationeffortsofourDirectorofMembership,TheresePorter.Ournewaddressis1003AO’ReillyAvenueandweencourageyoutocomebyandseethenewoffices.WeareholdinganopenhousetoshowoffournewplaceinApril.

ThismovemarksthebeginningofanewerafortheMedicalSociety.LastNovembertheBoardofDirectorsheldaplanningsessiontostrategizeaboutthefutureofSFMS.FromthissessionemergedfourareasthatSFMSwillfocusonforthenextseveralyears:membership, information technology,political advocacyandfellowshipandwellness.Dr.StephenFollansbee,theSFMSPresident-electisservingaschairoftheMembershipServicesCom-mitteetodevelopourmembershipagenda.Dr.TomLeeisheadingthe InformationTechnologyCommitteeand isoverseeingourwebsitedevelopment.SFMSPresident,Dr.GordonFung,chairsthePoliticalAdvocacyCommitteeandimmediatepast-president,AlanGreenwald,ischairingtheFellowshipandWellnessCommittee.

Asaresultofthisplanningsession,SFMSwillalsobeconduct-inganeedsassessmentofthemembershipinthenextfewmonths.ThepurposewillbetoelicitfromourmemberswhattheSocietycandotobestservetheirneedsandtodeterminethevalueoftheservicesand informationwecurrentlyprovide. Wehope thatmanyofourmemberswillrespondtotheshortquestionnairethatwewilldistribute.

Anothermajoreventof thepastyearwas theoverhaulofourwebsite.Ouraddressremainsthesame,www.sfms.org,butwehavechangedthelookandthecontentandwillbeworkingondevelopinginteractivefeaturesthatwillbetterserveourmember-shipandthepublic.

Coincidingwithourmoveandourself-assessmentisasignifi-cantincreaseinourmembershipnumbersfor2006.Perhapsournewspiritandournewdirectionarealreadypayingoff.

The sfms Board of Directors Invites All members to:

THe SFMS oPen HoUSe

Come see our new headquarters in the Presidio

Friday,April283-6PM

Hors d’ouvres and refreshments

1003AO’ReillyAvenueBetweenGorgasandTorneyAvenuesinthePresidio

SanFrancisco

rsVP to Carol Nolan at 561-0850, ext. 0 or [email protected]

Directions from Lombard street: Enter through the Lombard gate.

Take the second right onto Presidio Blvd.Take the second right onto Torney Ave.

Drive to end and turn left onto o’reilly Ave. Look for parking.

or Continue past the Lombard gate, past Lyon street and take the Chrissy field exit on the far left At the stop sign turn left onto gorgas Ave. Travel straight on gorgas to o’reilly Ave.(about

one long block)Turn right and look for parking.

Mary Lou Licwinko, JD, MHSAExecutive Director

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Gordon L. Fung, MD, MPHPresident

Health Advocacy– A Good Lesson

PRESIDENT’S MESSAGE

Over the past years of involvement in the SFMS, I have beenin awe of how some people were just more aware of the cityand state political scenes and how they were able to inter-

vene or give input to make a difference. They always seemed justas busy, if not busier, than me doing all the things necessary to runa full practice, but they seemed to be the go-to people—the peoplelegislators turned who had the pulse of the city or state. And as soonas thepublicfirstheardof theactualproblemor issue, theseadvocateswere knee deep in the discussion trying to find the solution or wereready to announce a compromise. From the SFMS standpoint, theissues were always pertinent to the health of San Francisco residentsand the resolutions were usually better with the input of the SFMSthan prior to our involvement.

Just last month, I had an opportunity to be one of those peoplewho was able to respond to a serious problem that would have af-fected the health of the entire state and nation. The EnvironmentalProtection Agency (EPA) was convening public hearings on itsrecommendations for air quality standards. When the EPA wasestablished, the regulations stated that it must review the air qualitystandards every five years and revise them to protect the health ofthe American public.

The scientific committee had reviewed the best scientific evi-dence to date and recommended that the Bush Administration andtheEPAadoptairquality standards thatwoulddecrease themortalityfromair pollutioncauseddiseases– e.g., severalkinds of cancers, lungdisease, heart disease, and stroke. The American Lung Association,American Cancer Society, and other reputable healthcare organiza-tions weighed in and supported the recommendations of loweringthe annual standard PM2.5 to no greater than 12 micrograms percubic meter and a daily standard of no greater than 25 microgramsper cubic meter. They also recommended that the EPA not allowa waiver for agricultural industry on large particulate matter. TheEPA seemed to ignore the recommendations of all these reputablescientists, the scientific and health care communities, and their ownscience committee and recommended the status quo which hadbeen estimated to account for over 1100 deaths per year. In order tosupport stronger standards the ALA, ACS, and ATS even modeledprojections to predict the death rate from these particulate mattersat different levels. The savings was over 600 lives. It seemed outra-geous that thegovernmentalorganizationestablishedtosetairquality

standards for the protection of the public’s health would ignore therecommendations of the scientific community.

Asyourpresident,IwasaskedifIcouldspeakatthehearing.Afteraquickreadof thesituationandthe fact sheetof recommendationsof thescientificcommunity,Iwasmovedtomaketimetodothis.Airpollutionissomethingthatweinourclinicalpracticescandonothingaboutexceptto recommend that our patients move to other parts of the country, orworld,wheretheairqualityisbetter.SoIpreparedmyremarksandspokeas your elected officer. I presented my own experience of how air pollu-tion has increased the number of my patients that end up in emergencywardsthroughoutthecityinasthmaticexacerbationsorwithchestpain,and how some of my patients who have heart attacks and strokes don’thave any measurable traditional risk factors and yet are victims of thesedevastating diseases. The current literature suggests that air pollution isa contributing factor.

Afterwards, I was overcome with a great feeling of being able tohelp by being at the right place and time. I gave the EPA a perspectivefromthephysicianscaring forpatients thatwouldbethevictimsof theirdecisions on air quality. Even though the outcome is not yet known,participating in this advocacy effort has been a tremendous experienceforme.Notonlywas Iable to talkdirectly to thepeoplewhoweregoingtomakethefinalrecommendations,Ilearnedmoreaboutenvironmentalmedicine and how much the government impacts the standards underwhich we live.

Ilearnedmanythingsduringthisexperience,nottheleastofwhichis that the government through its agencies need to be carefully moni-toredas theymakedecisionsthataffect thehealthof thepublicandthatphysiciansneedtobewillingtospeakoutwhenmoreappropriateactionscould save lives.Asphysiciansweareexpected toknowa lotabouta lotofthings inmedicineandnon-medicalthings.Whenwedon’tknowwetry to learn. And after we learn we use the criteria of doing what is bestfor our patients’ health based on the best science available. We need toadvocate this type of thinking to our governmental officials.

Another thing about advocacy is keeping up on the medical infor-mation and knowledge base to couple with our clinical experience andput the two together to practice more effectively. Just to let you know,the SFMS is sponsoring a major conference to discuss environmentalpollution and its effect on heart disease and cancer in October. Keepyour calendars open for a great educational conference.

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Mike Denney, MD, PhD

Kind Wisdom, Gentle Hands

EDITORIAL

In Greek mythology, the extraordinary centaur Chiron, whosename means hand, was revered by all on Mount Olympus andacknowledged as being sometimes wiser than even the gods and

goddesses. Apollo prepared his young son, Asclepius, to become theGreek god of healing by taking him to Chiron for training in theart and science of medicine and surgery. Chiron himself once curedthe blindness of Phoenix II, and he taught Achilles and Herculesabout surgical procedures such as treating various wounds of war.It was said that he was very kind and had a way of evincing thehighest potential of his students.

Chiron’s name is identified also with the ancient word forsurgery, chirurgia, a conjunction of thenoun chiron, hand, with the verb ergon,to work. Thus, the Random House dic-tionary defines surgery as: The art, prac-tice, or work of treating disease, injuries,or deformities by manual operation orinstrumental appliances.

This practice of working manuallywith instruments has become amazinglyhigh-tech over the years – diagnostic palpation and auscultationhave developed into electrocardiograms, angiograms, and advancedimaging techniques, while therapeutic manipulations with scalpelsand hemostats have progressed to minimally invasive endoscopicoperations, sonographic guided manipulations, and even endovas-cular surgery.

And, there is a twist to this mythological and historical narra-tive about the increasing use of hands and instruments for the treat-ment of patients. During the 18th century, when London hospitalsfirst opened casualty departments, when doctors began to advocatehands-on first-aid and mouth-to-mouth resuscitation, and when theItalian naturalists Galvani and Volti presaged heart defibrillationby electrically “reanimating” the dissected muscles of dead frogs,the English physician, William Buchan, published his best-sellingself-help handbook, Domestic Medicine, in which he stated flatly,“Every man is in some measure a surgeon whether he will or not.”

Aside from the period gender bias of such a statement, perhapsthis notion of the ubiquitous use of hands and appliances to helpthe sick and injured has manifested in the modern world by thereality that the bold manipulation with high-tech instruments has

become integral not only to surgery but in some measure to allspecialties of medicine, including radiology, cardiology, internalmedicine, and dermatology.

As in this issue of San Francisco Medicine we read in wonderabout sonographic screening for aortic aneurysms, endoscopic ab-dominal surgery, and neuroradiological endovasacular coiling andstents. We become highly impressed with how much more keen isthe vision of advanced imagery than the human eye can possiblyachieve even using various scopes, and we are astounded at howbold are these medical diagnostic and therapeutic pioneers who usesuch complex, high-tech techniques to probe and manipulate the

human body.Obviously, we must be cautious

about the increasing use of technologyin the healing arts. Not only do newtechniques bring new complicationsbut technology can distance us fromour patients and can cause us to viewthem too objectively – thus failingto acknowledge the healing power of

hands-on human contact and caring. In response to those concerns,we notice that these new methodologies, in the hands of a variety ofspecialists, are more gentle and far less invasive and wounding thanthe scalpel. Patients need less anesthesia, suffer less tissue damage,and recover much more comfortably and rapidly.

Yes, we might remember that on Mount Olympus Chiron wasrevered by all the gods and goddesses not only for his knowledge andwisdom. He was most admired for being kind and gentle.

And so it is that although our increased technology canthreaten to distract us from our patients, it can actually carry us toour highest potential if we follow the skills, wisdom, and kindnessof Chiron. Indeed, our new extraordinary technology offers us eyeswith the keenness of an eagle, hearts with the boldness of a lion,and hands that are ever and ever more gentle.

A surgeon must have . . .The eye of an eagle,The heart of a lion,The hands of a woman.

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Peter Hui, MD, FACC, FSCAI

Is Coronary Bypass Surgery Obsolete in the Era of Drug-Eluting Stents?

Less than 3 decades ago, coronarybypass grafting was only treatmentoption for patients with medically

refractory angina. In 2006 patients withcomplex, multivessel coronary artery dis-ease can be successfully treated with drug-eluting stents and be discharged within 24hours post procedure. The patient whoseangiogram is seen in figures 1 and 2 is suchan example. With results like this, havedrug-eluting stents rendered coronarybypass surgery obsolete?

An 84 year old man underwent coro-nary angiography because of progressiveangina despite medical therapy. He hassevere three vessel CAD but declinedsurgery. Percutaneous intervention wasperformed and he received drug-elutingstents in all 3 major coronary vessels. Hewas discharged the day after the procedureand has been asymptomatic after one yearof follow-up.

Brief history of percutaneous coronary intervention

In 1977 Dr. Andreas Gruntzig pio-neered the development of balloon angio-plasty (percutaneous transluminal coronaryangioplasty or PTCA) as a nonsurgicaltreatment of obstructive coronary arterydisease. Compared to bypass surgery, pa-tients treated successfully with balloonangioplasty had a lower risk of periproce-dural MI, stroke and death and were ableto resume normal physical activity withindays. However, up to 30-40% of patientsdevelop restenosis or renarrowing of thetreated site within the first six months after

FIGURE 1: 90% stenosis of the proximal left anterior descending artery and 90% stenosis of the mid circumflex artery

angioplasty. More than 50% of those whodeveloped restenosis have significant symp-toms or noninvasive test abnormalitiesand will require a second revascularizationprocedure, either repeat PTCA or bypasssurgery. The mechanism of restenosis iscomplex, but the three most importantfactors are elastic recoil,neointimal hyperplasia(scar tissue formation)and negative vascularremodeling (shrinkageof the treated segment).Multiple trials havefailed to identify any ef-fective pharmacotherapyto prevent restenosis.Several major clini-cal studies comparingPTCA to coronary ar-tery bypass surgery haveshown equivalent 3-5year survival and MI rates in non-diabeticpatients randomized to either treatment.However, the need for a second procedurewas significantly higher in those treated

with PTCA. Restenosis has therefore beencalled the Achilles’ heel of percutaneousintervention.

In the mid 1990’s the Gianturco-Rou-bin stent was introduced to treat coronarydissections and threatened vessel closureduring balloon angioplasty. This first gen-

eration coil stent wasapproved for bailoutuse only and it wasable to reduce therate of emergencybypass and improvethe overall safety ofPTCA. The Palmaz-Schatz (PS)stentwas later released fortreatment of de novocoronary stenosis. Byproviding mechani-cal scaffolding of thediseased segment, the

stent prevents both elastic recoil and nega-tive remodeling. In the pivot clinical trialscomparing PTCA and stenting, the PSstent was found to lower the restenosis rate

In 2006 patients with complex, mul-tivessel coronary artery diseasecan be successfully treated with drug-eluting stents and be discharged within 24 hours post proce-dure.

