Florida MD April 2021 by FloridaMD

APRIL 2021 • COVERING THE I-4 CORRIDOR

Atlantic Cardiovascular & Thoracic Surgeons, LLC Leaders in CVT Surgical Services Since 1985

contents 4

APRIL 2021 COVERING THE I-4 CORRIDOR

 COVER STORY

PHOTO: DONALD RAUHOFER / FLORIDA MD

Atlantic Cardiovascular & Thoracic Surgeons, LLC (ACTS), is the only private cardiothoracic practice in the Ormond Beach area. With more than 10,000 open-heart surgeries combined, Drs. William H. Johnson, III, F.A.C.S. and John B. Holt, F.A.C.S. have been providing cardiac, thoracic, vascular and endovascular surgical services in Volusia and Flagler counties for nearly 60 combined years, and are still going strong with excellent results. ACTS also offers an on-site accredited vascular (peripheral arterial and venous) lab, which is convenient and available to cardiologists and other physicians in the area whose patients need diagnostic results, and is especially beneficial for those who need fast patient diagnoses. EVOLVES Vascular Lab gives Johnson and Holt, who’ve been practicing surgeons in the area for 33 and 26 years respectively, an edge as a private surgical practice in the area because it makes it easy for them to monitor and provide continuity of care to their own post-operative patients. ON THE COVER: Dr. William H. Johnson, III, FACS, and Dr. John B. Holt, FACS

ADULT-USE LEGALIZATION LAWS NOT ASSOCIATED WITH ADVERSE IMPACTS ON PUBLIC HEALTH

PHOTO: DONALD RAUHOFER / FLORIDA MD

12 WHEN SCOLIOSIS REQUIRES TREATMENT

DEPARTMENTS 2

FROM THE PUBLISHER

7 DERMATOLOGY 8

HEALTHCARE LAW

10 PHARMACY UPDATE

11 MARKETING YOUR PRACTICE

FLORIDA MD - APRIL 2021

FROM THE PUBLISHER

am pleased to bring you another issue of Florida MD. Sometimes a patient may have the opportunity to participate in a clinical trial. Sometimes a patient may need specialized treatment that is not available in Central Florida. And sometimes there’s no money for that patient to get to those places. Fortunately there is Angel Flight Southeast to get those patients where they need to go. I asked them to tell us about their organization and how you, as physicians, can help. Please join me in supporting this truly wonderful organization. Best regards,

Donald B. Rauhofer Publisher

ANGELS ON EARTH HELP PATIENTS GET TO LIFESAVING MEDICAL TREATMENT Everyone knows angels have wings! But did you know in Florida and many parts of the nation they have engines and tails with dedicated volunteers who donate lifesaving services every day? Leesburg, Fla.-based Angel Flight Southeast is a network of approximately 650 pilots who volunteer their time, personal airplanes and fuel to help passengers get to far-from-home medical care. A member of the national Air Charity Network, Angel Flight Southeast has been flying passengers since 1993. Almost all of its passengers are chronic-needs patients who require multiple, sometimes 25-50 treatments. Passengers may be participating in clinical trials, may require post-transplant medical attention or are getting specialized treatment that is not available near home. Each passenger is vetted to confirm medical and financial need and is often referred to Angel Flight Southeast by medical personnel and social workers. Angel Flight Southeast “Care Traffic Controllers” arrange flights 24 hours a day, 365 days a year. In the event of a transplant procedure, the Care Traffic Controllers have precious minutes to reach out to its list of volunteer pilots who have agreed to be prepared on a moment’s notice to fly a patient to receive his or her potentially lifesaving organ. The organization is completely funded through donations by individuals and organizations. A typical Angel Flight Southeast pilot donates $400 to $500 in services-per-trip. In fact, Angel Flight Southeast has earned the Independent Charities of America Seal of Approval as a good steward of the funds it generates from the public. Each $1 donated generates more than $10 worth of contributed services by Angel Flight Southeast. The charity always seeks prospective passengers, volunteer pilots and donations. For additional information, please visit https://www.angelflightse.org or call 1-888-744.8263.

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Publisher: Donald Rauhofer Photographer: Donald Rauhofer / Florida MD Contributing Writers: John “Lucky” Meisenheimer, MD José Herrera-Soto, MD, Sandra Sheets, JD, Sonda Eunus, MHA, Michael Patterson NHA, OTR/L, CEAS, Juan Lopez, Pharm D, John Meisenheimer, VII, John Andersen Art Director/Designer: Ana Espinosa Florida MD is published by Sea Notes Media,LLC, P.O. Box 621856, Oviedo, FL 32762. Call (407) 417-7400 for more information. Advertising rates upon request. Postmaster: Please send notices on Form 3579 to P.O. Box 621856, Oviedo, FL 32762. Although every precaution is taken to ensure accuracy of published materials, Florida MD cannot be held responsible for opinions expressed or facts expressed by its authors. Copyright 2021, Sea Notes Media. All rights reserved. Reproduction in whole or in part without written permission is prohibited. Annual subscription rate $45.

Adult-Use Legalization Laws Not Associated with Adverse Impacts on Public Health By Michael Patterson, NHA, OTR/L, CEAS When it comes to cannabis legalization, a common strategy by prohibitionists is to use “doom and gloom” or “fear of the unknown” to convince constituents or voters that legal cannabis will make our society much worse, and the “sky will fall” and “the world will end” if cannabis is made legal (for adult use). However, a recent comprehensive analysis report by the CATO Institute studied the effect of state marijuana adult use legalization across the United States. The report concluded that the enactment of statewide laws regulating the adult use, production, and retail sale of cannabis is not associated with significant adverse impacts on public health.

