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MEDICINE S A N A N TO N I O

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WWW.BCMS.ORG • $4.00 • SEPTEMBER 2026 • VOLUME 79 NO. 9

IN THIS ISSUE The Therapeutic Revolution in Rare Pediatric Disorders The Adolescent Varicocele: What primary care providers need to know Beyond Behavior: Executive function as the missing link in children’s mental health

Children's Health

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TABLE OF CONTENTS

THE OFFICIAL PUBLICATION OF THE BEXAR COUNTY MEDICAL SOCIETY

MEDICINE S A N A N TO N I O

THE OFFICIAL PUBLICATION OF BEXAR COUNTY MEDICAL SOCIETY

WWW.BCMS.ORG • $4.00 • SEPTEMBER 2026 • VOLUME 79 NO. 9

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SEPTEMBER 2026

CHILDREN'S HEALTH The Therapeutic Revolution in Rare Pediatric Disorders: A clinical overview of XLH and FCS

By William F. Trigoso, MD; and Tina Copple, DNP........................16

The Adolescent Varicocele: What primary care providers need to know

By Gaayana A. Raju, MD.............................................................18

Sudden Infant Death Syndrome

By Tricia Saputera, OMS-II; Nethra Giri, OMS-II; and James Mayberry, MD...................................................................20

Breaking New Ground in Pediatric Bone Cancer Research

By Panneerdoss Subbarayalu, PhD.............................................22

Protecting Children's Vision: Preventing eye injuries at home, at play and in sports

IN THIS ISSUE

By Manpreet S. Chhabra, MD......................................................24

The Therapeutic Revolution in Rare Pediatric Disorders The Adolescent Varicocele: What primary care providers need to know Beyond Behavior: Executive function as the missing link in children’s mental health

Children's Health

Beyond Behavior: Executive function as the missing link in children’s mental health

By Grizelda Morales Anguiano, MD..............................................26 BCMS President’s Message By Jennifer Rushton, MD, President, Bexar County Medical Society...............................8 General Membership Meeting Invitation By Jayesh “Jay” Shah, MD............................................................................9 Recollections: Rajam Ramamurthy, MD By Kreny Savaliya, OMS-III..........................................................................10 Perspectives: Cleft Care at Home and Abroad By Christian L. Stallworth, MD.............................................................12 SA Kids BREATHE: A community partnership helping children with asthma thrive By Cara Hausler, MPH...............................................................................................................................................28 Texas Medical Association Foundation's "Hard Hats for Little Heads" Initiative: One pediatrician's experience By Leah H. Jacobson, MD, FAAP..............................................................................................................................30 2027 BCMS Election Candidates...............................................................................................................................32 Before You Open a Role: Salary, structure and hiring strategy basics Courtesy of Favorite Healthcare Staffing..........39 Bexar County Medical Society Business Partners Program........................................................................................40 2026 Range Rover By Stephen Schutz, MD.............................................................................................................44 Recommended Auto Dealers.....................................................................................................................................46

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BCMS BOARD OF DIRECTORS ELECTED OFFICERS

Jennifer Rushton, MD, President Lauren E. Tarbox, MD, Vice President Lubna Naeem, MD, President-Elect Dan Powell, MD, Treasurer Lyssa N. Ochoa, MD, Secretary John Shepherd, MD, Immediate Past President

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PRESIDENT’S MESSAGE

Advocating for Children’s Health, From Clinic to Community By Jennifer R. Rushton, MD, President, Bexar County Medical Society

Dear friends and colleagues, Children’s health is a reflection of the health of Bexar County. Unfortunately, local statistics are staggering. Nearly one in five Bexar County children lives in poverty and/or experiences food insecurity. Fewer than half of our children enter kindergarten meeting readiness benchmarks. Mental health needs among children and adolescents continue to grow. Childhood obesity, diabetes, asthma and poor air quality, and access to pediatric primary care are all significant issues affecting the children of our community. As physicians, we know that the foundations of lifelong health are built in childhood. Preventive care, immunizations and early screening can significantly improve lifelong outcomes. Other drivers such as nutrition, physical activity, reading and language development are crucial for healthy children. Physicians play a role in protecting children beyond the clinic as advocates for healthy communities. We can advocate for injury prevention, firearm safety, water safety and drowning prevention, car seat and bicycle helmet use, and tobacco and vaping prevention. We can also participate in mentorship and workforce development, encouraging young people to pursue healthcare careers. Caring for today’s children is an investment in the future of Bexar County. BCMS supports children’s health through advocacy, physician leadership, community partnerships and educational initiatives. One of the clearest examples is the work of the BCMS Alliance, which received a TMA Foundation grant through the Be Wise-Immunize program. In partnership with the San Antonio Metropolitan Health District, the Alliance helped fund HPV vaccinations for eligible children during back-to-school immunization drives while providing education about cancer prevention and vaccine confidence. The theme of children’s health is particularly timely given the recent executive order regarding childhood vaccines. The new order signed by the President reduces the number of routinely recommended childhood vaccinations at the federal level from 18 to 11, advises that the MMR vaccine be split into three separate, spaced-out injections despite single-pathogen vaccines not being available in the U.S., and directs the Justice Department to challenge state vaccine laws that conflict with the administration’s approach to parental and religious exemptions. The American Academy of Pediatrics, the AMA and other medical organizations have expressed concern that reducing or delaying routine vaccinations could increase preventable disease and create confusion for families. Spacing out the shots would also create unnecessary barriers for families and increase the total number of painful injections. As a federal order, it does not automatically eliminate Texas’s school-entry vaccination requirements as these fall under state law. However, these concerns come amid declining vaccination coverage and significant measles activity in Texas. As physicians, our obligation is to provide families with clear, evidence-based information and to advocate for policies that protect children’s health. Childhood immunizations are just one focus area for organized medicine. BCMS physicians advocate for our children at the local, state and national levels. In partnership with the TMA, we help shape legislation affecting Texas children. 8

SAN ANTONIO MEDICINE • SEPTEMBER 2026

TMA policy supports: • Universal access to preventive care for infants, children and adolescents, including well-child visits and developmental screening. • Child injury prevention, including education on child safety and healthy development. • Early identification of developmental and behavioral concerns, and timely referral for appropriate services. • Improving access to care for Texas children through Medicaid and CHIP, and reducing barriers to physician services. The AMA has longstanding policies supporting: • Evidence-based childhood immunization as one of the most effective public health interventions. In 2026, the AMA reaffirmed its support for continued access to recommended childhood vaccines. • Children’s mental health, including early identification, access to behavioral healthcare and reducing stigma. • Protecting children from the harms of tobacco and vaping, including support for restrictions on flavored vaping products that appeal to youth. • Healthy nutrition and addressing food insecurity, including “Food is Medicine” initiatives that benefit children and families. • Digital safety for children and adolescents, advocating for safeguards for social media, online privacy and digital literacy. • Child injury prevention, including firearm injury prevention and poison prevention. All of us as physicians can help shape children’s health. As a hospital-based pathologist, I collaborate with neonatologists and pediatricians to provide the laboratory testing they need to care for our tiniest patients. To decrease the amount of time patients and their physicians wait for lab results, we bring testing in-house, such as molecular testing for CMV, HIV and HSV. We also partner with reference labs to improve turnaround time, such as for rapid genetic testing. We help ensure we draw as little blood as necessary for the required testing and that our blood supply is adequate and safe when a transfusion is needed. The challenges facing children in Bexar County are significant, but so is our collective capacity to address them. The health of our children will shape the future of San Antonio. Let us continue to care for them, advocate for them, and invest in them. With gratitude, Jennifer R. Rushton, MD Jennifer R. Rushton, MD, 2026 President of the Bexar County Medical Society, is a partner at Oculus Pathology and the Medical Director of Pathology and Laboratory Medicine for the Baptist Health System. She is board certified in Anatomic and Clinical Pathology, Hematopathology and Molecular Genetic Pathology. Dr. Rushton currently serves as Chief of Staff for Baptist Medical Center Hospital. She is a long-time member and co-chair of the BCMS Legislative Committee, serves on the TMA Council on Healthcare Quality, and is a Texas Delegate to the AMA.

SAN ANTONIO MEDICINE

You’re Invited to Our General Membership Meeting Dear Colleague, I invite you to join us on September 10, 2026, for the Bexar County Medical Society General Membership Meeting. During this meeting, we'll review the significant legislative victories BCMS achieved on behalf of physicians during the past session and discuss the challenges that remain. More importantly, we want to hear from you as we begin developing our legislative priorities for the upcoming 2027 Legislative Session. In addition, attendees will have the opportunity to earn 1 hour of Ethics CME, making this an excellent opportunity to stay informed, fulfill continuing education requirements, and engage with fellow physicians. Your voice is essential in helping shape TMA and BCMS's advocacy efforts. Together, we can continue protecting the practice of medicine, advancing our profession, and ensuring physicians have a strong voice in the legislative process.

Please use the QR code below to RSVP. We hope you'll join us for this important and informative meeting. If you have any questions, please contact the BCMS Membership Department at 210-301-4398 or membership@bcms.org. Sincerely,

Jayesh “Jay” Shah, MD TMA Immediate Past President BCMS Past President

Visit us at www.bcms.org

RECOLLECTIONS CHILDREN'S HEALTH

Rajam Ramamurthy, MD By Kreny Savaliya, OMS-III

Long before she became a leader in neonatology and medical education, Dr. Rajam Ramamurthy was a young girl growing up in Kolar Gold Fields, a small gold-mining town near Bangalore, India. It was a close-knit community shaped by British colonial influence, where discipline and education were highly valued. She attended a Catholic convent school run by French nuns, an experience that instilled in her both structure and intellectual curiosity, qualities that would later define her career. Her earliest impressions of the world beyond India came from her father, a mining engineer who traveled to the United States for graduate studies when she was very young. From afar, he sent aerogram letters describing American life. One story stayed with her: newspapers placed at street corners where people would take one and leave money in a box without supervision. To her, it symbol-

ized a society built on honesty and trust. Even as a child, she quietly resolved that one day she would see that world for herself. At home, her mother provided an equally profound influence. At a time when many women had limited access to education, she had completed high school and believed deeply in independence. She encouraged her daughters to pursue education and stand on their own, reinforcing values of discipline and self-reliance. In an era when many young girls were expected to marry early, Dr. Ramamurthy was supported in her academic ambitions. Medicine was not her first dream. As a teenager, she was drawn to Indian classical dance and imagined a future on stage. However, limited opportunities and social expectations made that path difficult. Like many academically strong students, she turned toward science. After completing her pre-uni-

versity studies, a family physician suggested medical school, and at just 15 years old, she began her training. From her first day in the anatomy lab, she understood the demands of medicine. Standing among cadavers alongside classmates equally young, she felt both awe and determination. Under strict but dedicated professors, she developed a fascination with the human body. Dissection became a discipline that required patience, precision and respect. As her training progressed into clinical rotations, she learned medicine in its most human form. In government hospitals, diagnosis relied on observation, touch and attentive listening. These experiences shaped her belief that medicine is as much about connection as it is about knowledge. The final examinations were intense and demanding, testing both intellect and resilience, and marking a defining moment in her journey.

2004 Bexar County Medical Society Presidential Installation

Dr. Ramamurthy being honored with the Presidential Teaching Award by Dr. Francisco Cigarroa

Dr. Ramamurthy being honored for her sevice as Bexar County Medical Society President by Dr. Sheldon Gross

Dr. Ramamurthy, with colleagues, was part of the faculty at the UT Health, formerly UT Health Science Center, for 37 years

Felicitation at the Texas Indo-American Physicians Society Southwest Chapter, President 1996

Dr. Ramamurthy with colleague Carolyn McLerran, in the University Hospital NICU, caring for premature babies

SAN ANTONIO MEDICINE • SEPTEMBER 2026

RECOLLECTIONS CHILDREN'S HEALTH

Dr. Ramamurthy was President of the Association of Retired Faculty and Associates, 2024 and 2025

Grand Opening of the new Bexar County Medical Society building

Interreligious Council of San Antonio, formed in 1996

Her path became clear during her internship. While observing a pediatrician perform a spinal tap on a child, she was struck by both his technical skill and his dedication to teaching. Inspired, she began to follow him closely, absorbing his approach to patient care. In that moment, pediatrics and, ultimately, neonatology found her. After passing the Educational Commission for Foreign Medical Graduates examination, she moved to the United States to begin her residency at Cook County Hospital in Chicago. Adjusting to a new culture and environment presented challenges, but her strong clinical foundation helped her succeed. She eventually became chief resident, a reflection of her skill and perseverance. During this time, she discovered her passion for neonatology, a field still in its early development. At a time when the survival of premature infants was uncertain, she contributed to advancing neonatal care and resuscitation techniques. She worked with engineers to develop the “Bionic Baby,” an

early simulation model that transformed medical training. She also helped establish neonatal resuscitation programs in rural hospitals across South Texas, bringing critical care skills to underserved areas. Teaching became a defining part of her career. She mentored generations of students and physicians, emphasizing that compassion must accompany technical expertise. Her dedication to education earned her numerous awards, reflecting the lasting impact she had on her trainees. Her influence extended into leadership and advocacy. She became the first female president of the Bexar County Medical Society in its 150-year history, breaking barriers for women in medicine. She also advocated for international medical graduates, helping create opportunities and representation within major medical organizations. Despite her professional achievements, she remained deeply connected to her passion for Bharatanatyam, a classical Indian dance form. In San Antonio, she became

a respected figure in the arts community, using dance to promote cultural awareness and unity. Now retired, Dr. Ramamurthy reflects on a life shaped by perseverance, purpose and compassion. While she recognizes the challenges facing modern healthcare, she remains hopeful. She believes that medicine will ultimately return to its foundation: the human connection between physician and patient — a sacred bond that has guided her throughout her remarkable journey.

Dr. Ramamurthy was the second President of the India Association of San Antonio in 1980, honored on the Indian Independence Day celebrations

TMA Foundation Board of Directors, with a student from UTHSCSA who received the Diversity Scholarship supported by the Drs. Ramamurthy

Kreny Savaliya, OMS-III, is a medical student at the University of the Incarnate Word School of Osteopathic Medicine, Class of 2028. She is deeply interested in children’s health and pediatric surgery, with a passion for improving outcomes in vulnerable populations. She aspires to provide compassionate, high-quality medical and surgical care to communities that lack adequate access to healthcare services. Kreny serves on the BCMS Publications Committee.

