Thursday, September 18, 2014

San Francisco Medical Society Blog


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Proposition 45 - The “Other” Trial Lawyer Proposition Puts a State Politician in Charge of Your Patients’ Health Care

There is more than one proposition on the California ballot this November that threatens health care providers and patients. The same groups pushing to change the Medical Injury Compensation Reform Act (MICRA) – “Consumer Watchdog” and their trial lawyer allies – are also pushing Proposition 45 that would give the state Insurance Commissioner sweeping new power over health care benefits, rates, and co-payments for individuals and small groups. 

SFMS is part of a broad coalition opposed to Proposition 45, including the California Medical Association, California Hospital Association, specialty societies, hospitals, health plans, labor, and small businesses.

Prop 45 threatens physicians’ ability to provide the care that patients need by giving a single elected politician – the Insurance Commissioner – vast new power over health care benefits and rates. With recent cuts to the Medi-Cal program, we are already seeing the devastating impact it can have on patient access to care when politicians cut reimbursement rates below the cost of providing care. Additional cuts would result in an even more difficult time for patients that need care the most.

Prop 45 also has a hidden agenda – allowing trial lawyers and the sponsors to file costly new health care lawsuits. They buried a provision in the fine print that allows them to “intervene” in the regulatory process created under the Initiative and file lawsuits if they don’t like the results. In doing so, they can pocket millions of dollars in so-called “intervenor fees” – as much as $675/hour. In fact, the proponents have already received more than $11.5 million from a similar provision used in auto and home insurance regulation.

Prop 45 establishes new and conflicting rules that could interfere with California’s implementation of the Affordable Care Act. It provides more uncertainty, delays, and confusion at a time when California providers and patients are already dealing with massive changes to our health care system.

Join SFMS and CMA to oppose Prop 45. For more information, visit

Updated POLST Form Effective October 1

The new California POLST form goes into effect on October 1, 2014, and health care professionals must take note of key changes to the form.

POLST (Physician Orders for Life-Sustaining Treatment) is a physician order signed by both a doctor and patient that specifies the types of medical treatment a patient wishes to receive toward the end of life. POLST is a tool that encourages conversation between providers and patients about their end-of-life treatment options, and helps patients make more informed decisions and communicate their wishes clearly. As a result, POLST can prevent unwanted or medically ineffective treatment, reduce patient and family suffering, and help ensure that patient wishes are followed.

The new version of the POLST form includes goal statements for each potential treatment option so patients can better understand their choices. The treatment options are also listed more consistently (from most aggressive to least aggressive), so patients can better understand what is involved in their choices.

Difference Between 2011 and 2014 Forms

  • In order to be consistent with Section A, treatment choices for Sections B and C have been switched in their order, and each section begins with the most aggressive and invasive treatment choices.
  • In Section B, the choice of “Limited Additional Interventions” has been renamed to “Selective Treatment,” and the choice of “Comfort Measures Only” has been renamed to “Comfort-Focused Treatment.
  • Goal statements have been added for each treatment choice in Section B. These descriptions help patients understand the goals of care within each option, and aim to promote quality conversations with a patient and/or legally recognized decision-maker.
    The goal statements are as follows:
    • Full Treatment – primary goal of prolonging life by all medically effective means
    • Selective Treatment – goal of treating medical conditions while avoiding burdensome measures
    • Comfort-Focused Treatment – primary goal of maximizing comfort
  • In Section B, the Full Treatment option features a box which can be marked to indicate: “Trial Period of Full Treatment.” This option is beneficial for patients who want to try short-term ventilatory support but do not want prolonged life support.
  • “Address” was clarified and now reads as “Mailing Address.”
  • The new “Office Use Only” box is in place for internal use only.

2014 POLST Forms

The new version of the POLST form, printed on bright pink paper, will be effective October 1, 2014. Beginning October 1, physicians should only use the new version of the POLST form, though previous versions will continue to be honored.

Click on the links below to download the 2014 POLST form:

5 Things Physicians Need to Know About Reclassification of Hydrocodone

5 things you need to know about DEA’s final rule reclassifying hydrocodone as Schedule II. The changes will go into effective on October 6, 2014. 