THE EFFECT OF STATE MARIJUANA LEGALIZATIONS: 2021 UPDATE | CATO INSTITUTE The report went through data prior to adult use cannabis legalization in states, and after legalization to assess claims that public health would decrease and society would be worse off than keeping cannabis illegal. The data has created the following objective facts: * Since the 1970s, which started the first wave of marijuana decriminalization by states, marijuana use by state residents did not change in response to relaxed restrictions. * Increase in use of cannabis in states who have recently legalized recreational/adult use cannabis started years before full recreational legalization- Therefore, cannabis use was increasing prior to legalization and has not demonstrated a significant increase in usage since full legalization. ^ Marijuana use rates in children- Many prohibitionists have fought legalization spouting fear tactics of many children getting “hooked” on cannabis if made legal. However, the data shows that in the six states that have post-legalization data, Maine, Massachusetts, Alaska, and Colorado- adolescent use of cannabis decreased in the years leading up to legalization. Then, after legalization, usage rates returned to typical usage rates prior to legalization but have not continued to increased past previous usage rates. * Alcohol usage when cannabis is legalized- The report found that alcohol usage went up a few percentage points in some states (Washington State-1%, California-1.9%, Massachusetts (2.3%) after cannabis legalization. However, the same report found Colorado, Maine, and Alaska, and Nevada decreased alcohol consumption approximately 1% when cannabis was made legal. * Suicides and Mental Health- after studying all the data in legal states (before and after legalization of cannabis), the researchers could find no statistical difference in the number of suicides in legal states before or after cannabis legalization. * Crime- Cannabis related offenses have plummeted due to cannabis being legal in certain states (which is to be expected). However, when reviewing data on violent crime in these states, violent crime has neither soared nor plummeted in the wake of marijuana legalization. * Road Safety- Overall, the data extrapolated could not find any correlation between an increase or decrease in traffic fatalities among states that have legalized cannabis.

- Economic/ Budget impacts- The largest impact that was identified from the study was economic impact via state tax revenues. The initial tax revenue projections have been dramatically exceeded by actual revenues. Colorado now collects $20 million per month from adult use cannabis. Washington State collected $70 million in sales tax revenue in the first year of sales (double the projected tax revenue). Oregon had projected $2-$3million per month in sales tax for cannabis, but are actually recording $10 million per month. California is now collecting $50 million per month in cannabis tax revenue. ANALYSIS: Cannabis legalization has not led to society’s downfall, as many prohibitionists have predicted. Also, we now see with this report we that legal cannabis is very good for generating tax revenue. As more data becomes available, you will start to see other areas of society and the economy that will be positively affected from the legalization of cannabis for adult use. The biggest area globally that will be impacted with cannabis being made legal for adult use in America and other countries is health care costs. As cannabis becomes more mainstream, more people will start using cannabis as a “wellness” product, and not so much to get “high” or stoned. You will begin to see nutritional supplement products with cannabinoids in them (low dose THC, CBD, CBG, CBN, etc.) being used by millions of people for some medical reason. (sleep, anxiety, depression, pain, etc.). This increase in use of legal cannabis products for adults and medical cannabis (by prescription), will make our population more healthy and less susceptible to chronic health problems of tobacco smoking, alcohol, and diabetes. We are already starting to see a decrease in number of monthly prescriptions for patients who start using cannabis by 2-3 prescriptions per month. Imagine a country like Germany that has socialized medicine paid for by the government. If the German population can decrease their prescriptions per month by 2-3 prescription drugs by starting to use cannabis, the entire German population will be healthier and save the Government billions in prescription drug costs. Cannabis will continue to be legalized across the USA and the world. If you are trying to help your state or country legalize, use this report and data to assist in your efforts. Michael Patterson NHA, OTR/L, CEAS is CEO of US Cannabis Pharmaceutical Research and Development LLC. (uscprd.com). He is a healthcare executive with 25+ years experience in: Cannabis-Hemp investment, Law, Regulation, Compliance, Operations, & Management, Skilled Nursing, Pharmacy, Laboratory, Assisted Living, Home Healthcare, & Healthcare Analytics. He is a subject matter expert in the Global Cannabis and Hemp Industry with Gerson Lehrman Group (glg.it) & Guidepoint. He is an editorial board member of the American Journal of Medical Cannabis, licensed Nursing Home Administrator, & licensed Occupational Therapist in 4 states..  FLORIDA MD - APRIL 2021

COVER STORY

Atlantic Cardiovascular & Thoracic Surgeons, LLC – Leaders in CVT Surgical

Services Since 1985 By Lisa Monroe

Atlantic Cardiovascular & Thoracic Surgeons, LLC (ACTS), is the only private cardiothoracic practice in the Ormond Beach area. With more than 10,000 open-heart surgeries combined, Drs. William H. Johnson, III, F.A.C.S. and John B. Holt, F.A.C.S. have been providing cardiac, thoracic, vascular and endovascular surgical services in Volusia and Flagler counties for nearly 60 combined years, and are still going strong with excellent results. ACTS also offers an on-site accredited vascular (peripheral arterial and venous) lab, which is convenient and available to cardiologists and other physicians in the area whose patients need diagnostic results, and is especially beneficial for those who need fast patient diagnoses. EVOLVES Vascular Lab gives Johnson and Holt, who’ve been practicing surgeons in the area for 33 and 26 years respectively, an edge as a private surgical practice in the area because it makes it easy for them to monitor and provide continuity of care to their own post-operative patients. “We follow our patients with Doppler examinations which is done through the vascular lab usually every six months or as allowed by their health insurance, as follow-up after carotid surgery, abdominal aneurysm surgery and after peripheral vascular

PHOTOS: DONALD RAUHOFER / FLORIDA MD

Dr. Johnson providing patient interaction alongside Rita, LPN.