HANDS AND HIGH TECHNOLOGY:MINIMALLY INVASIVE SURGERY

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FIGURE 2: 99% subtotal occlusion of the distal right coronary artery

Over the last two years, larger clini-cal registries of “real world” use of the DES have shown that this stent is not a magic bullet and it has not completely eliminated resten-osis.

to 15-30% and the repeat revasculariza-tion to 10-15%. The rate of acute vesselclosure and emergency bypass surgeryduring coronary intervention was alsodramatically reduced. The improvedsafety and durability of results achievedwith coronary stenting expanded thepatient and lesion subsets which are ableto be treated by percutaneous technology.Randomized trials of stenting versus by-pass surgery have also shown equivalentclinical outcome in survival and MI ratesafter 3-5 years of followup. However,patients treated with stents are still morelikely to undergo repeat procedures be-cause of restenosis.

Although the development of thestent was a major advance in interven-tional cardiology, restenosis still remaineda challenging problem in a significantminority of patients. Despite its abilityto prevent elastic recoil and negativeremodeling, the metallic stent inducesa greater degree of neointimal hyper-plasia at the treated segment comparedto balloon angioplasty. The ingrowth ofintimal hyperplasia within and sometimesbeyond the stent is termed in-stent re-stenosis. Managementof in-stent restenosisis a difficult problem,and until recently theonly effective treat-ment has been brachy-therapy or localizedradiation. In addition,stent thrombosis hasalso been recognizedas a complication ofthis new technologyand occurs in up to 1%of patients. The strutsof the stent are a nidusfor thrombus formation and the risk ofstent thrombosis is greatest within thefirst four weeks until endothelializationis complete. Although uncommon, stentthrombosis is a potentially catastrophiccomplication and is associated with a 25-50% fatality. The use of dual anti-platelettherapy is mandatory to minimize the riskof stent thrombosis. If aspirin and clopi-dogrel are discontinued prematurely, thelikelihood of stent thrombosis increases

substantially. Furthermore, patientstreated with brachytheray for in-stentrestenosis also have a higher risk of stentthrombosis. Despite the limitations of in-stent restenosis and stent thrombosis, thedevelopment of the stent was a landmarkbreakthrough in percutaneous coronaryintervention.

The drug-eluting stent-a magic bullet?

In 2003 the sirolimus-eluting stentwas approved by the FDA for treatment ofcoronary artery disease. The current gen-

eration of drug-elutingstent (DES) consists ofa stainless steel mesh,a polymer coveringand an anti-restenosisdrug contained withinthe polymer. The twoFDA approved stentsare the sirolimus andthe paclitaxel elutingstents. These drugsare released over aperiod of 30-90 daysafter implantation toattenuate the devel-

opment of neointimal hyperplasia.Sirolimus is a macrocyclic triene

antibiotic which has immunosuppressiveand anti-proliferative properties. It wasfirst discovered in Easter Island where theactinomycete Streptomyces hygroscopicuswas found to produce a macrolide antiobi-otic with antimitotic and immunosuppres-sive properties. Paclitaxel is a drug isolatedfrom the Pacific yew tree (Taxus brevifo-lia) and is the active ingredient in Taxol,

which has been used in the treatment ofbreast and ovarian carcinoma. Both drugshave been shown to be highly effective inreducing neointimal hyperplasia.

The release of the DES was greetedwith great fanfare as the early clinicaltrials showed the angiographic restenosisrate to be near zero. These spectacularearly results raised the hope that coronaryartery disease could be treated with drug-eluting stents, and that bypass surgerywill become obsolete. However, over thelast two years, larger clinical registries of“real world” use of the DES have shownthat this stent is not a magic bullet and ithas not completely eliminated restenosis. Compared to the bare metal stent, DEShas significantly reduced the restenosisrate to 5-10%. However diabetic patientsand high risk, complex lesions such asbifurcation disease, left main stenosis,saphenous bypass grafts, and small vesselsremain challenging problems.

In addition, the risk for stent throm-bosis is potentially greater in patientstreated with a drug-eluting stent . Whilesirolimus and paclitaxel are highly effec-tive in preventing intimal hyperplasia,they also delay the complete endotheli-alization of the stent struts. The nakedstent struts are therefore exposed toblood for a longer period of time and 3-6months of continuous dual antiplatelettreatment with aspirin and clopidogrelis recommended. Premature interruptionof anti-platelet therapy can lead to stentthrombosis. Furthermore, there have beencase reports of late stent thrombosis occur-ring more than six months following theprocedure. Based on these observations,

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patientswhohaveundergonemultivesselor complex stenting have been recom-mendedtoreceive12monthsorlifelongantiplatelettherapytoreducetheriskoflate thrombosis. DES should thereforenotbeusedinpatientswhoaremedicallynoncompliant or in those will requireearlystoppageofASA/plavixbecauseofanticipatedsurgery.

In summary, the drug-eluting stentisanevolutionarytechnologicaladvancein interventional cardiology. Comparedto bypass surgery we are now able tosuccessfully treat many patients whohave complex coronary artery disease,achievingtheseresultswithalowerriskofperiproceduralmyocardial infarction,strokeanddeath.ComparedtoPTCAandbaremetalstents,restenosisandtherateof repeat intervention are significantlyreduced, but not entirely eliminated.Several randomized trials comparingoutcomes achieved using DES versusCABGareongoinginpatientswithcom-

plexcoronaryanatomysuchasleftmainand/ormultivesseldisease.Theresultsoftheseimportanttrialswillhopefullyhelpus develop the best treatment strategyforourpatients.Untilthenthedecisionto perform percutaneous interventionor CABG in an individual patient willbe influencedbythecoronaryanatomy,comorbid medical conditions, surgicalrisksandpersonalpreferences.Inpatientswith left main or multivessel diseaseand decreased left ventricular function,coronaryarterybypasssurgeryisingeneralrecommended. In2006,coronaryarterybypasssurgeryremainsanimportantpartofourtherapeuticarmamentarium.

Dr. Hui is the Medical Director of the Coronary Care Unit at California Pacific Medical Center. He is recognized as one of the leading interventional cardiologist in the Bay Area and has implanted over 1200 drug-eluting stents since 2003.

RENEW is Coming to the San Francisco

Medical Society!

The Medical Society will be introducing a RE-

NEW program for the members of the San Francisco

Medical Society in the very near future.

Founded and led by Linda Hawes Clever, MD,

MACP, RENEW’s methods are based on her 25

years experience as an internist and occupational

health specialist. RENEW was developed to help

people who juggle work, family and community

commitments sustain - or regain - their enthu-

siasm, effectiveness and purpose. The personal-

professional intersection can be treacherous – and

RENEW helps people explore and reaffirm values,

then tap deep sources of energy, motivation, and

talent so we all can move ahead with optimism, as

we build community and reclaim vitality and joy in

our work and lives.

Dr Clever and the medical Society are devel-

oping a pilot program tailored to the unique needs

of the Society’s membership. The first meeting will

be in July, details to be announced in the next issue

of San Francisco Medicine.

For more information on RENEW, visit www.

renewnow.org.

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Randall Higashida, MD

Interventional Neuroradiology: Less Invasive Approaches For The Treatment Of Complex Cerebrovascular Diseases & Stroke

Interventional neuroradiology/endovas-cular neurosurgery has recently emergedas a new medical subspecialty over the

past 2 decades, with its own specializedtraining program which is now ACGMEapproved. This relatively new subspe-cialty of medicine, combines the imagingtechnology based within Radiology, thetechnical skills derived from Neurosurgery,and the clinical evaluation and acumenof the Stroke Neurologist, from which toperform the “minimally invasive procedureof brain surgery through an endovascularapproach from within the blood vessels ofthe brain”.

Interventional neuroradiology began inthe mid-1980’s as an adjuvant technologywithin diagnostic neuroradiology, to dealwith the treatment of complex intracranialvascular diseases, such ascerebral aneurysms,arteriovenous malformations, and traumaticvascular injuries to the head, neck, brain,and spinal cord. It was initially offered topatients in whom traditional neurosurgicalapproaches by craniotomy, were not fea-sible, or in whom neurosurgery procedureshad high rates of surgical morbidity andmortality.

As an alternative to traditional openneurosurgery, interventional neuroradiologyis now providing therapy for patients withruptured and unruptured brain aneurysmsby endovascular coiling techniques, carotidand intracranial atherosclerosis therapy byballoon angioplasty and stenting, acutestroke therapy with mechanical clot extrac-tion and/or intra-arterial cerebral throm-bolysis, and also an adjunct prior to surgery

for vascular tumors of the head, neck, brain,and spinal cord.

Acute Ischemic StrokeAccording to the American Heart

Association, acute stroke in the UnitedStates resulted in >750,000 new cases peryear, is the 3rd leading cause of death, is theleading cause of adult disability, and currentcosts now exceed $50B dollars annuallyfor treatment and due to lost productivity.Following an acute stroke, one-fourth of

patients die, and one third are significantlydisabled. The major cause for stroke is dueto thrombo-embolic disease, usually fromcarotid or cerebral atherosclerosis, smallvessel occlusion, and/or atrial fibrillation. In 1996, the FDA approved the use ofintravenous tissue plasminogen activator,given within 3 hours from acute strokeonset. Unfortunately, <3-5% of all strokepatients currently receive this treatment,due to the short time window.

In 2005, the U.S. FDA approved anew device, the Concentric Merci ClotRetriever, indicated for use in patientsbetween 3-8 hours of stroke onset, withan angiographically demonstrated clot ina major cerebral artery, amenable to thisform of therapy. The national PrincipalInvestigator for this trial, Dr. Wade Smith,is Chief of the Stroke Neurology Divisionat UCSF Medical Center. He successfullydirected this large, multi-center, prospectivetrial in an effort to gain approval, as thefirst medical device worldwide, specificallyindicated for clot retrieval, during an acuteischemic stroke. This study demonstratedthat in patients suffering an acute stroke,and in whom clot extraction is successful,there is a significant rate of neurologicalimprovement with a decrease in overallmortality, associated with successful reperfu-sion. (Figure 1)

Carotid Stenting For Cerebral Atherosclerosis

Carotid atherosclerosis accounts for15%-20% of all strokes in the United States.Last year it was estimated that there were

FIGURE 1: Picture demonstrating a blood clot in the middle cerebral artery of the brain, a common location, due to carotid atherosclerosis or atrial fibril-lation, leading to an embolic stroke. Techniques have now been developed, which allow the interventional neuroradi-ologist the ability to mechanically remove the clot, from an endovascular approach, under X-ray visualization, and open up the blockage in the brain blood vessel to restore normal blood flow.

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150,000-175,000 carotid revascularizationprocedures performed. Carotid surgeryby endarterectomy has now been provento be superior to best medical therapy forsymptomatic patients with carotid athero-sclerosis >50%, and in several other trials forasymptomatic carotid atherosclerosis >60%,for stroke prevention. In the past 5 years,a number of trials have now been reportedcomparing the less invasive technique of ca-rotidartery stentingvs. carotidendarterecto-my,asanalternative to“open” surgery.Thesestudieshavedemonstratedthat in“high-risk”

surgical or medical patients with significantcarotidatherosclerosisof>50%-70%,carotidartery stenting was equivalent to surgery, forprevention of recurrent stroke or death, andhad less procedure morbidity and mortality,particularly for myocardial ischemia, sincethe procedure is performed under local vs.general anesthesia. (Figure 2)

Based upon these trials, the FDA hasrecently approved the technique of carotidartery stenting as a treatment alternative tocarotid surgery, in certain “high risk” groupsof patients. The UCSF InterventionalNeuroradiology section, participated in anumber of these trials, and UCSF Medi-cal Center is now currently approved byMedicare (CMS) as an approved site forperforming carotid artery stenting.

There are further on-going trials in-cluding the NIH sponsored CREST (Ca-

rotid Revascularization of Endarterectomyvs. Stenting Trial), which is now directlycomparing carotid surgery vs. carotid stent-ing for “low risk” patients with moderate tosevere carotid atherosclerosis for primaryand secondary stroke prevention.

Cerebral Aneurysm TherapySubarachnoid hemorrhage due to rup-

ture of a brain aneurysm, carries a 30%-40%risk of death, and a 50% risk of irreversiblebrain injury in patients who survive theirinitial bleed. Traditional surgery involvesa craniotomy, exposing the aneurysm, andplacing a surgical clip on the neck of theaneurysm.

In 2002, a landmark study called ISAT(International Subarachnoid AneurysmTrial) was published, which was a prospec-tive, randomized, multicenter clinical trial,directly comparing surgical clipping vs. theless invasive technique of endovascularcoiling to treat patients who presented witha ruptured brain aneurysm. A total of 2143patients were evaluated over an 8 year pe-riod. The trial was prematurely stopped bythe Steering Committee, after the interimanalysis demonstrated a 23% reduction independency or death in patients treatedby endovascular coiling. The conclusionfrom this trial was that in “patients with aruptured intracranial aneurysm, for whichendovascular coiling and neurosurgical clip-ping are therapeuticoptions, the outcomein terms of survivalfree of disability at 1year is significantly bet-ter with endovascularcoiling”. This trial hassignificantlyaltered theway patients are nowbeing treated world-wide, with a trend to-wards the less invasivetechnique of endovas-cular coiling performedin the neuroradiologysuite instead of the operating room.