Visit us at www.bcms.org

PERSPECTIVES CHILDREN'S HEALTH

Cleft Care at Home and Abroad By Christian L. Stallworth, MD | Photography courtesy of the FACES Foundation

y first medical mission trip was in February 2010. At the time, I was completing fellowship training in facial plastic and reconstructive surgery at OHSU in Portland, Oregon. An important part of that training involved the care of children and adolescents with cleft and craniofacial anomalies. The fellowship carried the unique expectation that each fellow would travel with their surgical team to South America to provide care for children born with clefts and other craniofacial conditions. Up to that point, I had traveled internationally only to Mexico. I had certainly never practiced medicine in rural South America. I remember arriving in Peru feeling completely outside of my comfort zone. The experience challenged me physically and mentally, and, more significantly, it made me question the way I thought about medicine. In the United States, we are accustomed to an extraordinary medical infrastructure. If we need a particular suture, medication, instrument, imaging study, consultation or piece of equipment, it is generally available. In rural Peru, nearly everything we might need had to come with us. That included medications, surgical instruments, sutures, dressings and every other medical supply imaginable. When resources are limited and home is thousands of miles away, there is no easy solution to an unexpected problem. Clinical judgment, preparation and surgical experience are elevated in importance. That first mission trip was life changing for me. In July 2026, more than 16 years after my first trip to Peru, I completed my fifth mission (and fourth trip to Peru) with the FACES Foundation (https://facesfoundation.org). Serendipitously, the mission coincided with the annual National Cleft and Craniofacial Awareness and Prevention Month in the United States. Ever since my first experience in Peru, I have tried to maintain this type of service as a regular part of my career because I find it simultaneously rewarding and challenging. However, over time, I have also come to view it as something more than personal fulfillment. For those of us fortunate enough to acquire highly specialized skills, I believe we have a professional obligation to share those skills with people who have extremely limited access to that level of care. For those outside the field, cleft lip and palate anomalies are classified, obviously, as a surgical problem. In theory, a child is born with a cleft, an operation repairs it, and the problem is solved. In reality, though, the operation is just one step in a much longer process. Regardless of where a child is born, caring for a cleft or craniofacial dif12

SAN ANTONIO MEDICINE • SEPTEMBER 2026

ference is a commitment that can begin shortly after birth and continue through childhood, adolescence and early adulthood. In the United States, care is ideally coordinated through a multidisciplinary cleft and craniofacial team. The core team must include a care coordinator, an orthodontist, a speech and language pathologist and a surgeon (neurosurgeon, plastic surgeon, facial plastic surgeon, and/or oral & maxillofacial surgeon). The team is also required to have additional access to an otolaryngologist, audiologist, geneticist, feeding nurse, pediatrician, pediatric dentist, psychologist, social worker and representatives from other specialties as they are needed. The needs of these children change as they grow. Feeding and airway issues are often immediate concerns in infancy. Lip repair is generally completed around 3-4 months of age, while palate repair follows around 10-12 months of age. Placement of myringotomy/tympanostomy tubes is also frequently required during the first year of life and may need to be repeated. Throughout childhood, most children are followed for management of hearing and middle-ear disease, speech and resonance problems, dental development, orthodontic treatment, bone grafting, nasal reconstruction, and, for some patients, orthognathic surgery. The social and emotional aspects of growing up with a visible facial difference must also be addressed. Outward facial visibility and orofacial function are integral to healthy and successful development socially. Without access to care, especially in impoverished nations, children often become socially isolated if they never have the lip and/or palate repaired. Social isolation and speech delays or limitations can affect children scholastically as well. Often these children face limited work opportunities as they age and can even encounter difficulty finding companionship, making them less likely to form families of their own. Successful cleft care, therefore, cannot be measured simply by what a lip looks like when the sutures are removed. The greater objectives include helping children look more like their peers, as well as being able to eat, drink, hear, speak, breathe, grow, learn, and develop socially with as few limitations as possible. This long-term perspective is essential when discussing care, both here at home and for international medical missions. The Responsibility That Accompanies Mission Work Medical mission work deserves thoughtful scrutiny. There are legitimate criticisms of short-term medical missions, particularly those that

PERSPECTIVES CHILDREN'S HEALTH arrive in a community, perform procedures, and leave without providing adequate follow-up care or establishing relationships with local healthcare professionals. Good intentions alone do not guarantee good medicine. The ethical standards we uphold as medical professionals should not fundamentally change because an operation is performed in another country. If anything, practicing in an environment with fewer resources requires greater preparation and an even clearer understanding of what will happen after a visiting team returns home. A key reason I have remained involved with the FACES Foundation is that its philosophy has never been simply to arrive, operate and leave. The program has returned to the same region in Peru for more than two decades. That continuity has built trust and encouraged relationships to develop among patients, families, physicians, clergy, civic leaders and community organizations. Over time, the mission effort has become about much more than surgery. Relationships have been established with local dentists and orthodontists. Peruvian physicians work alongside visiting specialists. Community support networks have developed through organizations, including the regional Lions Club and the Catholic Church. Perhaps one of the most important accomplishments has been the education and support of local speech-language pathologists. The role of speech therapy perfectly illustrates why complete cleft care cannot be delivered during a one-week surgical trip. A technically successful palate repair does not automatically produce normal speech. Some children require years of therapy and periodic re-evaluation, while other children ultimately require additional surgery for velopharyngeal dysfunction. Long before Zoom meetings and modern telehealth became routine, the FACES team was using Internet-based video conferencing to connect speech professionals in Peru with specialists in Oregon. Technology allowed expertise to cross thousands of miles without requiring either the patient or specialist to physically make that journey. This is the model of international work that I believe has the greatest potential — not simply delivering care but helping to create a system that continues to provide care after the surgical team leaves. From Peru to San Antonio Interestingly, my 2010 trip to Peru also influenced how I viewed cleft care when I returned home. I joined the faculty at the University of Texas in San Antonio in 2010. At that time, comprehensive cleft care was not available within the University Health System nor at UT Health. Excellent accredited cleft teams existed elsewhere in South Texas and in San Antonio, but our own patients frequently had to be referred to these teams outside the system for coordinated multidisciplinary treatment. It seemed incongruous to travel thousands of miles to help build cleft care in another country while recognizing that there was an unmet need within my own institution. Building a comprehensive team, however, proved more challenging than performing cleft surgery. It required bringing multiple specialties together, creating systems for referrals and longitudinal follow-up, coordinating care among patients and multiple specialists, and demonstrating and documenting success. The program had to meet the established national standards of the American Cleft Palate and Craniofacial Association (ACPA, https://acpacares.org). That process took years. After approximately 13 years of development, our cleft and craniofacial team achieved approval through the ACPA in 2023. Today, the

team continues to grow, in both the number of participating specialists and in the number of patients. We can now provide comprehensive, state-of-the-art cleft and craniofacial care to children throughout South Central Texas and well beyond. San Antonio is particularly well positioned for this work. Our proximity to the border means we care for children from many different backgrounds and nationalities, some who face substantial barriers to specialized healthcare. University Health has also become a clinical site for Fresh Start Surgical Gifts (https://www.freshstart.org), a national nonprofit organization based in San Diego that facilitates multidisciplinary medical care for children in need. Fresh Start uses a somewhat different model from the traditional international mission. When appropriate, the organization brings the child to an established medical team in the United States, rather than bringing an entire medical team to the child in another country. There are important advantages to this approach. Complex craniofacial patients may need sophisticated imaging, subspecialty consultation, intensive perioperative support or multiple procedures that simply cannot be safely performed in a temporary international setting. Bringing a patient into an established healthcare system gives us access to those resources and allows us to provide a broader level of care. We have been fortunate to extend this opportunity to children with cleft conditions. Both approaches have value. The important question is not whether care occurs in San Antonio or South America. The question is whether the child receives appropriate, safe and sustainable care. Returning to Peru My most recent trip found me returning to Lambayeque, Peru, in July with a team of 26 volunteers. This trip was an intermediate trip at one-half the size of the normal annual trip that happens in February. I served as one of three senior surgeons, and we also brought two surgeons in fellowship training. We were accompanied by a multidisciplinary group that included pediatric anesthesiologists, CRNAs, preoperative and postoperative nurses, anesthesia technicians, speech-language pathologists, administrative personnel, a photographer and individuals who helped coordinate the many logistical needs and governmental relationships necessary to make a trip like this possible. I am particularly proud that seven members of our group were from San Antonio, representing both the CHRISTUS Health and University Health systems. On our first clinical day, we evaluated 105 patients. Over the following five days, our team performed 34 surgical procedures on 26 children. Those numbers tell only a small part of the story. Some of the children were new patients. Others were established patients who had built relationships and received care on previous trips. Each child arrived with a family and a story, often after traveling considerable distances for the opportunity to be evaluated. Our responsibility did not end when the final operation was completed. Technology has made continuity of patient care dramatically easier than it was during my first trip to Peru in 2010. By using tools such as WhatsApp and video conferencing, we can communicate with our medical partners in Peru, review photographs, receive updates, and help address concerns between visits. The patients from this trip will continue to be followed locally and will be evaluated again when the next team returns in January 2027. The continuity of care matters. The success of a mission should not be measured by how many operations are performed in a week. Visit us at www.bcms.org

PERSPECTIVES CHILDREN'S HEALTH It should be measured by whether the patients are healthy and still receiving supportive care one year, five years and ten years later. Finding Our Own Way to Serve International mission work is not for everyone. Physicians and other healthcare professionals have obligations to their own families, practices and communities; and international work requires considerable time and resources. In addition, there are countless opportunities to serve underserved populations that do not require boarding an airplane. Regardless of where you can serve, I would encourage those of us in medicine to consider sharing the skills we have been fortunate enough to acquire with populations with limited access to healthcare. Sharing our talents can take many forms. It might mean traveling internationally, but it could also mean volunteering at a local clinic, mentoring younger physicians, teaching colleagues in an underserved region, participating in a nonprofit organization, providing uncompensated specialty care, or helping to build a program within a local institution. My own experience has taught me that “mission work” does not have to describe a destination. Some of the children I have been priv-

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ileged to care for live in small communities in the Andes. Others live within a few miles of my office in San Antonio. Their locations are different, but their needs are remarkably similar. A child born with a cleft lip and palate needs a healthcare infrastructure committed to being there through infancy, childhood, adolescence and even young adulthood. The surgery performed is only one piece of a large puzzle. When I traveled to Peru for the first time in 2010, I thought I was going there primarily to operate. However, I returned home understanding that the greater responsibility was to participate in something that would last and truly make a difference in patients’ lives. Sixteen years and five trips later, that lesson continues to shape how I think about cleft and craniofacial surgery, both thousands of miles from San Antonio and right here at home. Ultimately, the most meaningful measure of our work is not how far we travel to provide it, but how long we are willing to remain committed to the children and populations who need it. Christian L. Stallworth, MD, is Clinical Professor in the Division of Facial Plastic & Reconstructive Surgery, Department of Otolaryngology – Head & Neck Surgery at UT Health San Antonio. He serves as a founding member and co-director of the University Health Cleft and Craniofacial Center and is owner and President of Texas Plastic Surgery. He is board certified in both Facial Plastic and Reconstructive Surgery and in Otolaryngology. Dr. Stallworth is a member of the Bexar County Medical Society.

CHILDREN'S HEALTH

Visit us at www.bcms.org

CHILDREN'S HEALTH

The Therapeutic Revolution in Rare Pediatric Disorders: A clinical overview of XLH and FCS By William F. Trigoso, MD; and Tina Copple, DNP

ver since we were in medical school, to get to know about rare disorders was basically a rhetorical exercise in futility. We learned them superficially to pass exams, memorized a unique pathophysiology, and hoped we would never encounter these patients. We had virtually nothing to offer outside of a referral to a distant research facility, hoping they might qualify for an obscure study, never to return to our care. Targeted therapies have fundamentally changed this paradigm, sharpening our clinical awareness and enabling us to recognize these rare conditions in daily practice. These treatments do more than optimize an individual's immediate quality of life. The presence of an affected patient in our clinic opens a vital door for their descendants. By leveraging cascade screening and early genetic testing, we can intervene in second and third generations at an asymptomatic stage. This shifts our role from reactive management to true prevention, halting systemic deterioration before it begins for the next generation. Nowadays there are many disorders where new therapeutic and preventive measures are within the scope of most physicians. Two pearls to begin looking are X-linked Hypophosphatemia (XLH) and Familial Chylomicronemia Syndrome (FCS). Pediatric medicine frequently encounters rare, monogenic disorders that disrupt vital pathways. While XLH and FCS represent completely different biochemical pathologies, one affecting skeletal mineralization and the other disrupting lipid metabolism, both present unique diagnostic challenges during early childhood. They require systematic clinical screening and specialized lifelong management to prevent catastrophic complications like permanent bone deformities or disabling recurring pancreatitis. 16

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X-Linked Hypophosphatemia (XLH) in Children XLH is an inherited skeletal disorder characterized by profound renal phosphate wasting and is the most common heritable rickets. This rare disease affects male and female patients and is caused by the dominant loss-of-function mutation in the PHEX gene. Under healthy conditions, the PHEX protein counterbalances Fibroblast growth Factor 23 (FGF23), an osteocyte-secreted hormone regulating systemic phosphate balance. When PHEX is mutated, circulating FGF23 rises to pathologically high levels, preventing kidneys from reabsorbing phosphate while suppressing active Vitamin D (1,25(OH)₂D) production, resulting in chronic hypophosphatemia and failed bone mineralization. The clinical presentation can begin in the first two years of life as weight-bearing begins. The phenotype can be mild with no clinical manifestations to severe manifestations resulting in disability. Progressive bowing of lower extremities leads to lower extremities genu varum or genu valgum, distinct waddling gait, short stature. Other manifestations include spontaneous dental abscesses often without any caries notes, that occurs more often than in the average pediatric population. Severe cases may suffer from craniosynostosis. Diagnosis requires pairing the clinical suspicion presentation with everyday biochemical labs and later molecular profiles. The hallmark of XLH is low fasting serum fasting phosphorus with renal phosphate wasting. The patient will have a normal calcium and normal vitamin D hydroxy. Confirmation can be confirmed by obtaining a FGF23 level and/or PHEX gene testing through commercial laboratories. Today, therapeutic management strategies are moving beyond previous therapy that relied on oral phosphate and active Vitamin

CHILDREN'S HEALTH D (calcitriol), which resulted in mixed outcomes. Now, with targeted biologic therapy, treatment burden along with outcomes have improved over previous therapy. More recently the current pediatric standard of care is burosumab, a recombinant human IgG1 monoclonal antibody directed against FGF23 that can be administered in the office setting. Burosumab optimizes and neutralizes excess circulating FGF23, restoring normal renal tubular phosphate reabsorption, elevating serum phosphorus, increasing active Vitamin D production, and healing rickets. Patient that are not identified earlier may also need corrective osteotomies and physical therapy. Regular dental care to monitor caries and abscess is also necessary. Not only can this improve the patient’s outcomes and quality of life, but also counsels parents/families on the importance of gene testing as males with the gene PHEX variant pass to all daughters but no sons. If a female is positive for the variant PHEX gene, all of her children have a 50% chance of inheritance. The PHEX gene variant has 100% penetrance. It is pivotal to identify children, if possible, by age 6 months as there is therapy that can return phosphate to normal range and limit allowing the body to mature with normal phosphate hemostasis. Familial Chylomicronemia Syndrome (FCS) FCS is an autosomal recessive metabolic disorder disrupting dietary fat clearance from the bloodstream. Once dietary fats are packaged into large, triglyceride-rich chylomicrons, they may remain in circulation for a long time unless Lipoprotein Lipase (LPL), an enzyme that sits on the vascular endothelium, breaks down these chylomicrons into free fatty acids, and removes them from the circulation. Any significant loss of LPL function prevents chylomicron clearance leading to a toxic buildup of circulating triglycerides regularly exceeding 1,000mg/dl to 10,00mg/dl. The classic academic presentation in infants and children we were familiarized with was a phlebotomy tube with milky plasma. Such a finding would make Dr. House run to the lab in panic. But before we go that route, we can review other symptoms, which include failure to thrive and babies with chronic refractory colic. Also, unexplained frequent pancreatitis that might lead to potential organ failure, that in severe cases could be fatal. Eruptive Xanthomas and lipemia retinalis when seen are diagnostic but are hard to catch in clinical practice, but more often than not are tools of torment by board examiners. The more frequently seen are systemic indicators like failure to thrive, hepatosplenomegaly and severe refractory colic. FCS in its purer form is rare, but on the other hand it is not infrequent for us to see patients with symptomatology and very high triglycerides (between 750 and 1000) — those are labeled as multifactorial chylomicronemia syndrome (MCS) triggered by secondary factors like diabetes hypothyroidism medications and obesity, which once fixed, resolve the problem. The FCS ones will not respond to the conventional treatments (fibrates and omega-3 fatty acids). In addition to clinical presentation, occasional genetic testing could be required for diagnosis. Traditional lipid-lowering drugs fail in FCS because they rely on an operational LPL enzyme system. Ultra-Low-Fat Nutrition is the primary management approach, restricting dietary fat intake to less than 10% to 15% of daily calories (roughly 10 to 15 grams of fat per day). Medium-Chain Triglyceride (MCT) Oil is utilized as pure MCTs bypass chylomicron formation entirely. They enter the portal vein

directly to travel to the liver, providing essential caloric intake without elevating serum chylomicrons. Novel RNA-targeted therapeutics such as APOC3 inhibitors are approved for adults — currently there are clinical studies seeking FDA approval for age 2-18. Once approved, the focus of treatment will be to alleviate this severe disability disorder in children. If a patient checks positive for either standard lab or clinical parameters above, initiate immediate confirmatory molecular testing (PHEX gene for XLH; LPL/APOC2/GPIHBP1 panel for FCS). Once confirmed, leverage cascade screening to test siblings and parents at an asymptomatic stage, halting systemic deterioration before it begins for the next generation. The evolving clinical landscapes of XLH and FCS highlight a paradigm shift in pediatric medicine. Rare genetic conditions are no longer theoretical footnotes relegated to academic examinations, but lab tests that can be ordered at the appointment As this is an overview, please review clinical guidelines and recommendations. References: 1. Haffner D, et al. (2019). Clinical practice recommendations for the diagnosis and management of X-linked hypophosphatemia. Nature Reviews Nephrology, 15(7), 435–455 2. Imel EA, et al. (2019). Burosumab versus conventional therapy in children with X-linked hypophosphatemia. The Lancet, 393(10186), 2416–2427 3. National Lipid Association. (2025). Expert clinical review on familial chylomicronemia syndrome (FCS). Journal of Clinical Lipidology, 19(2), 110–125 4. Moulin P, et al. (2018). Guidelines for the diagnosis and management of familial Chylomicronemia syndrome. Atherosclerosis, 275, 183–194. Cariou, B., & Moulin, P. (2024). Efficacy and safety of next-generation APOC3 inhibitors in severe hypertriglyceridemia. The Lancet Diabetes & Endocrinology, 12(4), 245–256 5. A Study of Olezarsen for the Treatment of Familial Chylomicronemia Syndrome (FCS) in Pediatric Participants, a study on Chylomicronemia Syndrome https://clinicaltrials.ucsf.edu/ trial/NCT07727538 William F. Trigoso, MD, FACE, is a physician and surgeon who graduated from Universidad Peruana Cayetano Heredia in Lima, Peru. Dr. Trigoso is board certified in internal medicine, endocrinology, diabetes and metabolism, clinical lipidology, clinical bone densitometry and neck ultrasound. He is a Fellow of the American College of Endocrinology, member of the American Association of Clinical Endocrinologists, American Diabetes Association, National Lipid Association and International Society for Clinical Bone Densitometry. Dr. Trigoso is the Vice-President of Diabetes and Glandular Disease Clinic and a member of the Bexar County Medical Society. Tina Copple DNP, FNP-BC, CDCES, received her Doctorate of Nursing Practice at The University of Alabama at Tuscaloosa. She is a Certified Diabetes Care and Education Specialist, Certified Diabetes Educator, Clinical Lipid Specialist, and Certified Clinical Densitometrist and is accredited by the Council for Clinical Lipidology. Visit us at www.bcms.org