4 FLORIDA MD - APRIL 2021

surgery on the leg. It’s very important that these patients are followed long-term and EVOLVES makes it very convenient for us to be able to do that,” Dr. Johnson said. “You know from a surgical standpoint, when patients are either getting surgical bypasses or they’re getting stents placed, we need to make sure everything’s still open and working well and if they start having buildup or start having some partial occlusions, the sooner you detect those, the easier it is to fix them,” he added. “If you can provide continuity of care like that and you know the person doing the tests, and when you have a good ultrasound technologist like we do performing them, you can trust the results.” Sometimes physicians get results from unfamiliar labs or mobile labs somewhere in a parking lot and the results just aren’t reliable, he said. “EVOLVES Vascular Lab also provides varicose vein treatment for the medically necessary. We treat varicose veins with minimally invasive radiofrequency ablations after they are evaluated by the lab. And we really want to grow the venous aspect within EVOLVES,” said Johnson, adding that the lab welcomes referrals from family physicians as well as internal medicine specialists. We’ll tell you more about the minimally invasive CLOSUREFAST™ Radiofrequency Ablation Procedure performed in the lab later in this article. Besides their heart surgery patients, the two surgeons have also performed thousands of thoracic surgeries over the past two-and-ahalf decades, primarily in patients with lung cancer. “Now that we have a new cancer center adjacent to the hospital, that helps, but we are mainstays in doing lung cancer surgery and that’s in coordination with the oncologists and the radiation oncologists. Every two weeks we have a surgical cancer conference to present cases and talk about the cases - all of us participate - even our competitors. We all are there,” said Johnson, who recently finished a two-year stint as president of the Florida Society of Thoracic and Cardiovascular Surgeons. We’ll tell you more about his experience as president later in the article.

COVER STORY

ACTS welcomes referrals from new physicians and practitioners in Volusia and Flagler counties, and the surrounding counties of Putnam, Orange, Seminole and Cape Canaveral. “We are always looking for new referrals from those new in the medical community,” Johnson explained. Referrals to ACTS typically come from the other cardiologists in town, he said. “We have a good rapport with them now as we have through all these years, but as for vascular and thoracic, it’s a little different. The family physicians or internists can refer Dr. Holt and Amanda, RVT, with patient using current, quality imaging systems for proficient ultrasound directly to us for their patients result. that need our type of specialties. We do currently have a steady referral pattern from family practice, internists, pulmonary physiEVOLVES Vascular Lab is an accredited facility by the Intercians, cardiologists, and basically the whole gamut of the medical societal Accreditation Commission and is staffed by a Registered specialists.” Vascular Technician (RVT), certified by the American Registry for Diagnostic Medical Sonographer. “I’ve dedicated my services to Florida Hospital which has grown significantly over the past 25-years,” Dr. Holt said. Both “We have a very comfortable office setting for patients and we Johnson and Holt perform their surgeries at Florida Hospital are very good at getting them in and out quickly for ultrasounds,” Memorial Medical Center, a large general medical and surgical according to practice manager Vicky Fuller, whose been with the facility in Daytona Beach. practice since 1997. “They have an allotted time so there’s no prolonged waiting. And being in an office setting, if they have “We participate with many major insurances and we particiout-of-pocket fees, those fees are typically lower than that of a pate with the hospital’s insurance plan and so we’re on the same radiology facility.” plan as the employee physicians are through the hospital so anybody, whether they are employed by the hospital or not, can refer The following duplex ultrasounds are performed in the lab: to us,” said Johnson. Aorto-Iliac Duplex or Abdominal Aorta Ultrasound, Aneurysm Imaging in Extremities, Arterial Duplex Lower & Upper ExtremMORE ABOUT THE EVOLVES VASCULAR LAB ities, Duplex Imaging for Pseudoaneurysm, Duplex Imaging & What does EVOLVES stand for? It’s an acronym for East Color Flow Analysis of Carotids, Subclavian, Vertebral & PeriphVolusia’s Optimal Lab for Vascular Evaluation and Surveillance, eral Arteries, Mapping of Radial and Ulnar Arteries, and Vein according to Fuller, who came up with the name back in 2006 Mapping of the Greater Saphenous. when Dr. Johnson first came up with idea for opening a new lab—which has proven to be an invaluable asset to his and Dr. Holt’s patients. But having EVOLVES Vascular Lab on-site can benefit other physicians as well because it’s close by and they can get their patients into the lab conveniently and quickly. Speed can be crucial, and sometimes even the different between life and death, explained Dr. Johnson. For example, the lab can test for blood clots in the leg and abdominal aneurysms, which can potentially be life threatening, making time of the essence. “Accessibility is also big thing. Other physicians can call our office and schedule a patient and, if need be, we can test that day or the next day. We can do it as soon as they need it so there’s no waiting,” he added.