  1. Refills aren’t allowed for prescriptions that are written beginning 10/6.
  2. Prescriptions issued before 10/6 won’t necessarily qualify for refills; plan to issue new ones.
  3. Prescriptions can’t be called in or faxed; written scripts required. Emergency treatment only exception to rule.
  4. Allied health professionals might not be able to write prescriptions for these drugs going forward.
  5. Multiple prescriptions may be issued at one time if the prescriber has determined it is appropriate to see the patient only once every 90 days.

Click here for detailed information on the DEA's final rule.

Article References for September 2014 San Francisco Medicine

References cited in Our Bodies’ Best Buddies by Elisabeth M. Bik

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  4. Qin J, Li R, Raes J, Arumugam M, Burgdorf KS, Manichanh C, Nielsen T, Pons N, Levenez F, Yamada T, Mende DR, Li J, Xu J, Li S, Li D, Cao J, Wang B, Liang H, Zheng H, Xie Y, Tap J, Lepage P, Bertalan M, Batto JM, Hansen T, Le Paslier D, Linneberg A, Nielsen HB, Pelletier E, Renault P, Sicheritz-Ponten T, Turner K, Zhu H, Yu C, Li S, Jian M, Zhou Y, Li Y, Zhang X, Li S, Qin N, Yang H, Wang J, Brunak S, Doré J, Guarner F, Kristiansen K, Pedersen O, Parkhill J, Weissenbach J; MetaHIT Consortium, Bork P, Ehrlich SD, Wang J. A human gut microbial gene catalogue established by metagenomic sequencing. Nature. 2010; 464(7285):59-65. DOI: 10.1038/nature08821.
  5. Ridaura VK1, Faith JJ, Rey FE, Cheng J, Duncan AE, Kau AL, Griffin NW, Lombard V, Henrissat B, Bain JR, Muehlbauer MJ, Ilkayeva O, Semenkovich CF, Funai K, Hayashi DK, Lyle BJ, Martini MC, Ursell LK, Clemente JC, Van Treuren W, Walters WA, Knight R, Newgard CB, Heath AC, Gordon JI. Gut microbiota from twins discordant for obesity modulate metabolism in mice. Science. 2013; 341(6150):1241214. DOI: 10.1126/science.1241214.
  6. David L, Materna AC, Friedman J, Campos-Baptista MI, Blackburn MC, Perrotta A, Erdman SE, and Alm EJ. Host lifestyle affects human microbiota on daily timescales. Genome Biology. 2014; 15:R89. DOI: 10.1186/gb-2014-15-7-r89.
  7. Dethlefsen L, Relman DA. Incomplete recovery and individualized responses of the human distal gut microbiota to repeated antibiotic perturbation. Proc Natl Acad Sci USA. 2011; 108 Suppl 1: 4554-61. DOI: 10.1073/pnas.1000087107. 
  8. Seekatz AM, Young VB. Clostridium difficile and the microbiota. J Clin Invest. 2014. DOI:10.1172/JCI72336.
  9. Blaser ML. Missing Microbes: How the Overuse of Antibiotics Is Fueling Our Modern Plagues. Henry Holt and Co., Publ. 2014. ISBN-10: 0805098100. 
  10. Vaz LE, Kleinman KP, Raebel MA, Nordin JD, Lakoma MD, Dutta-Linn MM, Finkelstein JA. Recent trends in outpatient antibiotic use in children. Pediatrics. 2014; 133(3):375-85. DOI: 10.1542/peds.2013-2903. 

References cited in The "Second Genome" and Women's Health by Linda C. Giudice, MD, PhD