CHILDREN'S HEALTH

The Adolescent Varicocele: What primary care providers need to know By Gaayana A. Raju, MD

aricocele affects approximately 15% of post pubertal boys and is the most common surgically correctable cause of male infertility. Most adolescent varicoceles are asymptomatic and detected incidentally during routine physical examination. The primary challenge lies in identifying those boys who will benefit from surgical intervention while avoiding unnecessary treatment. What Is a Varicocele? A varicocele is the abnormal dilation of the internal spermatic vein and pampiniform venous plexus within the spermatic cord. Approximately 85–90% are left-sided, owing to the left testicular vein draining into the left renal vein at a right angle, which creates higher hydrostatic pressure and less effective valves, whereas the right-sided vein drains obliquely into the vena cava providing a greater valve mechanism.1,2 Bilateral varicoceles occur in up to 30% of cases. The mechanisms of varicocele-related testicular injury include increased scrotal temperature from venous stasis, oxidative stress and germ cell apoptosis.3 The EAU pediatric guideline currently states that fertility problems arise in approximately 20% of adolescents with varicocele, but also emphasizes that the ultimate effect on paternity remains unknown. Detection and Grading Most adolescent varicoceles are discovered during well-child or sports physical examinations. When symptoms occur, they typically consist of a dull, aching scrotal discomfort worsened by prolonged standing and relieved by lying down. The examination should be performed with the patient standing, as well as supine. The classic finding of a grade III varicocele is a palpable mass of dilated veins described as a "bag of worms," accentuated by the Valsalva maneuver.1 Varicoceles are graded using the WHO classification:2 Grade I: Palpable only during Valsalva maneuver Grade II: Palpable at rest but not visible Grade III: Visible through the scrotal skin 18

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Subclinical varicoceles (detectable only by ultrasound) do not warrant treatment per current guidelines from the American Urologic Association (AUA) and American Society of Reproductive Medicine (ASRM).3 Testicular size should be assessed bilaterally. An orchidometer provides a reasonable estimate in the office, but scrotal ultrasonography with color Doppler is the most accurate method for measuring testicular volumes and confirming the diagnosis. Scrotal ultrasonography with color Doppler provides objective measurement of testicular volume and assessment of venous reflux. Color Doppler ultrasound has reported sensitivity of approximately 97% and specificity of 94% for varicocele detection.4 Semen analysis and hormonal testing can be useful in determining which patients may benefit from varicocelectomy. Although significant data suggest that adolescent patients with varicoceles have abnormal semen parameters, the impact this has on future fertility and paternity is still being investigated. Likewise, hormonal testing, such as elevated FSH and LH and decreased inhibin B have been shown to be associated with adolescent varicoceles, but testing continues to be studied for routine use.3 When to Refer Referral to a pediatric urologist is recommended for: • Any palpable varicocele with testicular size discrepancy on examination • Persistent scrotal pain despite conservative measures • A varicocele that does not decompress when supine • A varicocele in a prepubertal boy • Parental or patient concern about future fertility Even without these findings, referral of any clinically apparent varicocele for baseline evaluation and counseling is reasonable given the potential long-term fertility implications.5 Management: Observe or Operate? The management of adolescent varicocele remains one of the most debated topics in pediatric urology. Current pediatric urology

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guidance from the EAU/ESPU, together with the available AUA/ ASRM literature, generally supports selective treatment based on evidence of testicular dysfunction rather than treatment of the varicocele alone.3,5 Treatment is indicated for adolescents with persistent ipsilateral testicular volume loss (≥20% asymmetry or ≥2 mL difference), abnormal semen parameters in sexually mature boys, or pain unresponsive to conservative management. Observation with serial monitoring (every 6–12 months) is an appropriate option for adolescents with mild or no testicular asymmetry and no symptoms. Subclinical varicoceles should not be treated. Surgical Options and Outcomes When intervention is indicated, the most commonly used techniques include microsurgical subinguinal varicocelectomy and laparoscopic varicocelectomy. Percutaneous embolization has also been used as a minimally invasive alternative. Laparoscopic repair remains widely used in pediatric practice, with survey data showing it is the most common approach among pediatric urologists.7 A meta-analysis from the EAU/ESPU encompassing over 16,000 pediatric and adolescent patients found that varicocele treatment improved testicular volume (mean difference 1.52 mL) and increased total sperm concentration (mean difference 25.54 × 10⁶/mL) compared with observation.8 Lymphatic-sparing techniques significantly decreased postoperative hydrocele formation.8 There remains a paucity of long-term data on the outcomes of varicocelectomy. A recent single-center, nonrandomized longitudinal study of 125 patients followed to age 20 reported catch-up testicular growth in 92% of surgically treated patients compared with 20% of those managed conservatively, with higher adult testicular volumes and total motile sperm counts in the surgical group. Earlier surgery was also associated with more favorable adult testicular and spermatogenic outcomes; however, the study design limits conclusions regarding causality.5 Key Takeaways for Primary Care 1. Examine the scrotum with the patient both standing and supine. Varicoceles can be missed if the patient is examined in only the supine position. 2. Assess testicular symmetry. A noticeable size difference between sides warrants referral and consideration for ultrasound. 3. Do not treat subclinical varicoceles. Intervention is generally reserved for clinically palpable varicoceles associated with evidence of testicular dysfunction, persistent pain or abnormal semen parameters in appropriately mature adolescents. 4. A varicocele diagnosis does not mean infertility. The majority of men with varicoceles father children without difficulty. Reassure families while emphasizing the importance of follow-up. 5. Coordinate long-term care. Adolescents managed conservatively should transition to adult urology for continued monitoring until paternity is achieved.

Conclusion Adolescent varicocele management requires a collaborative, individualized approach between primary care and pediatric urology. Current evidence supports selective intervention guided by objective markers of testicular dysfunction, not the mere presence of dilated veins. The primary care provider's role in detection, timely referral and family counseling is essential to preserving the reproductive potential of affected adolescents. References: 1. Scrotal Masses. Langan RC, Puente MEE. American Family Physician. 2022;106(2):184-189 2. Management and Treatment of Varicocele in Children and Adolescents: An Endocrinologic Perspective. Cannarella R, Calogero AE, Condorelli RA, et al. Journal of Clinical Medicine. 2019;8(9):E1410. doi:10.3390/jcm8091410 3. Adolescent Varicocele: A Surgical Conundrum. Beland LE, Davis MF, Aiyar S, et al. Fertility and Sterility. 2026;126(1):17-25. doi:10.1016/j.fertnstert.2026.04.015 4. Evaluation and Management of the Adolescent Varicocele. Kolon TF. The Journal of Urology. 2015;194(5):1194-201. doi:10.1016/j.juro.2015.06.079 5. Long-Term Outcomes of Varicocelectomy in Children and Adolescents: Impact of Timing on Testicular Growth and Spermatogenesis. Shiraishi K, Tokitaka S, Ban Y, Oka S. The Journal of Urology. 2026;215(5):603-612. doi:10.1097/ JU.0000000000004934 6. A Novel Method for Investigating the Role of Reflux Pattern in Color Doppler Ultrasound for Grading of Varicocele. Bagheri SM, Khajehasani F, Iraji H, Fatemi I. Scientific Reports. 2018;8(1):6517. doi:10.1038/s41598-018-24890-2 7. Diagnostic and Management Approaches to Pediatric and Adolescent Varicocele: A Survey of Pediatric Urologists. Pastuszak AW, Kumar V, Shah A, Roth DR. Urology. 2014;84(2):450-5. doi:10.1016/j.urology.2014.04.022 8. Treatment of Varicocele in Children and Adolescents: A Systematic Review and Meta Analysis From the European Association of Urology/European Society for Paediatric Urology Guidelines Panel. Silay MS, Hoen L, Quadackaers J, et al. European Urology. 2019;75(3):448-461. doi:10.1016/j.eururo.2018.09.042

Gaayana A. Raju, MD, obtained her medical degree from the University of Saskatchewan College of Medicine and completed her Urology Residency at the University of Ottawa in Ontario, Canada. Her Pediatric Urology Fellowship was completed at Children’s Hospital of Pittsburgh in Pennsylvania. Dr. Raju is board certified in urology and sub-specialty board certified in pediatric urology by the American Board of Urology. She is also a fellow of the Royal College of Surgeons of Canada. She enjoys all aspects of pediatric urology with a special interest in minimally invasive surgery and stone disease. Dr. Raju is a member of the Bexar County Medical Society. Visit us at www.bcms.org

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Sudden Infant Death Syndrome By Tricia Saputera, OMS-II; Nethra Giri, OMS-II; and James Mayberry, MD

udden infant death syndrome (SIDS) is defined as the unexpected death during sleep of an infant younger than 1 year old when a postmortem investigation cannot determine the cause. This investigation includes a thorough examination, involving an autopsy, a review of the infant's medical records, and an assessment of the circumstances of the death. SIDS is one type of sudden unexpected infant death (SUID), a broader term that includes all sudden, unexpected deaths of infants during sleep. SUID may have known or unknown causes. Known causes include suffocation, entrapment, injuries and accidents; deaths with unknown causes are classified as SIDS. According to the Centers for Disease Control, there were approximately 3,700 SUID cases in the United States in 2022, making SUID a significant contributor to cause of death in infants. Of those cases, 1,529 deaths were from SIDS, 1,131 were from unknown causes and 1,040 were from accidental suffocation. In 1994, the “Back to Sleep” campaign was initiated as a public health measure to raise awareness surrounding SIDS. The National Institutes of Health recommended infants be placed on their backs while sleeping to decrease the risk of SIDS. Johnson & Johnson distributed pamphlets containing “Back to Sleep” brochures, and public service announcements were broadcast on the radio to educate about sleep safety. This resulted in a decrease of approximately 40% of infant sleep-related deaths, but SUID remains a major public health concern in the United States. SIDS is a complex issue that is multifactorial. According to the Triple Risk Model, SIDS happens when three factors overlap. The 20

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factors include infants with an underlying biological vulnerability, exposure to external stressors and occurrence during critical periods of development. Underlying vulnerabilities may involve pulmonary, cardiac and neurological factors such as arousal or brainstem regulation. External factors can include the use of soft bedding, placing the infant in certain sleep positions such as prone or side sleeping, unsafe surfaces, tobacco use, overheating and premature bed sharing. Critical periods of development are marked by rapid growth such as between 1 and 4 months of age with most cases before 6 months. The combination of these overlapping factors is thought to contribute to the incidence of SIDS. Researchers have studied biological and genetic factors that can contribute to SIDS. In some studies, it has been found that some infants had differences in brainstem function, which controls breathing, heart rate and arousal during sleep. Lower levels of serotonin and serotonin receptors were also found in addition to a decrease in butyrylcholinesterase, which is an enzyme of the cholinergic system related to regulation of the arousal pathways and the autonomic system. Genetic differences involving variations in genes that regulate heart rhythm, breathing, brain signaling and metabolism have also been studied. Genes studied include genes such as SCN5A, KCNQ1 or KNH2, which affect sodium and potassium channels that can lead to arrythmias, or long QT syndromes that may be triggered during times of low oxygen or high carbon dioxide while sleeping. Variants in genes such as PHOX2B, which is associated with congenital central hypoventilation

CHILDREN'S HEALTH syndrome (CCHS) and plays a key role in autonomic nervous system development. Variants in genes that regulate serotonin in the brainstem such as SLC6A4 and TPH2 can reduce the ability for infant autoresuscitation during periods of apnea while sleeping. These among other variants in genes involved in mitochondria and metabolism have been studied as possible candidates linked to SIDS. Historically, some unexplained sudden deaths in infants that have an identifiable medical cause have been mislabeled as SIDS. One example worth mentioning is infants with medium-chain acyl-Coa dehydrogenase deficiency (MCAD). MCAD is an autosomal recessive metabolic disorder due to a mutation in the ACADM gene that affects the body’s ability to break down medium-chain fatty acids. Since fatty acids are an essential source of fuel during times of fasting, MCAD can lead to low levels of blood sugar, and ketones leaving the body without the energy cells need to function. Although there are newborn screens designed to detect MCAD, many patients are missed and will not present until the first-time parents decide to let the infant sleep through the night, which puts them in a fasting state. Even though MCAD represents less than 1% of SIDS cases, it has sparked much of the research into finding other potential genetic causes for SIDS that also may be attributable to medical reasons. Because SIDS is multifactorial, the goal is to take preventive measures with the factors that caregivers can control. Such preventive actions can help alleviate additional stressors on an already vulnerable infant, promoting a safer sleep experience. Measures should include placing the infant on their back during periods of sleep. This position should be maintained until the infant is mature enough to roll independently from their back to their stomach. Caregivers should also use a firm and non-inclined mattress covered only with a fitted sheet, and avoid placing pillows, comforters, bumper pads and stuffed animals near the infant while sleeping. Room sharing without bed sharing is encouraged. It is also important to avoid exposure to smoking both during pregnancy and afterwards, avoid overheating and attend all well-child visits. Additional protective factors against SIDS include vaccinations, breastmilk and pacifiers. Family counseling can provide recommendations and strategies for safer sleeping locations for infants. Although SIDS is not preventable in all cases, with public awareness and education regarding proper sleep guidelines, sleep-related infant deaths can be reduced as much as possible.

6. Duncan JR, Paterson DS, Hoffman JM, Mokler DJ, Borenstein NS, Belliveau RA, Krous HF, Haas EA, Stanley C, Nattie EE, Trachtenberg FL & Kinney HC. (2010). Brainstem serotonergic deficiency in sudden infant death syndrome. JAMA, 303(5), 430–437. https://doi.org/10.1001/jama.2010.45 7. Eunice Kennedy Shriver National Institute of Child Health and Human Development. (n.d.). Campaign history. Safe to Sleep®. https://safetosleep.nichd.nih.gov/campaign/history 8. Eunice Kennedy Shriver National Institute of Child Health and Human Development. (n.d.). SIDS definition. https://safetosleep.nichd.nih.gov/about/sids-definition 9. Guare EG, Zhao R, Ssentongo P, Batra EK, Chinchilli VM & Paules CI. (2024). Rates of sudden unexpected infant death before and during the COVID19 pandemic. JAMA Network Open, 7(9), e2435722. https://doi.org/10.1001/jamanetworkopen.2024.35722 10. Jullien S. (2021). Sudden infant death syndrome prevention. BMC Pediatrics, 21(Suppl. 1), Article 320. https://doi. org/10.1186/s12887-021-02536-z 11. Mitchell E. (2003). Sudden infant death syndrome and unclassified sudden infant deaths: A definitional and diagnostic approach. https://www.researchgate.net/profile/ Edwin-Mitchell-2/publication/8476684_Sudden_Infant_ Death_Syndrome_and_Unclassified_Sudden_Infant_ Deaths_A_Definitional_and_Diagnostic_Approach/ links/00b4952530c2f849d0000000/Sudden-Infant-Death-Syndrome-and-Unclassified-Sudden-Infant-Deaths-A-Definitional-and-Diagnostic-Approach.pdf 12. Opdal SH, Stray-Pedersen A, Eidahl JML, Vege Å, Ferrante L & Rognum TO. (2025). The vicious spiral in sudden infant death syndrome. Frontiers in Pediatrics, 13, Article 1487000. https:// doi.org/10.3389/fped.2025.1487000 [ous-research](https:// ous-research.no/home/efm/Group+members/19994) 13. StatPearls Publishing. (n.d.). Sudden infant death syndrome. In StatPearls. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK513378/