VARICOSE VEIN TREATMENT

EVOLVES offers the CLOSUREFAST™ Radiofrequency Ablation Procedure, a minimally invasive procedure for treating Venous Reflux Disease and Chronic Venous Insufficiency, which are associated with varicose veins, at its Ormond Beach site. Varicose vein patients are referred to ACTS by family physicians and occasionally from internal medicine physicians in the area. The CLOSUREFAST™ procedure is performed on-site in the EVOLVES exam room. During the procedure, a catheter guided by ultrasound technology and powered by a portable generator is inserted into the vein through a sheath. Then using the catheter, a segment of the vein is heated to precisely close the vein so that blood is redirected to surrounding healthy veins in the leg. FLORIDA MD - APRIL 2021

PHOTO: DONALD RAUHOFER / FLORIDA MD

NEW REFERRALS TO ACTS ARE ALWAYS WELCOME

COVER STORY Varicose veins are not just cosmetic. They can result in poor circulation and may eventually lead to pain and serious medical issues that can lower a patient’s quality of life if left untreated, according to Dr. Johnson. “These include the inability to heal wounds, inflammation and skin diseases. Varicose veins can cause significant problems if not treated – pain, swelling and it gets extremely serious when you start getting skin breakdown and leg ulcerations and then you can obviously proceed on to infections of the leg,” he said, emphasizing that early intervention is key. “Long-term varicosities that aren’t treated eventually end up causing these big ulcerations around the ankles and the lower legs that just don’t heal,” he explained. “It’s a really bad thing to treat from a physician’s standpoint, but if you can treat these varicosities and the varicose veins then you can have a chance at getting these things healed up. But the number one thing is to not let it get to that point and that’s why we’d like to see patients earlier on.”

THE IMPORTANCE OF A GOOD PARTNERSHIP AND STAFF Although ACTS has been in practice for just four successful years, Drs. Johnson and Holt have been practicing in the same location since 1985 and 1992, respectively. And they have been partners for 26 years, providing quality surgical services for the community. Drs. Johnson and Holt have a good rapport with each other which they’ve nurtured over the years. “We can run cases by each other and we both have a lot of experience so you get two minds on each case trying to figure out which is the best thing to do for each patient. I think it means a lot to be able to have somebody to, you know, sort of bounce ideas off of and to get another trusted opinion,” Johnson said. The physicians also have the support of a very efficient, professional and dedicated staff. “They are a small group that are all easy to work with,” Dr. Holt said. In addition to the registered vascular technologist, Fuller said the staff includes herself, her assistant who also supervises the front office, a licensed practical nurse, a vascular scheduler who also assists with appointment scheduling, a receptionist who also assists with appointment and surgery scheduling, and a main scheduling coordinator who can help out as a medical assistant when needed. Basically, Fuller feels it is best that most staff be cross-trained in all departments as it assures more proficient patient care.

Dr. Holt moved to town in 1992. He and his wife Diane are members of Salty Church and are active with the American Heart Association. They have three children; Blake, Meredith and Madeline. “Besides being dedicated to his family and practice”, he said, “My hobbies are fishing and road biking for exercise.” Both Dr. Johnson and Dr. Holt are certified by the American Board of Thoracic Surgery and are fellows of the American College of Surgeons, in addition to membership in a number of other medical organizations.

THE FLORIDA SOCIETY OF THORACIC AND CARDIOVASCULAR SURGEONS Florida is one of only a handful of states in the U.S. to have its own medical society specifically for cardiovascular and thoracic medical practitioners, said Johnson, and the Florida society is very well respected. He recently completed a two-year stint as president of the society and is currently serving in an advisory capacity to the new president. “It was a great experience to be able to get to know the cardiac surgeons around the whole state of Florida basically,” he said of the experience. “And by being associated with the society, you certainly can see the trends in cardiac surgery in the different areas of Florida and how certain areas are doing certain cases and you can learn a lot from all the other surgeons…It was a great learning experience for me.” Dr. Johnson has been involved with the society, which is moving into its 52nd year, for 25 years. The group meets annually for three days in July at the Ocean Reef Resort in Key Largo, and everyone brings their families so it turns into a real family event. “Just getting that meeting together—getting the speakers and all the logistics of it, you certainly talk to a lot of surgeons not only from the state of Florida, but also from peers in the same field of specialty spanning across the United States,” Johnson said. “We have out-of-state national speakers and it’s a well-rounded academic event. Everyone brings their kids and family and it’s really a very nice time,” he added. Prior to serving as president, Johnson served as secretary/treasurer for two years, and was active as a councilman for many years prior to that. To learn more about Atlantic Cardiovascular & Thoracic Surgeons, LLC or the EVOLVES Vascular Lab, visit www.actsllc.org. 

