Florida MD December 2021

DECEMBER 2021 • COVERING THE I-4 CORRIDOR

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

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DECEMBER 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.

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TOP USA FEDERAL DRUG OFFICIAL- THERE IS “NO EVIDENCE” THAT MARIJUANA USE IS HARMFUL FOR ADULTS

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HEALING ECZEMA: BEYOND SKIN DEEP

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MULTIMODAL PAIN MANAGEMENT WITH OPIOID MINIMIZATION

PHOTO: DONALD RAUHOFER / FLORIDA MD

ON THE COVER: Dr. William H. Johnson, III, FACS, and Dr. John B. Holt, FACS

DEPARTMENTS 2

FROM THE PUBLISHER

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MARKETING YOUR PRACTICE

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PULMONARY

10

DERMATOLOGY

12

PEDIATRICS

FLORIDA MD - DECEMBER 2021

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FROM THE PUBLISHER

I

am pleased to bring you another issue of Florida MD. .This time of year is special to all of us regardless of religious persuasion. It is especially important to children. However, it can be a particularly distressing time for children that are neglected, abandoned or live in abusive homes.

The Children’s Home Society of Florida tries to make a better life for these children by finding them a loving home either temporarily through foster care or permanently through adoption. But there are a lot of children – nearly 20,000 – in Florida who can’t live safely with their families right now.

They need more than Children’s Home Society of Florida … they need all of us. I hope some of you can find the time to assist this very worthwhile organization in its efforts to help these special children. To find out more information please visit www.chsfl.org.

Have a wonderful holiday season and a happy, healthy and prosperous New Year.

Best regards,

Donald B. Rauhofer Publisher

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Publisher: Donald Rauhofer Photographer: Donald Rauhofer / Florida MD Contributing Writers: John “Lucky” Meisenheimer, MD, Daniel T. Layish, MD, Joseph Cannizzaro, MD, Luke Elms, MD, Brian C. Kellogg, MD, Sonda Eunus, MHA, Michael Patterson NHA, OTR/L, CEAS, John Meisenheimer, VII 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.

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Top USA Federal Drug Official- There is “No Evidence” that Marijuana Use is Harmful for Adults

By Michael Patterson, NHA, OTR/L, CEAS The head of the nation’s top federal drug research agency, Director Nora Volkow of the National Institute on Drug Abuse (NIDA), says that she has yet to see evidence that occasional marijuana use by adults is harmful.

“There’s no evidence to my knowledge that occasional [adult] marijuana use has harmful effects. I don’t know of any scientific evidence of that,” Volkow said. “I don’t think it has been evaluated. We need to test it.”

The quote stood out because NIDA typically highlights possible risks of cannabis use while providing an overview of studies that run the gamut on marijuana health impacts. Volkow also said she found it “surprising” that research has indicated that cannabis consumers tend to have a lower body mass index (BMI).

“BMI is lower in marijuana users, and that was very surprising, and yet we know that high BMI, particularly the older you get, can have negative effects,” she said. “This is why we need to study it.”

However, this does not mean that the NIDA director supports marijuana commercialization efforts. Nora verbalized she is “absolutely” concerned about use by young people and said that daily consumption of high-THC products “can have harmful effects even on the adult brain.”

But Volkow has taken a fairly level-headed approach to marijuana, pointing out potential dangers for adolescents and pregnant women, for example, while at the same time acknowledging that her expectations about the impact of state-level reforms haven’t always come to fruition.

For example, she recognized in a podcast interview released in August that cannabis legalization has not led to increased youth use despite her prior fears, and she spoke about the therapeutic potential of certain psychedelics that have long been deemed “dangerous” under federal law. Nora has also emphasized the need to address substance misuse with a public health lens, rather than subject people to criminalization for using drugs.

She said in an op-ed earlier this month that “stigma remains one of the biggest obstacles to confronting America’s current drug crisis,” and the government bears some responsibility in perpetuating those stigmas.

“Government policies, including criminal justice measures, often reflect—and contribute to—stigma,” she said. “When we penalize people who use drugs because of an addiction, we suggest that their use is a character flaw rather than a medical condition. And when we incarcerate addicted individuals, we decrease their access to treatment and exacerbate the personal and societal consequences of their substance use.”

