Florida MD JanuaryFebruary 2024 by FloridaMD

JANUARY/FEBRUARY 2024 • COVERING THE I-4 CORRIDOR

GI Urgent Care Center of Florida Treating GI Patients in a Thorough and Timely Manner

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JANUARY/ FEBRUARY 2024 COVERING THE I-4 CORRIDOR

 COVER STORY

PHOTO: DONALD RAUHOFER / FLORIDA MD

According to the CDC, there were 139.8 million visits to U.S. emergency rooms in 2023. Many of these patients sought care for common emergencies, such as serious injuries, chest pain, breathing difficulties, and poisonings. Others who sought care at an ER were referred there by their PCPs after reporting symptoms associated with GI distress, such as pain, vomiting, nausea, and bleeding. Some of these GI patients self-referred to the ER or to an urgent care facility after being unable to schedule an appointment with their GI physician in a timely manner. Harinath Sheela, MD, and Srinivas Seela, MD, are each board certified in gastroenterology and internal medicine. They co-founded Digestive and Liver Center of Florida nearly twenty years ago. The practice has offices throughout the Orlando area.

ON THE COVER: Srinivas Seela, MD and Harinath Sheela, MD at GI Urgent Care Center of Florida

IMPORTANT CRITERIA FOR SELECTING MEDICAL OFFICE SPACE PHOTO: DONALD RAUHOFER / FLORIDA MD

Recently, the physicians opened GI Urgent Care Center of Florida. This innovative GI care concept is the only such center in Florida and one of only four in the country. GI Urgent Care Center of Florida is open from 7:00am to 7:00pm seven days a week. Sameday appointments are available, but walk-in appointments are accepted as well. Referrals are not required, and the center accepts most major insurances.

DEPARTMENTS 2

FROM THE PUBLISHER

DERMATOLOGY

MARKETING YOUR PRACTICE

PULMONARY AND SLEEP DISORDERS

HEALTHCARE LAW

ORTHOPEDICS

PEDIATRICS

INFECTIOUS DISEASES FLORIDA MD - JANUARY/FEBRUARY 2024

FROM THE PUBLISHER

am pleased to bring you another issue of Florida MD. I can only imagine the emotional and physical trauma that a woman goes through when she has a mastectomy. The procedure affects not only her body, but her mind and her self-esteem. Now add in the inability to not be able to reconstruct her breasts and give that part of her life back, because she’s uninsured or under insured, and it becomes an unthinkable crushing blow. Fortunately there is My Hope Chest to help women who are unable to afford reconstructive surgery. 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

MY HOPE CHEST — Making Women Whole Again In 2010, more than 22,000 uninsured women lost their breasts to cancer and were left disfigured, deformed and feeling “less than whole.” How many years has this figure been growing? Many organizations raise funds for research, education and “awareness” of breast cancer. Most have no idea there lies a huge gap in assistance for delayed reconstruction and co-pays for survivors wanting this surgery. My Hope Chest is the ONLY national 501c3 non-profit organization focused on funding breast reconstruction for the uninsured and under insured survivors. Our services “pick up” where other breast cancer organizations leave off… providing the “final step in breast cancer treatment. ” My Hope Chest is about addressing the needs of survivors now. Through wonderful surgeon partnerships we are able to transform the lives of breast cancer survivors who otherwise have no hope of reconstruction. We hope to hear from you to learn how we can work together to eliminate our wait list and take action to help every woman who desires reconstruction after mastectomy and feel restored in body, mind and spirit. Wish List • Surgeons to create awareness for My Hope Chest and to identify new clients • Doctors of Distinction- Surgeon partners nationwide to join our program. • Corporate partners, interested in Win-Win, Commercial- coventure marketing campaigns promoting their product or service by sharing our vision to make sure there is always coverage for reconstruction surgery. For additional information on how you can help or refer a patient please go to www.MyHopeChest.org.

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Publisher: Donald Rauhofer Photographer: Donald Rauhofer / Florida MD Contributing Writers: JJohn “Lucky” Meisenheimer, MD, Daniel T. Layish, MD, John Meisenheimer, VII, MD, Sonda Eunus, MHA, Julie Tyk, JD, Paul J. Watkins, George Haidukewych, MD, Frank Ricci 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 2024 Sea Notes Media. All rights reserved. Reproduction in whole or in part without written permission is prohibited. Annual subscription rate $45.