THE SURGEONS BELONG TO THE COMMUNITIES THEY SERVE Dr. Johnson was born and raised in the small town of Wildwood, Florida. He moved with his family to Ormond Beach in 1985. He has participated in a number of community awareness events such as public TV, radio, newspaper, and hospital-based awareness conferences regarding the advancement of surgical procedures he performs. He is also a huge Florida Gators fan. He and his wife Kaye are involved in their church. They have four grown children. 6 FLORIDA MD - APRIL 2021

588 Sterthaus Dr • Ormond Beach, FL 32174 Phone: 386.672.9503 • Facsimile: 386.672.0386 website: www.actsllc.org

DERMATOLOGY

By John “Lucky” Meisenheimer, MD and John Meisenheimer, VII

There are scores of prescription anticoagulants out there. I have lost track of how many, but there is a boatload. You add this on to the vast number of over the counter products that also “thin” the blood such as aspirin other nonsteroidal anti-inflammatories and then throw in things like ginseng and garlic and fish oil. It would seem that just about every patient over the age of fifty is on at least one or more anticoagulant type of medicines or supplements. America is now the land of easy bleeders and this bleeding frequently affects the skin.

A blood blister following cryosurgery on a verruca.

As a Mohs surgeon doing skin cancer surgery all day long, the anticoagulant bandwagon, of course, creates what I refer to as a bloody mess. Almost all of my patients, having surgery, are of the age range where they are taking some form of anticoagulation. When you ask a patient if they are on anything that might “thin” the blood, if it was not prescribed, the answer is usually no. You think to yourself, great, finally someone not on a blood thinner, this case will be easy peasy. When the next question asked is, are you taking aspirin or a NSAID? The invariable answer is “yes, but that’s for my heart, joints, muscle aches, etc.” Many patients are not aware that these OTC drugs “thin the blood.”

PHOTO: JOHN MEISENHEIMER, VII

Bleeding into the skin following a cupping procedure.

Shambergs Purpura.

However, sometimes medical practice is influenced by the judicial system. Courts have determined, in California anyway, that if you stop an anticoagulant even with the permission of the prescribing cardiologist, if there is a temporally related cardiovascular event, you can also be sued and lose. The justification is that it is much better to deal with bleeding complications of skin surgeries a hundred times over than having one major cerebrovascular or cardiovascular event. When you think about it, this does make some sense. I try to remind myself as I am sopping up blood and doing continuous cautery on vessels that do not seem to want to stop bleeding, that it is all for the better good of the patient. I’m sure this debate will rage on over the years by folks much wiser than me, but in my practice, for the last several years, I typically don’t stop anticoagulants started by other physicians. I deal with the bleeding and move on. So far, so good! No major cerebrovascular events or blood transfusions needed. Below are photographs of different skin findings you will see when people are on blood thinners and various expressions of bleeding into the skin.

PHOTO: JOHN MEISENHEIMER, VII

The question may arise, well, why don’t you stop the anticoagulants before procedures, and medically this would make a lot of sense on the surface. Cessation of the anticoagulants certainly would make the surgeries go smoother without having to deal with so much bleeding. I used to do this routinely when I had the blessings of the prescriber of the anticoagulant.

Solar purpura or sometimes called “Senile purpura.”

PHOTO: JOHN MEISENHEIMER, VII

A Bloody Mess

Lucky Meisenheimer, M.D. is a board-certified dermatologist specializing in Mohs Surgery. He is the director of the Meisenheimer Clinic – Dermatology and Mohs Surgery. John Meisenheimer, VII is a medical student at USF.



Talon noir - An intraepidermal hemorrhage caused by shear force trauma. FLORIDA MD - APRIL 2021

HEALTHCARE LAW

Is Your Family Protected in the Event of an Unexpected Health Crisis? By: Sandra Sheets, Shareholder, GrayRobinson, P.A. Do you have a Will? For many, the answer is no. You may be surprised to learn that, even if you have not signed a Last Will and Testament, you do have a “Will” written into Florida law. Contrary to common belief, your assets likely will not “go to the State” or otherwise disappear at your death if you die without a Will. But, the statutory “Will” laid out for you under Florida law may surprise you. In fairness, the Florida Legislature has gone to some length to effect distribution of a decedent’s property in such a manner that most people would expect. I recently helped someone who was suddenly diagnosed with terminal cancer, giving her a short time to order her affairs — she is divorced with two adult children. For her, the statutory Will works perfectly — all of her assets will be distributed to her children, equally. But if she had remarried, her assets would be distributed one-half to her surviving spouse and one-half divided equally between her children. If she had no spouse and no descendants, her estate would go to her parents or, if none, then to her siblings. If she had no spouse, descendants, parents, or siblings, her estate would go one-half to the family of her father and one-half to the family of her mother (ultimately to those we refer to as “laughing heirs” because they never knew the decedent). Is this what most people would want? In my experience, no. There are many snags that can happen in distributing assets at a person’s death, which can be avoided with proper estate planning. These include the Florida homestead rules (which affect to whom you may devise your homestead), elective share rules (which determine the amount to which your surviving spouse is entitled — generally, 30% of your estate), and creditor rights. To properly protect your family’s inheritance and provide for an orderly distribution of your assets, all of these issues must be addressed in the context of the overall estate plan. Another trap for the unwary is neglecting to update an existing Will upon a significant life event, such as remarriage, divorce, or a child’s birth or death. Any of these changes may adversely impact an existing Will and result in protracted litigation over identifying your beneficiaries and their interest in your estate. For example, if you remarry and do not update your Will, the “pretermitted” spouse rules provide for distribution of at least one-half of your estate to your surviving spouse. If you divorce and do not update your Will, your spouse is deemed to have predeceased you (again, the Legislature looking out for us!). However, if you and your former spouse coordinated a charitable gift, for example, at the survivor’s death, that gift will now be made at each death unless both Wills are updated. So that is the Will — the instrument that disposes of assets in your individual name at your death through the probate process. Another important instrument in the estate planning arsenal is 8 FLORIDA MD - APRIL 2021