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  2. Round JL, Sarkis K. The gut microbiota shapes intestinal immune responses during health and disease. Nature Reviews Immunology. 2009; 9:313-323. 
  3. Kau AL, Ahern PP, Griffin NW, Goodman AL, Gordon JI. Human nutrition, the gut microbiome and the immune system. Nature 2011;474:327-336.
  4. Markle JGM et al. Sex differences in the gut microbiome drive hormone-dependent regulation of autoimmunity. Science. 2013: 339;1084-1088.
  5. Witkin SS, Linhares IM, Giraldo P. Bacterial flora of the female genital tract: Function and immune regulation. Best Pract Res Clin Obstet Gynaecol. 2007; 21(3):347-54. 
  6. Zhou X, Bent SJ, Schneider MG, Davis CC, Islam MR, Forney LJ. Characterization of vaginal microbial communities in adult healthy women using cultivation-independent methods. Microbiology. 2004; 150(Pt 8):2565-73. 
  7. Verhelst R, Verstraelen H, Claeys G, Verschraegen G, Delanghe J, Van Simaey L, De Ganck C, Temmerman M, Vaneechoutte M. Cloning of 16S rRNA genes amplified from normal and disturbed vaginal microflora suggests a strong association between Atopobium vaginae, Gardnerella vaginalis and bacterial vaginosis. BMC Microbiol. 2004; 4:16.
  8. Hyman RW, Fukushima M, Diamond L, Kumm J, Giudice LC, Davis RW. Microbes on the human vaginal epithelium. Proc Natl Acad Sci USA. 2005; 102(22):7952-7. 
  9. Human Microbiome Project Consortium Collaborators (248). Structure, function and diversity of the healthy human microbiome. Nature. 2012; 13:486(7402):207-14. 
  10. Fredricks DN, Fiedler TL, Marrazzo JM. Molecular identification of bacteria associated with bacterial vaginosis. N Engl J Med. 2005; 353(18):1899-911. 
  11. Ravel J, Gajer P, Abdo Z, Schneider GM, Koenig SS, McCulle SL, Karlebach S, Gorle R, Russell J, Tacket CO, Brotman RM, Davis CC, Ault K, Peralta L, Forney LJ. Vaginal microbiome of reproductive-age women. Proc Natl Acad Sci USA. 2011; 15:108 Suppl 1:4680-7. 
  12. Yatsunenko T, Rey FE, Manary MJ, Trehan I, Dominguez-Bello MG, Contreras M, Magda Magris M, Glida Hidalgo G, Robert N. Baldassano RN, Andrey P. Anokhin AP, Heath AC, Warner B, Reeder J, Kuczynski J, Caporaso JG, Lozupone CA, Lauber C, Clemente JC, Knights D, Knight R, Gordon JI. Human gut microbiome viewed across age and geography. Nature. 2012; 486:222-228.
  13. Verstraelen H, Verhelst R, Claeys G, De Backer E, Temmerman M, Vaneechoutte M. Longitudinal analysis of the vaginal microflora in pregnancy suggests that L. crispatus promotes the stability of the normal vaginal microflora and that L. gasseri and/or L. iners are more conducive to the occurrence of abnormal vaginal microflora. BMC Microbiol. 2009; 9:116. DOI: 10.1186/1471-2180-9-116. 
  14. Gajer P, Brotman RM, Bai G, Sakamoto J, Schütte UME, Zhong X, Koenig SSK, Fu L, Ma Z, Zhou X, Abdo Z, Forney LJ, Ravel J. Temporal dynamics of the human vaginal microbiota. Sci. Transl. Med. 2012; 4:132ra52.
  15. Aagaard K, Riehle K, Ma J, Segata N, Mistretta TA, Coarfa C, Raza S, Rosenbaum S, Van den Veyver I, Milosavljevic A, Gevers D, Huttenhower C, Petrosino J, Versalovic J. A metagenomic approach to characterization of the vaginal microbiome signature in pregnancy. PLOS ONE. 2012; 7(6):e36466. 