References: 1. American Academy of Pediatrics. (2022). Sleep-related infant deaths: Updated 2022 recommendations for reducing infant deaths in the sleep environment. Pediatrics, 150(1), e2022057990. https://doi.org/10.1542/peds.2022-057990 2. BehnamTerneus M, & Clemente G. (2019). SIDS, BRUE, and safe sleep guidelines. Pediatrics in Review, 40, 443–455. 3. Carlin RF & Moon RY. (2017). Risk factors, protective factors, and current recommendations to reduce sudden infant death syndrome: A review. JAMA Pediatrics, 171(2), 175–180. https:// doi.org/10.1001/jamapediatrics.2016.3345 4. Carlin R & Moon R. (2025). Sudden unexpected infant death. Pediatrics in Review. 46(9), 528–530. 5. Centers for Disease Control and Prevention. (2024). Data and statistics for SUID and SIDS. https://www.cdc.gov/sudden-infant-death/data-research/data/index.html

Tricia Saputera, OMS-II, is a medical student at the University of the Incarnate Word School of Osteopathic Medicine, Class of 2029. She is interested in pursuing a career in pediatrics and immunology. She is passionate about medical technology, animation and science visualization to enhance public health education. Nethra Giri, OMS-II, is a medical student at the University of the Incarnate Word School of Osteopathic Medicine, Class of 2029. She is passionate about artificial intelligence in healthcare, disability medicine, women's health, medical technology and preventive care. James Mayberry, MD, is an Assistant Professor in the Clinical Applied Sciences and Education Department at the University of the Incarnate Word School of Osteopathic Medicine. He is board certified in Family Medicine and trained in Clinical Genetics and Genomics. Dr. Mayberry serves on the BCMS Publications Committee. Visit us at www.bcms.org

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Breaking New Ground in Pediatric Bone Cancer Research: How discoveries in San Antonio are opening new therapeutic opportunities for children with osteosarcoma By Panneerdoss Subbarayalu, PhD

steosarcoma is an aggressive cancer that grows quickly, spreads early to the lungs, and has a remarkable ability to resist treatment. It is the most common primary bone cancer in children and is diagnosed each year in children and adolescents throughout the United States. The disease is relatively rare, but its effects can be devastating. Chemotherapy and surgery have advanced dramatically over the past several decades, leading to greatly improved outcomes for patients with localized disease. Treatment usually involves a combination of chemotherapy and surgically removing the tumor. These strategies have improved survival, but the prognosis for patients with recurrent or metastatic disease has not changed substantially for more than 30 years. For these patients and their families, the challenges are more than just the cancer. Long-term complications of intense chemotherapy can include hearing loss, infertility, heart and kidney damage, growth abnormalities and a higher risk of secondary cancers. Osteosarcoma is more common in children, adolescents and young adults so the physical and emotional impact of treatment can be substantial. Decades of research have failed to make osteosarcoma a tractable scientific problem. Unlike many other cancers, it does not contain one genetic mutation that can be easily targeted with existing preci22

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sion-medicine approaches. But instead, researchers have found a disease of astonishing genetic complexity and diversity, highlighting the critical need for novel therapeutic approaches. Our lab at the Greehey Children’s Cancer Research Institute at UT San Antonio is committed to better understanding the biological mechanisms that drive osteosarcoma growth, metastasis and treatment resistance. Our work has been concentrated into two promising directions of investigation: RNA epigenetics and Leukemia Inhibitory Factor (LIF)/ its Receptor (LIFR) signaling pathway. Looking Beyond DNA For years, scientists concentrated most of their efforts on DNA mutations as the main cause of cancer development. However, more recently, it has been demonstrated that chemical modifications of RNA also have a major role in the regulation of gene expression and cellular behavior. In our laboratory, we have been especially interested in a process known as m6A RNA modification. Small chemical changes affect how genes are expressed and how cells respond to their environment. In this study, we found that a gene, ALKBH5, critically controls osteosarcoma progression. Our data showed that ALKBH5 was frequently

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overexpressed/amplified in osteosarcoma cells and promoted tumor growth and survival. We also found a surprising link between RNA regulation and other epigenetic pathways that lead to the aggressiveness of cancer cells. Finding New Uses for Existing Medicines One of the most exciting aspects of cancer research is the opportunity to rapidly translate laboratory discoveries into new therapies. After we had identified ALKBH5 as a promising target, we screened hundreds of compounds to see if any existing drugs could inhibit its activity. This search, based on a drug repurposing approach, led us to a surprising candidate, mefloquine, a drug originally developed for treating malaria. There is an important advantage to this strategy — the drug has already been studied extensively, potentially accelerating the path from laboratory discovery to clinical application. As a result, therapies identified through drug repurposing may reach patients more quickly than entirely new compounds developed from scratch. Discovering Another Therapeutic Opportunity In our latest work, we have identified a new promising target in osteosarcoma, the LIF/LIFR signaling pathway. We have shown that the LIF receptor is highly expressed in pediatric osteosarcoma tumors. Blocking the pathway dramatically slowed tumor growth and greatly reduced the ability of cancer cells to migrate and spread. Most importantly, we saw a dramatic reduction in the number of cancer stem cells. These specialized cells are thought to be critical in disease recurrence, metastasis and therapy resistance. By targeting this pathway, we hope to disrupt one of the key mechanisms that allows osteosarcoma to survive and progress. A Collaborative Effort Scientific discovery rarely happens in isolation. Progress in osteosarcoma research depends upon close collaboration among basic scientists, clinicians, computational biologists and experts in drug development. In recognition of the potential impact of this work, the American Cancer Society awarded our laboratory a four-year $879,000 Research Scholar Grant to support the development of innovative therapeutic

strategies for osteosarcoma. This effort brings together investigators from multiple institutions across Texas who share a common goal: developing safer, more effective treatments for children and young adults facing this disease. Collaborators include Peter Houghton, PhD, UT San Antonio professor emeritus; Gail Tomlinson, MD, PhD, division chief of Pediatrics Hematology/Oncology in the Department of Pediatrics, Greehey Institute and Mays Cancer Center at UT San Antonio; Yidong Chen, PhD, professor in the Department of Population Health Sciences at the Long School of Medicine and the Greehey Institute at UT San Antonio; Suryavathi Viswanadhapalli, PhD, associate professor in the Division of Reproductive Research in the Department of Obstetrics and Gynecology in the Long School of Medicine at UT San Antonio; and Hareesh B. Nair, PhD, associate professor at Texas Tech University Health Science Center. Nair, the lead inventor of a patented LIFR inhibitor, provides a particularly important translational perspective that strengthens the path from laboratory discovery to clinical application. Together this collaborative team is working to translate fundamental discoveries in osteosarcoma biology into innovative treatments that may ultimately improve outcomes for children and young adults affected by this disease. Looking Toward the Future Recurrent and metastatic osteosarcoma remains one of the greatest unmet challenges in pediatric oncology. Our research has discovered two promising therapeutic opportunities: targeting the m6A RNA demethylase ALKBH5 and disrupting LIF/LIFR signaling. These findings are, taken together, beginning to provide new insight into the molecular mechanisms that contribute to tumor growth, metastasis and treatment resistance. We will keep investigating the relationship between RNA epigenetics, cellular stress responses and oncogenic signaling pathways for better, less toxic therapies. Ultimately, we want to translate these discoveries to innovative clinical approaches that improve survival and quality of life for children, adolescents and young adults with osteosarcoma. These advances move us closer to establishing targeted therapies that offer new hope for patients and their families, but much work remains to be done. Panneerdoss Subbarayalu, PhD, assistant research professor in the Department of Cell Systems and Anatomy in the Joe R. and Teresa Lozano Long School of Medicine and the Greehey Children’s Cancer Research Institute at UT San Antonio, is a cancer biologist specializing in RNA regulation and m6A epigenetics in pediatric cancers. His research integrates mechanistic studies of tumor biology with translational therapeutic development to advance novel treatment strategies for osteosarcoma and other aggressive childhood malignancies. His work has generated foundational preclinical evidence supporting clinical trial development and has facilitated the translation of laboratory discoveries into potential therapies for pediatric cancer patients. Visit us at www.bcms.org

CHILDREN'S HEALTH

Protecting Children's Vision: Preventing eye injuries at home, at play and in sports By Manpreet S. Chhabra, MD

ne of the hardest conversations I have with parents in my clinic is explaining that their child's eye injury could have been prevented. Fortunately, those conversations are uncommon. Most children have healthy eyes, and most everyday bumps and scrapes heal without lasting problems. But every year, I also treat children whose vision is altered forever because of a split-second accident — a toy that flew a little too fast, a baseball that took a bad bounce, or a household chemical that splashed into an eye. One of the most heartbreaking injuries to treat is an open-globe injury in a child. Despite advances in microsurgery, we cannot always restore the vision that has been lost. That is why prevention remains far more effective than any surgery we can perform. The encouraging news is that a majority of serious eye injuries are preventable with simple precautions and appropriate protective eyewear. As both a parent and an ophthalmologist, I firmly believe that awareness, not anxiety, is our best defense. Home Is Where Many Eye Injuries Happen When parents think about physical eye trauma, organized sports usually come to mind first. Surprisingly, public health data shows that nearly half of all pediatric eye injuries occur much closer to home. Young children are naturally curious and energetic, but they have little appreciation for danger. They reach for scissors, pencils, kitchen utensils, spray bottles and anything colorful sitting within reach. They run through the house, wrestle with siblings, and invent games adults could never imagine. That's exactly what childhood is supposed to look like, but it also creates unexpected opportunities for accidents. Some of the most severe injuries I have treated didn't happen on a playing field; they happened in kitchens, garages, backyards or living rooms. Fortunately, making a home safer doesn't require major renovations, just a few consistent habits: 24

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• Lock Away Cleaning Chemicals: Keep household cleaners, bleach, ammonia and laundry detergent pods locked away or stored on high shelves. • Know Emergency First Aid: If a chemical accidentally splashes into a child's eye, time is critical. Do not wait to see if it improves. Immediately begin flushing the eye with clean, lukewarm water for at least 15 to 20 minutes while seeking emergency medical care. Those first few minutes can make an enormous difference in preserving vision. • Watch Out for Everyday Objects: Be cautious with seemingly harmless household items. Elastic cords, bungee straps, wire hangers, sharp school supplies, and even the force from opening a shaken bottle of soda can generate enough force to cause significant eye injuries. • Bystander Safety During Yard Work: Flying debris from lawnmowers, weed trimmers and edgers can travel much farther than people realize. Children should remain safely indoors whenever yard equipment is in use. Toys Deserve a Second Look As eye physicians, our goal is never to discourage active play; we simply want to make it safer. Projectile toys deserve particular attention from parents. Foam dart guns may look completely harmless, but I have treated young patients with painful corneal injuries after being struck at close range. Higher-velocity devices such as BB guns, pellet guns and airsoft guns pose an even greater risk and can cause vision-threatening trauma. A single projectile can result in a corneal laceration, bleeding inside the eye (hyphema), a retinal tear or detachment, or even rupture of the eyeball. These are true ophthalmic emergencies that often require urgent surgery and may lead to permanent vision loss. Whenever parents ask me about projectile toys, my advice is simple: if a toy can launch an

CHILDREN'S HEALTH

object, children should wear appropriate protective eyewear, and adult supervision should never be optional. Sports Are Wonderful — When We Play Them Safely I never want families to avoid sports because of injury concerns. Sports teach discipline, teamwork, resilience and confidence. As physicians, we actively encourage children to stay active. Our goal is not to keep kids off the field, but to keep them safe while they are on it. A study published in International Ophthalmology found that over 36% of all school-associated eye injuries are explicitly sports-related. Baseball, softball, basketball, soccer, tennis, lacrosse, hockey, and even pickleball, all carry a risk of eye trauma. Fortunately, one simple piece of equipment can dramatically reduce that risk: protective sports eyewear. One of the most common misconceptions I hear from parents is, "My child already wears glasses." Regular prescription eyeglasses are not designed to withstand the impact of a baseball, basketball or another player's elbow. In fact, standard plastic lenses and frames can break during a collision, potentially making an eye injury even worse. That's one reason I routinely recommend polycarbonate lenses for all of my pediatric patients' everyday glasses; they are significantly more impact resistant than standard lenses. However, everyday glasses are not a substitute for sports eye protection. Children who participate in sports should wear sport-specific goggles made with polycarbonate lenses. These goggles are lightweight, comfortable and designed to withstand the types of impacts that occur during practices and games. Prescription sports goggles are also readily available, allowing young athletes to see clearly while protecting their vision. We would never send a child onto a football field without a helmet or allow them to ride a bicycle without one. Protective eyewear deserves to become just as routine for children participating in sports. Summer Means Fireworks, and Eye Injuries Every Fourth of July, emergency departments across the country treat children with preventable eye injuries caused by fireworks. What surprises many parents is that the injured child is often not the one lighting the fireworks. Many are innocent bystanders simply watching nearby. Even sparklers deserve respect. They burn at temperatures hot enough to melt certain metals (exceeding 1800°F) and can cause severe thermal burns to the eye and surrounding tissues. My recommendation to every family is always the same: enjoy professional public fireworks displays and leave the pyrotechnics to trained experts. It is one holiday tradition that simply isn't worth the risk. When Should Parents Seek Emergency Care? Parents often ask, "How do I know if an eye injury is serious enough for emergency care?" Seek immediate medical evaluation if your child experiences any of the following after an accident: • Decreased or blurry vision • Severe, persistent eye pain • Double vision or light sensitivity • Visible blood inside the eye • A cut or puncture to the eye or eyelid • Direct chemical exposure

Two important safety rules are worth remembering: Never attempt to remove an object embedded in the eye and never apply pressure to an injured eye. Do not rub the eye or apply a patch, bandage or dressing that presses on the eye. When necessary, eye care professionals protect the eye with a rigid shield that rests on the bones around the eye rather than on the eye itself. Prevention Begins with Us Children pay far more attention to what we do than what we say. If they see us wearing safety glasses while mowing the lawn, trimming trees, or using power tools, they begin to understand that protecting our eyes is simply part of doing the job right. The same applies to coaches. When protective eyewear becomes part of the team's routine rather than an afterthought, children accept it without hesitation. Nobody questions wearing a helmet on a bicycle anymore. Years ago, that wasn't the case. Today, it is second nature. Protective eyewear deserves to follow the same path. Vision is central to nearly everything children do. They read, learn, compete, explore, and experience the world through their eyes. A few simple precautions at home, appropriate protective eyewear during sports, and knowing when to seek emergency care can spare a child and an entire family from a lifetime of consequences. Protecting a child's vision is a responsibility we all share, and perhaps one of the greatest gifts we can give to the next generation. References: 1. American Academy of Ophthalmology. (2021). Eye injury prevention: Wearing the proper protective eyewear reduces 90% of injuries. AAO Public Health Resources. https://www.aao.org/ eye-health/symptoms/preventing-injuries 2. Boston Children’s Hospital. (2024). Pediatric sports eye injuries: Risk factors, diagnosis, and treatment. Clinical Condition Guides. https://www.childrenshospital.org/conditions-treatments/sports-eye-injuries 3. Patel P, Uppuluri A, Zarbin M & Bhagat N. (2021). Epidemiology of pediatric school-associated ocular injuries from 2000 to 2019. International Ophthalmology, 41(10), 3257–3259. https://doi.org/10.1007/s10792-021-01901-2 4. Prevent Blindness. (2024). Preventing eye injuries: 90 percent of eye injuries are preventable with safety eyewear. Prevent Blindness America. https://preventblindness.org/preventing-eye-injuries/ 5. The Vision Council. (2023). Eye safety at-a-glance: Protecting your child's vision in sports. Sports Eyewear Safety Report. https://thevisioncouncil.org/sites/default/files/SportsEyeSafetyReport.pdf

Manpreet S. Chhabra, MD, is a board-certified ophthalmologist with focus on Pediatric Ophthalmology and related conditions. He did his ophthalmology residency at the University of Cincinnati in Ohio and pediatric ophthalmology fellowship at the Northwestern University in Chicago. Dr. Chhabra has over two decades of clinical experience in his field, and practices at Alamo Pediatric Eye Center. Dr. Chhabra is a member of the Bexar County Medical Society. Visit us at www.bcms.org

CHILDREN'S HEALTH

Beyond Behavior: Executive function as the missing link in children’s mental health By Grizelda Morales Anguiano, MD

uring my second year of medical school, I failed a test I “should” have passed. I had never struggled in school before, so a psychologist was brought in to ask whether I could handle the exams at all. The conclusion was deceptively simple: study with a dictionary, because I had not known the word for a common device, a vise. I had grown up bilingual, and my vocabulary, they reasoned, had gaps. And yet I could have described a vise in detail; my father is a mechanic, and one was bolted to the workbench in our garage. I knew the thing. I just didn’t have the label. It would be years, well into my career as a pediatrician, before I understood that the gap was never really language. It was attention, working memory, and how my brain took in and retrieved information. I have ADHD, though I didn’t know it while I was already telling patients, and later my own daughter, to sit still and try harder. What strikes me now is that once my training moved to the bedside, to hands and patients instead of a questionnaire, I thrived. Nothing about my brain had changed — only the way it was being measured had. I don’t tell that story because this article is about me, but because some version of it is in your exam room every week: the child who is “so smart but won’t apply himself,” the teenager who is “lazy” or “just doesn’t care,” the exhausted parent quietly afraid it is somehow their fault. The label almost always lands on character. The problem almost always lives somewhere else. Increasingly, I’m convinced that the link between the behavior in front of us and the child’s mental health underneath it is executive function. What we are actually looking at Executive function is the set of brain-based skills that let a child steer their own behavior toward a goal: response inhibition, working memory, emotional regulation, attention, task initiation, planning and flexibility. Psychologists Peg Dawson and Richard Guare, whose Smart but Scattered has shaped how many of us think about this, call these 26

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skills, not traits or virtues, and not a measure of how much a child cares. They are the brain’s management system, and they run largely out of the prefrontal cortex. That matters, because the prefrontal cortex is the slowest part of the brain to mature, still wiring into the mid-20s, a long window of vulnerability. A simple picture helps: the “smarts” part of the brain, often unusually capable in these kids, and the frontal part that holds regulation, planning and prioritizing. Under stress, poor sleep or hunger, the frontal part pops offline, and the child drops into fight, flight, freeze or fawn. However intelligent the system, when the manager steps out, the work does not get done. Why this is bigger than ADHD We tend to assume executive function problems must be ADHD, and often they are. But this is bigger than ADHD. If executive function is a product of prefrontal development, then anything that disrupts that development can produce the same picture. Prematurity, especially before 32 weeks, carries well-documented risks, as do prenatal exposure to alcohol or nicotine, toxic stress and chronically fragmented sleep; obstructive sleep apnea alone can mimic ADHD convincingly. Iron deficiency, lead, head injury, epilepsy and childhood cancer treatment leave the same fingerprints. Executive dysfunction, in other words, is less a single diagnosis than a final common pathway — many roads to one vulnerable place. That is why it belongs in the mental-health conversation, not off to the side. Weak executive skills are not the private property of ADHD; they run beneath anxiety, depression, learning disability and disruptive behavior, and they feed the shame that so often becomes the presenting complaint. A child who cannot start the assignment, hold the plan, or pump the brakes on a big feeling learns quickly that something is wrong with them. The anxiety and the low mood are often not separate problems. They are the interest accruing on years of being misread.