the Revocable Trust (often referred to as a “Will substitute”). A revocable trust, created by you as the grantor and trustee, survives your death so that assets titled in the trust’s name may be transferred by the successor trustees under the trust provisions (outside of probate). Such a trust is coupled with a Will that “pours over” to the trust (via probate) any assets that were titled in the decedent’s name at death (ideally all assets are titled in the trust before death, but that is not always the case). During your lifetime, the revocable trust can help protect your assets if you become incapacitated — your successor trustee can manage your assets for you during your incapacity, and of course manage administration and distribution of your estate at your death. Generally, assets may be transferred at death in one of three ways, and all can play an important part of the coordinated estate plan: by probate, by operation of law, or by contract. As mentioned before, the Will is administered via probate to transfer assets held in the decedent’s name pursuant to its terms. Other assets are transferred pursuant to operation of law (how the asset is legally titled), including the revocable trust, real estate titled jointly with survivorship rights, and joint bank accounts. And finally, assets may be transferred pursuant to contractual arrangements, including by beneficiary designation on a retirement account and life insurance policy, and “pay on death” designation on a brokerage or other financial account. Properly completing and maintaining these beneficiary designations are critical to preserving these assets from creditor claims and accelerated taxes. Finally, some of the most important estate planning documents terminate at your death, operating during your lifetime to preserve your assets. These documents include the durable power of attorney, health care surrogate designation, and living Will. These relatively simple documents can avoid a costly and public guardianship proceeding. If you become incapacitated, the agents you name in these documents are empowered to handle your financial and health decisions. These documents are often prepared for clients automatically, as part of their estate plan, and it is recommended their adult children also have these documents in place. As you can see, in the event of an unexpected health crisis or other devastating event, a well-considered estate plan can protect you, your family, and your assets from the expense of unwelcome surprises and legal missteps. Be sure to review your estate plan every three years or upon occurrence of a significant life event. You will rest easier knowing you have the plan you want in place.

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HEALTHCARE LAW Sandra Sheets is a shareholder in GrayRobinson’s Lakeland office focusing her practice on estate and tax planning and estate and trust administration. She has practiced

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COVER STORY

PHARMACY UPDATE

Midrin® No More. Now What? By Juan Lopez, PharmD, FIACP Attention headache patients! Midrin® is no longer available commercially, but the therapy you have come to trust can be prepared from scratch - by a pharmacist! Midrin® is a multiple ingredient medication typically prescribed for use in patients suffering from tension and migraine headaches. The Food and Drug Administration (FDA) notified manufacturers and labelers to stop distributing drug products that contain isometheptene mucate, one of the active ingredients found in Midrin®. Isometheptene mucate was originally approved for safety in 1948 before the current FDA drug approval process. For this reason, the FDA considers isometheptene-containing products unapproved new drugs, requiring pharmaceutical companies to submit a new drug application and perform clinical trials proving effectiveness before these products can be manufactured again.

Our goal as personalized medicine pharmacists is to meet the individual needs and circumstances of patients and practitioners. Headache patients may be at risk for suboptimal or nonexistent therapy following the discontinuation of Midrin® and Prodrin®. For more information on how our pharmacists can help with headache therapy, please call 407-260-7002. Juan Lopez, PharmD, FIACP is a personalized medicine pharmacist with Pharmacy Specialists Compounding Pharmacy in Altamonte Springs, FL. For more information on how personalized medicine can help you, please call 407260-7002 or email us at Info@MakeRx.com. 

As of January 1, 2018, all companies producing isometheptene-containing drugs have agreed to cease distribution. Midrin® is composed of acetaminophen, isometheptene mucate, and dichloralphenazone. Acetaminophen acts as a pain reliever by raising the body’s threshold to painful stimuli. Isometheptene mucate constricts certain blood vessels to reduce stimuli leading to vascular headaches. Dichloralphenazone is a mild sedative that helps reduce a patient’s emotional response to painful stimuli. Another commercial product, Prodrin®, which has also been discontinued, is a similar medication that contains two of the three ingredients found in Midrin®, plus caffeine. Following various shortages and the eventual discontinuation of products like Midrin® and Prodrin®, patients have been forced to find new therapies to manage their headaches. Patients using Midrin® for several years to successfully manage their migraine episodes may experience a less than satisfactory response to alternative therapy. What can these patients do? Fortunately, a pharmacist skilled in the science and art of compounding can prepare therapy containing the same active ingredients found in the commercially discontinued Midrin® and Prodrin® capsules. A medication prescribed by a doctor for a specific patient is exempt from the new drug application process if certain criteria are met. The formulation prepared by the pharmacist must not contain ingredients that were discontinued due to safety reasons or appear on an FDA published “Do Not Compound List”. The active ingredients for the formulation must either be found in an already FDA approved drug product, a published positive formulary list, or have a United States Pharmacopeia (USP) monograph. All three ingredients found in Midrin® have a USP monograph and can be ordered as a compounded medication by a prescriber for a patient seeking this therapy. 10 FLORIDA MD - APRIL 2021