  16. Hyman RW, Fukushima M, Jiang H, Fung E, Rand L, Johnson B, Vo KC, Caughey AB, Hilton J F, Davis R W, Giudice LC. Diversity of the vaginal microbiome correlates with preterm birth. Reproductive Sciences. 2014; 21: 32-40.
  17. Koren O, Goodrich JK, Cullender TC, Spor A, Laitinen K, Backhed HK, Gonzalez A, Werner JJ, Angenent LT, Knight R, Backhed F, Isolauri E, Salminen S, Ley RE. Host remodeling of the gut microbiome and metabolic changes during pregnancy. Cell. 2012; 150:470-480.
  18. Aagaard K, Ma J, Antony KM, Ganu R, Petrosino J, Versalovic J. The placenta harbors a unique microbiome. Sci. Transl. Med. 2014; 6:237ra65.
  19. Muglia LJ, Katz M. The enigma of spontaneous preterm birth. N Engl J Med. 2010; 362(6):529-35. 
  20. Dominguez-Bello MG, Costello EK, Contreras M, Magris M, Hidalgo G, Fierer N, Knight R. Delivery mode shapes the acquisition and structure of the initial microbiota across multiple body habitats in newborns. Proc Natl Acad Sci USA. 2010; 107:11971-11975.
  21. Bergstrom A, Skov TH, Bahl MI, Roager HM, Christensen LB, Eilerskov KT, Molgaard C, Michaelsen KF, Licht TR. Establishment of intestinal microbiota during early life: A longitudinal, explorative study of a large cohort of Danish infants. Appl Environ Microbiol. 2014; 80:2889-2900.
  22. Siddiqui H, Nederbragt AJ, Lagesen K, JeanssonSL Jakobsen KS. Assessing diversity of the female urine microbiota by high throughput sequencing of 16S rDNA amplicons. BMC Microbiology. 2011; 11:244-251.
  23. Alan J, Wolfe AJ, Toh E, Shibata N, Bong B, Kenton K, FitzGerald MP, Mueller ER, Schreckenberger P, Dong Q, Nelson DE, Brubaker L. Evidence of uncultivated bacteria in the adult female bladder. J Clin Microbiol. 2012; 50:1376-1383.
  24. Lewis DA, Brown R, Williams J, White P, Jacobson SK, Marchesi JR, Drake MJ. The human urinary microbiome: Bacterial DNA in voided urine of asymptomatic adults. Front Cell Infect Microbiol. 2013; 3:41.
  25. Brubaker L. Annual Meeting of the Ammerican UroGynecologic Society 2013.
  26. Pearce MM, Hilt EE, Rosenfeld AB, Zilliox MJ, Thomas-White K, Fok C, Kliethermes S, Schreckenberger PC, Brubaker L, Gai X, Wolfe AJ. The female urinary microbiome: A comparison of women with and without urgency urinary incontinence. mBio. 2014; 5(4):e01283-14.
  27. Siddiqui H, Lagesen K, Nederbragt AJ, Jeansson SL, Jakobsen KS. Alterations of microbiota in urine from women with interstitial cystitis. BMC Microbiology. 2012; 12:205-211-215.
  28. Fouts DE, Pieper R, Szpakowski S, Pohl H, Knoclach S, Suh M-H, Huang S-T, Ljungberg I, Sprague BM, Lucas SK, Torralba M, Nelson KE, Groah. Integrated next-generation sequencing of 16S rDNA and metaproteomics differentiate the healthy urine microbiome from asymptomatic bacteriuria in neuropathic bladder associated with spinal cord injury. J Transl Med. 2012; 10:174.
  29. Imirzalioglu C, Hain T, Chakraborty T, Domann E. Hidden pathogens uncovered: Metagenomic analysis of urinary tract infections. Andrologia. 2008; 4066-71.