The UCSF Cerebrovascular Serviceworks as a team, and is composed of full timespecialists in InterventionalNeuroradiology,Vascular Neurosurgery, Stroke Neurology,

Neurocritical Care, and currently has oneof the busiest services in the United States,treating >250 new patients per year witha brain aneurysm. (Figure 3) A recentanalysis of patients treated, continue todemonstrate overall better outcomes for pa-tients, when treated by this “team approach”

in which expertise frommultiple specialized ser-vices are involved in theoverall management ofthese patients.

SummaryMinimally inva-

sive neurosurgery, alsoknown as interventionalneuroradiology/endo-vascular neurosurgery,has made significantadvances over the past2 decades, and has now

emerged as a new subspecialty within theoverlapping fields of neurosurgery, neuro-radiology, and neurology. Almost everymajor academic hospital now offers thesetreatments routinely to patients as an alter-

The FDA recently approved the tech-nique of carotid artery stenting as a treatment alterna-tive to carotidsurgery in certain “high risk” groupsof patients.

FIGURE 2: Placement of an endovascu-lar stent in the carotid artery for treat-ment of carotid atherosclerosis.

FIGURE 3: MRA brain scan demonstrat-ing a large aneurysm of the basilar ar-tery. The combined expertise of a “team approach” by interventional neuroradiolo-gists, neurosurgery, stroke neurology, and neuro-anesthesiology, has signifi-cantly improved the overall outcome for many of these patients.

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nativetotraditional“openneurosurgical”procedures.Inthisveryshorttimeperiod,interventionalneuroradiologyisnowbeingofferedasaviablealternativetopatientswithbothrupturedandunrupturedbrainaneurysmsfortherapy;treatmentof“high-risk”carotidatherosclerosisby stentingvs. carotidendarterectomy;acutestroketherapyinterventionwhenpatientspresentwithina6-8hourtimeintervalfromsymptomonset;andothercomplexdiseases suchas intracranialatherosclerosis, traumaticvascularlesions,andvasculardisordersofthehead,neck,spinalcord,andotherpartsofthebody.

referencesHigashida RT: Evolution of a new multidisciplinary subspecialty:

Interventional Neuroradiology/Neuroendovascular Surgery. American Journal of Neuroradiology. Volume 21, Pages 1151-1152. 2000.

International Subarachnoid Aneurysm Trial (ISAT) Collabora-tive Group: International Subarachnoid Aneurysm Trial (ISAT) of Neurosurgical Clipping vs. Endovascular Coiling in 2143 Patients With Ruptured Intracranial Aneurysms: A Randomized Trial. Lancet; Vol 360; October 26, 2002, 1267-1274.

Dr. Randall T. Higashida is Chief of the Division of Interventional Neurovascular Radiology at the University of California, San Francisco Medical Center. He is a world expert in the area of stroke therapy, endovascular treatment of complex cerebral vascular disorders includ-ing brain aneurysms, arteriovenous malformations, and carotid and intracranial atherosclerosis.

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Gaetano Zanelli, MD

Non-Surgical Techniques and Modalities for Skin Rejuvenation

HandS and HiGH TecHnoLoGY: MiniMaLLY inVaSiVe SUrGerY

Thepastdecadehasseenanexplosioninthenumberofdevicesandtech-niquesforrejuvenationoftheaging

face.Thisisundoubtedlyfueledbyanagingpopulationsubstantiallypreoccupiedwithpersonalappearance,andagreaterpercent-ageofsocietywiththefinancialmeanstopayforcosmeticproceduresandproducts.The promotion of youth and physicalbeauty in themediaandcompetition intheworkplaceareonlysomeofthemajorexternal influences thatdriveprocedureswhichpeoplebelievewill enhance theirbeautyand thus their lives.Thedemandfornon-surgicalmethodsof rejuvenationwithlittlehealingtimeincreasessteadily,withaparallel increase inthenumberofphysicians and non-physicians offeringtheseservices.Thisisashortoverviewofsomeofthenewandnotsonewmodalitiesforrejuvenation.

BotoxBotulinumToxintypeA(BTX-A,“Bo-

tox”)hasbeenusedtocounteractmuscularhyperactivityformorethan20years,andin1990thefirstpublishedreportsappearedconcerningitsusetocosmeticallyimprovefacial linesandwrinklessecondarytody-namicmotion.Thisreductionofmuscularactivityiscausedbychemodenervationduetoacetylcholineblockadeatthepresynapticneuromuscular junction. ThefirstFDAapprovedcosmeticusedofBTX-Awasforglabellarfurrowscausedbythecontractionofthecorrugatorsupercilii,orbicularisoculi,andprocerusmuscles.Atthesametimeitwasalsobeingused to improvewrinkles

oftheforeheadduetocontractionofthefrontalismuscle,and“crows feet”aroundtheeyesfromcontractionofthelateralpor-tionoftheorbicularisoculi.SkillfuluseofBTX-Acanallowaphysiciantoshapetheeyebrowarchofapatient,femaleespecially,andevenopentheeyesafewmillimetersforarejuvenatedlook.

Botulinumtoxinadvancedtechniquesarenowemployedforthelowerface—ad-vancedbecauseonemustbeverycarefulintheamountandplacementoftheBTX-Ainordertoproducethedesiredeffectyetavoid over treatmentof the target muscleswhich would result inundesiredmuscularlax-ity. Treatment of theorbicularis oris musclewillreduceperioralrhyt-ides, and down-turn-ing of the oral anglesand melomental foldsor so-calledmarionettelinescanbeimprovedbytreatmentofthedepres-sor anguli orismuscles.BTX-A injected intothe mentalis muscle will decrease chincreasesanddimplingofthechinskinuponcontraction.BTX-Amayalsobeusedfor“bunny”linesofthenose,melolabialfoldsincertainpatients,facialasymmetry,anduppergingivalshow.Horizontalcreasesoftheneckskin,verticalplatysmalbanding,and décolletage wrinkling can also beimprovedwithBTX-A.

Thesearchfortheidealinjectablemate-rialforeffacementoffacialrhytidesandfoldscontinuesandinthepastfewyearsseveralnewagentshavemadetheirappearance,anddisappearance,fromtheAmericanmarket.Theperfectfillerwouldbeeconomical,safe,andeffective. Itwouldbe freeofadversereactionsand long lastingorevenperma-nent.Medicalgradesiliconeusedinamicrodroplettechniquecomestheclosestofanymaterial.AtthistimeitisFDAapprovedforintraocularinjectionbutnotforsofttissueaugmentation.ItsoverwhelmingsuccessforcorrectionoffaciallipoatrophyduetoHIV

diseaseandtreatmentwillhopefully leadtoitsapprovalforthisin-dicationinthenottoodistantfuture.Untilafewyearsagotheonlyapproved injectablefiller in the UnitedStateswasbovinecol-lagen,andsince thattimeseveralotherin-jectable collagensofhuman and porcineoriginshaveappeared.In most cases their

longevityofcorrectionisdisappointingandwhileadditionofotherelements suchaspolymethylmethacrylatemicrosphereswillresultinlongerlastingaugmentation,thesideeffectprofileisunacceptableformanyjudi-ciousphysicians.Severalgradesofinjectablehyaluronicacid(HA)arenowavailablesuchas“Restylane”Hylaform”,and“Captique”withmoreonthehorizon“Juvederm”.

The demand for non-surgical meth-ods of rejuvenation with little heal-ing time increases steadily with a par-rallel increase in the number of physi-cians offering these services.

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While HA treatments often do last afew months longer than collagen, clinicalexperience does not seem to replicate thelongevity claims of manufacturers and theirspokespersons. Very often the best results areachieved with a large amount of material,and this is prohibitively expensive for mostpatients. Radiesse’ is an injectable form ofcalcium hydroxylapatite microspheres usedby some for melolabial fold augmentation.It can last as long as a year but is not yetapproved for that indication. Injectablepoly-L-lactic acid (Sculptra”) was approvedlast year by the FDA for volume correctionof lipoatrophy due to HIV disease and treat-ment. Subdermal injection of the materialinduces an inflammatory reaction that forsome patients results in collagen deposition,which produces an often satisfying but tem-porary correction of the facial defects. Thehigh cost, temporary effect, and relativelyhigh rate of palpable and sometimes visiblegranuloma formation with Sculptra makeit a disappointing option for soft tissuevolumization. The manufacturer of Sculptrais aggressively marketing the product to pa-tients and physicians for correction of non-HIV lipoatrophy due to general aging.

Chemical Peeling AgentChemical peels causing ablation of

the stratum corneum and papillary dermishave long been the standard method fornon-surgical rejuvenation of facial skin andin skilled hands the appropriate patient canreceive beautiful results with resolution ofdyspigmentation, rhytid effacement, reduc-tion of solar keratoses, and general improve-ment of skin tone and texture. Lighter peelsare performed with glycolic and salicylicacids and Jessner’s solution, medium depthpeels with 30-35% trichloroacetic acid(TCA), and deeper peels with 50% TCA,and phenol and croton oil. As one wouldexpect, the deeper the peel the moredramatic the results, but risks of scarringand hypopigmentation increase with thedeeper peels.

Laser TherapiesThe advent of lasers to treat aging skin,

by the principle of selective photother-molysis, brought an exciting new tool intothe discipline of non-surgical rejuvenation.

With the pulsed carbon dioxide laser anderbium laser one can achieve rhytid efface-ment equal to a deep chemical peel withthe added benefit of collagen contractionsecondary to the thermal injury by the lasers. The surge in popularity of this procedure inrecent years has been tempered because ofthe unfortunate side effects of long-term ery-thema and even permanent hypopigmenta-tion of the treated areas in many patients.Many patients and physicians are unwillingto bear the risks of infection, scarring andhypopigmentation as well as healing timeassociated with aggressive ablative proce-dures, and this is in part responsible for theongoing search for methods of nonablativerejuvenation.

New devices for facial rejuvenationsuch as lasers utilizing less immediately de-structive methods of stimulating new colla-gen production appear almost monthly. Theattraction of these modalities to patientsand especially non-physician practitionersis their non-surgical approach with a shorthealing time. They often require severaltreatments for a desired effect, which maystill not be very dramatic. The least invasiveof these devices include microdermabrasionunits utilizing aluminum oxide or salt crys-tals and suction to superficially ablate andmassage the skin. Intense pulsed light (IPL)devices, unipolar and bipolar radiofrequencydevices, Nd:YAG, diode and pulsed dyelasers, fractional photothermolysis erbiumlasers (Fraxel’), and infrared heating unitsare all being used for nonablative rejuve-nation. Fractional photothermolysis is aninteresting and promising concept in whichthe skin is treated fractionally with patternsof microscopic laser spots, resulting in aunique wounding and healing process. Theexact mechanism by which these devicesproduce skin rejuvenation has not beenthoroughly elucidated but is thought to oc-cur by stimulation of fibroblast productionof new collagen through heat denaturingof tissue.

The Future of Skin RejuvenationResults of nonablative rejuvenation

are often not reproducible and it is thethought of many experts that the releaseof new devices is occurring before the sci-

ence of the process is clearly established.Complications of scarring and dyschromiacan and do occur even in the best of hands.Laser companies aggressively market theirdevices to physicians and other potentialbuyers with promises of exorbitant increasesin their practice profits. This may happentemporarily, but as a result of the lack oflong-term clinical experience with thedevices the reality is that clinical trials arebeing played out in physicians’ offices and“medi-spas” on paying patients.

Some devices which were touted bytheir companies and physician spokespeoplejust a few years ago as being miracles ofrejuvenation are no longer being used be-cause the technology is already obsolete ortoo many complications resulted with thedevices. As an example: in the week of Janu-ary 3, 2006, you may see offered on eBay anEpiLight’ device for $10,000 and a CuteraCoolGlide’ laser for $29,000. These unitsoriginally sold for $150,000 and $90,000,respectively, and were marketed by theircompanies as the solution for permanenthair reduction. Safer and more effectivelasers and intense pulsed light devices havenow superseded them. It is certain that inthe near future we will see the continuedintroduction of new techniques and devicesfor skin rejuvenation as the technologyprogresses and the demand undoubtedlycontinues.

Gaetano Zanelli is Assistant Clinical Professor in the Depart-ment of Dermatology at UCSF and has a practice at the Davies Campus of California Pacific Medical Center.

He has been published in the Journal of the American Academy of Dermatology, Clinics in Dermatology, and the Journal of the American Society for Laser Medicine and Surgery.

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Gretchen A.W. Gooding, MD

Screening for Abdominal Aortic Aneurysm with Ultrasound Can Save Lives

HANDS AND HIGH TECHNOLOGY:MINIMALLY INVASIVE SURGERY

Anabdominalaorticaneurysm(AAA)isa dilated aorta, usually below the renalarteries, thatmeasuresonanterior/pos-

terior dimension, 3.0 cm or greater. Fig 1Abdominal physical examination for

abdominal aortic aneurysmisnotaccurate foranumberofreasons, includingmorbidobesity,which preclude detection of the abdominalaorta. At the other extreme, marked pulsa-tion in a thin normal person may simulatedisease.