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MARKETING YOUR PRACTICE

Is Your Online Reputation Costing You Patients? By Sonda Eunus, MHA, CMPE What does your online reputation say about your practice? If you have a negative online reputation, you are missing out on new patients every day. Most medical practices now get the majority of their new patients through Google and other search engine queries, such as “Pediatrician in Orlando”. If your practice appears in these searches, the most common next step for a potential new patient would be to check out your reviews – what are other patients saying about your practice? It has been reported that 90% of consumers read online reviews before visiting a business and that online reviews influence 67% of purchasing decisions (Bright Local). For this reason, it is incredibly important to pay attention to the rating and reviews that your practice has on search engines, social media platforms, and local online business directories. However, despite the importance of cultivating a positive online reputation, only 33% of businesses report actively collecting and asking for reviews (1). One great process to set in place at your practice is asking for patient reviews after each patient visit. It can be as simple as training your front office staff to ask each patient how their visit went while checking them out, and if they receive favorable feedback then they can ask the patient to please leave a review on Google or Facebook about their experience. If they receive negative feedback, this feedback should be taken very seriously, and management should be notified as soon as possible so that the issue can be mitigated before the patient decides to post a negative review. Setting up an automated text or email campaign that asks each patient for their feedback after their appointment is also a great way to improve your online reputation as well as to correct any issues that may be occurring at your practice. When you receive feedback from patients, you are then able to prompt them to leave a public review on Facebook, Google, Yelp, Healthgrades, or other applicable review platforms. However, you must be aware that legally, you are not allowed to only direct people with favorable feedback to leave reviews, which is known as review-gating – so if you are implementing an automated system like this, just make sure that you are aware of this limitation. There are online reputation management platforms which allow you to customize the messages that people see when they leave negative feedback as opposed to positive feedback, but both of those messages must still offer the option to leave a public review. However, if you create your message in such a way as to communicate to the patient who may leave negative feedback that you are working hard on resolving the issue and that someone will be in touch shortly, that may prevent them from leaving a public negative review. When you receive a public review on Google, Facebook, or other review sites, make sure that you respond to it – either by thanking them for a good review or by asking them to contact you to discuss how you can improve their experience. Do not argue or try to defend yourself online – try to speak about it with them privately, fix the issue, and ask them to remove the review

if possible. When you receive great reviews, make sure to cross-share them on your various social media platforms. You should also create a “Reviews” page on your website and add all great reviews to this page. This instantly adds credibility to your website. Finally, make sure that when you look over the feedback and reviews that you receive, you are paying attention to what the negative reviews are saying – this is a great opportunity to identify current process challenges and improve your patients’ experience at your practice. Need help managing your practice’s online reputation? Visit www.lms-plus.com to see how Leading Marketing Solutions can help. Sonda Eunus is the CEO of Leading Marketing Solutions, a Marketing Agency working with Medical Practices and other Businesses to help them identify the best marketing strategies for their business, create a strong online presence, and automate their marketing processes for a better return on their Marketing budget. Learn more about Leading Marketing Solutions at www.lms-plus.com.

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When Scoliosis Requires Treatment By José Herrera-Soto, MD

ABOUT SCOLIOSIS Scoliosis affects an estimated 2 to 3 percent of the U.S. population, both children and adults. But because scoliosis tends to progress as a child develops, this abnormal C- or S-shaped curvature of the spine is most often diagnosed in children between the ages of 10 and 15. A vast majority of cases, up to 85 percent, are classified as idiopathic, and less than 10 percent of children experience any back pain or other symptoms. In fact, it is often during a routine physical exam or Adam’s forward bend test that a spine curvature or rib hump is discovered. Scoliosis tends to be passed down to children through genetics. Although parents may not have had scoliosis as a child, it may have occurred in other family members or gone undiagnosed. Whether a documented family history of scoliosis is present or not, a child having scoliosis is no one’s fault; scoliosis itself is not preventable. The biggest risk associated with scoliosis is significant curve progression over time. Referral to a specialist ensures a full orthopedic and neurologic evaluation as well as diagnostic imaging tests to determine the exact location and extent of the curvature in order to develop a customized treatment plan. With about 1,800 visits in 2019, the Scoliosis Center at Orlando Health Arnold Palmer Hospital for Children cares for children across the full scoliosis spectrum, including idiopathic, congenital, neuromuscular and syndromic scoliosis from earlyonset to adolescent diagnoses.

TREATMENT THERAPIES Only a small percentage of children with scoliosis — about 30 percent — will require treatment such as physical therapy or bracing, and an even smaller number — about 10 percent — will require surgery. The standard determination of severity in scoliosis is measured in terms of the degree of curvature. Spinal curves measuring less than 25 degrees generally do not require treatment. For these patients, ongoing observation with regular checkups is recommended to watch for any progression of disease. If the curvature increases over time or presents at 25-45 degrees, nonsurgical treatment encompassing physical therapy, bracing and casting options — used individually or in combination — can help to slow or prevent disease progression. A growing child often can overcome minor spinal curvatures and deformities through these less invasive options; for major deformities, these treatments provide ongoing care until the child is older and showing signs of skeletal maturity needed for surgery. The Schroth Method is a relatively new type of physical therapy, which began in Germany and has continued to develop as its use around the world has grown. The Scoliosis Center at Orlando Health Arnold Palmer is one of the few centers in Florida that has a specialist trained in this unique treatment option. The Schroth Method focuses on customized posture, positioning and 12 FLORIDA MD - APRIL 2021