Furthermore, when it comes to marijuana research, Volkow has said that scientists should be allowed to investigate products from state-legal dispensaries instead of using only government-grown plants.

NIDA separately submitted a report to congressional lawmakers emphasizing that the Schedule I status of controlled substances like cannabis is preventing or discouraging research into their potential risks and benefits.

It also said that current restrictions that block scientists from studying the actual cannabinoid products that consumers can purchase at dispensaries is impeding research to an extent that constitutes a public health concern.

ANALYSIS To put this in perspective, these statements are extremely welcomed and beneficial to the legalization movement. It is extremely encouraging to see a federal health official rely on the science and acknowledge that, as it stands, the evidence hasn’t pointed to serious harms for adults who occasionally use cannabis.

Also, it is very notable admission given that NIDA has historically gone to great lengths to highlight the potential risks of cannabis consumption. NIDA has been notorious for only approving studies related to cannabis that will show detrimental affects of the use of cannabis, but never studies which show positive results of using cannabis on specific health issues.

This is one more of the many roadblocks to US federal legalization that is slowly being removed. As more federal agencies continue to report on the benefits of cannabis legalization in different aspects of our society (medical, research, societal benefits, etc.), it is now not “if ” cannabis is legalized by the US Government, but “when.”

Michael Patterson NHA, OTR/L, CEAS is CEO of US Cannabis Pharmaceutical Research and Development LLC. (uscprd.com). Mr. Patterson is a healthcare executive with over 25 years experience in the following areas: Cannabis-Hemp investment, Law, Regulation, Compliance, Operations, and Management, Skilled Nursing, Pharmacy, Laboratory, Assisted Living, Home Healthcare, and Healthcare Analytics. Michael is a subject matter expert in the Global Cannabis and Hemp Industry with Gerson Lehrman Group (glg.it) and Guidepoint. Mr. Patterson is an editorial board member of the American Journal of Medical Cannabis, licensed Nursing Home Administrator, and licensed Occupational Therapist in 4 states. 

FLORIDA MD - DECEMBER 2021

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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.

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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 - DECEMBER 2021

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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 - DECEMBER 2021

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

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.

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.lmsplus.com. 

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 FLORIDA MD - DECEMBER 2021

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PULMONARY AND SLEEP DISORDERS

Pulmonary Rehabilitation

By Daniel T. Layish, MD, FACP, FCCP, FAASM Pulmonary rehabilitation can benefit patients with a wide variety of lung diseases including COPD, pulmonary fibrosis, cystic fibrosis, and sarcoidosis (among other chronic respiratory illnesses). Pulmonary rehabilitation does not replace standard medical and/or surgical treatments for these lung diseases. Rather, it supplements and complements standard therapy.

Patients with COPD (and other chronic lung diseases) develop shortness of breath with activity. This leads to the tendency to avoid activity, which in turn leads to deconditioning. It is felt that one of the main benefits of pulmonary rehabilitation is to break the cycle of deconditioning. Pulmonary rehabilitation programs typically include two or three outpatient sessions per week for 10 to 12 weeks. Typically, a pulmonary rehab program will include aerobic exercise, strength training, patient education in management of lung disease - including nutrition, energy conservation, medication compliance, bronchial hygiene, and breathing strategies. The component of group support is also felt to be a significant contributor to the success of these programs. The group support motivates the patient to attend the pulmonary rehab sessions. It also allows the patient to realize that there are other people suffering from chronic respiratory illness and to see how they are able to overcome these obstacles. Pulmonary rehabilitation is considered to be critical both before and after lung transplantation. Occasionally, a patient will have such a significant functional and symptomatic improvement after pulmonary rehab that transplant can be delayed.

Pulmonary rehabilitation programs are typically multidisciplinary in nature and may include a respiratory therapist, registered nurse, exercise physiologist, nutritionist, physical and/ or occupational therapists. The staff is trained to encourage the patient’s self management and coach them to adopt healthier habits through lifestyle modification. To enroll in a pulmonary rehabilitation program requires a medical referral. Pulmonary rehabilitation is covered by most third party payors. Pulmonary rehabilitation is appropriate for any stable patient with a chronic lung disease who is disabled by respiratory symptoms.