A noninvasive way to look at theabdominal aorta and screen for aneurysm isavailable with ultrasound. Since about 9000patients die from AAA related disease eachyear in the United States, who should beconsidered candidates?

Q: Is your patient 65 to 75 years old , amale and a smoker or former smoker?

A:HeisatriskforAAA.ConsiderAAAscreening.

Q: How important is the number ofcigarettes smoked?

A: Patients who have smoked over 100cigarettes are felt to be at risk.

Q: Is your patient 65 to 75 years old, amale that has never smoked?

A: He may benefit from AAA screen-ing, but the prevalence of AAA is less thanfor smokers and the benefit must be weighedwith the potential that he could perhaps beharmedbyearlysurgerywithrisksofmorbidityand mortality.

Q: Should your 85 year old male patient

FIGURE 1: This is an ultrasound examination of a large distal abdominal aortic aneurysm in an elderly man which shows flow in color on this longitudinal image with a large amount of avascular mural thrombus anteriorly

be screened?A: Patients over 75 years

old may be at risk for AAA,but because of their decreasedlife expectancy and probableother co-morbid factors, theyare probably not suitable can-didates for screening. An alter-nate view from the consensusof theVascularSurgerySocietysuggests screeningmenfrom60to 85 years.

Q:Doesyourpatienthavea brother with an AAA?

A: Then, your patient isat risk for AAA, too. Male Patients 65 andover are at risk for development of an AAA.Brothers have a higher risk of AAA; sistershave a lesser risk.

Q: Is your patient an elderly woman?A: Since this is a low risk group, only

consider screening with strong family and /orsmoking history and serious cardiovascularrisk factors in female patients 65 or over sincescreeningprobablydoesmoreharmthangoodin these patients causing unnecessary worryand also carries the risk of possible early prob-ably unnecessary treatment.

Q: Is your patient less than 65 years andnever smoked?

A:You patient is at low risk and unlikelytobenefit fromAAAscreeningunless there isa strong family history of AAA..

Q: Is your patient diabetic?

A: Diabetes mellitus is not a risk factorfor AAA.

Q: Is your patient African American?A: The risk of AAA is reduced.

Q: If yourpatientwas screenedatage65,when should he be rescreened?

A: Those first screened at 65 years orgreater with normal values for the aorta needno further followup since the risks of develop-ing an AAA are quite low.

Ultrasound Screening:Ultrasound (US) is both sensitive and

specific for the diagnosis of abdominal aorticaneurysm. It is much cheaper than computedtomography (CT) or magnetic resonanceimaging (MRI) which studies can also detectAAA, and ultrasound has no radiation orotherrisksandnocontrastmaterial is requiredfor an abdominal aortic examination. Ultra-sound is the cost-effective study of choice for

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abdominalaorticscreening.Thestudyrequiresthe patient to lie supine, have some acousticgelplacedonhisabdomen,thenatechnologistglidesa transducerover theabdominal skintogenerate images of the abdominal contentsthat appear on a screen.

Occasionally, portions of the abdominalaorta are obscured by overlying bowel gas.Although the aortic root can be identifiedby US at the heart, the thoracic aorta usu-ally cannot be identified by ultrasound, sincethe surrounding air in the lungs diffuses theacoustic beam.

An abdominal aorta that is 3 cm orgreater in anterior/posterior diameter is aneu-rysmal.Patientswithasmallabdominalaorticaneurysm of 3 to 3.9 cm are usually followedannually. Those with 4 to 5.4 cm aneurysmsare likely to be followed at six month inter-vals. Vascular surgeons prefer to see patientswhen the aortic diameter is greater than 4.5cm. Those patients with aneurysms 5.5 cmor larger are candidates for consideration ofsurgery or endovascular stent. Surgical repairof large AAA of 5.5 cm or greater decreasesAAA mortality. Surgical repair of AAA hasa mortality of 4-5%. Screening of 65-75 yearoldmenreducesby43%AAAspecificmortal-ity. Screening for abdominal aortic aneurysmshouldalsoreducethenumberofpatientswhoare first detected with huge abdominal aorticaneurysms of 8-10 CM AP who have littlechance of survival with or without surgery orendovascular stent.

For an examination of the highest qual-ity, it is important that patients who are toget a screening ultrasound have it done byan accredited institution with credentialedtechnologists. Vascular accreditation is anindicator that the quality of the operationhasbeenreviewedbypeersand foundworthy.The Intersociety for the Accreditation ofVascularLaboratories, theAmericanInstituteof Ultrasound in Medicine (AIUM), and theAmerican College of Radiology (ACR) allhave accreditation programs for the diagnosisof abdominal aortic aneurysm.

The ACR/AIUM collaborative effortrequiresthattheabdominalaortabeexaminedproximal,mid,anddistal, intwoplanes, trans-verse and longitudinal, that measurements beobtained from outer wall to outer wall., that ameasurementof3cmorgreateris indicativeofaneurysmalenlargement.Apermanentrecord

ofthestudy,availableforreview,withawritteninterpretation of the findings for the medicalrecordisrequired,withtimelycommunicationof the results to the referring physician.

Ultrasound screening for abdominalaortic aneurysms is safe, effective, and cansavelives.Weighingriskwithbenefit,considerscreening for the 65 to 75 year old man., par-ticularly if he is or has been a smoker.

ReferencesU.S. Preventive Services Task Force.

Screening for Abdominal Aortic Aneurysm: Recommendation Statement. Annals of Internal Medicine 2005;142:198-202.

Fleming,C, Whitlock, EP, Bell, TR, Led-erle, FA. Screening for Abdominal Aortic Aneu-rysm: a Best-Evidence Systematic Review for the

U.S. Preventive Services Task Force. Annals of Internal Medicine 2005;142:203-211.

Dr. Gretchen AW Gooding is Professor in Residence, Department of Radiology, at the University of Califor-nia, San Francisco, and Chief of Ultrasound at the Dept of Veteran Affairs Medical Cen-ter in San Francisco. She is a Fellow of the ACR, AIUM, Society of Radiologists in Ultrasound, and the American Association of Emergency Radiologists. She cur-rently serves as Chair of the American College of Radiology Ultrasound Guidelines and Standards Committee.

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Leonard Shlain, MD

Phoenix Rising: And the Big Bird is Looking Through a Laparoscope

HandS and HiGH TecHnoLoGY: MiniMaLLY inVaSiVe SUrGerY

Itwasnofair.Generalsurgerymadetheendangeredspecieslistatatimewhenmycolleaguesinophthalmology,ENT,

transplant,andorthopedicswereinventingnewoperations–seeminglyonadailybasis.Totalhips,lasercornealsurgery,arthroscopicthisandthat,anddon’tevengetmestartedtalkingabout theplastic surgeons.Theychurnedoutnovel techniques like somekindofa sorceress. Itwas the late1980sandprospectswerenot lookinggood formyfield.Where,oh,wherewereournewprocedures?

How timeshadchanged. I can stillrecall the excitement crackling amongmyfellowsurgicalresidentswhenIbegantrainingatBellevue in the sixties. Inno-vativemeans tocurediseasebyapplyingjudiciousaliquotsoftinctureofcoldsteelabounded.Trumpetedinourjournalswerespleno-renalshunts,rectopexiesforpeoplewhosegutswere fallingout their rectum,andaxillo-axillo-femoralarterybypasses.Afewcourageoussoulseventriedtoremove95percentofthepancreas.Thosewerethedaysmy friend,we thought they’dneverend. It seemed thatnokrankbedevilingthehumanspeciescouldconfoundaskillfulgeneralsurgeon.

Andthencame“TheGreatWast-ing”.Onebyone,theORschedulererasedfromthemorning’soperatingboardthepro-ceduresthathadformedtheveryfoundationofgeneral surgery.Thegastroenterologistsnared sigmoid polypectomies. Tagametswallowednearlyallthegastrectomies.CTscanscookedthegooseofthatoldpopularstandby,theexploratorylaparotomy,mak-

ingitasrareasasightingofthedodobird.Alarmingly, radiologistsbegan tobreachthebarrier guarding the surgeon’s innersanctum.First,theyhonedtheirskillsroto-rooteringarteriesandsoonthereseemedtobeno“-itis”theycouldn’thealwiththeirmagictwistywands.

MyGod!Eventhecardiologistsweremuscling inonourworld, showingup inourdressingloungetryingonscrubs.Asifthesetroubleswerenotenough,TheGreatWastingcoincidedwiththetimeof“Ter-ribleTurfWars”.Theheadandneckguysplantedtheirflaginourthyroid,whileattheotherend,anewbreedofcolonandrectalsurgeonsfirststakedoutthehemorr-roidandthenmoveduptherectumontothesigmoidwiththeintentonwrestingthececumfromthegeneralsurgeon.AsJimmyDuranteoncecracked,“Everybodywantstogetintoda’act.”

The future forgeneral surgerybleak-ened.Wecircledthewagonsaroundbreastbiopsies,gallbladdersandherniasplanningtomakeour last stand.Butdeepdown,weweredemoralized.Generalsurgerywasedgingtowardtheprecipiceof,ifnotextinc-tion,irrelevancy.

OnemorningIattendedgrandroundsand sat throughapresentationbyaUCradiologist.Heannounced(notwithoutahintofmalevolentgleeinhisvoice)thatheandhisdepartmentwereworkingoutthekinksonapercutaneousmeanstoextractgallstones.Ileftdepressed.

Determined thatwe surgeons couldnotcede thisvitalorgan to the radiolo-gists,Ibegantocollaboratewithmyfriend,

urologistRobKahn, todevelopa similarpercutaneousmeans to removegallstonesusingultrasoundtoidentifywheretopunc-ture thegallbladder.Weperformedsixofthese(lame)procedureswithmycolleagueslookingondoubtfully.

Oneafternoon,arepwalkedintomyofficeandplayedavideoofanoperationcalledalapcholeperformedbyEddieJoeReddick,ageneralsurgeoninprivateprac-ticeinTennessee.Throughtheuseoffourtinyincisionsandascopeconnectedtoavideodisplayusingminiaturizedlengthenedinstrumentshedemonstratedhowhecoulddisconnectthegallbladderfromitsattach-mentsunderneaththeliver,suctionoutitscontentsandthenwithaflourish,extractthenowflaccidsacthroughthetinyholeinthebellybutton.Patientswenthomethesamedaywithasmileontheirfaces.Iaskedthereptoplaytheclipagainandagain.

Bycoincidence,laterthatafternoonIwaschattingwithagoodfriendandsurgeoninAtlanta.ShoptalkturnedtothisobscuresurgeonReddickandhisnewtechnique.Ohyes,myfriendreplied,hehadheardofhimand theoperationwasgaining trac-tionintheSouth.Fortuitously,myfriendandIplannedtoobserveaday’sworthoflapcholesatGeorgiaBaptistHospitalthenextmorning.

Ihungup thephoneandmade res-ervationson the red-eye toAtlanta thatnight,arrivingintheoperatingroomthenextmorning.AfterobservingEdMasonremovefive gallbladders in record time,eachdischargedthesameday,Ibecameatruebeliever.Thisoperationwasjustwhat

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the doctor ordered to cure The Great Wast-ing. Within weeks of each other, JonathonLeightling, Sam Esterkyn, and I introducedthis operation to San Francisco. Barry Gar-diner and William Otero in the East Baywere the first to accomplish the feat in theGreater Bay Area (I should mention thatthe gynecologists had been light years aheadof us in this department. They, however,only pointed their scopes south. Not untilgeneral surgeons pointed the same scope inthe opposite direction, did they realize thatthere was a rich northern load waiting tobe mined).

Many of my colleagues’ attitudestowards lap choles was a combination ofcaution mixed with skepticism. Too muchparaphernalia, they muttered. Damnedgimmickry was the scuttlebutt in the ORlounge. Then, like a flock of starlings, asif on some prearranged signal all swervingsimultaneously, the surgical community inthe entire Bay Area did a one hundred andeighty on a dime. Within months, surgeonsperformed lap choles at every hospital.Few innovations in the history of surgeryso utterly transformed the field in as shorta time and as dramatically as did this newtechnique. And so, in the spring of 1990began the era of laparoscopic surgery inSan Francisco.

The TechniqueFirst, we insufflate the peritoneal cav-

ity with carbon dioxide gas until it attainsbeach ball status. This maneuver lifts theabdominal wall away from the intestinesby about four inches. Next, we puncturethe skin near the umbilicus with a trochar.After removing its sharp obturator, thetrochar becomes an airtight sleeve. Wethen place a highly sophisticated telescopethrough it and Voila! Similar to a fifth rowcenter seat at the Hollywood Bowl, wehave a panoramic view of the abdominalcontents. A few more trochars, and thenwe thread very long instruments with tinyheads through the sleeves.

Now for the hard part. The instrumentsact as levers balanced on the fulcrum ofthe abdominal wall. I observe the tip of theinstrument on a video display. If I want thetip to move to the right, I must move myhand to the left. If I want the tip to move

up, I move my hand down. So far, so good.However, if I want the tip to go in, then Imust move my hand in. Therein lies theproblem. If all the movements of one’shand were the opposite, then it would bea skill easier to master. Unfortunately, twoof the three vectors of Euclidian space arethe opposite but one remains the same.The brain of a surgeon in its first attemptat making any complex three-dimensionalmovement laparoscopically will precipitatea serious neuro-hiccup because the instruc-tions the brain must send to the hand violateintuition-sort of like trying to cut a nose hairin the mirror.