breathing exercises, as well as on activities of daily living and self-image, and is often used in conjunction with bracing. Some studies have found that this treatment option has a positive effect on a child’s sense of well-being and perception of curve improvement, leading to better patient engagement and thus, better outcomes. If a patient is still skeletally immature but has progressed to a point that physical therapy and/or bracing is ineffective, growing rods become the next course of treatment. Conventional growing rods are surgically inserted either in the lumbar spine or ribs, based on the type of instrumentation used, or a hybrid. Proven to be a very effective treatment, the growing rods are surgically changed or lengthened approximately every six months. Some patients may benefit from a system called MAGEC® (MAGnetic Expansion Control), which utilizes innovative magnet technology. Once the adjustable growing rods are surgically inserted, the lengthening can be done as an in-office procedure using an external remote controller to operate a motor inside the rods to lengthen them as needed. This method can be especially effective for debilitated or very weak patients, reducing the potential risks of repetitive surgeries and anesthesia. When the angle of curvature is more than 50 degrees, surgical correction is recommended, as studies have shown that deformity over 50 degrees will continue progressing. Spinal fusion is a major surgery, performed to correct the curvature permanently. Hooks or screws are placed into the vertebral column, which are then attached to rods that are maneuvered and rotated to straighten the spine. Orlando Health Arnold Palmer performs about 150 spinal surgeries annually, providing patients with a more functional spine and symptom relief. A multidisciplinary approach includes a dedicated team of specialists utilizing advanced technology, such as spinal cord monitoring and fluoroscopy to aid in the placement of instruments and devices. Ongoing follow up with the patient occurs every six months or yearly, depending on the age and the degree of severity.

A NEW SURGICAL TREND Orlando Health Arnold Palmer also will soon be participating in a study of a new procedure known as vertebral body tethering (VBT), becoming one of only a handful of centers in Florida to offer this surgical option. Guided by very specific indications of bone maturity and curvature, this procedure harnesses the growth potential on the concavity of the spine while holding or limiting the growth on the convexity. So, as the concavity catches up with convexity in height, the spine straightens. With access through a minimal incision in the chest, anchors are placed on the front of the spine, anchoring the growth centers. But because it is not a fusion, the spine can continue to move in a normal range of motion. This allows for correction of the spine slowly, as the spine matures and grows.

THE TAKEAWAY When a child is diagnosed with scoliosis, many parents are understandably worried about how this diagnosis will affect their child’s health and future. This type of response is normal. Referral to a specialty center to learn more about the science behind scoliosis and its treatments can help patients and families feel less anxious. While scoliosis requires monitoring with a specialist and — depending on its severity — possible life adjustments, it is a manageable condition with positive outcomes, with kids able to compete in sports, play with their friends and enjoy a fun, carefree childhood. José Herrera-Soto, MD, is a pediatric orthopedic surgeon at Orlando Health Arnold Palmer Hospital for Children. Board certified in orthopedic surgery, Dr. Herrera-Soto sees patients at the Orlando Health Arnold Palmer Center for Orthopedics. He specializes in treating congenital, neuromuscular and idiopathic scoliosis, kyphosis and other spinal conditions as well as hip preservation surgery and hip conditions. He is also involved in the design and development of implants for the correction of spinal deformities. Dr. JANUARY – Digestive Disorders Herrera-Soto earned his Diabetes medical education from the University of Puerto Rico School of Medicine. He also completed his residency at the University of Puerto Rico and a fellowship in pediatric orthopedic surgery at Cincinnati Children’s Hospital Medical Center. 

2021

EDITORIAL CALENDAR

Florida MD is a four-color monthly medical/business magazine for physicians in the Central Florida market. Florida MD goes to physicians at their offices, in the thirteen-county area of Orange, Seminole, Volusia, Osceola, Polk, Flagler, Lake, Marion, Sumter, Hardee, Highlands, Hillsborough and Pasco counties. Cover stories spotlight extraordinary physicians affiliated with local clinics and hospitals. Special feature stories focus on new hospital programs or facilities, and other professional and healthcare related business topics. Local physician specialists and other professionals, affiliated with local businesses and organizations, write all other columns or articles about their respective specialty or profession. This local informative and interesting format is the main reason physicians take the time to read Florida MD. It is hard to be aware of everything happening in the rapidly changing medical profession and doctors want to know more about new medical developments and technology, procedures, techniques, case studies, research, etc. in the different specialties. Especially when the information comes from a local physician specialist who they can call and discuss the column with or refer a patient. They also want to read about wealth management, financial issues, healthcare law, insurance issues and real estate opportunities. Again, they prefer it when that information comes from a local professional they can call and do business with. All advertisers have the opportunity to have a column or article related to their specialty or profession.

FEBRUARY –

Cardiology Heart Disease & Stroke

MARCH –

Orthopaedics Men’s Health

APRIL –

Surgery Scoliosis

MAY –

Women’s Health Advances in Cosmetic Surgery

JUNE –

Allergies Pulmonary & Sleep Disorders

JULY –

Neurology / Neuroscience Advances in Rehabilitation

AUGUST –

Sports Medicine Robotic Surgery

SEPTEMBER – Pediatrics & Advances in NICUs Autism OCTOBER –

Cancer Dermatology

NOVEMBER – Urology Geriatric Medicine / Glaucoma DECEMBER – Pain Management Occupational Therapy

Please call 407.417.7400 for additional materials or information. FLORIDA MD - APRIL 2021 13

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