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COVER STORY

GI Urgent Care Center of Florida – Treating GI Patients in a Thorough and Timely Manner

By Paul J. Watkins According to the CDC, there were 139.8 million visits to U.S. emergency rooms in 2023. Many of these patients sought care for common emergencies, such as serious injuries, chest pain, breathing difficulties, and poisonings. Others who sought care at an ER were referred there by their PCPs after reporting symptoms associated with GI distress, such as pain, vomiting, nausea, and bleeding. Some of these GI patients self-referred to the ER or to an urgent care facility after being unable to schedule an appointment with their GI physician in a timely manner. Harinath Sheela, MD, and Srinivas Seela, MD, are each board certified in gastroenterology and internal medicine. They cofounded Digestive and Liver Center of Florida nearly twenty years ago. The practice has offices throughout the Orlando area. Recently, the physicians opened GI Urgent Care Center of Florida. This innovative GI care concept is the only such center in Florida and one of only four in the country. GI Urgent Care Center of Florida is open from 7:00am to 7:00pm seven days a week. Same-day appointments are available, but walk-in appointments are accepted as well. Referrals are not required, and the center accepts most major insurances.

MEETING A LONG-EXISTING NEED Dr. Sheela says the concept of a dedicated GI urgent care center is brand-new, but the need has existed for a long time. He describes the center as a bridge between a regular office visit and an ER visit. He offers the example of a patient with abdominal pain who calls their primary care physician. “The PCP tells the patient

PHOTO: DONALD RAUHOFER / FLORIDA MD

Guiding the path to wellness: Our physician assistant strides into action, preparing a patient for IV infusion Therapy.

to see a GI doctor, but general GI doctors are busy with their regular clinic hours, procedures, and hospital rounds, so getting an appointment is often difficult. They may have one or two slots for walk-ins, but those fill up quickly, so other patients may have to wait three or four months to get in to see a GI doctor. Meanwhile, the patient is very uncomfortable and concerned because they don’t know what’s going on with their health. That patient has two choices: Go to a regular urgent care clinic, where the staff cannot diagnose the patient accurately and provide appropriate treatment, or go to the ER, where the patient waits several hours to be seen by a healthcare provider who will do whatever tests they can do, but those tests are unlikely to be the right tests.” Unfortunately, neither of these options is ideal for addressing the patient’s needs quickly and thoroughly. GI Urgent Care Center of Florida meets GI patients’ needs in ways standard urgent care facilities and ERs cannot. “Urgent care facilities are usually staffed by mid-level providers and a primary care physician,” says Dr. Seela, “and most of these facilities are not equipped with any laboratory or imaging capabilities. When a patient presents with abdominal pain, bleeding, blood in the stool, nausea, or vomiting, the staff don’t have the ability to accurately diagnose and treat that patient. They may try flu testing and might check for a clinical diagnosis, but there’s no radiological or laboratory investigation.” “The staff of an ER don’t provide appropriate GI treatment either because they’re not set up to deal with GI issues directly,” adds Dr. Sheela. “The doctors there don’t necessarily know the right tests to order, the right images to obtain, and the right medications to prescribe. They just give steroids or some other broadspectrum antibiotics that may or may not be helping the patient in the long run. Acutely, it might be a patchwork, and they think they’re stabilizing the patient, but that might actually be harming the patient. For patients with chronic conditions, such as inflammatory bowel disease, ulcerative colitis, or Crohn’s disease, these agents can actually worsen symptoms. GI patients exposed to broad-spectrum antibiotics can develop side effects, such as C. diff, which can cost more for their insurance companies financially and further compromise the patients physically. At our GI urgent care center, we can develop a very focused treatment plan so patients aren’t exposed to unnecessary treatment agents.” The physicians note that when a GI patient goes to an ER and receives some form of treatment, the physician there still ends up directing the patient to follow up with their GI doctor, who is most likely very busy. The patient might have to wait a couple months to get an appointment, and they can end up going back to the ER again if they have any issues in the meantime. GI Urgent Care Center of Florida can facilitate that transition as soon as possible because it has a large staff of providers, so patients can

4 FLORIDA MD - JANUARY/FEBRUARY 2024

COVER STORY obtain an appointment sooner rather than later.

“With our GI urgent care concept, not only have we seen the patient quickly, diagnosed the issues, and provided treatment, but we’ve also prevented an ER visit and the hospital admission that sometimes results,” notes Dr. Sheela. “Fifteen to twenty percent of ER visits are GI related, and out of those twenty percent, only one or two percent need to be admitted in the hospital, often for endoscopies, colonoscopies, surgeries, or radiological imaging. We are preventing those unnecessary admissions.”