The pulmonary rehab program should involve assessment of the patient’s individual needs and creation of a treatment plan that incorporates realistic goals tailored to each patient. Evidence based analysis consistently reveals improvement in health related quality of life after pulmonary rehabilitation as well as improved exercise tolerance. Pulmonary rehabilitation has been shown to improve the symptom of dyspnea and increase the ability to perform activities of daily living. Pulmonary rehabilitation has also been shown to reduce health care utilization (including frequency of hospitalization) and decreases length of stay (when hospitalization is required). Pulmonary rehabilitation has not been demonstrated to improve survival.

The benefit from a pulmonary rehabilitation program may decline over time if the individual does not maintain their con8 FLORIDA MD - DECEMBER 2021

ditioning. Some pulmonary rehabilitation programs will therefore include a “graduate” or maintenance program after the patient finishes the initial program.

Patients who develop shortness of breath often become anxious which in turn exacerbates the sensation of dyspnea and this can become a vicious cycle. Pulmonary rehabilitation can be very helpful in addressing this problem. Sometimes pulmonary rehabilitation will require supplemental oxygen with exercise.

Although the strongest evidence regarding pulmonary rehabilitation programs is in the setting of COPD, it has been shown to be beneficial in a variety of disease states. Pulmonary rehabilitation has been shown to be a cost effective tool in the fight against chronic lung disease. It is currently felt to be underutilized.

Daniel Layish, MD, graduated magna cum laude from Boston University Medical School in 1990. He then completed an Internal Medicine Residency at Barnes Hospital (Washington University) in St.Louis, Missouri and a Pulmonary/Critical Care/Sleep Medicine Fellowship at Duke University in Durham, North Carolina. Since 1997, he has been a member of the Central Florida Pulmonary Group in Orlando. He serves as Co-director of the Adult Cystic Fibrosis Program in Orlando. He may be contacted at 407841-1100 or by visiting www.cfpulmonary.com.

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9

DERMATOLOGY

The $8500 Tube of Cream

By John “Lucky” Meisenheimer, MD and John Meisenheimer, VII Several years ago, a patient came back to my office for a return visit. She had been seen earlier that week for a small amount of intertrigo underneath her breasts. Intertrigo is a common inflammatory condition of the skin folds, and it is aggravated by heat, moisture, and friction. Occasionally a patient might get a minor secondary yeast infection in the area as well. The treatment is keeping the area dry and using a topical cream to clear the yeast and decrease the inflammation.

Now, if they filled the prescription and didn’t use the medicine, I am flummoxed as I am not sure how to respond. So, I usually say “oh” and stop talking, leaving a long moment of uncomfortable silence that eventually forces the patient to speak. Then the response comes, “so you think I should use the medicine you prescribed?” I reply, “Well, yes, as we have tried not using the medicine, and that plan is not working so good.” Amazingly, the patient seems okay with this response and goes happily on his or her way. Yes, this very conversation has happened on more than one occasion.

Now, in this case, since this patient had not filled her prescription, I wanted to know why. In the past, the cream I prescribed called Alcor: Intertrigo - Would you spend $8500.00 on a tube of cream to tin sold for about $35 a tube, so I didn’t think the cost was a concern. treat this eruption?

She then told me that the pharmacist wanted to charge her $8500.00 for a tube of the cream. I laughed out loud because I knew there had been some gross misunderstanding regarding the cost, and I said there must have been a decimal put in the wrong place. I was confident she didn’t understand the pharmacist correctly.

The patient was very adamant that she had spoken with the pharmacist in person, and there was no question that the price was $8500.00. I asked her for her pharmacy, and I contacted the pharmacist myself. I started by saying, “well, I am just clearing up a misunderstanding. There is a patient here that is trying to tell me that Alcortin is $8500.00 a tube. I am sure the decimal point has been put in the wrong place, or you mistakenly thought I ordered a tractor-trailer full of the cream. There was a long pause, and the pharmacist said, “no, $8500 is correct,” and it wasn’t for a flatbed truck loaded with cream; it was for one lousy 60-gram tube. At the time, that cream was selling for four times its weight in gold! The pharmacist had no explanation for why the medicine went up so much in price; all he knew was that was the price.