Surgeons overcame these difficultiesbecause laparoscopic surgery was a majoradrenaline rush. One by one, traditionaloperations transformed into keyhole op-erations. First gallbladders, then hernias,appendectomies, gastric fundoplications,colon resections, and even cardiac bypassesbecame doable. The current craze to sweepthe field is bariatric surgery.

Double-Edged SwordsPrior to the advent of the laparoscope,

surgeons used instruments that were modi-fied variants of a knife, fork, and a spoon.Compared to orthopedics or neurosurgery,we were definitely low tech. Since the ad-vent of laparoscopic surgery, however, newstar-wars technologies emerge every yearenabling surgeons to convert old standbyopen procedures to laparoscopic ones.However, Sophocles once warned, “Noth-ing vast enters the life of mortals without acurse.” So, we might ask, what has been thedownside of all this technology?

Many a misadventure has occurred inthe performance of laparoscopic surgery. These disasters have been chalked up tothe learning curve. But it is now 15 yearslater and there is still a lot of learning goingon. Regrettably, there is no Journal of Bad Results and many of these misadventures gounder-reported. Gnawing at the edges of theremarkable advances that constitute muchof laparoscopic surgery lurks the hubrisof the surgeon’s bugaboo-the triumph oftechnique over judgment. Just because it isfeasibly possible to do, does not mean that asurgeon should do it...laparoscopically.

This caveat aside, laparoscopic surgery

rejuvenated the field of general surgery.Speaking for myself, it made me feel likean excited schoolchild. I had to learn anentirely new set of skills. I had to familiarizemyself with exceedingly hi-tech toys while Iacquired an exotic vocabulary and mastereda new body of knowledge. But topping thelist, laparoscopic surgery is the best damnvideo game I have ever played.

Leonard Shlain is the chairman of lapao-scopic surgery at Cali-fornia Pacific Medical Center and is also the author of three national best-selling books. His latest, Sex, Time and Power: How Women’s Sexuality Shaped Human Evolution, recently won the Quality Paperback Book Club Award for the Best Non-Fiction in its category. He may be contacted at [email protected].

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FIGURE 1: Port Placement for Laparo-scopic Right Colectomy

all of these advantages, including a decreasein operative time and dramatically reducinghospital stay.

In addition to the small incisions, thesurgical precision of the laparoscopic ap-proach to colectomy may lead to improvedoutcomes. Recent technologic advancesin digital optics allow for magnificationand clarity much superior to the nakedeye during open surgery. This can allowfor more accurate recognition of anatomicdetail which translates into more precisedissection. Innovative new instruments andsealing devices have allowed for more deli-cate handling of tissues, which can result indecreased blood loss, less contamination andwound infection, decreased adhesion forma-tion and a lower rate of post-operative smallbowel obstruction. Furthermore, the overalldecrease in stress to the host immune system

Laurence F. Yee, MD and Michael E. Abel, MD

The Past, Present, and Future of Laparoscopic Colectomy 2006

HANDS AND HIGH TECHNOLOGY:MINIMALLY INVASIVE SURGERY

W ith the successful introductionof laparoscopic cholecystectomyin 1987, the laparoscopic ap-

proach for other operations such as Nissenfundoplication, splenectomy, gastric bypassfor obesity, and appendectomy have beenestablished and embraced. Laparoscopiccolectomy, conversely, has been slow togain widespread utilization over the past15 years. This slow acceptance has beenprimarily due to two concerns inherent tolaparoscopic colectomy: 1) the quality ofresection for colon cancer, and 2) the lack ofstandardization and training in a technicallydemanding operation.

As a result of these concerns, only 5%of all colectomies were performed laparo-scopically in the US in 2004. However,with the recent publication of multipletrials comparing laparoscopic and open col-ectomy for colon cancer and vast improve-ments in new technology, experts predictthat by 2010 70% of all colectomies will beperformed using a laparoscopic approach.

Rationale for laparoscopic colectomy

Compared to open colectomy, laparo-scopic colectomy is performed using muchsmaller incisions, which can lead to lesspostoperative pain, decreased narcotic us-age, improved pulmonary function, fasterreturn of bowel function, shorter hospitalstay, earlier return to work and normalactivity, improved cosmesis, and decreasedhospital costs. The rapid acceptance oflaparoscopic cholecystectomy as the “goldstandard” was a result of providing patients

provided by the laparoscopic approach maybenefit cell-mediated immunity resulting insuperior oncologic outcomes.

Indications for laparoscopic col-ectomy

Virtually any patient who has an indi-cation for an open colectomy is a candidatefor a laparoscopic colectomy. Indicationsfor laparoscopic colectomy include cancer,large polyps, diverticular disease, inflam-matory bowel disease, volvulus, ischemia,and stricture.

There are, however, patients who areless likely to benefit from a laparoscopicapproach due to longer operative times.Relative contraindications for laparoscopiccolectomy include patients with completeor high grade obstruction, locally invasivetumors (T4), peritonitis, rapid bleeding, andmultiple abdominal operations for adhesivedisease.

Oncologic concerns regarding laparoscopic colectomy

With the introduction and rapid ac-ceptance of laparoscopic cholecystectomyin 1987, it was natural for surgeons to applythe laparoscopic approach to colectomy forbenign and malignant disease.

By 1994, however, several case reportsof port site metastases (tumor implantationin the laparoscopic incisions) were pub-lished leading to essentially a moratoriumon a laparoscopic colectomy for coloncancer by the American Society of Colonand Rectal Surgeons (ASCRS). This realconcern that the laparoscopic approach to

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FIGURE 3: California Pacific Medical Center Experience in Colectomies

Year Open Laparoscopic % Laparoscopic

2000 244 31 11%

2001 264 38 13%

2002 247 40 14%

2003 208 97 32%

2004 170 130 43%

2005 183 152 45%

colon cancer may result in tumor spreadand/or inadequate resection led to the de-velopment and initiation of parallel clinicaltrials in 1994. Both the Clinical Outcomesof Surgical Therapy trial (COST) sponsoredby the ASCRS in the US and the CLAS-ICC trial in the UK began accruing patientsin 1996 comparing laparoscopic and opencolectomy for colon cancer resection.

In May 2004, the results of the COSTtrial comparing open and laparoscopiccolectomy for cancer were published inthe New England Journal of Medicine. 872patients with colon cancer were randomizedto open or laparoscopic colectomy in 48centers in the US (1996-2002). Surgeonsperforming these operations were almostexclusively board-certified colon and rectalsurgeons. With a 4.4 year follow-up, the lap-aroscopic colectomy did not result in higherrates of recurrent cancer and demonstratedequivalent complication and mortality ratescompared to open colectomy. In addition,the COST study found that laparoscopiccolectomy was advantageous in reducingboth narcotic usage and hospital stay.

Similar results from the CLASICCtrial comparing open and laparoscopic col-ectomy for cancer were published in May2005 in Lancet. 794 patients with coloncancer were randomized to laparoscopic oropen colectomy in the UK (1996-2002).Their findings were similar to the COST

trial, demonstrating equivalent oncologicoutcomes and complication rates for lapa-roscopic and open colectomy. In addition,laparoscopic colectomy resulted indecreasedhospital stay.

Overall, the recent publication of theseand other clinical trials have, in essence,

lifted the 10 year moratorium on laparo-scopic colectomy for cancer. In response tothese findings, many expert colon and rectalsurgeons have predicted a rapid increase inlaparoscopic colectomy from its current 5%to upwards of 70% of all colectomies in thenext five years.

Operative technique of laparoscopic colectomy

Unlike the standardized approach tolaparoscopic cholecystectomy, there area number of “acceptable” approaches tolaparoscopic colectomy. Approaches de-scribed have included up to four surgeons,eight ports, hand assist devices, and multiple

patient positions. In addition, the operativeapproach can either begin by devasculariz-ing the colon followed by mobilization, orvice versa. The heterogeneity of approachesmakes laparoscopic colectomy difficult tolearn

Since 2000, our standard approach has

consisted of 2 surgeons and 1 optical portand 2 operating ports without the use ofhand-assist devices (Figures 1 & 2).

5 steps in laparoscopic colectomy

1) Pre-operative localization oftumors with colonoscopy is essential.India ink tattoo at the time of colonos-copy is especially useful for any tumors orpolyps in the colon and rectum as theyare readily seen on the colon wall duringlaparoscopy.

2) Exploratory and staging laparos-copy to assess the liver and peritonealsurfaces, perform biopsies, lyse adhesions,and to localize tumors and tattoos

3)Devascularize the segment of colonto be resected. Dissection is done in a medialto lateral fashion (mesenteric resection priorto lateral mobilization). Laparoscopic clipsor sealing devices are used to divide thevascular supply and resect the lymph nodebearing mesentery.

4)Mobilize the colon from retroperito-neum, omentum, splenic or hepatic flexuresusing laparoscopic cutting and sealing de-vices using a two instrument approach.

5) Resect the colon and create theanastomosis through a 4-5 cm incision.

This step-by-step comprehensive ap-proach has facilitated organization andeconomy of time and equipment in theoperating room. The simplicity of this ap-proach allows for a minimal requirement inthe number of surgeons, incision sites, andequipment utilization, yet provides excel-lent ergonomics, flexibility, and precisionof dissection.

Results of laparoscopic colectomy at California Pacific Medical Center (CPMC)

Our programin laparoscopiccolectomyat CPMC began in 1998 and the volumehas increased every year (Figure 3). Ourmean operative time (143 minutes) andconversion rate to open colectomy (2.4%)compares favorably to those reported inthe COST trial (150 minutes and 21.0%,respectively).

As a result of our experience and therecent introduction of new instrumenta-

FIGURE 2: Port Placement for Laparo-scopic Left or Sigmoid Colectomy

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tion, many patients now experience a 90minute operation and a 3-4 day hospitalstay. Furthermore, similar to laparoscopiccholecystectomy, we are now carefully ap-plying laparoscopic colectomy to selectedelderly or higher risk patients who wouldotherwise not be good candidates for opencolectomy.

Future of Laparoscopic Colectomy

With the ever-growing stream of newtechnology and instrumentation, the abilityto perform an increasingly more precise andless invasive laparoscopic colectomy is onthe horizon. Clinical trials and evidence-based outcomes will be essential to guidethe careful introduction of novel surgicalinstrumentation and products.

Forthcoming new technology includedevices to improve the creation of the intra-abdominal anastomosis using colonoscopicstapling devices, biological “glue” to replacesutures and staples, robotic and tele-roboticlaparoscopic colectomy, and novel pro-mo-tility agents to reduce postoperative ileus.Integration of these new devices and tech-niques into laparoscopic colectomy shouldfacilitate a further reduction in operative

time, decrease incision number and size,improve precision of dissection, decreaseinfection rate, decrease hospital stay, andimprove oncologic outcomes. Perhaps“outpatient” laparoscopic colectomy willbe in our near future.

ReferencesBerends FJ, Kazenmier G, Bonjer HJ,

Lange JF. Subcutaneous metastases after lapa-roscopic colectomy. Lancet 1994;344:58.

The Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparo-scopically assisted and open colectomy for colon cancer. N Engl J Med 2004;350:2050-9.

Pappas TN, Jacobs DO. Laparoscopic resection for colon cancer - the end of the begin-ning? N Engl J Med 2004;350:2091-2

MRC CLASSIC trial group. Short term endpoints of conventional versus laparoscopi-cally assisted surgery in patients with colorectal cancer. Lancet 2005;365:1718-26.

Visser BC, Reilly LM, Volpe, PA, Gar-cia-Aguilar J, Abel ME, Chiu YC, Sternberg J, Russell, TR, Yee LF. Laparoscopic colectomy: Who will be trained to do it? Presented at the 76th Annual Meeting of the Pacific Coast Sur-gical Association February 17th, 2005.

Dr. Yee is the Vice-Chairman of Surgery at California Pacific Medical Center, a member of San Fran-cisco Surgical Medical Group, and an Assis-tant Clinical Professor of Surgery at UCSF.

Dr. Abel is a member San Francisco Surgical Medical Group and an Associate Clini-cal Professor of Surgery at UCSF.

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The San Francisco Earthquake 1906: Quick Action Saved Countless Lives

HISTORICAL PERSPECTIVE

On April 18, 1906 at 5:13 am, an earthquake, the greatestnatural disaster (at that time) in the United States, struckcities along the West Coast of Northern California. In San

Francisco, “The Paris of the West”, it was followed by a fire which,with disruption of the water supply, burned for three days. The SanFrancisco Medical Society, founded in 1868 and housed in theYMCA building downtown, found its library of 6000 volumes andits records destroyed. Fortunately, Emmett Rixford, the treasurer,had taken his cash records and buried them in the yard of his homeand office on the corner of Franklin and California streets. Althoughthe fire jumped Van Ness at that point for six blocks, they wereretrieved intact.