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This is also why the 15-minute visit and the rating scale give me pause. A teacher’s questionnaire is useful, but it describes what the behavior looks like from across a classroom, not why it is happening, and the two are easy to confuse. The real question is rarely just whether it is ADHD, but whether it is ADHD, ADHD plus something else, or something that was never ADHD at all. Diagnose quickly and treat anyway when the real driver was sleep, anxiety, grief or a home under strain, and the child gets the side effects without the benefit. Getting the diagnosis right is most of the work. What we can actually do about it Much of how I practice now I did not learn in residency. I learned it in a behavioral parent-training program called Sanity School® for Parents, from the team at ImpactParents, and I have kept studying since, including courses with Peg Dawson. It gave me language I use every day. Behavior is communication. It is neurologic, not naughty. Connection comes before correction. And no chart, reward or system is worth building until we understand the real reason a behavior is happening. A strategy that never asks why is only a consequence in disguise, and consequences work for naughty, not for neurologic. Behavioral parent training is already the first-line treatment for our youngest patients with ADHD, ahead of medication. My conviction is that it should not stop there: it belongs in line with every other treatment, at every age — the ground the rest is built on rather than a step we abandon once a prescription is written. And here is the hopeful part: executive skills can be built. They are developmental, taught and grown with the right support, and that support is often far more ordinary than families expect. Much of it is simply practice — the everyday rehearsals of school, friendship and being out in the world, which is part of why the pandemic set so many children back. Screens pull the same way, offering instant reward and effortless entertainment, so the muscles of waiting, tolerating boredom, and working out a real friendship get far less practice than they used to. Response inhibition, the brake, is strengthened by the games we know: Red Light, Green Light; Simon Says; freeze dance; Jenga. We can, quite literally, prescribe play. Working memory and planning respond to structure: visible cues, timers, checklists, tomorrow’s clothes set out tonight. These are not crutches; they are ramps a still-building brain uses until it can manage the stairs. Two things decide whether a child gets that scaffolding, and both are in our hands. The first is co-regulation before self-regulation: a calm adult nervous system is where a child’s frontal lobe learns to come back online, which is why supporting the whole family matters more than correcting one child’s symptoms. The second is subtler, not only the language we use but the language we accept. It is rarely we who call a child lazy or unmotivated; it is the exhausted parent across from us, and the danger is that we take it as the truth rather than the first line of a better question. “He just doesn’t care” is the moment to get curious, not furious, and to ask what the behavior is telling us. None of this is an argument against medication. It is a legitimate and often essential tool, deserving of respect, not a magic wand, not a moral failure, not a last resort. For many children, it quiets the noise enough that the skills can take hold, and I know that personally. Skills and relationships are the main work, and medication supports

them. No supplement and no pill will do it all, and no punishment will shake this out of anybody. I did not learn what a vise was called until someone finally looked past my performance to how my brain actually worked. Our young patients cannot do that for themselves; they need us to do it for them. And it is never too late, and not only for children. ADHD runs in families, and often, when we finally name it in a child, a parent in the room quietly recognizes themselves. These skills can be built at any age. When we treat executive function as the missing link it so often is, as neurology to be understood rather than character to be corrected, we stop asking children, and ourselves, to try harder at the one thing the brain has not yet built, and we start building it instead. Grizelda Morales Anguiano, MD, is a board-certified pediatrician and Certified Professional Coach, and the founder of Anchored Pediatric Mental Health & Anchored Coaching in San Antonio. A UT Health Houston graduate and FAAP, she has built a practice devoted to children’s mental health, ADHD in particular, and to supporting the whole family system, channeling her own hyperfocus into the work. She practices, and parents, with ADHD, and builds it all around a simple conviction: behavior is communication, and it is neurologic, not naughty. Dr. Anguiano is a member of the Bexar County Medical Society.

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SA Kids BREATHE: A community partnership helping children with asthma thrive By Cara Hausler, MPH | Photography courtesy of SA Kids BREATHE

In Bexar County, pediatric asthma has long been more than a clinical problem — it's a community challenge touching families, schools, housing conditions and health systems. Several years ago, three tragic pediatric asthma deaths and persistently high emergency and hospitalization rates made clear that children here needed a different kind of support. From that need came SA Kids BREATHE (San Antonio Kids - Building Relationships, Effective ASTHMA Teaching in Home Environments or SAKB), a collaborative, evidence-based, home-centered asthma program that is transforming how families manage pediatric asthma and how our community supports them. Building a Program Where Children Can Truly Breathe SA Kids BREATHE operates under the San Antonio Metropolitan Health District, serving children aged 3–17 with poorly controlled asthma. Its mission is simple but powerful: to reduce asthma burdens for high-risk families by teaching self-management skills, improving housing environments, and strengthening connections between caregivers, healthcare providers and schools. The program’s vision goes even further — toward regional health equity where every child can breathe safely, regardless of zip code, income or housing quality. With many participating families living in older rental housing and facing financial or health-literacy barriers, SAKB is intentionally designed as a culturally competent, community-rooted intervention. A Community-Driven Response to a Community-Level Crisis SAKB did not emerge in isolation. It was forged through a coalition of pediatric clinicians, community advocates and public health leaders who re-energized the South Texas Asthma Coalition (STAC). Their advocacy secured recurring funding from the City of San Antonio, launching SAKB in 2019. Since then, the initiative has continued to grow through partnerships with organizations such as UT Health San Antonio, Community First Health Plans, Superior Health Plan, Texas DSHS, and the CDC’s public health workforce programs. It also serves as a training site for medical residents, nursing students and public health trainees who directly support real-world asthma care improvements. Who the Program Serves The children most affected by asthma in Bexar County often share similar social and environmental conditions. Program data show: • 86% are covered by Medicaid or CHIP. • 80% of caregivers have less than an associate's degree. • 51% of families live with annual incomes under $25,000. • 93% of participants are Hispanic or Black children, reflecting disproportionate burdens in these populations. For these families, asthma is interwoven with environmental triggers, limited resources and structural housing issues that clinic-based care cannot fully address. 28

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What SA Kids BREATHE Provides In Homes, Schools and Clinics SAKB centers around Community Health Workers (CHWs) who meet families where they are — literally in their homes or through virtual visits — to provide a wide range of supports: In-Home Asthma Education: Families receive hands-on training in proper inhaler and spacer techniques, recognition of early symptom zones, and understanding their child’s Asthma Action Plan (AAP). CHWs audit medications to identify gaps, confusion or incorrect use. After each visit, a clinical summary is faxed directly to the child’s provider. Environmental Assessments: Using the EPA Asthma Home Environment Checklist, CHWs inspect homes for mold, pests, dust mites, smoke exposure, humidity issues and ventilation concerns. They then help families reduce asthma triggers through free remediation supplies: • Allergen-proof sleeping kits for bedding • Green Cleaning Kits with lowVOC ingredients • Integrated Pest Management kits with safe, nonaerosol tools When families face serious structural issues — such as leaks, HVAC failures or mold — CHWs draft formal advocacy letters for landlords or refer cases to housing repair programs. School and Clinic Coordination: SAKB collaborates with school nurses to address daytime symptoms, missed class time and medication access. It also partners with major healthcare systems — University Health, UT Health, Methodist Children’s Hospital, Christus Children’s Hospital, FQHCs and private pediatric practices — to streamline referral pathways and ensure continuity of care. A Program Where Measurable Results Are the Norm The SA Kids BREATHE model works — and the data proves it. From 2019–2026, SAKB enrolled 997 children with high-risk asthma. Program evaluation shows: Dramatic Improvements in Asthma Control: Participants experienced an average 6.2-point increase in Asthma Control Test (ACT) scores — double the clinically significant threshold. The ACT is a symptom assessment that ranges from 5 to 25. At 12 months, 90% of graduates had well-controlled asthma. Emergency and Hospital Use: Among high-risk children referred by a health plan, those enrolled in SAKB saw a 47.8% decline in hospitalizations, compared to 20.4% among nonparticipants. Emergency, urgent care and steroid burst use also fell substantially. Healthier Homes: Homes free of cigarette and vape smoke increased by 10.8 percentage points, reaching more than 93% smokefree environments. Structural hazards like leaks and mold also saw measurable improvements after CHW advocacy. Stronger Families & Less Stress: Caregiver confidence grew significantly, with a 34-point increase in caregivers who rarely feel helpless during their child’s asthma symptoms. Better School Attendance & Family Stability: Children missed fewer school days and had fewer nighttime symptoms, allowing families to maintain consistent work schedules and reduce financial strain.

SAN ANTONIO MEDICINE Why This Program Matters to Medical Providers Pediatric asthma is not only a medical condition — it’s a social, environmental and community issue. Clinicians see the effects: children returning repeatedly for exacerbations, caregivers unsure of medication routines, and families overwhelmed by environmental hazards they cannot afford to fix. SA Kids BREATHE gives providers a partner in addressing these factors. Referring your eligible patients means: • CHWs will reinforce your clinical guidance inside the home. • Environmental triggers will be systematically identified and reduced. • Families will receive free remediation supplies and asthma education they can use. • You will receive visit summaries to inform your care plans. This is more than a referral — it’s joining a coordinated network dedicated to improving asthma outcomes at the community level. Seasonal Alert for Providers The third week of September is recognized nationally as Asthma Peak Week, when pediatric asthma attacks, ER visits and hospitalizations rise to their highest levels of the year. This surge is driven by the combination of ragweed pollen, mold, return-to-school respiratory viruses, and poor indoor air quality in aging school buildings. Children are often the first affected, with as many as 25% of annual pediatric asthma hospitalizations occurring in September. Clinicians can help families prepare by: • Reviewing and updating Asthma Action Plans in late August/ early September. • Ensuring children receive seasonal vaccinations (flu, COVID19, RSV as appropriate). • Reinforcing trigger-avoidance strategies and correct inhaler technique. This simple annual reminder can reduce preventable exacerbations and support better outcomes during a predictable high-risk period. Why this matters: Pairing clinical care with seasonal awareness improves outcomes. With program referral and earlier intervention during Asthma Peak Week, children are less likely to deteriorate into crisis — supporting the positive trends SA Kids BREATHE strives for year-round.

L-R: Dr. Claude A. Jacob, Health Director; Ric Galvan, Councilman D6; Rodrigo Cornejo, CHW; Dr. Dan Dean, SAKB Advisor; Jennifer Falcon, CHW; Tracy Compean, CHW; Imelda Avina, CHW; Dr. Junda Woo, Metro Health Medical Director; Dr. Eva Prieto, SAKB Advisor; Dr. Mandie Svatek, SAKB Medical Advisor; Kathy Shields, PH Administrator; Cara Hausler, Manager; Morjoriee White, Asst. Director; Paul Kloppe, Program Coordinator; not pictured: Amy Mattson, Sr. Admin. Asst.; and Dr. Rose Ramos, Data Analyst.

How Providers Can Refer a Patient Clinicians can refer children aged 3–17, living in Bexar County, who meet any of the following criteria within the last year: • ≥1 asthma-related hospitalization • ≥2 emergency or urgent care visits • ≥2 oral steroid bursts • ≥2 unscheduled school clinic visits in one week • ≥10% school absenteeism due to asthma symptoms Referral Pathways • Secure Fax: 210-207-9757 • Secure Email: SAKidsBREATHE@sanantonio.gov • Program Phone: 210-207-7282 • Website: https://www.sa.gov/sakidsbreathe • Fillable Asthma Action Plan: https://www.sa.gov/Directory/Departments/SAMHD/Health-Professionals/Asthma-Action-Plan-AAP SAKB responds to referrals within 2 business days, beginning the home‑visit cycle that has demonstrated sustained improvements for hundreds of local families. A Healthier Future for Bexar County’s Children SA Kids BREATHE has helped more than a thousand children breathe easier — literally and figuratively. By combining asthma education, environmental remediation, clinical coordination and community partnerships, it offers a model of pediatric asthma care that addresses both symptoms and the systems that influence them. For providers, this program is more than a referral option — it’s a chance to help families overcome barriers that no prescription alone can fix. For families, it is life-changing. For Bexar County, it is a healthier future. Cara Hausler, MPH – Health Program Manager, SA Kids BREATHE, has over two decades of public health experience within local government, supported by a Bachelor of Science, four years of medical training and a Master of Public Health. Her work spans surveillance, disease prevention, case management, program operations, grant development, policy initiatives, and both department and community strategic planning. In 2019, she was selected to launch SA Kids BREATHE. Under her leadership, the program has expanded through clinical and community partnerships, two technical assistance grants, a state grant, and the establishment of service reimbursement. The program has since received national attention. She continues to advance sustainable, evidence‑based approaches to pediatric asthma care in the community.

The SA Kids BREATHE (SAKB) asthma education team celebrated their seventh year of serving the community on May 9, 2026. At the May celebration, we also honor all of the children who graduated (completed) the program and those still in the program. A dozen kids with their families came to our celebration this year! Most of the children are pictured here.

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Dr. Leah Jacobson with Alamo Heights City Councilman Trey Jacobson and City Manager Buddy Kuhn

Texas Medical Association Foundation's "Hard Hats for Little Heads" Initiative: One pediatrician's experience By Leah H. Jacobson, MD, FAAP

At the heart of Texas medicine, health and safety take the spotlight. One program that embodies this is the Texas Medical Association (TMA) Foundation's “Hard Hats for Little Heads” initiative, which seeks to protect Texas children from preventable injuries. On a warm Saturday in April, at the City of Alamo Heights Family Fun Run, we showcased this vital cause. The Importance of Safety: Hard Hats for Little Heads The “Hard Hats for Little Heads” program was launched by the Texas Medical Association Foundation in 1994, marking a pivotal step toward injury prevention for children across the state. The initiative's primary mission is to decrease head injuries among children by promoting the use of helmets during activities such as biking, skating and scootering. Helmets, when properly fitted and used, can reduce the risk of head injury 30

by up to 85%, a statistic that underscores the critical nature of this program. Understanding the importance of community engagement and education, the program not only provides helmets, but also offers resources to educate both children and parents on the significance of wearing them. The program has successfully distributed over 350,000 helmets to date, a testament to its impact and reach. “Hard Hats” provides a hands-on way to encourage your patients and community to exercise safely. Members of the TMA Family — physicians, county medical societies, medical students and local Alliance chapters — can host helmet giveaway events in their communities. Medical family hosts are invited to collaborate with community organizations on events, as we did with the City of Alamo Heights and its annual Family Fun Run. The TMA Foundation collaborates with sponsoring physicians to create a cost-sharing

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program that significantly reduces expenses, enabling the provision of free helmets to children and families. This initiative, aimed at promoting safety and preventing injuries, is further supported by contributions from the Texas Pediatric Society (TPS) and the Texas Neurology Society (TNS), ensuring that as many children as possible can benefit from this protective gear while maintaining financial accessibility. These organizations offer a limited number of free helmets to their members on a firstcome, first-served basis. The TPS and TNS will help cover the cost of up to 25 helmets for their members who host a helmet giveaway. The staff at the TMA Foundation make this an easy event to host as they provide a tool kit, timeline on preparing and promoting the event, and all necessary items, including links to videos and handouts on how to appropriately fit a bike helmet, education materials, photo waivers, etc.