References cited in Pre- and Probiotic Foods for a Healthy Gut by Jo Ann T. Hattner, MPH RDN and Susan Anderes, MLIS 

  1. Pollan M. Some of my best friends are germs. New York Times Magazine. May 15, 2013.
  2. Food and Agriculture Organization of the United Nations, World Health Organization. Probiotics in food: Health and nutritional properties and guidelines for evaluation. Rome: Food and Agriculture Organization of the United Nations: World Health Organization. 2006; viii:50.
  3. Hattner JAT, Anderes S. Gut Insight: Probiotics and Prebiotics for Digestive Health and Well-Being. San Francisco: Hattner Nutrition. 2009.
  4. German JB. The future of yogurt: Scientific and regulatory needs. Am J Clin Nutr. 2014; 99(5 Suppl):1271S-8S. DOI: 10.3945/ajcn.113.076844. PubMed PMID: 24695899; PubMed Central PMCID: PMC3985222.
  5. Hertzler SR, Clancy SM. Kefir improves lactose digestion and tolerance in adults with lactose maldigestion. J Am Diet Assoc. 2003; 103(5):582-7. DOI: 10.1053/jada.2003.50111. PubMed PMID: 12728216.
  6. Farnworth ER, Mainville I, Desjardins MP, Gardner N, Fliss I, Champagne C. Growth of probiotic bacteria and bifidobacteria in a soy yogurt formulation. Int J Food Microbiol. 2007; 116(1):174-81. DOI: 10.1016/j.ijfoodmicro.2006.12.015. PubMed PMID: 17292991.
  7. Moshfegh AJ, Friday JE, Goldman JP, Ahuja JK. Presence of inulin and oligofructose in the diets of Americans. J Nutr. 1999; 129(7 Suppl):1407S-11S. Epub 1999/07/08. PubMed PMID: 10395608.
  8. Saavedra JM, Dattilo A. Microbiota of the intestine. Encyclopedia of Human Nutrition: Elsevier. 2013.
  9. van Loo J, Coussement P, de Leenheer L, Hoebregs H, Smits G. On the presence of inulin and oligofructose as natural ingredients in the western diet. Crit Rev Food Sci Nutr. 1995; 35(6):525-52. DOI: 10.1080/10408399509527714. PubMed PMID: 8777017.

References cited in The NIH Human Microbiome Project by Erica Goode, MD

  3. Huttenhower C. Functional analysis of the human microbiome, metagenomes, metatranscriptions, and multi-omics. Broad Institute, Raes Lab, VUV-KU Leuwens lecture. July 24, 2013.
  4. Morgan. TiG 2012. Huttenhower, ibid.
  5. Tan P. The neonatal microbiome and NEC. Washington University, St. Louis, collaborative study, NIH HMP. 2014.
  6. Turnbaugh P, Gordon J et al. Washington University, St. Louis. 2013.
  7. Huenemann R. U.C. Berkeley, School of Public Health. Communication, 1968.
  8. Clement K. Bariatric surgery, adipose tissue, and gut microbiota. Int’l. J. of Obesity. 2011;  35:S7-15.
  9. Kong LC et al. Gut microbiota after gastric bypass in human obesity: Increased richness and associations of bacterial genera with adipose tissue genes. Am. J. Clinical Nutrition. 2013; 98:(1), 16-24.
  10. Turnbaugh, ibid.
  11. Aroth T, Sharma R et al. Fermentation potential of the gut micro biome: Implications for energy homeostasis and weight management. Nutr. Rev. 2012; 69:(2), 99-106.

References cited in Why the Microbiome Matters: One Primary Care Physician's Journey toward Understanding Its Significance by Payal Bhandari, MD

  1. Hattner JA. 2013.
  2. Dong TL, MD. Healthy at Home: Get Well and Stay Well Without Prescriptions.  2014. Published by National Geographic Society.
  3. Robinson, J. Eating on the Wild Side. 2013. Published by Little & Brown.
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Vote No on Proposition 46

Originally published on on September 12, 2014

By Michael H. Rokeach, MD

As an emergency-room doctor in San Francisco for more than 30 years, I see some of the city’s most critical patients — people suffering heart attacks, life-threatening infections, gunshot wounds and more. Proposition 46, which seeks to increase the limit on the amount of medical malpractice lawsuit awards, is a critical threat to the health care of all Californians. The thoughtful response is to oppose it.

The initiative is a complicated, costly measure — written and funded by trial attorneys — which makes sweeping changes to California’s health system without any input from health care experts or medical practitioners.

It’s also deceptive. It uses alcohol and drug testing of doctors (whether they are on or off duty — unprecedented in the U.S.) to disguise the real intent, which is to lift the cap on the medical malpractice lawsuit awards to $1.1 million from $250,000, thereby raising attorney fees, while increasing costs for everybody else.

But, worst of all, it’s bad for health care and health access for low-income communities. It will cost the state and local governments hundreds of millions of dollars and it will make it harder for community clinics such as Planned Parenthood to provide specialty services.

With millions of newly insured patients looking for quality care under the Affordable Care Act, I can’t think of a worse possible time to increase cost and decrease access to trusted health providers. Vote NO on Prop. 46.

Michael H. Rokeach is an emergency-room physician and past president of the San Francisco Medical Society.

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