Since that bit of medical-cultural shock, other medicine prices have skyrocketed as well as everyone reading this knows. Nobody seems to know why, but I suspect this is due to our government meddling with the free market system. When the last big round of Medicare laws changed the way Medicare buys drugs, and this had bipartisan support I might add, this is when the chaos started. Drug companies loved the clause that they could name their price without any negotiation on price, and we are all now living the outcome.

Just recently, a study showed that worldwide, when several first world countries were compared for the average cost spent on nineteen different conventional medicines, the United States was paying 300% more than the average price paid by other countries.

Iceland, for example, was paying approximately 50% the average cost, which means that we are spending six times as much as the Icelanders for the same medication. So why don’t we go to Iceland and buy all our medicines straight from Iceland? The answer is the drug companies have convinced the government that reimportation should be illegal. Therefore, it is unlawful to reimport medicines (a bill has been passed in Florida to allow reimportation, but it still faces an uphill battle for implementation). In other words, the United States is subsidizing the healthcare of the rest of the world by paying outrageous prices, allowing other countries to continue paying bargain-basement prices. Yet, we wonder why our healthcare costs so much here in America.

So how did I resolve the problem of the $8500 cream? Well, we sent the prescription to the local compounding pharmacy and had virtually the same medicine compounded up for $75. The patient did well and saved $8425 along the way. And what happened to the company that made Alcortin and raised the price thousands of dollars? Well, they went bankrupt. What goes around comes around.

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.  10 FLORIDA MD - DECEMBER 2021

PHOTO: JOHN MEISENHEIMER, VII

The patient said, “doctor, I am worse.” I asked how she was using the cream, and she responded that she had not filled her prescription. Now I have lived through this scenario before with other patients. I am always amazed when people seem surprised that their condition has not improved when they have either not filled their prescription or filled the prescription and never used the medicine.

Healing Eczema: Beyond Skin Deep

By Joseph Cannizzaro, MD Oftentimes the children we treat in our practice suffer from asthma, allergies, eczema and other comorbid conditions, which create a persistent inflammatory state in the body. In these cases, we apply a synergistic mix of healing factors: nutrition with dietary modifications, supplements, enhanced detoxification, and medications when necessary. We determine food intolerances, look for nutritional deficiencies, and analyze chemical exposures.

Additionally, salt therapy has proven to be a safe and effective healing modality that helps clear eczema completely.

HOW DOES SALT THERAPY HELP HEAL ECZEMA? In January 2018, our pediatric center became the newest location for The Salt Room® in Central Florida. Salt therapy is performed in this special spa-like room with salt-coated walls and floor, called a halochamber. Pharmaceutical-grade salt is pulverized into microscopic particles and pushed into the room by a halogenerator.

Salt therapy involves lounging in this cozy room and passively breathing in the particles while listening to soothing music, reading, or just relaxing in a zero-gravity chair. Toys are provided so children can play with the salt in the room, much like sand at the beach.

The salt particles enter the lungs and nasal passages, accelerating mucus clearance and improving lung function while killing harmful bacteria and soothing the respiratory system. The antibacterial, anti-fungal, and anti-inflammatory properties of salt have been documented to help with symptoms of both respiratory and skin conditions.

the skin’s barrier against infections and allergens. The skin and respiratory tract are cleansed of allergens like pollen, dust, or smoke. Salt therapy also reduces stress and strengthens the body’s defense system. Salt therapy is a clinically-proven, natural, safe, and beneficial method of treatment for every age group.

Taking a holistic approach to eczema—identifying the underlying cause(s), applying the appropriate integrative protocol, and incorporating salt therapy—has yielded successful outcomes for our patients. This “beyond the surface” approach to a skin condition has proven to shorten the journey to lasting relief—with a side effect of smiles.