SAN ANTONIO MEDICINE

Community Spirit: The Family Fun Run In Alamo Heights, the AH09 5K Fun Run is more than a race; it's a celebration of health and community. In its eighth year, this year's proceeds went to support Alamo Heights Animal Care Services. Families gathered to embrace community care and fitness. Hosting the “Hard Hats for Little Heads” booth during the run allowed us to reach diverse participants of all ages and interact with our community. Learning and Fun At the booth, we offered educational materials, free helmet fittings and games promoting bike safety and a healthy lifestyle. The event began with a safety workshop, where children learned about helmet importance. Volunteers showed families how to fit helmets correctly. Parents watched, and were provided resources to utilize at home. At the heart of our commitment to personalized pediatric care and improved accessibility, we're thrilled to offer free helmets to children and teens in our community. We believe that safety is a cornerstone of healthy growth and development, and providing helmets ensures that our young explorers can enjoy their adventures with an added layer of protection. By making helmets accessible to everyone, we aim to foster a safer environment for biking, skating and other activities that promote active lifestyles and well-being.

A Lasting Impact As the morning concluded, the program left a lasting mark by promoting safer practices and injury prevention advocacy. Plus, there were pet adoptions and a Fun Run for all ages through the beautiful neighborhoods of Alamo Heights. The success of this event highlights the power of community collaboration in fostering a culture of safety. The “Hard Hats for Little Heads” program continues to build safer, healthier communities through gifting one helmet at a time. Every effort counts and every helmet saves lives! I look forward to hosting our next “Hard Hats for Little Heads” event in October in collaboration with the City of Alamo Heights and National Night Out. If you or a physician you know is interested in hosting a TMA Foundation “Hard Hat for Little Heads” event, call 800880-7955, or email the TMA Knowledge Center at knowledge@texmed.org. Join us in this initiative to keep our kids safe and thriving! Stay well and be safe! Leah H. Jacobson, MD, FAAP, is a pediatrician and founder of Personal Pediatrics by Leah Jacobson, MD, a Direct Patient Care Practice. Dr. Jacobson is the BCMS Past President 2017, Current Vice Chair of the Public Health & Patient Advocacy Committee, and Vice Chair of the TMA Board of Councilors. Visit us at www.bcms.org

BEXAR COUNTY MEDICAL SOCIETY

2027 BCMS Election Candidates The Bexar County Medical Society is pleased to present the slate of candidates for the 2027 elected leadership positions. Your participation helps shape the future leadership of the Bexar County Medical Society, and we encourage all eligible voting members to participate in this important election.

Please watch your email for your official ballot. Ballots will be emailed to eligible voting members on September 13, 2026. Voting will close at 5:00 p.m. on October 13, 2026.

Executive Board These elected officers shall be elected by the Bexar County Medical Society membership and constitute, along with the Executive Director, the Executive Committee of BCMS. One position available in each category.

President-Elect | Lyssa Ochoa, MD Dr. Lyssa Ochoa is a board-certified vascular surgeon and founder of the San Antonio Vascular and Endovascular Clinic. Born and raised in the Rio Grande Valley, she completed her undergraduate degree at UT Pan American and her medical school, general surgery residency and vascular surgery fellowship at Baylor College of Medicine. In 2018, Dr. Ochoa founded The SAVE Clinic in South San Antonio, with a mission to reduce diabetes-related amputations, particularly in underserved communities where amputation rates remain disproportionately high. Through her work with The SAVE Clinic as well as being a Founding Chair of the Center for Health Equity in South Texas, she has worked with physicians, academic institutions, public health agencies, nonprofits and community leaders to improve access to care and address the social drivers of health. Dr. Ochoa has also been active in organized medicine and physician advocacy. At TexMed, she authored two resolutions: Resolution 312, which was adopted and supports PAD screening and efforts to address diabetes-related amputations; and Resolution 313, focused on

adequate screening for dyslexia, which was referred for study. Dr. Ochoa has served on TexMed Reference Committees and is currently serving on the Texas Medical Association Council on Socioeconomics, where she engages in policy discussions affecting physicians, patients and the practice of medicine. With multiple leadership positions within the Bexar County Medical Society (BCMS), including two years as Vice President and currently as Secretary, Dr. Ochoa has worked to engage members, strengthen advocacy, and elevate physicians’ voices in local and state policy discussions. As BCMS President-Elect, Dr. Ochoa’s goal is to support physician leadership, strengthen communication among members, advocate for policies that improve patient care and the practice of medicine, and ensure BCMS remains a trusted voice for physicians and the communities it serves.

Vice President | Lauren Tarbox, MD Dr. Lauren Tarbox grew up in Corpus Christi, Texas and graduated from Southern Methodist University with a Bachelor of Science in Chemistry. After college, she moved to San Antonio and attended UT Health San Antonio, finishing medical school, residency, chief residency and nephrology fellowship. She is a partner with South Texas Renal Care Group, focusing in the Northeast area of San Antonio for the past 11 years. She has a particular interest in home therapies for dialysis patients and their families. The Bexar County Medical Society (BCMS) helps to bring physicians together in San Antonio and advocate/support physicians in their practices, and Dr. Tarbox has valued her experience in the organization.

From member to Board member and now from Secretary to Vice President in the Executive Board, she hopes to continue the BCMS mission to support physicians in the city she calls home. Dr. Tarbox loves spending time with her three children and husband. She tries to keep orchids alive and enjoys baking. She cannot wait to start another year on the Executive Board of Bexar County Medical Society to assist her fellow physicians through a fabulous 2027.

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BEXAR COUNTY MEDICAL SOCIETY

Treasurer | Gerardo Ortega, MD, FACS Dr. Gerardo Ortega has worked as a board-certified vascular surgeon in San Antonio for 42 years, along with being a continuous member of the Bexar County Medical Society (BCMS) for 45 years, and BCMS President in 2001. He currently serves as the Chair of the Bexar County Medical Library Association Philanthropic Committee as well as a BCMS Delegate to the Texas Medical Association (TMA). Dr. Ortega has participated in many projects and committees for BCMS, was a past recipient of the BCMS Golden Aesculapius award, attended all TMA First Tuesdays at the Capitol in 2025, and plans

to do so again in 2027. He is also the Past President of Baptist Health System Medical Staff. Dr. Ortega truly believes in the individual impact that BCMS members can have in organized medicine. After all these years, he still believes he can make meaningful contributions to the Bexar County Medical Society and is dedicated to serving as Treasurer.

Secretary | Lori Kels, MD, MPH, FAPA Dr. Lori Kels is a board-certified psychiatrist who has worked at the University of the Incarnate Word School of Osteopathic Medicine (UIWSOM) since 2017, after her husband’s military service brought their family to San Antonio. She has served on the Bexar County Medical Society (BCMS) Board of Directors representing UIWSOM for the past several years and would be honored to serve her colleagues as an elected member of the Board. Dr. Kels has found great value in serving on the BCMS Board and is especially grateful for the organization’s work supporting women in medicine and physicians in recovery. In addition to supporting these efforts, she hopes to increase trainee participation in BCMS as well as student and resident interests in organized medicine to help the Society advocate even more strongly for patients

and the future of medicine. Dr. Kels has worked closely with students to contribute content to San Antonio Medicine and looks forward to engaging trainees in BCMS’s advocacy and education. She has also served on the Texas Medical Association Council on Medical Education and helped support BCMS interests as part of the BCMS Delegation to TexMed. Dr. Kels is grateful to be a part of this community of physicians in San Antonio and in Texas, and believes it is an honor to serve the supportive and close-knit San Antonio physician community through BCMS.

Board of Directors The Board of Directors establishes and implements policies, is responsible for long-range planning of the medical society, and serves as governing Board of the Bexar County Medical Society. One position available in each category.

Jeffrey Dean, MD Dr. Jeffrey Dean graduated from the United States Military Academy at West Point then went to medical school at Wright State University and completed orthopaedic residency at Brooke Army Medical Center in San Antonio. He served a total of 22 years in the U.S. Army before moving back to San Antonio to start civilian practice. Dr. Dean’s three sons have dyslexia and have had challenges in school that could have been mitigated with early diagnosis and early

intervention. His desire to serve in the Bexar County Medical Society (BCMS) is based on seeing how the advocacy process helps those who have not received the optimal benefits from the current system, and his commitment to work together with others to improve our system to help all people achieve their optimal potential.

Visit us at www.bcms.org

BEXAR COUNTY MEDICAL SOCIETY Board of Directors continued Vijay K. Gunuganti, MD Dr. Vijay K. Gunuganti is a dedicated medical oncologist at Texas Oncology in San Antonio, where he has proudly served the local medical community and patients for the past 20 years. Board-certified in internal medicine, medical oncology, and hospice and palliative care, he brings a holistic, comprehensive approach to patient care. After completing his fellowship and serving as faculty at the University of Wisconsin-Madison, Dr. Gunuganti chose San Antonio as home. Over the last two decades, he has established deep roots in Bexar County, working collaboratively with local physicians, hospitals and healthcare networks to elevate the standard of community medicine. Dr. Gunuganti is a principal investigator for numerous clinical trials through the US Oncology Research (USOR) network where robust patient accrual rates have directly contributed to the FDA approval of several breakthrough oncology and hematology therapeutics. Beyond clinical research, he is a national speaker and consultant, including

presenting for the American Cancer Society and serving as a healthcare keynote speaker, and dedicates his time to educating healthcare providers on the safety and efficacy of newly approved drugs and community advocacy. Dr. Gunuganti will continue to bridge the gap between community practice and cutting-edge clinical research, ensuring Bexar County physicians remain at the forefront of medical innovation. He commits to firmly advocating for physician wellness, protecting community practices against administrative burdens, and fostering mentorship for our next generation of doctors, and he looks forward to bringing his extensive clinical, research and educational experience to the Board to serve diligently.

Crystel Harb, DO Dr. Crystel Harb is an Assistant Clinical Professor of Family Medicine and Public Health at the University of the Incarnate Word School of Osteopathic Medicine and currently serves as the Director of Osteopathic Education, Director of Lifestyle Medicine Residency Curriculum, and core faculty in the community-based Family Medicine residency program at the Texas Institute of Graduate Medical Education & Research. She is board certified through the American Osteopathic Association in Family Medicine, Osteopathic Manipulative Medicine and Addiction Medicine. Additionally, she is board-certified in Lifestyle Medicine through the American Board of Lifestyle Medicine and the International Board of Lifestyle Medicine. Dr. Harb holds a MPH in Epidemiology from the University of Texas School of Public Health, and has authored the Public Health Epidemiology textbook.

Her leadership roles outside of academia include serving as Secretary for the Texas Academy of Family Physicians, and previously on the Board of Directors for MedHab, a company whose primary goal is to empower both patients and healthcare providers with real-time data for chronic care management through innovative remote patient monitoring technology to augment lifestyle medicine. Dr. Harb wishes to serve on the Board of Directors for the Bexar Couty Medical Society to engage within tyhe community for an opportunity to shape the future of healthcare and advocate for physicians in this area.

Olawale Olabiyi, MD Dr. Olawale Olabiyi is a dual board-certified pediatrician and pediatric cardiologist. He is also a co-founder of Pediatric Cardiology Consultants of South Texas. For more than 20 years, he has cared for children and families across Bexar County and South Texas while working alongside pediatricians, family physicians, hospitals and healthcare organizations to expand access to specialized pediatric cardiovascular care. He has helped grow a multi-site pediatric cardiology practice, incorporated telehealth to reach children in rural and underserved communities, and remains committed to ensuring families have timely access to high-quality specialty care close to home. Beyond his clinical practice, Dr. Olabiyi is dedicated to strengthening both the medical profession and the communities he serves. He mentors medical residents during their pediatric cardiology rotations,

volunteers with Community Under the Bridge, participates in heart screening events through August Heart to promote early detection of heart disease in young athletes, and serves on annual medical missions to Africa providing pediatric cardiology care to children with limited access to specialty services. Dr. Olabiyi is seeking election to the Bexar County Medical Society Board because he believes physicians have a responsibility to lead beyond their individual practices. He is committed to supporting physician engagement, encouraging collaboration across specialties, and advancing organized medicine to better serve both physicians and patients.

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BEXAR COUNTY MEDICAL SOCIETY

Thomas Pollard, MD Dr. Thomas Pollard completed his medical training in San Antonio, including medical school, general surgery residency and cardiothoracic surgery fellowship at UT Health San Antonio. During those formative years, he came to appreciate the essential role of the Bexar County Medical Society in supporting physicians and helping them succeed in the community. The importance of local medical society involvement and strong physician leadership was emphasized to him when he entered practice as a cardiovascular surgeon in Knoxville, Tennessee, in 1996. Over the years, Dr. Pollard served on several medical staff committees, including quality and peer review, and ultimately as Chief of Staff at two hospitals served by his surgical group. He also served on the Board of the Knoxville Academy of Medicine and as its President from 2015 to 2016, which led to his service as a member of the Tennessee Medical Association House of Delegates. In 2017, Dr. Pollard chaired the Tennessee Medical Association Professional Relations Committee, working to protect the leadership role of physicians as nurse practitioners and physician assistants expanded their presence

on the medical team. These experiences also allowed him to pursue his interest in IV drug-related endocarditis, a condition that significantly affected East Tennessee, whose local medical society's efforts to address it became nationally known and were later featured in The New York Times. Since returning to San Antonio in 2018, Dr. Pollard has continued to serve in medical leadership roles, including his current position as Director of Cardiovascular Surgery Services for the Baptist Health System. Over the years, he has seen cardiovascular surgery and the broader practice of medicine challenged by hospital employment issues, fair reimbursement, physician shortages and burnout, and he believes active participation in local and state medical societies is vital to advancing physician leadership, supporting workforce sustainability, and improving patient care.

Patrick Reeves, MD Dr. Patrick Reeves is a quadruple board-certified general pediatrician, obesity medicine specialist, clinical informatics physician, and pediatric gastroenterologist with advanced care in the management of children with medical complexity, tube feeding needs and rare gastrointestinal disorders. He is an associate professor of pediatrics at the Long School of Medicine at UT Health San Antonio and the Uniformed Services University of the Health Sciences in Bethesda, Maryland. He is also an associate professor of Military Medicine at Texas A&M University Health Science Center in College Station. Dr. Reeves’ specific niche research focus over the last 10 years has been the intersection of

patient education and the management of children and young adults with medical complexity. He is the CEO of his consulting firm, Wild Child Medicine, PLLC, and has pioneered a new mobile health technolog y called Clinical Action Plans, which provides automated clinical decision support to medical teams and serves as low health literacy care plans for the home management of chronic needs.

Shruti Sharma, DO, FACP The first event Dr. Shruti Sharma attended as a Texas oncologist was the Bexar County Medical Society Women in Medicine event. She had just completed her hematology and medical oncology fellowship and was transitioning into her role as an attending during this time. She remembers looking around the room at these extraordinary women with sincere admiration of their work and how impactful it would be to join the Society, influencing local medical policies and creating a voice for community oncology in San Antonio. Dr. Sharma was given that chance weeks later when she was approached by her liaison to submit an article to the San Antonio Medicine magazine. She spoke on the important differences in community and academic oncology and how the marriage between these two is what makes a successful medical community. While overwhelmed by the positive feedback from her colleagues, she was more exhilarated by the process of writing.

One of the reasons why Dr. Sharma went into community oncology was because she wanted patients all over Texas to have access to cancer treatments. There is still a lot of work to be done within this platform, especially with the unfunded population. If elected to the Board of Directors, she will continue to build relationships between the community and university centers to allow individuals who do not have insurance the opportunity to receive chemotherapy in a timely manner. In addition, she would like to provide the tools to fellow medical oncologists to help bridge this gap, allowing more patients access to standard of care, novel therapies and clinical trials. Dr. Sharma looks forward to collaborating with colleagues to create ways to improve the quality of care to patients. Visit us at www.bcms.org

BEXAR COUNTY MEDICAL SOCIETY Board of Directors continued Nancy J. Vacca, MD Dr. Nancy J. Vacca has practiced clinical and academic medicine throughout her career and currently serves as Medical Director for the Department of Population Health Management at Community First Health Plans. She is also Adjoint Faculty for the Department of Family and Community Medicine at UT Health San Antonio. Although born in New York, Dr. Vacca earned her Doctor of Medicine Degree in Colombia, where she was raised and educated. After graduating , she returned to the United States to complete her residency at UT Health San Antonio. Dr. Vacca also earned her MBA with a concentration in healthcare at UT San Antonio. She was honored as a Richard A. Garcia Jr. and South Area Health Education Center Scholar, and upon graduation, she received the Residency Award for Excellence in the Care of Children and Adolescents and the Residency Award for Excellence in Maternity Care.