As we observe the centennial of the greatquake and fire, this article focuses on the activi-ties of the Army personnel in the Presidio whowere instrumental in treating the wounded andproviding sanitation to prevent the spread ofdisease in the various refugee camps locatedin the western part of the city. Although theofficial death toll is still given as 478, so asnot to scare away investors, modern estimatesplace it nearer to 5,000. However, this numberwould have been much higher had it not beenfor the efforts of the military, many of whomhave been commemorated by streets namedafter them in the Presidio - including ArmySurgeon General Robert O’Reilly, the street on which the MedicalSociety is now located.

The Army personnel were headed by Lt. Colonel GeorgeHenry Torney (1850-1913) Deputy Surgeon General and ChiefSurgeon of the Department of California, who had been placed incommand of Presidio General Hospital in March 1904.

Torney acted immediately after the earthquake by orderinga survey of damage done to the hospital and medical supplies. Hefiled a report of his activities (by telegraph) to Major General A.N.Greely, commander of the Pacific Division on May 14. The ArmyGeneral Hospital (later known as Letterman) was badly wrecked

by the earthquake with damage to the structure, power plant, watersupply, and communications system. In addition, throughout thecity, both water supply and sewage disposal had been affected. OnApril 18th all available Medical Department Officers were alertedfor work, and Company B Hospital Corps, accompanied by troopsfrom the Presidio, went into the city for active relief work in fightingthe fires which were a continuing problem especially throughoutthe next three days.

The actual relief for the refugees and the sick and injured be-gan at the General Hospital 4/18. Army personnel were instructedto give relief where needed and notify the city authorities that

this hospital was open. By 1 PM, seventy-fivepatients had been admitted. By 11 PM the totalhad reached one hundred and twenty seven.The next day 145 patients were admitted to theGeneral, mostly from other hospitals in the citywhich were either burning or threatened by fire.The numbers lessened but the bed capacity ofthe wards at the General Hospital was exhaustedso four barracks of the men of the Hospital Corpsat the Presidio were evacuated and establishedas wards.

The hospitals at the post of the Presidioand Fort Mason were ordered open April 19and received large numbers of refugee patients.That same day, because of the great demand on

the General Hospital for first-aid work, a tent emergency hospitalwas organized and established on the plain in front of the hospitalreservation. Capt. H.H. Rutherford, U.S. Army was placed in chargeto advise patients arriving from the city, direct them to the properhospitals, and to render assistance, treatment and first-aid dressingsfor those on the ground.

On the morning of April 20th, the president of the HealthCommission of the City of San Francisco requested Lt. ColonelTorney to act as the head of the Sanitary committee to coordinateaction between the Army and civilian authorities on the sanita-tion of the city. Brigadier-General Funston authorized this and Lt.

Nancy G. �omson, MD

Although the offi-cial death toll is still given as 478, mod-ern estimates place it nearer to 5,000. This number would have been much higher had it not been for the efforts of the military.

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ColonelTorneyimmediatelytransferredcommandoftheGeneralHospitaltoCapt.JamesMKennedy,U.S.Army.Themanythou-sandsofpeoplestillwanderingtheroadsandstreetsseekingrefugewereassisted.ThecampsinthePresidio,GoldenGatePark,FortMason,andthesmallcityparks(suchasLafayetteSquare)wereprovidedwithtents,toolsandconveniencesforcookingandcar-ryingoutnecessarysanitarymeasures.Inaddition,personscausingdisturbance in thecampswereejected,andnot tobeadmittedelsewhere.

TheHealthCommissionof thecity selected sites forper-manentcamps.Thesewereprovidedwithacommunitykitchens,corresponding to thecompanykitchens inmilitarycamps,andsanitary troughsandmedical supplies sentby theWarDepart-ment.Inaddition,onApril21bytheauthorityoftheMayorofSanFrancisco,HarborViewParkadjacenttothePresidiowithtents,beddingandhospitalapplianceswasestablishedasaplaceforinfectiousdiseases.Ithadadmirablefacilitiesincludingitsownwatersupply,itsownlaundryandalargepavilionwhichcouldac-commodate200patients.Inthis,casesofmeasles,scarletfeveranddiphtheriawerecaredfor.

Fortunately,theGeneralHospitalhadasupplyofmedicalsupplies,sincethoseofthecityhadbeendestroyedbyfire.Moresupplies,includingvaccinevirusweresuppliedfromreliefstores,

andtwenty-sixfreedispensariesweresetupreceivingtheirsupplyofmedicinesfromtheMedicalSupplyDepotoftheArmy.OnApril23,attheSantaFeDepotinPointRichmond,thirteenrailwaycarswereexamined,removingsevenbarrelsandnineteenboxesofdrugsanddisinfectants,originallyintendedforLangleyandMichaels,wholesaledrugdistributorinSanFranciscowhosebusinesshadbeendestroyedbythefire.TheseweredeliveredtothePresidiodockbyCaptainBadgeroftheU.S.Navyandthetugboat,Vigilance.Also,milkwasmadeavailable.

Thiswell-coordinatedeffort,aboutwhichlittleisknown,didmuchtosavelivesandrelievesufferingandthespreadofinfectiousdisease.

acknowledgments:1. Richard Torney, great-grandson of George Henry Torney whose

much more detailed article will appear in the Argonaut, published by the San Francisco Museum’s Historical Society

2. 1906 by James Dalessandro. A well-researched work treated as fiction

3. The History of the San Francisco Medical Society 1850-1900.4. There is also a wonderful display of earthquake/fire photographs

currently at the Palace of the Legion of Honor.

financial solvency regulationsapplyonlyto risk-bearingmedicalgroups/IPAs.Thefinancialsolvencystandardsandthereport-ingrequirementsdonotapplytoindividualphysicians.

ThePacifiCarearticlealsoincorrectlyimpliesthattheregulationsrequirerisk-bear-ingorganizations(RBOs)tosubmitfinancialstatementstoeachhealthplanwithwhichtheyarecontracted.TheregulationsonlyrequireRBOstosubmitfinancialstatementstoDMHC.Somehealthplancapitationcontractsmay requireRBOs to regularlysubmitfinancialstatements,butthisisnotsomethingthatisrequiredbystatelaw.

Contact:AileenE.Wetzel,916/[email protected].

cMa’s 9th annual Leadership academy is May 5-7

PhysicianscannowregisteronlineforCMA’s9thAnnualHealthCareLeadershipAcademy.TheconferenceisMay5-7attheRenaissanceEsmeraldaResortnearPalmSprings.Adynamicmultidisciplinaryfacultywilldiscusstrendsaffectingyoureconomicfutureasaphysicianandteachessentiallead-

ershipskills.Thisyear’sconference,“Reengineering

HealthCare:MeetingFutureExpectationsWithoutBreakingtheBank,”willaddressthechallengesofcost,quality,andaccesstocareas“locomotives”ofhealthsystemreform.Notedeconomistsandleadersfromthegovernment,business,andlaborsectors,aswellas fromthehealthcareindustryitself,willpresentavarietyofperspectivesonhowtoaverta“trainwreck”andputthesystemontracktowardaviablefuture.

Theacademyalsowillfeatureapowerfulslateofnuts-and-boltsleadershipskillswork-shopsincluding:•Leadershipskillsformanagingchange•Conflictresolutiontechniques•Howtoprepareacompellingpresentation•Howtomaximizecommitteeeffectiveness•Howtodelivermedicine’s(oryourorgani-zation’s)messagetothepublic

Participantscanearnupto17hoursof

CategoryICME.Toregister:http://www.cmanet.org/lead-

ership/Contact:LeadershipAcademyHotline,

800/[email protected].

Medical Board Mail Stolen in Sacramento; Physicians encouraged to Guard against identity Theft

AnunknownquantityofmailwasstolenMarch4fromthegeneralmailboxat aDepartmentofConsumerAffairs(DCA) facility inSacramento,whichhousestheMedicalBoardofCaliforniaand sevenotherprofessional licensingboards.

Aslicenseapplicationsandrenewalscontainpersonalandfinancialinforma-tion,physicianswhomailedmedicalli-censeapplications,renewals,orothermailcontainingpersonalinformationbetweenFebruary25andMarch3 to theDCAHoweAvenue facility are encouragedtocontactthemedicalboard(916/263-1080)todetermineiftheirapplicationshavearrivedsafely.Ifyourapplicationhasnotarrived,pleasevisittheDCAOfficeofPrivacyProtection(COPP)websiteathttp://www.privacy.ca.govforinformationonstepsyoucantaketoprotectyourselffrom the possibility of identity theft.COPPcanalsobereachedbyphoneat866/785-9663

OnYourBehalf continued from p5

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Paul B. Hofmann, Dr. PH andHaile Debas, MD

Surgeons Volunteer Locally through Operation Access

ANNOUNCEMENTS

It all began with a question. In the early 1990’s, Operation Accessco-founder Dr. Douglas Grey attended an American College ofSurgeons conference and heard this question asked by a pre-

senter: “Why don’t surgeons do more to help people in their owncommunity, instead of flying on surgical missions to foreign coun-tries.” Dr. Grey thought about it . . . and decided to take action.

Dr. Grey and Dr. William Schecter, Chief Surgeon at SanFrancisco General, together with a senior health care executive,decided to start a program (now called Operation Access) to providefree outpatient surgical care to people in our community with nohealth care insurance. Uninsured patients who are unable to affordnon-emergency surgery face overwhelming financial obstacles toobtaining necessary treatment. Excluding professional fees, forexample, an uninsured patient would be charged approximately$12,000 by a private hospital in the San Francisco Bay Area torepair a hernia.

The vision to create opportunities for surgeons and othermedical professionals to give back to their local community beganwith 1 hospital and 15 medical volunteers. In 1994 25 surgicalprocedures were performed. Last year 368 people received surgicalcare. Operation Access has now grown to become a network of over300 physicians, nurses, and surgical technicians, 60 referring com-munity clinics and 16 participating hospitals in the six county BayArea. When it began, there was no comparable organization in thecountry that coordinated a broad range of free surgical proceduresfor uninsured, low-income populations through the mobilizationof medical professionals and private hospitals. In recognition of itsunique attributes, the program received the American HospitalAssociation’s prestigious NOVA Award in 2002.

Over 150 physicians currently donate their time and expertiseto provide the uninsured with outpatient surgical procedures thatsignificantly improve their health, ability to work, and quality oflife. Anesthesiologists, general surgeons, and sub-specialists (fromotolaryngologists to urologists) volunteer, thus allowing OperationAccess to offer a wide variety of ambulatory surgical procedures.

Potential patients are referred to Operation Access from com-munity primary healthcare clinics, such as the San Francisco FreeClinic. Operation Access staff screen the individuals for eligibility.Eligible patients are matched with a surgeon volunteer who, withoutcharge, provides the surgical consult, surgery if necessary and post

operative care. Patients return to their primary care provider for anyongoing health care needs. All of the participating hospitals offertheir facilities and supplies without charge.

Through this model program of providing non-emergentsurgical care, over 1,950 individuals have received surgical servicesranging from breast biopsies to hernia repairs to gall bladder removal.The opportunity to make a contribution locally has been welcomedby all the volunteers. One said, “medical care should be availableto everyone. We are happy to volunteer for Operation Access andto provide surgical care to thosein need.”

Operation Access volun-teers and participating hospitalshave proven that donated medi-cal care can have a significantimpact in improving access for atargeted patient population thatwould otherwise likely go with-out care or utilize the emergencyroom. The charity care impact,based on medical provider billingcharges, but waived through Op-eration Access, was $1,837,162in 2005, and now totals over $10 million dollars since the programbegan. The words of a former patient speak to what may be themost important impact: ”I want to give infinite thanks to Opera-tion Access and the medical volunteers who give ... their time toexercise their excellent profession. The experience was excellent;the hernia had made it impossible to work, and today it is differentbecause I can...”

To learn more about Operation Access, go to www.operatio-naccess.org.

Paul B. Hofmann, Dr. P.H., president of the Hofmann Healthcare Group in Moraga, California, worked with Drs. Grey and Schecter in establishing Operation Access, and serves as a consultant to health systems and hospitals.

Haile T. Debas, MD, is the Executive Director, UCSF Global Health Sciences and Vice Chancellor Emeritus for UCSF Medical Affairs.

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A Successful Community Hepatitis B Screening and Vaccination Program

PUBLic HeaLTH UPdaTe

ChronichepatitisB(HBV)infectioniscurrentlyoneofthetopfivecausesofprematuremortalityintheAsiancommunityinSanFrancisco.Recently,theSanFranciscoDepartmentof

PublicHealth,inpartnershipwiththeAsianLiverCenteratStanfordUniversity(ALC),completedacommunitybasedpilotprojectcalled“3ForLife”targetingadultAsianPacific/Islander(API)residentsofSanFranciscoforhepatitisBscreeningandvaccination.

WithanAPIpopulationofover250,000andanestimatedrateofchronichepatitisBinfectionat10%inthispopulation,therearepotentially25,000chronically infectedresidents(infectioninthispopulationistransmittedverticallyfrommothertoinfantatbirth).Enormousstrideshavebeenmadeinthelast10yearsinthetreatmentoptionsforchronicHBV,buttheonlywaytoknowifsomeoneischroni-callyinfectedisthroughbloodtests.AsignificantnumberofinfectedindividualsareunawareoftheirHBVstatus.Withouttreatmentorregularscreening,oneinfourofthosewhoarechronicallyinfectedisatriskofprematuremortalityfromlivercancerorliverfailure.