Joseph Cannizzaro, MD has been practicing pediatrics in Central Florida for over 40 years and is the author of “Answers for the 4-A Epidemic: Healing for Kids with Autism, ADHD, Asthma and Allergies.” As a classicallytrained primary care physician who practices functional integrative medicine, Dr. Cannizzaro believes that integrative medicine can bring conventional and complementary healing modalities together, creating a highly personalized and high-touch healing environment. Call the Cannizzaro Integrative Pediatric Center at 321-2805867 for a meet and greet or to book a session at The Salt Room® Longwood. www.MyCIPC.com. 

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Kerri and Clay: “My son’s allergy medicines were causing terrible side effects. Now that we have been coming to The Salt Room we have been able to control his symptoms with salt therapy.”

Jessica L.: “My son looked and felt better after just one session. His cough wasn’t as bad. I felt he could breathe so much better.”

Joseph Cannizzaro, MD: “I have been recommending The Salt Room for years. It has helped my patients with respiratory nuisances and skin problems, reducing symptoms while we address the root cause to improve their long-term quality of life.”

407.862.1163 l 357 Wekiva Springs Rd., Longwood l www.SaltRoomLongwood.com

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Located inside Cannizzaro Integrative Pediatric Center. Offering relief to all ages.

FLORIDA MD - DECEMBER 2021 11

PEDIATRICS

22q11.2 Deletion Syndrome

By Brian C. Kellogg, MD, Chief of Plastic and Craniofacial Surgery, Nemours Children’s Health

Q: WHAT IS 22Q11.2 DELETION SYNDROME? A: 22q11.2 deletion syndrome (22qDS) is a common microdeletion disorder of variable expressivity that results in multi-organ system dysfunction. Patients may present with heterogenous combinations of cardiac anomalies, genitourinary anomalies, endocrinopathies, immunodeficiencies, overt or submucous cleft palate, velopharyngeal dysfunction (hypernasal speech), hematologic problems, gastrointestinal problems, developmental delays, neuropsychiatric illness and characteristic facial features. Several previously described disorders, including DiGeorge syndrome, velocardiofacial syndrome, conotruncal anomaly face syndrome, Opitz G/BBB syndrome and Cayler cardiofacial syndrome, are now recognized as different manifestations of 22qDS. The incidence of 22qDS is estimated to be around 1 in 4,000. It is the second most common cause (behind Down syndrome) of congenital heart disease and developmental delays, and it is the most common genetic cause of structural anomalies of the palate.

Q: WHAT CAUSES 22QDS? A: 22qDS is caused by a microdeletion on the long (q) arm of the 22nd chromosome. It has an autosomal dominant inheritance pattern with variable expressivity, but 90-95% of cases are believed to result from de novo mutations. 22qDS has not been linked to any extrinsic or environmental factors during fetal development.

Q: WHAT ARE THE SIGNS AND SYMPTOMS OF 22QDS? A: Congenital heart anomalies are often the earliest sign that a patient may have 22qDS. Further investigation into other organsystems and genetic testing can confirm the diagnosis. Other patients may escape diagnosis in the neonatal period only to present to a specialist later in life with very specific complaints, such as hypernasal speech. Specific signs and symptoms affecting different organ-systems that may be present include: General: 22q facies (short forehead, hooded eyelids, upslanting palpebral fissures, prominent ears, malar flatness, bulbous nasal tip, small nasal alae, generalized hypotonia, multiple congenital anomalies, polyhydramnios, learning disabilities Cardiac: Any congenital heart anomaly, especially conotruncal (tetralogy of Fallot, truncus arteriosus, interrupted aortic arch, transposition of the great vessels, etc.)

Endocrine: Hypoparathyroidism, hypocalcemia, growth hormone deficiency, hypothyroidism Palate: Submucous cleft palate, overt cleft palate, high-pitched cry, nasal regurgitation, recurrent otitis media, hearing loss, hypernasal speech (velopharyngeal dysfunction) 12 FLORIDA MD - DECEMBER 2021