Dr. Vacca is board certified by the American Board of Family Medicine. She has practiced clinical medicine in the private setting and as a Civilian Medical Officer for the Department of Defense – U.S. Air Force. She has also practiced academic medicine at UT Health San Antonio and the University of the Incarnate Word School of Osteopathic Medicine. Dr. Vacca is an active member of the Texas Medical Association, Bexar County Medical Society (BCMS), American Academy of Family Physicians and the Texas Academy of Family Physicians. She is a former President of the Alamo Chapter of the Texas Academy of Family Physicians and currently serves as a Board member for BCMS. She was a 2022 Honoree of the Women Leaders in Medicine Award by BCMS.

Subhashini Valavalkar, MD Dr. Subhashini Valavalkar is a board-certified pediatrician who has had the privilege of caring for children and their families for the past 25 years. She has proudly called Bexar County home since 2011. Dr. Valavalkar first became involved with TIPS (the Texas Indo Physician Society, Southwest Chapter) seven years ago, and had the privilege of serving as its president in 2024. The Bexar County Medical Society (BCMS) and TIPS have always worked closely together, supporting each other’s events and activities, and through this collaboration, she came to truly appreciate the meaningful impact that physicians, working together as a community, can have in serving others. During her tenure with TIPS, she gradually became more involved with BCMS, and inspired by the important work of the senior physi-

cians and by the valuable CME activities offered to members. She was also deeply honored and humbled to receive the BCMS Women in Medicine Award in 2024. Dr. Valavalkar believes BCMS is doing remarkable work to advance the medical profession and serve this community, and this nomination to its Board of Directors represents an opportunity to become more involved. She plans to fully immerse herself in the work of BCMS, contributing experience, energy and commitment to initiatives that strengthen the profession and improve the health of the community.

Delegation to TMA The Texas Medical Association is governed by a 500-member House of Delegates, the legislative and policymaking body. The house is made up of elected county medical society delegates and ex officio members. Being a delegate to TMA means you will be involved in determining the policies of the Texas Medical Association and the officers of the TMA.

Delegates Stephen Gelfond, MD Alice Kim Gong, MD Gerald Greenfield, Jr., MD James Loyd Humphreys, MD

Alternate Delegates David Lam, MD Lubna Naeem, MD J. Marvin Smith, III, MD

SAN ANTONIO MEDICINE • SEPTEMBER 2026

Cynthia Cantu, DO Ramon Colen, MD Alonzo Guzman, Jr., MD K. Ashok Kumar, MD Sekinat McCormick, MD

Pratik Parikh, MD Patrick Reeves, MD Evon Rose, DO Charles Stephen, MD

BEXAR COUNTY MEDICAL SOCIETY Board of Ethics The Bexar County Medical Society Board of Ethics upholds the highest standards of medical ethics among its members by providing guidance, reviewing membership applications, investigating potential code of conduct violations, and taking appropriate action when necessary. The Board also evaluates complaints of unethical conduct submitted by members and ensures proper resolution. Three positions available. Sheldon Gross, MD Dr. Sheldon Gross has been an active member of the Bexar County Medical Society (BCMS) since 1983. Throughout the years, he has served as the 2018 BCMS President, State Chair of the Texas Medical Association Political Action Committee

(TEXPAC), National Chair of the American Medical Association Political Action Committee (AMPAC), and participated in multiple committees.

Justin Robbins, MD Dr. Justin Robbins is an orthopaedic foot and ankle surgeon with 18 years of clinical practice in both military and civilian settings. Throughout his career, he has practiced in three different military treatment facilities, completed two deployments to Iraq, and now practices in a large community-based orthopaedic group. These experiences have exposed Dr. Robbins to a broad range of clinical, professional and ethical challenges, caring for patients in both combat environments and everyday practice. In addition to his clinical experience, he has served on peer review committees in both the military and current practice, where he worked

collaboratively to evaluate complex cases and promote professionalism, accountability and high standards of patient care. Dr. Robbins is interested in serving on the Board of Ethics because he values fairness, integrity and thoughtful decision-making. He believes his diverse experiences have prepared him to contribute a balanced perspective and help uphold the ethical standards of this profession.

John Shepherd, MD Dr. John Shepherd has been an active lobbyist for the family of medicine at the Texas State Capitol and has held several “Party of Medicine” events introducing physicians on how to get involved with legislation that affects medical issues. He has served as the 2025 Bexar County Medical

Society President, Chief of Surgery at Christus Santa Rosa Children's Hospital, been a past member of the Board of Directors of Tejas Anesthesia, and currently serves on several BCMS committees.

GENERAL MEMBERSHIP MEETING REMINDER Topic: Legislative & AMA Update Speaker: Jayesh "Jay" Shah, MD, TMA Immediate Past President 1 CME Ethics Credit Scan QR Code to RSVP:

When: September 10, 2026 Networking: 5:30 PM Meeting: 6:30 PM Where: RBFCU Main Campus 1 IKEA-RBFCU Pkway San Antonio, TX Visit us at www.bcms.org

ATTENTION PHYSICIANS from the Bexar County Medical Society

Help Us Recognize Outstanding Leaders in Medicine The Bexar County Medical Society (BCMS) periodically recognizes physicians and other individuals whose dedication, leadership and service have made a lasting impact on organized medicine and the medical community. Through our Special Awards Program, we honor those whose contributions deserve to be celebrated and remembered. The BCMS Special Awards Committee invites your nominations for individuals you believe are deserving of recognition. While we are unable to honor every worthy candidate, your recommendations help ensure that exceptional service and achievement do not go unnoticed. Please tell us who you believe should be considered and why. Golden Aesculapius Award As BCMS' Highest Honor, the Golden Aesculapius Award recognizes a BCMS physician member whose lifetime of distinguished service has advanced the patients, physicians and medical profession of Bexar County. Recipients have demonstrated extraordinary leadership and sustained commitment to organized medicine through active participation in both BCMS and the Texas Medical Association. Eligibility • Reserved for BCMS physician members. • Recognizes a lifetime of distinguished service to organized medicine and the medical profession. • May be awarded only once during a recipient's lifetime. Distinguished Service Award The Distinguished Service Award recognizes physicians and non-physicians whose exceptional service, accomplishments or contributions have significantly benefited the physicians and patients of Bexar County or advanced the practice of medicine. Unlike the Golden Aesculapius Award, this honor is intended to recognize specific achievements, leadership or contributions rather than a lifetime of service. Eligibility • BCMS physician members may be recognized for distinguished service or significant accomplishments. • Non-physicians are also eligible for their outstanding contributions to medicine and healthcare.

Scan the QR code to submit your nominations.

Thank you for helping us recognize those whose dedication, leadership and service strengthen the medical profession and improve the health of our community. Nomination Deadline: September 28, 2026 38

SAN ANTONIO MEDICINE • SEPTEMBER 2026

SAN ANTONIO MEDICINE

Before You Open a Role: Salary, structure and hiring strategy basics Courtesy of Favorite Healthcare Staffing

Opening a position may seem like the first step in the hiring process, but successful healthcare hiring often starts before the job is ever posted. While compensation is an important factor, candidates are evaluating much more than salary when deciding whether an opportunity is worth pursuing. Job responsibilities, reporting structure, schedule expectations, flexibility, leadership support and long-term career growth all influence a candidate's decision. Organizations that take time to align on these details before launching a search are often better positioned to attract and secure the right talent. Salary is Only Part of the Equation Competitive compensation helps generate interest, but it rarely closes the deal on its own. Healthcare professionals want a clear understanding of what the role actually looks like day to day. Questions about workload, team structure, call requirements, leadership access and advancement opportunities often carry just as much weight as salary discussions. Before opening a role, make sure your organization can clearly communicate: • Compensation range and benefits • Schedule and workload expectations • Reporting structure • Team dynamics and support resources • Growth and development opportunities The more clearly these details are defined, the easier it becomes to attract candidates who are genuinely aligned with the opportunity. Build a Hiring Strategy Before the Posting Goes Live A job posting should never be the starting point for planning the hiring process. Before candidates begin applying, healthcare organizations should establish who owns each step of the search and how decisions will be made. This helps prevent delays that can cause strong candidates to lose interest. Consider these questions before launching a search: Who will review candidates? Determine who is responsible for evaluating resumes and making initial decisions. Who will participate in interviews? Identify interviewers early and confirm availability. What defines the ideal candidate? Align on required qualifications and key attributes before reviewing applicants. How quickly can decisions be made? Establish expectations for feedback and next steps throughout the process. Having these answers in place creates a smoother experience for both candidates and hiring teams.

Why Speed Matters in Healthcare Hiring Many healthcare professionals enter the market with multiple opportunities already under consideration. Delays that seem minor internally can have a significant impact on candidate engagement. When communication slows or interview timelines stretch, candidates may begin to question whether the organization is fully committed to the search. In many cases, another employer with a faster process may move forward first. A well-organized hiring process helps maintain momentum by: • Providing timely interview scheduling • Delivering prompt feedback • Setting clear expectations for next steps • Reducing uncertainty throughout the process Speed alone doesn't guarantee a successful hire, but responsiveness helps build confidence and keeps candidates engaged. Communication Shapes Candidates’ Perception Every interaction during the hiring process sends a message about the organization. Candidates notice when interview schedules are coordinated efficiently, feedback is provided promptly and expectations are communicated clearly. These details help create a positive impression long before an offer is extended. If timelines change or decisions take longer than expected, proactive communication can help maintain candidate interest. A simple update often prevents uncertainty from turning into disengagement. Preparation Leads to Stronger Hiring Outcomes Opening a role isn't just an administrative task. It's a market-facing decision that directly impacts your ability to attract talent. Organizations that define role expectations, align hiring teams, and establish a clear process before posting are often better equipped to compete in today's healthcare hiring market. When preparation happens first, recruiters can move faster, candidates stay engaged and hiring decisions become more effective. Explore how Favorite Healthcare Staffing can support your workforce needs by visiting our Staffing Services page at www.FavoriteStaffing.com/workforce-solutions/staffing-services. Favorite Healthcare Staffing is a Platinum Sponsor in the Bexar County Medical Society Business Partners Program. Visit us at www.bcms.org

Bexar County Medical Society Business Partners Program As a BCMS member, you can find exclusive discounts on premium products and services that you and your practice use every day.

Shop Businesses Who Support BCMS ACCOUNTING FIRMS

Sol Schwartz & Associates P.C. (HHH Gold Sponsor) Sol Schwartz & Associates is the premier accounting firm for San Antonio-area medical practices and specializes in helping physicians and their management teams maximize their financial effectiveness. Christopher Davis, CPA 210-384-8000, ext. 118 cbd@ssacpa.com www.ssacpa.com “Dedicated to working with physicians and physician groups.” CLA - CliftonLarsonAllen LLP (HH Silver Sponsor) Transform complexity into opportunities. Work with professionals who understand the specific financial, operational, clinical, and strategic needs of physician practices and medical groups. Our team is made up of knowledgeable, accessible, and responsive individuals devoted to the healthcare industry. Bryan Garcia, CPA Principal 210-298-7924 (direct) Bryan.Garcia@CLAconnect.com www.CLAconnect.com "Right there with you"

ASSET WEALTH MANAGEMENT

Aspect Wealth Management (HHH Gold Sponsor) We believe wealth is more than money, which is why we improve and simplify the lives of our clients, granting them greater satisfaction, confidence and freedom to achieve more in life. Michael Clark President 210-268-1520 (direct) MClark@aspectwealth.com www.aspectwealth.com “Your wealth. . .All aspects”

Atlas Retirement Strategies LLC (HHH Gold Sponsor) Atlas Retirement Strategies LLC is a comprehensive financial planning firm dedicated to serving the unique needs of the medical community. We offer customized strategies in business planning, retirement planning, risk management, wealth preservation, estate planning, and wealth transfer – empowering healthcare professionals to achieve long-term financial security, clarity, and peace of mind. David M. Webb, Ph.D., MSM, CLF, CLTC, LACP Founder & Principal 210-281-4400 (office) David@atlas-plans.com www.atlas-plans.com

BANKING

Bank of Texas (HHH Gold Sponsor) Bank of Texas, powered by BOK Financial, is a top U.S.-based financial services company, offering sophisticated wealth, commercial, and consumer products and services. Still, we do business one client at a time—focused on delivering thoughtful expertise and tailored advice—because we know that when our clients succeed, we succeed. Orlando Hinojosa VP, Senior Sales Manager NMLS# 513530 210-240-9743 (cell) OHinojosa@bankoftexas.com George Pedraza SVP, Private Wealth Management Market Executive 210-568-7685 (direct) GPedraza@bankoftexas.com “We go above. So you can go beyond.”

Broadway Bank (HHH Gold Sponsor) Healthcare banking experts with a private banking team committed to supporting the medical community. Thomas M. Duran SVP, Private Banking Team Lead 210-283-6640 (direct) TDuran@broadway.bank www.broadway.bank “We’re here for good.”

SAN ANTONIO MEDICINE • SEPTEMBER 2026

Texas Partners Banks (HHH Gold Sponsor) Our private banking team specializes in healthcare banking and will work with you to craft and seamlessly integrate financial solutions for you and your practice, including practice loans, lines of credit and custom local lockbox solutions headquartered in San Antonio. Maria Breen 210-807-5562 (direct) Maria.Breen@texaspartners.bank www.texaspartners.bank Amegy Bank of Texas (HH Silver Sponsor) We believe that any great relationship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability. We work hard and together with our clients to accomplish great things. Eric Johnston SVP, Private Banking Team Lead 210-343-4485 (direct) Eric.Johnston@amegybank.com Scott Gonzales Vice President, Private Banking 210-343-4494 (direct) Scott.Gonzales@amegybank.com Chris Stewart Assistant Vice President, Private Banking 210-343-4425 (direct) Chris.Stewart@amegybank.com www.amegybank.com “Community banking partnership” First Citizens Bank (HH Silver Sponsor) For more than 125 years, First Citizens Bank has served the financial needs of our clients and communities with specialized support and an emphasis on service. We bank on a first-name basis, taking a genuine interest in our clients' well-being. Our values-driven approach combines deep sector expertise with high-touch service, helping clients achieve their financial goals and aspirations. Jorge Saenz Jr. VP Business Banker III 210-749-3022 (cell) Jorge.SaenzJr@firstcitizens.com Robert Moreno VP Business Banker II 210-310-8411 (cell) no@firstcitizens.com www.firstcitizens.com “Forever First”

South State Bank (HH Silver Sponsor) In healthcare, success depends on precision, expertise and smart financial management. At SouthState Bank, our dedicated healthcare banking team combine industry knowledge, tailored products and relationship-focused service to deliver forward thinking financial solutions that help your practice thrive. Robert Lindley Senior Vice President, Private Banking 210-806-5506 (direct) Rob.Lindley@southstatebank.com www.southstatebank.com “Banking Forward” Synergy Federal Credit Union (HH Silver Sponsor) Looking for low loan rates for mortgages and vehicles? We've got them for you. We provide a full suite of digital and traditional financial products, designed to help physicians get the banking services they need. Synergy FCU Member Services 210-750-8333 (office) info@synergyfcu.org www.synergyfcu.org “Once a member, always a member. Join today!”