ThegreaterSanFranciscoBayAreahas33%oftheState’sAPIpopulationandhasthehighestincidenceoflivercancerinCaliforniaandinthecountry.The2004ComprehensiveCancerControl inCaliforniaReportstatesasoneofitsgoalsfor2010thatallAsian/Pa-cificIslandersbescreenedforhepatitisBtodecreasethelivercancermortalityrateamongthisgroup.1

InSeptemberof2004the3ForLifeProjectwaslaunchedattheRichmondDistrictYMCA.Threeoftheprimarygoalswere:ToraiseawarenessamongAPIadultsoftheimportanceofbeingtestedforhepatitisB,beingvaccinatedifunprotectedandbeingmonitoredifchronicallyinfectedwiththehepatitisBvirus;TogaininformationaboutthebarrierstohepatitisBscreeningandvaccinationfortheAPIpopulation;Andtoraiseawarenessamonghealthcareprovidersoftheneedtotestand/ormonitorthehepatitisBstatusofAPIpatients.

Theprogramprovidedlow-cost2hepatitisAandhepatitisBvaccinationsandfreehepatitisBtesting(surfaceantigenandsurfaceantibody)twoSaturdaysamonthforayear.Duringthose72clinichoursover1,200adultswerescreenedandmorethan3,000shotswereadministered.Thistranslatedtoapproximately1shotevery2minutes!SFDPHsuppliedthevaccineandthenursestoadministerthevaccinewhileALCprovidedthephlebotomist,transportedthebloodtoStanford,andmailedtestresultstoclientswithacomprehensive,bi-lingualletterexplainingthetestresultsandwhatstepstotakenext.Inaddition,ALCrecruited,trainedandcoordinatedtheutilizationof

120volunteersranginginagefrom16to66.Thedatacollectedindicated10%oftheclientsaresurfaceantigen

positive(chronicallyinfected)and40%aresurfaceantibodypositive(immuneduetopreviousinfection),leaving50%vulnerabletoinfec-tionandinneedofprotection.Nearly54%havehealthinsuranceyetonly16%saidtheirdoctorhadeversuggestedhepatitistestingtothem.Amongthosewhotestedpositiveforchronicinfection,75%indicatedthattheirdoctorhadneversuggestedtesting,orthattheydidnotknowiftestinghadeverbeensuggested.

Asanticipated,thesestatisticshighlighttheneedforfurthereduca-tionandoutreachtoboththeat-riskpopulationandtheproviderswhocareforthem.TheCommunicableDiseasePreventionUnitisrespond-ingtothisneedbyembarkingoncreativeandcollaborativestrategiestoraiseawarenessandimproveknowledgelevelsamongprimarycareprovidersoftheimportanceofscreeningAPIpatientsforhepatitisB,educatingpatientsabouttheirstatusandriskfactors,following-uponthechronicallyinfectedandvaccinatingthevulnerable.ThiseffortincludesmakingsuretheseprovidersknowthatthehouseholdandsexualcontactsoftheirchronicallyinfectedpatientsmaybeeligibleforfreetestingandvaccinationthroughtheappropriatechannelsattheHealthDepartment.

Thewidespreadparticipationinthe3forlifeprogramindicatesthataccessibility,convenience,andaffordablevaccinationareimpor-tantfactorsinaneffectiveoutreachprogram.Locally,anewhepatitisBcollaborativeatUCSFisabouttoestablishthe3ForLifeconceptsinthecommunityoneSaturdayamonth,indefinitely.EarlierthisyeartheChineseChristianHeraldCommunityCenterofLosAngeleslaunchedtheprogramforitsowncommunity.ThestateofHawaiiisalsopreparingtoreplicate3forLifeinthecomingyear.PrimarycarephysicianswhoarenotalreadyaddressingthisheathissueintheirpracticecancontactSFDPHforinformationandguidance.

1ComprehensiveCancerControlinCalifornia,2004.Oakland,CA:CaliforniaDialogueonCancer,April2004.

2Chargeforvaccination:combinationhepatitisAandB,$90forthreeshotseries;hepatitisBonly,$60forthreeshotseries;hepatitisAonly,$45fortwoshotseries.

Janet Zola is the Health Educator of the Communicable Disease Con-trol and Prevention Section. She can be reached at [email protected].

Eric Sue is the Special Projects Coordinator for the Asian Liver Center at Stanford University. He can be reached at [email protected].

Janet Zola, MPH and Eric Sue, BA

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George Susens, MD and Steve Heilig, MPH

Removing Bad Money From GoodMedicine: Time for Some Bitter Pills

on MY Mind

medicine,besidesbeingfoundedonscienceandcompas-sion,isbuiltontrust.Andtrust,betweenpatientandphysicianandamongphysiciansandmedicalresearch-

ers,requiresassurancethatfinancialincentiveshavenotskewedresearchortreatment.Controversyabouttheintrusionofmarketingandotherincentivesintomedicalresearchandtreatmentprotocolsisnotnew,butdoesseemtohaveintensifiedinrecentyears.Realorperceivedmonetaryissueshavedamagedpublicandpatienttrustinmedicineasaprofession,andeffortstoavoidsuchintrusions,andtorestoretrust,arelaggingbehindtheneedforcorrectiveaction.

Thepharmaceuticalindustryspends$13,000perphysicianperyeartomarkettheirproducts.Thisdoesnotmeanthoseproductsarebad,ofcourse,butphysicianscanandwilllearnthefactsaboutthemwithoutsuchmarketing.Medicaljournalsmustcleantheirownhouses,andseemtobeattemptingtodothat.Physicians,inorganizationsandasindividuals,shoulddolikewise,andhavemadesomeattemptswithvoluntaryrestrictionsonmarketingactivities.However,theevidenceisthatvoluntaryeffortsarerarelysufficient.Thus‘strongermedicine’seemsnecessary

Kaiser Permanente’s new Policy: ThispastDecember,thePermanenteMedicalGroup(TPMG)

adoptedstringentnewpoliciesregarding“ConflictofInterest.”Theorganizationhasdeniedpharmaceuticalsalesrepresentatives fromphysicianofficesforfifteenyears,andthenewpoliciesarestrengtheningthatrestriction.Wequotefromtheintroduction:

“TPMGphysiciansshallnotengageinanyactivitieswhichcreate,orappeartocreate,aconflictofinterest,andwhichcould(1)AdverselyimpacttheindependenceandobjectivityoftheirjudgmentincarryingouttheirresponsibilitiesasaTPMGphysician,or(2)ConflictwiththeinterestsofTPMG,theKaiserPermanenteMedicalCareProgram,orKaiserPermanentemembersandpatients,or(3)Createtheappear-anceofimproprietyfromanethical,legalorcomplianceperspective.“Conflictofinterest”meansanypersonalrelationshipsorinterests,includingfinancial interests,whichinterfereorhavethepotentialtointerferewithprofessionalroles,responsibilitiesorjudgmentsofTPMGphysicians…”

Notethateventhe“appearance”ofor“potential”conflictistobeavoided.Thepolicygoesontoprohibitanyfinancialrelationshipsofphysicianswithequipment,drug,serviceorothervendors,includingservingasadirectororconsultant,orownershipinstocks–including

byphysicians’familymembers.Thencomesomesections(excerptedhere)thatmightinvolvea

bitofpainforsomephysicians:Gifts:“TPMGphysiciansmaynotacceptproductsorservicesfrom

Vendors,ConsultantsororganizationsdoingbusinessorseekingtodobusinesswithTPMG,orwithKaiserPermanente,whicharefree,oratreducedordiscountedprices,andwhichareforthebenefitofthephysiciansortheirfamilymembers.”

CommercialSupportforCME/Education:“CommercialentitiesprovidingunrestrictedgrantsforCMEmaynotdisperseseparatefromthecontract,andTPMGphysiciansmaynotacceptdirectlyfromthecommercialentity,honoraria,facultyexpenses,travelreimbursement,gifts,gratuitiesorothercompensation.Drug,device,equipmentandbiotechcompanies(Vendors)andothercommercialentitiesmaynotprovidefundingformeals,snacks,giftsorotherformsofcompensationfordepartmentalmeetings,CMEmeetingsornon-CMEeducationalmeetings…VendorsupportformealsprovidedtoallparticipantsaspartofaCMEmeetingorprofessionalsocietymeetingwhichisopentoallphysiciansisconsideredtobealegitimatepartofattendanceatthemeetingandisallowed.”

“TPMGphysiciansmaynotreceiveremuneration,gifts,gratu-ities,travelexpensesorhonorariafromVendorsforparticipationinaVendor’sSpeakers’Bureau…TPMGphysiciansmaynotacceptandretainhonorariafromaVendorforteachingorgivingpresentations,includingpaymentfortime,travelexpenses,meals,entertainment,recreationalorsocialactivities….TPMGphysiciansmaynotacceptreimbursementfromVendorsforthecostoftraveland/orattendanceatproductdemonstrations,conferences,ornon-CMEeducationalprograms.”

Harshmedicine?Perhaps.ButYale’smedicalgrouphasadoptedsimilarpolicy,andHarvardMedicalSchoolauthors,writinginJAMArecently,notethat“Conflictsof interestbetweenphysicians’com-mitmenttopatientcareandthedesireofpharmaceuticalcompaniesandtheirrepresentativestoselltheirproductsposechallengestotheprinciplesofmedicalprofessionalism.”Soweareingoodcompanyinfeelingthattheseundeniablyrestrictivepoliciesareindicatedinthesetimes,andarerecommendedforothermedicalorganizationswhowishtotrulyjoinintheefforttocleanmedicine’shouseandregaintrust.

Dr. George Susens is an internist at Permanente Medical Group and SFMS past-President and Steve Heilig is on the SFMS staff and editor of the Cambridge Quarterly of Healthcare Ethics.

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SFMS Annual Dinner January 26, 2006

SPECIAL EVENTS

The San Francisco Medical Society’s2006 Annual Dinner was held atTown Hall, Delancey Street Catering

in San Francisco. The 2006 SFMS President,Gordon Fung, MD, served as emcee for thememorable evening. The evening began withImmediate Past President, Alan Greenwald,MD, passing the gavel to Dr. Fung, whobecame the 138th President of the SFMS.Dr. Fung’s inaugural remarks celebrated pastaccomplishments and provided a vision forthe future of SFMS.

A number of special guests enjoyedthe evening, including Dr. Edward Chow,President of the San Francisco HealthCommission, and Commissioner Dr. JohnUmekubo; Dr. Michael Sexton, President ofthe California Medical Association, and Dr. Jack Lewin, ExecutiveVice President and CEO of the CMA; William Guertin, ExecutiveDirector of the Alameda-Contra Costa Medical Association; andLamont Paxton, MD, President of ACCMA, and his wife JoAnnPaxton. Dr. Fung also recognized all SFMS past presidents in at-tendance, board members, outgoing officers, and the SFMS staff.

A highlight of the evening was the recognition of 50-yearmembers of SFMS. Dr. Fung presented 50-year member pins to Dr.Pedro Pinto, who graduated from the Central University of Ecuadorin 1952 and specialized in Family Practice at St. Luke’s Hospital for40 years; Dr. Byron Pevehouse, who graduated from Baylor Collegeof Medicine in 1952 and specialized in neurosurgery at UCSF andPresbyterian Medical Center; and Dr. Louise Taichert, who gradu-ated from the University of Colorado in 1954 and specialized inpediatrics and psychiatry.

The evening’s featured speaker was Robert Wachter, MD,Professor of Medicine at UCSF and noted expert on improving thequality and safety of medical care. His thought-provoking presenta-tion was entitled, “Internal Bleeding: What We Need to Know andDo to Cure Our Epidemic of Medical Mistakes.”

As in past years, Dr. Steve Walsh provided piano accompani-ment for the cocktail hour.

Many Thanks to Our Sponsors

Special thanks tothe following spon-sors for supporting thisyear’s event: CaliforniaPacific Medical Cen-ter, Chinese Hospital,Kaiser PermanenteSan Francisco, MarshAffinity Group Ser-vices, St. Francis Me-morial Hospital, St.Mary’s Medical Cen-ter, University of Cali-fornia San FranciscoMedical Center, WellsFargo Bank, WhiskeyHill Financial Centerin Woodside, and Duramed Pharmaceuticals, a subsidiary of BarrPharmaceuticals, Inc. The program was also sponsored in part byan educational grant from Eli Lilly and Company.

Gavel is passed from Immediate Past President Alan Greenwald, MD to 2006 President Gordon Fung, MD

SFMS 2006 President Gordon Fung, MD

Gavel is passed from Immediate Past President Alan Greenwald, MD to

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Robert Larson, MD and Robert Wachter, MD

SFMS Officers: Mike Denney, MD, Editor; Gordon Fung, MD,President; Steve Follansbee, MD, President-Elect Alan Green-wald, MD, Immediate Past President; Charles Wibbelsman,MD, Secretary

Dottie Low, Kelly Fung, Peggy Fung, and Randall Low, MD

Byron Pevehouse, MD and President Gordon Fung, MDPedro Pinto, MD, with wife Alicia and sons Richard, Dennis, and Stephen

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Richard Clapp, D.Sc, MPHBoston University School of Public Health

Molly Jacobs, MPHU. Mass.- Lowell School of Health

and Environment

Report Links Environmental and Occupational Exposures to Cancers

MedicaL rePorT

Editor’s note: This project was supported with private funds via the SFMS Community Service Foundation; it is part of an ongoing series of scientific and educational efforts in environmental health being conducted by the Collaborative on Health and the Environment, a network founded at the SFMS in 2002.