Hematologic: Intrinsic platelet dysfunction, thrombocytopenia, easy bleeding, splenomegaly Immunologic: Humoral and cell-mediated immunodeficiencies, may manifest as recurrent infections GI: GERD, dysmotility/dysphagia, cholelithiasis, imperforate anus, malrotation, Hirschprung’s disease Genitourinary: Any structural GU anomaly, unilateral renal agenesis, multicystic dysplastic kidneys Skeletal: Scoliosis, C-spine anomalies Development: Failure to thrive, short stature, expressive and receptive language delays, gross motor delays, learning disabilities Neuropsych: Attention deficit or autism spectrum in young children, anxiety or depression, schizophrenia or other psychotic disorders in teens/adults

Q: HOW IS 22QDS DIAGNOSED? A: Genetic testing is required to confirm the diagnosis. Fluorescent in situ hybridization (FISH) or chromosomal microarray are two commonly employed modalities.

Q: HOW IS 22QDS TREATED? A: Patients require a multitude of tests at the time of diagnosis.

Per care guidelines, many of these assessments must be repeated at regular intervals. For example, children with 22qDS only require an immunologic evaluation at the time of diagnosis and once again in preschool years (unless specific concerns arise). However, guidelines recommend thyroid studies annually.

Due to the multi-system nature of 22qDS, these patients are most effectively managed in the setting of an interdisciplinary team experienced in treating patients with 22qDS and wellversed in the care guidelines. Care coordination is crucial when working with children with 22qDS because of the large number of specialists who are involved and the complexity of the child’s care. Studies have shown that interdisciplinary team care leads to significantly improved adherence to care guidelines.

Q: WHAT ARE THE OUTCOMES FOR CHILDREN WITH 22QDS? A: Outcomes for children with 22qDS are highly variable based on the systems involved and the degree to which they are affected.

22qDS can affect any system of the body, which is why early detection and treatment is so important. While there is no cure for 22qDS, therapies and medical interventions can help address its associated symptoms.

There is still very little information available for this population.

Most 22qDS clinics are housed in pediatric institutions, so a

CONTINUED ON PAGE 14

Multimodal Pain Management with Opioid Minimization

By Luke Elms, MD In 2016, overdoses accounted for more than 42,000 deaths in the United States according to data from Health and Human Services (HHS). While many of these deaths are multifactorial, a majority reportedly involved opioids. Despite HHS declaring a nationwide public health emergency regarding the opioid crisis in October 2017, the numbers have continued to rise, which many experts believe is being driven by counterfeit pills containing illicit fentalogues. Recently, the government released provisional numbers reporting more than 100,000 overdose deaths for the 12-month period ending April 2021. Although there is debate whether the number of overdose deaths attributable to legal prescription opioids is being overestimated, opioids and the overdose crisis has become a frequent topic of public discourse and raised concerns regarding opioid exposure in some patients.

As the opioid crisis was gaining national attention, I was involved in Orlando Health’s Right Care Initiative for the ERAS (Enhanced Recovery After Surgery) protocol. The ERAS protocol has multiple tenants, and one of the main tenants was the utilization of multimodal pain management. This area really sparked my interest, as alleviating the suffering of postoperative pain is always a battle I’m willing to fight. So, along with my colleague Dr. Bobby Gibbons, we began implementing the protocol in our practice. Through a gradual process over the next few years, we made modifications to the ERAS protocol’s multimodal pain regimen and settled on our own multimodal pain control protocol.

We now utilize this protocol in all our surgical patients without a contraindication, most of who undergo minimally invasive or robotic procedures. When we implemented the multimodal pain control, our patients started reporting much less use of the opioids we were prescribing and some even reported eliminating their use altogether. In response, we were able to transition from oxycodone to tramadol, which is a less powerful schedule IV drug compared to the schedule II status of oxycodone. After finding success with this change, we started decreasing the quantity of opioid pills we were prescribing. Now, with some smaller procedures we can achieve good pain control with no opioids, but most patients still get a one-day supply of 50 mg tramadol to ensure they have a rescue medication to add if non-opioid medications alone are not sufficient. Many patients do not fill the tramadol prescription or only take 1-2 pills and still report great pain control at their follow-up. With better pain control and reduction of the uncomfortable side effects of the opioids like nausea and constipation, our patient satisfaction increased.