BUILDING /CONTRACTOR SERVICES Huffman Developments (HH Silver Sponsor) Building spaces that inspire success. Huffman Developments specializes in custom commercial and medical projects from concept to completion. With over 40 years of experience, our team delivers high-quality, long-lasting facilities tailored to each client’s vision and business goals. Steve Huffman President 210-979-2500 x207 (direct) 210-213-2421 (cell) SHuffman@huffmandev.com www.huffmandev.com "Building Excellence One Project at a Time"

CREDENTIALS VERIFICATION ORGANIZATION

Bexar Credentials Verification, Inc. (HHHH 10K Platinum Sponsor) Bexar Credentials Verification Inc. provides primary source verification of credentials data that meets The Joint Commission (TJC) and the National Committee for Quality Assurance (NCQA) standards for healthcare entities. Betty Fernandez Director of Operations 210-582-6355 (direct) Betty.Fernandez@bexarcv.com www.bexarcv.com “Proudly serving the medical community since 1998”

FINANCIAL ADVISORS

Elizabeth Olney with Edward Jones (HHH Gold Sponsor) We learn your individual needs so we can develop a strategy to help you achieve your financial goals. Join the nearly 7 million investors who know. Contact me to develop an investment strategy that makes sense for you. Elizabeth Olney Financial Advisor 210-858-5880 (office) Elizabeth.Olney@edwardjones.com www.edwardjones.com/elizabeth-olney

FINANCIAL SERVICES

HOSPITALS/PRACTICE SERVICES Graystone Consulting (HH Silver Sponsor) At Graystone Consulting, an institutional consulting business of Morgan Stanley, we are focused on providing you with holistic, objective advice and strive to be your trusted partner by delivering the best of two worlds to you: the personalized service of a consulting boutique, and the resources of a global financial powerhouse. We offer a wide spectrum of investment consulting solutions designed to meet your desired level of service and discretion. And we can provide all the intellectual capital, specialized resources, and analytical tools you need to help implement a successful, personalized investment strategy. Logan Sammons Financial Advisor 210-366-6685 (direct) 210-500-8768 (cell) Logan.Sammons@msgraystone.com www.graystone.morganstanley.com/ graystone-sanantonio

GERIATRICS/PRIMARY CARE

UT Health San Antonio MD Anderson Cancer Center (HHH Gold Sponsor) UT Health provides our region with the most comprehensive care through expert, compassionate providers treating patients in more than 140 medical specialties at locations throughout San Antonio and the Hill Country. UT Health San Antonio Laura Kouba Business Development Manager 210-265-7662 (cell) NorrisKouba@uthscsa.edu Appointments: 210-450-1000 UT Health San Antonio 7979 Wurzbach Road San Antonio, TX 78229

Equality Health (HHH Gold Sponsor) Equality Health deploys a wholeperson care model that helps independent practices adopt and deliver value-based care for diverse communities. Our model offers technology, care coordination and hands-on support to optimize practice performance for Medicaid patients in Texas. Cristian Leos Network Development Manager 210-608-4205 (cell) CLeos@equalityhealth.com www.equalityhealth.com “Reimagining the New Frontier of Value-Based Care.”

Golden Billing & Benefits (HHH Gold Sponsor) Golden Billing is owned and operated for over 20 years in Houston, TX. The owner, Marcus Yi, is focused on creating a partnership with clients. We are dedicated to optimizing the small business doctor’s productivity and maximizing practice cash flow by accurate claims coding and timely processing. Call today for a free consultation. If you don’t want to use us at lease maybe we can help you fine tune your decision. Marcus Yi 713-263-0054 (office) MYi@goldenbilling.com www.goldenbilling.com

Practice Care Plus (HHH Gold Sponsor) We understand that your practice has real constraints: time, staffing, compliance risk, and revenue pressure. Practice Care Plus connects you to a curated network that can handle the business side of medicine, from targeted fixes to larger operational upgrades. You stay in control of scope and move at the pace that fits your schedule. What to expect from Practice Care Plus: Clear scope before any work begins, Direct contact with preferred partners, Support for practices of many sizes. Judy Brown Principal info@practicecareplus.com 817-686-3949 www.practicecareplus.com Start your practice assessment today.

Physicians Connection (Previously known as DialOPS) (HH Silver Sponsor) Dialops is a trusted U.S.-based medical answering service and virtual receptionist solution designed specifically for healthcare practices. We provide 24/7 live call handling, HIPAA-compliant messaging, appointment scheduling, and reliable after-hours and overflow support. Our medically trained agents answer every call with professionalism and care— just like your in-office staff—ensuring your patients always feel heard and supported. From solo providers to busy clinics, Dialops helps reduce missed calls, ease front desk overload, and improve the patient experience—all at a fraction of the cost of hiring in-house. Rachel Caero Rachel@dialops.net 877-2-DIALOPS/210-699-7198 www.dialops.net SpeedE'z (HH Silver Sponsor) For over three decades, SpeedE’z has been Bexar County’s truly local partner for answering service, contact center and courier solutions. R.N. owned and family-led, we combine compassionate care with professional expertise. Our HIPAA Certification, SOC 2 Type II Compliance and Woman-Owned HUB status reflect our commitment to integrity and security. Ranked Top Ten nationally in the ATSI Award of Excellence, our team delivers results that stand out – rooted right here in San Antonio! Lauren Garza Vice President 210-615-0964 (office) Lauren@speedez.com www.speedez.com Straight Edge Technology (HH Silver Sponsor) Straight Edge Technology is a San Antonio-based IT company that works with medical practices to manage their technology, security and compliance needs. With a methodical, partnership-driven approach, we work closely with practices to keep patient data protected and technology running smoothly behind the scenes, so providers can stay focused on patient care and practice optimization. We proudly support several members of the Bexar County Medical Society and welcome the opportunity to discuss how we can help safeguard your practice's IT infrastructure and help your business run smoother. Brooke Hernandez Director of Business Development 210-213-6189 BHernandez@straightedgetech.com Healthcare IT - Straight Edge Technology

Continued on page 42 Visit us at www.bcms.org

BCMS Business Directory INSURANCE

TMA Insurance Trust (HHHH 10K Platinum Sponsor) TMA Insurance Trust is a full-service insurance agency offering a full line of products – some with exclusive member discounts and staffed by professional advisors with years of experience. Call today for a complimentary insurance review. It will be our privilege to serve you. Guy Patterson Executive Director 512-370-1744 (direct) 800-880-8181 (toll-free) Guy.Patterson@tmait.org www.tmait.org“We offer BCMS members a free insurance portfolio review.”

INSURANCE/MEDICAL MALPRACTICE

Texas Medical Liability Trust (HHHH 10K Platinum Sponsor) With more than 20,000 healthcare professionals in its care, Texas Medical Liability Trust (TMLT) provides malpractice insurance and related products to physicians. Our purpose is to make a positive impact on the quality of healthcare for patients by educating, protecting and defending physicians. Patty Spann Director of Sales and Business Development 512-425-5932 (direct) Patty-Spann@tmlt.org www.tmlt.org “Recommended partner of the Bexar County Medical Society” MedPro Group (HH Silver Sponsor) Rated A++ by A.M. Best, MedPro Group has been offering customized insurance, claims and risk solutions to the healthcare community since 1899. Visit MedPro to learn more. Kirsten Baze, RPLU, ARM AVP Market Manager, SW Division 512-658-0262 (cell) 844-293-6355 (fax) Kirsten.Baze@medpro.com www.medpro.com

MEDICAL SUPPLIES AND EQUIPMENT Henry Schein Medical (HH Silver Sponsor) From alcohol pads and bandages to EKGs and ultrasounds, we are the largest worldwide distributor of medical supplies, equipment, vaccines and pharmaceuticals serving officebased practitioners in 20 countries. Recognized as one of the world’s most ethical companies by Ethisphere. Kelly Emmon Field Sales Consultant 210-279-6544 (cell) Kelly.Emmon@henryschein.com www.henryschein.com “BCMS members receive GPO discounts of 15 percent to 50 percent.”

PHYSICIAN ORGANIZATIONS LGND Acme Solutions (HH Silver Sponsor) LGND Acme Solutions provides essential revenue cycle solutions to clinics, hospitals, emergency departments, surgery centers, and physician groups. Our services include providing certified support teams and services, such as radiology technicians, phlebotomists, billing, coding, insurance verification, patient access, housekeeping and all types of administrative support. Yoceline Aguilar Chief Operations Officer 915-691-9178 (cell) YAguilar@lgndacme.com https://lgndacme.com

PROFESSIONAL ORGANIZATIONS The Health Cell (HH Silver Sponsor) “Our Focus is People” Our mission is to support the people who propel the healthcare and bioscience industry in San Antonio. Industry, academia, military, nonprofit, R&D, healthcare delivery, professional services and more! Kevin Barber President 210-308-7907 (direct) KBarber@bdo.com Valerie Rogler Program Coordinator 210-904-5404 (cell) Valerie@thehealthcell.org www.thehealthcell.org “Where San Antonio’s Healthcare Leaders Meet”

SAN ANTONIO MEDICINE • SEPTEMBER 2026

San Antonio Medical Group Management Association (SAMGMA) (HH Silver Sponsor) SAMGMA is a professional nonprofit association with a mission to provide educational programs and networking opportunities to medical practice managers and support charitable fundraising. Jeannine Ruffner President info4@samgma.org www.samgma.org

REALTOR SERVICES JLL (HH Silver Sponsor) Lee N. McKenna, MHA Managing Director, Healthcare 210-293-6842 (direct) Lee.McKenna@jll.com www.jll.com/en-us/ “See a brighter way.”

STAFFING SERVICES

Favorite Healthcare Staffing (HHHH 10K Platinum Sponsor) Serving the Texas healthcare community since 1981, Favorite Healthcare Staffing is proud to be the exclusive provider of staffing services for the BCMS. In addition to traditional staffing solutions, Favorite offers a comprehensive range of staffing services to help members improve cost control, increase efficiency and protect their revenue cycle. San Antonio Office 210-301-4362 (office) www.favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.”

This program is designed for companies and organizations looking to connect with our physician members and the broader medical community. It offers a strategic opportunity to showcase your products and services while fostering business growth within the healthcare sector.

JOIN TODAY

Visit us at www.bcms.org

AUTO REVIEW

2026 Range Rover By By Stephen Stephen Schutz, Schutz, MD MD

In 1994, BMW purchased the Land Rover and Range Rover business from the Rover group of England, and immediately got to work to make the Range Rover into a world-class SUV. It took a while, but the L322 generation Range Rover, which launched in 2001, is still considered to be one of the best Range Rovers ever (the late Queen Elizabeth of England famously refused to give up her L322 and kept it until her passing in 2022). I think that coupling a beautiful modern Range Rover with a BMW engine and transmission, as they did in this case, was a very good thing. However, BMW got tired of spending copious amounts of money on their Land Rover and Range Rover project so they sold the whole lot — as the Brits might say — to Ford in 2000.

An anonymous Ford executive famously informed a journalist that Ford, which also owned Jaguar at the time, was dying to swap the BMW engines and transmissions for Jaguar drivetrains because, “each BMW engine we put in these things costs us more than a new Mustang.” In 2006, Jaguar engines and transmissions became standard equipment on L322 Range Rovers, and that arrangement continued under the new owners of Jaguar Land Rover, the Tata group out of India. I know this story is dragging on, but we’ve now arrived (finally) at the current Range Rover, the fifth generation L460 version, which was introduced in 2022 as a 2023 model, and this one has reverted back to BMW as its engine and transmission supplier. We’ve come full circle.

SAN ANTONIO MEDICINE • SEPTEMBER 2026

After that long intro, I’ll give you the skinny then follow with deets: the L460 Range Rover has a modern design best described as reductive, is more luxurious than it was, and costs a lot more than it used to. The exterior design is beautiful. I could be more nuanced, but there’s no need. The Range Rover design team took the last Range Rover and subtracted design elements — bodywork folds and creases, chrome accents, what have you — until they had a completely minimalist final product. Few bodywork embellishments of any kind were preserved, even the taillights are hidden, and it looks fabulous. The same goes for the interior. Everything you see and touch looks and feels premium. If it looks like leather, it’s leather, and if it looks like metal, it’s metal. The Range Rover is available with a quartet of BMW-sourced powertrains, starting with a turbocharged inline-six with a 48-volt mild hybrid system dubbed P400 that develops 395HP. A 523HP twin-turbo 4.4-liter V8 engine (P530) is even swifter and ups the Range Rover's towing capacity to 8,200 pounds. A 542HP plug-in-hybrid option (P550e) is also available but only on the short-wheelbase models, and the range-topping SV comes with a 606HP V8 called P615. Range Rovers can be had with long- and short-wheel bases. The long one, conceived for the Chinese market where many executives ride in back and like lots of rear seat leg room, looks a little off and doesn’t offer a third row of seats, so I don’t recommend it.

AUTO REVIEW Driving the newest Range Rover is a pleasure. It’s a big SUV, which helps a lot, and that “big-ness” translates to a dreamy ride. Taking long road trips on the interstate is where this big SUV is at its best, but it’s also really good in town. Thank the advanced adjustable air suspension. Still, this is a big and heavy SUV, so it’s not athletic. Twisty back roads are not in its wheelhouse, nor is parallel parking. But I’ll say this for the L460 Range Rover: driving it makes you feel special. You feel good in a way that you didn't in the previous generations, or in many luxury cars this side of a Bentley. It’s selling very well, and I think that feeling of specialness explains why it’s so popular with well-heeled buyers. Which brings me to the biggest downer of this very nice luxury vehicle — it’s expensive. The base price is $115,750, and getting the most optioned long wheelbase Autobiography model will cost you an eye-watering $248,150. That’s a lot of money no matter what tax bracket you’re in, so take a deep breath and consider your personal financial situation before you click on “buy it now.” Another downer is fuel economy. The P400 six-cylinder model gets 19MPG City/23 Highway, the P530 gets 16/23MPG, and the big daddy P615 gets, weirdly, the same 16/23MPG. Having said all that, if you can afford the new Range Rover, I can tell you that it’s worth it. It’s a beautiful vehicle to behold, and every trip will make you feel special. Stephen Schutz, MD, is a boardcertified Gastroenterologist who lived in San Antonio in the 1990s when he was stationed here in the U.S. Air Force. He has been writing auto reviews for San Antonio Medicine magazine since 1995.

Visit us at www.bcms.org

RECOMMENDED AUTO DEALERS AUTO PROGRAM

GUNN ACURA

• We will locate the vehicle at the best price, right down to the color and equipment. • We will put you in touch with the right person at the dealership to handle your transaction. • We will arrange for a test drive at your home or office. We make the buying process easy! • When you go to the dealership, speak only with the representative indicated by BCMS.

NORTHSIDE CHEVROLET

11911 IH 10 West San Antonio, TX 78230

21105 West IH 10 San Antonio, TX 78257

9400 San Pedro Ave. San Antonio, TX 78216

NORTHSIDE FORD

12300 San Pedro San Antonio, TX 78216

NORTHSIDE HONDA

Coby Allen 210-725-5447

Rick Cavender 888-901-8483

Emilio Gonzalez 210-341-3311

David Starnes 210-319-5684

Daniel Garcia 210-988-9644

of Boerne

of San Antonio

GUNN HONDA

MERCEDES BENZ OF BOERNE 31445 IH 10 West Boerne, TX 78006

MERCEDES BENZ OF SAN ANTONIO

9600 San Pedro San Antonio, TX 78216

PORSCHE OF SAN ANTONIO

9455 IH 10 West San Antonio, TX 78230

CAVENDER TOYOTA

Mark Hennigan 210-941-4556

William Taylor 830-981-6000

James Godkin 210-366-9600

Jordan Trevino 210-738-3499

Spencer Herrera 210-862-9769

14610 IH 10 West San Antonio, TX 78249

AUDI DOMINION

9100 San Pedro Ave. San Antonio, TX 78216

5730 NW Loop 410 San Antonio, TX 78238

Kahlig Auto Group

611 Lockhill Selma San Antonio, TX 78216

NORTH PARK LEXUS AT DOMINION

25131 IH 10 W Dominion San Antonio, TX 78257

NORTH PARK LINCOLN

Jose Contreras 210-308-8900

James Cole 210-816-6000

Sandy Small 210-341-8841

NORTH PARK LEXUS

9207 San Pedro San Antonio, TX 78216

NORTH PARK TOYOTA

NORTH PARK SUBARU

NORTH PARK SUBARU AT DOMINION

Justin Boone 833-669-2401

Steven Markham 726-226-0028

Phil Larson 888-718-9510

10703 SW Loop 410 San Antonio, TX 78211

9807 San Pedro San Antonio, TX 78216

21415 IH 10 West San Antonio, TX 78257

Call Phil Hornbeak 210-896-4191 or email phil@bcms.org

As of March 31, 2026, our loan rate will be

3.85%

for initial borrowers with approved credit for up to 60 months.

Ready to experience the TMLT difference? • Email quote@tmlt.org • Call us at 800-580-8658 ext. 5026 • Get a quote at https://www.tmlt.org/get-a-quote

A New Way To Save On Group Health Insurance A New Group Health Option To Help Practice Owners With Staff Reduce Their Costs Running a practice today means managing rising costs across the board. For many practice owners, employee health coverage remains one of the largest expenses. It’s why affordability has become such a central focus. At TMA Insurance Trust, we continually evaluate the market to identify options that help Texas physicians provide quality coverage with affordability in mind. If your practice experienced an increase in the cost of your group health insurance this year, maybe it’s time to think about a new option we are offering Texas physicians for the first time – an option that offers real savings while maintaining the quality of your group’s coverage.

Ready to explore our new option? Scan the QR code to speak with one of our advisors, call us at 800-880-8181 Monday – Friday, 8:00 AM – 5:00 PM CST, or visit us at tmait.org.

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