TheUniversityofMassachusettsLowellreleasedareportinlate2005thatlinksdozensofenvironmentalandoccupationalexposurestonearly30typesofcancer.ThenewstudybytheUniversity’sLow-ellCenterforSustainableProductionreviewedscientificevidencedocumentingassociationsbetweenenvironmentalandoccupationalexposuresandcertaincancersintheUnitedStates—markingthefirsttimethismassivebodyofmaterialhasbeensummarizedinoneacces-sibledocument.

Weneedtopayattentiontoenvironmentalandoccupationalriskfactors.Knownandpreventableexposuresareclearlyresponsiblefortensofthousandsofexcesscancercaseseachyear.Itisunconscionablenottoimplementpolicychangesthatweknowwillpreventsicknessanddeath.

Environmental and Occupational Causes of Cancer: A Review of Recent Scientific Evidenceshowsthatmanycancercasesanddeathsarecausedorcontributedtobyinvoluntaryexposures.Theseinclude:bladdercancerfromtheprimarysolventusedindrycleaning(PCE),breastcancerfromendocrinedisruptorslikebisphenol-Aandotherplasticscomponents,lungcancerfromresidentialexposuretoradon,non-Hodgkin’slymphomafromsolventandherbicideexposure,andchildhoodleukemiafrompesticides.

Thesumoftheevidencemakesanairtightcaseforreconsidera-tionofchemicalspoliciesintheU.S.WeneedtofollowtheexampleoftheEuropeanUnion’sREACHprogram,whichpreventstheuseofknownorsuspectedcarcinogenswhensuitablesubstitutesarereadilyavailable.

Despitenotablegainsinreducingincidenceandmortalityratesforcertaincancers,especiallylungcancerinU.S.males,wefoundthatcancerconstitutesagrowingburdenonsociety.Wenotethatthemortal-ityrateforallcancerscombined(excludingnon-melanomaskincancer)isapproximatelythesametodayasitwasinthe1940sandtheannualrateofnewcasesincreasedby85percentoverthepast50years.

“Majorcanceragencieshavelargelyavoidedtheurgencyofactingonwhatweknowtopreventpeoplefromgettingcancerinthefirstplace,”saysfellowresearcherGenevieveHowe.

Thereportdisputestheoften-cited,25-year-oldanalysisbySirRichardDollandRichardPetothatattributesonly2to4percentofcancerstoinvoluntaryenvironmentalandoccupationalexposures.Ourreviewmakesitclearthatnewknowledgeaboutmultiplecausesofcancer,includinginvoluntaryexposures,early-lifeexposures,syner-gisticeffectsandgeneticfactors,rendersmakingsuchestimatesnotjustpointless,butcounterproductive.

Thefullpressrelease,executivesummary,andreportareavailableat:www.sustainableproduction.org/pres.shtmlandwww.healthanden-vironment.org.

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HOSPITAL NEWS

Chinese Hospital celebrated the “Year ofthe Dog” with another beautiful float at theChinese New Year Parade. The float featuredstatues of the three immortals, representing lon-gevity, happiness and prosperity. The three “live”representatives from the hospital were Dr. JosephWoo, our illustrious chief of staff, communityleader and Board member Mr. Franklin Fung,and Ms. Grace Gong, RN, who recently retiredafter 35 years of service to Chinese Hospital.The medical executive committee had originallyselected Dr. Collin Quock to represent the medi-cal staff on the float, honoring him for his pastleadership as chief of staff and chair of the lastInternational Conference on Healthcare of theChinese in North America.

A previous celebration, also with a liondance, was held January 17 to mark the grandopening of the Excelsior Health Services. Lo-cated at 888 Davis Street, this clinic joins thebusy Sunset Health Services Clinic (at NoriegaSt. and 31st Avenue) as Chinese Hospital’s twosatellite clinics, serving the community outsideof the Chinatown area.

ChineseFred Hom, MD

Kaiser Permanente San Francisco is creat-ing a unique and integrative system in its ap-proach to interventional procedures, and that isone of collaboration and departmental coopera-tion. This method is not only cost-effective andefficient, but it also promotes teambuilding andresource sharing.

The medical center is approaching en-dovascular medical care by circumventing theusual turf battles that take place when specialtiescompete. Interventional Cardiology (HowardLuria, MD), Interventional Radiology (JohnRego, MD), and Vascular Surgery (Doug Grey,

KPSFBruce Blumberg, MD,

Physician-in-Chief

Here at Saint Francis we have implementedtwo new surgical approaches: the Charite disc re-placement procedure and computer navigationalknee and hip replacement. Spine surgeons Ken-neth Light, MD and Clement Jones, MD haveadded the Charite artificial disc replacementprocedure to our complete array of spine ser-vices. This artificial disc procedure offers severaldistinct advantages including a 1.5-hour op-eration through the anterior approach, a shorterpostoperative course and greater preservation ofspinal motion. Dr. Light reports that the latteris part of the orthopedic creed, “Preservation ofmotion means the simulation of normal func-

St. FrancisGuido Gores, MD

St. Luke’s has created a new position forMedical Director of Surgical Services as part ofan ongoing plan to improve quality of care andincrease surgical cases. Sam Michaels, who hasbeen Chair of the Department of Anesthesia for12 years, will assume the new position as well ascontinue his current role. He will first focus onOR availability and scheduling, but all physi-cian concerns are under his purview. His workwill be particularly important in facilitating theintegration of surgical services with CPMC asour proposed merger takes place.

In related news, St. Luke’s has created aphysiciancommittee to reviewcapital andbudgetallocations. It is modeled after a CPMC programthat was initiated by Martin Brotman during hisfirst years as CEO. Dr. Brotman credits their work

MD) have joined forces to offer a combinedservice to Kaiser Permanente members.

Each specialty offers a unique perspectivewith advantages not offered if they were to com-pete with each other or work by themselves. Ourbelief is that the combined service will deliver ahigher quality service to members. The organiza-tion afforded by this cooperative venture shouldspill over into routine services and, consequently,create opportunities for innovative ideas andtechniques.

Recently, Kaiser Permanente San Fran-cisco has added two Interventional Radiologists(Shelley Marder, MD and George C. Lai) andtwo Vascular Surgeons (Hong Hua, MD andJames O’Dorisio, MD). Interventional Cardiol-ogy offers a regional service, consisting of eightInterventional Cardiologists who deliver theirinterventional care at Kaiser Permanente SanFrancisco, performing approximately 1,800coronary interventions annually.

Another cooperative aspect to KP SanFrancisco’s Endovascular medical care is the ac-quiring and sharing of equipment for diagnosticsand procedures. One specific project involves acarotid stent program where the three specialtieshave combined to develop a system, which in-cludes short and long-term follow-up of patients.Carotid stent procedures cross specialties andprovide an opportunity to join forces for betterhealth care.

tion, a goal we all are seeking for our patients.”This procedure was developed in Germany byorthopedic surgeons Kurt Schellnack and KarinButtner-Janz and has been available in Europefor the past two decades. Anecdotal studies fromGermany show patients playing tennis 20-yearspost-op and pain free.

An innovative new technology has come toSaint Francis with the use of the Stryker comput-er navigation system for total knee arthroplastysurgery. Orthopedic surgeons Thomas Sampson,MD, Dominic Tse, MD and Victor Prieto, MD,have all been certified in the use of the system.The system uses an infrared camera and markers,along with unique instrument tracking softwareto continually monitor the position and me-chanical alignment of the implant componentsrelative to the patient’s knee or hip anatomy.The use of this technology has helped to shortenthe length of stay, led to fewer post-operativecomplications, improved knee joint stability andassures leg length equality.

With National Doctors Day just around thecorner, March 30th, on behalf of my colleaguesat Saint Francis Memorial Hospital, let me con-gratulate the members of the Medical Society onyour commitment to patient care and to improv-ing the health of our community.

St. Luke’sJerome Franz, MD

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Excellence is one of the five core values ofSt. Mary’s Medical Center and clinical excel-lence is the expectation especially of the medicalstaff. Peer review is the mainstay of monitoringour quality, measuring our success and findingways to continuously improve. Peer review isa requirement of the Joint Commission, CMS,IMQ and other regulatory agencies and is car-ried out in Ssome fashion at every hospital. Butpeer review itself, as a discipline i undergoingevolution and change. To that end, CatholicHealthcare West has engaged the GreeleyCompany to assist St. Mary’s and all its facilitiesto look at what currently is being done and thanchallenge the institution to improve the processto reflect the need for more practitioner specificinformation and to apply more sophisticatedtools to measure our successes, opportunities forimprovement and to identify issues of immediaterisk and patient safety.This will be a collaborativeventure between medical staff and the commu-nity board that have been delegated authorityfor credentialing and maintaining quality atthe medical center.Developing OrganizationalCapacity (DOC) is the tool that St. Mary’s usesfor its employee satisfaction and values integra-

St. Mary’sKenneth Mills, MD

The San Francisco VA Medical Center(SFVAMC) opened a newly remodeled andrelocated outpatient clinic at Third and HarrisonStreets in January 2006 called the VA DowntownClinic. The new site is near Moscone Center andoffers a wide range of clinical and social servicesto homeless veterans, as it did when the clinicwas located at 13th and Mission. To serve thehealth care needs of veterans in the downtownSan Francisco area, the clinic now offers ex-panded primary care. Veterans in the area mayschedule appointments to see a primary care pro-vider and eliminate the commute to SFVAMC,located on the western edge of the City. The VADowntown Clinic is officially designated by VAas a Comprehensive Homeless Veterans Centerwhere veterans are offered mental health care,substance abuse services, and post traumatic stressdisorder treatment targeted for the homeless.It also provides compensated work therapy forhomeless veterans to help them gain the skillsand habits for employment.

SFVAMC geriatric researchers, Sei Lee,M.D., and Kenneth E. Covinsky, M.D. M.P.H.,conducted a study to predict mortality amongolder adults. The study, entitled “Developmentand Validation of a Prognostic Index for 4-YearMortality in Older Adults,” was published in theFebruary 15, 2006 issue of JAMA. Dr. Lee andhis colleagues developed a 12-question index

Veteran’sDiana Nicoll, MD,

PHD, MPA

for many of the improvements and successes atCPMC, because physicians have decided wheremoneys should be spent. A major investmentfacing St. Luke’s at this time is replacling theemergency department, which is overcrowdedand underequipped for the volume of patientsseen there. Marc Snyder, current Chair of thedepartment and ER director for many years, hasbeen closely involved in the planning and looksforward to completion in 2007.

We regret the retirement of Mary Fedak,Medical Staff Coordinator, November 30. Forfour years she brought order out of chaos in anincreasingly complex operation. Our Director ofPerformance Improvement, Judy Newman, hastaken over Mary’s office and will attempt to man-age both roles with adequate clerical assistance.I’m counting on her.

SetonStephen Conrad, MD

Although we work in Daly City, ourcardiologists are fond of singing that we ‘LeftOur Hearts In San Francisco.’ Seton recentlycelebrated the 40th anniversary of its migrationfrom San Francisco to the sand dunes of DalyCity. The move in 1966 was necessitated bypatient overflow, limited prospects for expansion,and the new seismic regulations of the 1950s.Sound familiar?

As you are aware, annual mammography isnow recommended for all women over the ageof 40. The Seton Breast Health Center now hasa CAD (Computer Aided Detection) system,which scans mammograms and assists the radi-ologist with the identification of malignancies.If the lesion is suspicious, a minimally invasiveStereotactic Breast Biopsy can be performed.These new devices have reduced the need foropen biopsy.

Our GI Department has acquired an Endo-scopic Ultrasound (EUS) device. This apparatusconsists of an ultrasound processor, which islocated at the tip of the endoscope and will allowdetailed imaging of GI lesions. (What will theythink of next?)

Seton now has a PET/CT Scanner. Themarriage of CT technology and PET technol-ogy allows for localization of lesions with greateraccuracy.

Our medical staff is alive, well, and evenflourishing. On 28 April 06, we will hold ahistoric event---the first annual Physicians Rec-ognition Dinner for the members of the ActiveMedical Staff. During this festive evening, awardswill be given for length of membership andlifetime achievement. The good sisters intendto give a Values Award. Music will provided bythe Anton Schwartz Jazz Quartet.

tion survey. This survey has an excellent responserate and has been administered biannually forthe past seven years. Such diverse areas such asspirituality, feeling valued, retention and healthand safety issues are monitored. This informationis shared with the medical staff, administrationand the board and is used in for strategic plan-ning and process improvement. It is just one ofmany reasons our turnover rate is exceedinglylow.St. Mary’s submits a Mission Report and areport of its charity care each month to CatholicHealthcare West. It’s this mission and valuesdriven approach to healthcare while command-ing clinical excellence and stewardship of ourresources that moves us forward.

that accurately predicts the likelihood of deathwithin four years among people 50 and older.The index, based on a simple point system, iseasy to use and can be obtained in a few minuteswith an interview or an intake form. For patientsand caregivers, predicting near-term likelihoodof death is useful when making decisions aboutmedical tests and clinical care.

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