In 2018, I realized that most patients who had poor pain control while using the protocol were unintentionally noncompliant with the instructions. This was addressed with more purposeful

CONTINUED ON PAGE 14

patient education prior to surgery and the creation of patient education handouts that were created and modified in response to patient feedback. Proper patient education includes explaining the benefits of opioid minimizing multimodal pain control, setting proper expectations so patients understand that surgery does cause pain, and that while they can expect to experience pain, it will be managed with the addition of an opioid is necessary. It is vitally important to have these conversations up front, because when patients are properly prepared and understand the reasoning, they are much more comfortable and willing to attempt opioid-minimizing analgesia. Now, with our updated education, we have found the need to prescribe oxycodone or refill their tramadol prescriptions to be less than 5 percent for most of our operations.

One underestimated opportunity is the use of multimodal pain control in the nonsurgical realm. There are people all over the country who had their first exposure to an opiate from accessing routine medical care. These people were in pain and needed intervention, but were opioids always necessary to provide adequate pain control? We have an opportunity for a paradigm shift in the way we think about postoperative pain management in the United States. Historically, in the United States, 90 percent of major or minor medical procedures were prescribed an opiate. After using opioids post-surgery to maintain adequate pain control during recovery, there are 3.3 billion opioid pills left over every year in the United States. With all this considered, there is an opportunity to shift our prescribing practices to opioids not as first-line treatment for acute pain, but as an adjunct when non-opioid alternatives are not sufficient to provide adequate pain relief. It is possible to drastically reduce that number while still providing compassionate pain control with opioids to those who need it.

The vitally important point is that medically indicated prescription opioid pain medications are not the enemy, and neither are the patients who rely on them. Prescription opioids are a vital tool in our battle to alleviate the suffering of pain. Opioids responsibly prescribed and utilized are both safe and necessary for many of our fellow Americans who suffer from chronic pain, palliative conditions and other causes of uncontrolled pain. The opportunity for discussion and change lies in the portion of our patients we have historically treated with an opioid as a first-line pain control method when non-opioids could provide high quality, compassionate pain control. Eliminating the use of opioids while leaving our patients in uncontrolled pain is not a compassionate, or ethical, solution. That practice runs afoul of many of the tenants that FLORIDA MD - DECEMBER 2021 13

22q11.2 Deletion Syndrome

By Brian C. Kellogg, MD, Chief of Plastic and Craniofacial Surgery, Nemours Children’s Health

CONTINUED FROM PAGE 12

transition to adult care should be carefully planned as these patients near adulthood.

Brian C. Kellogg, MD, serves as the chief of plastic and craniofacial surgery as well as the director of the Cleft Lip and Palate Program at Nemours Children’s Health. He completed a fellowship in pediatric plastic and craniofacial surgery at Nationwide Children’s Hospital after an integrated residency in plastic surgery at University of South Florida. Dr. Kellogg earned his medical degree at University of Cincinnati College of Medicine.

Multimodal Pain Management with Opioid Minimization

By Luke Elms, MD

CONTINUED FROM PAGE 13

we are called to uphold as medical providers. It should not be considered a victory if going “opioid-free” means leaving people in uncontrolled pain. Instead, when possible, we must replace the prescription opioids with a viable, effective alternative, and non-opioid multimodal pain control can fill that role. What multimodal pain control protocols have demonstrated is that significant opioid minimization while maintaining adequate pain control is possible in many cases. The broader application of opioid-minimizing multimodal pain control presents the opportunity for a much-needed discussion regarding how we approach acute pain control in a compassionate, safe manner, not just within our own practice, but throughout the entire healthcare system.

Luke Elms, MD, is a board-certified general surgeon with Orlando Health Medical Group at Orlando Health Dr. P. Phillips Hospital. He also has certification in robotic surgery and serves as teaching faculty for the general surgery residency program at Orlando Health. After earning his medical degree from the University of Oklahoma College of Medicine, Dr. Elms completed his general surgery residency at Orlando Health. Over his years in practice, Dr. Elms has developed both a professional and personal passion in the opioid epidemic. This passion has led to a focus on minimally invasive and robotic surgery techniques with postoperative opioid-minimizing multimodal pain control.

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14 FLORIDA MD - DECEMBER 2021

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2022

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