MANAGING CHRONIC GI PATIENTS “Patients with chronic GI conditions are usually stable, but they may experience some stress or a medication that isn’t working properly, and they have a flare-up,” explains Dr. Seela. “They have abdominal pain, fever, or bleeding. Usually, they contact the on-call doctor at their GI practice and are told, ‘Go to the nearest emergency room.’ At the ER, the patient gets blood work and the ER doctor gives steroids and admits the patient to stabilize them. That happens two or three times a year, sometimes more. This results in charges that are a huge burden for the insurance companies and for the patients. At GI Urgent Care Center of Florida, we can diagnose, treat, and stabilize the patient, and make sure the patient is going to follow up with their GI provider. The direct-focus treatment is there as well as the continuity of care.”

SPECIALIZED STAFF AND EQUIPMENT Dr. Sheela says the frequency with which GI patients are referred to the ER is why he and Dr. Seela saw the need for a GI urgent care center in their community. Such a resource was the ideal way to meet that need, but it required the physicians to bring together the physical infrastructure and the appropriate staffing. They have invested in the newest equipment for diagnosing and treating GI issues, and they have staffed the center with twelve GI physicians and fifteen nurse practitioners, all of whom have fifteen to twenty years of experience, are exceedingly well trained in the most up-to-date techniques and procedures, and are dedicated to treating GI conditions. “GI Urgent Care Center of Florida is the first of its kind in the state,” says Dr. Seela. “The idea behind this is to deliver care in a timelier fashion. That way, patents get the right treatment for their GI issues. We can do everything – blood work, CT scans, ultrasounds, and whatever else is needed to diagnose and treat the real issues GI patients are experiencing. We offer same-day appointments and accept walk-ins as well, and patients can be seen with little, if any, waiting time.”

PHOTO: DONALD RAUHOFER / FLORIDA MD

“GI Urgent Care Center of Florida is staffed by GI-trained physicians who can see patients immediately for acute emergencies like abdominal pain,” explains Dr. Seela. “We can conduct a physical exam and diagnose with radiology imaging, ultrasound, and laboratory work, including a chemistry panel and CBC. We can treat with IV antibiotics and IV fluids and stabilize the patient. He or she can then follow up with their GI provider, or if their provider isn’t available for several days or longer, the patient can follow up in a few days with a GI provider at GI Urgent Care Center of Florida.”

Comprehensive care in action: Our patients undergo a thorough examination by dedicated GI-trained medical professionals at the GI Urgent Care of Florida.

HELPING PCPS PROVIDE BETTER CARE Many PCPs refer their patients with acute GI issues to the GI Urgent Care Center of Florida rather than to the ER, says Dr. Sheela, adding that the center helps PCPs provide better care for their patients in specific ways. “One thing is timely diagnosis and management because if the patient has any acute issue with abdominal pain, such as perforated diverticulitis, the patient can develop sepsis and other issues if it’s not managed quickly. Also, some patients have acute GI bleeding issues, so if they’re not seen early enough and not scoped as soon as possible, that causes additional issues for the patient, and it becomes more complicated to manage.”

REDUCING HEALTHCARE COSTS Dr. Seela says insurance copays and out-of-pocket expenses are lower for visits to GI Urgent Care Center of Florida than for visits to a hospital ER. “If the patient has a CT scan in the ER, they’re charged almost $10,000. At GI Urgent Care Center of Florida, it’s $500 or $600 for the CT scan, which is significantly less cost for the insurance company. Also, if the patient has high deductibles and they have to pay that deductible to have those investigations done, the patient’s out-of-pocket cost at GI Urgent Care Clinic of Florida will be less than one hundredth of the cost at the ER. It’s significantly less cost for the patient as well as for the insurance company.” Demonstrating to insurance companies that the GI urgent care concept produces significant cost savings has been critical to GI Urgent Care Center of Florida’s success, relates Dr. Sheela. “One insurance plan wanted to pay us a global fee of $100 per patient, including IV fluids, IV antibiotics, CAT scans, office visit everything. We invited their chief medical officer and their vice president of the insurance plans to visit us at GI Urgent Care Center of Florida. Once they saw our state-of-the-art center and the comprehensive range of conditions we treat, they said, ‘We FLORIDA MD - JANUARY/FEBRUARY 2024

COVER STORY

PHOTO: DONALD RAUHOFER / FLORIDA MD

understand now. This is not a $100 thing. If we pay $1,000 here, it is not enough because they’re treating a condition that can cost $10,000 to $15,000 in an emergency room setting.’ Insurance companies are also realizing that it’s not only a matter of financial issues, it’s also a matter of the overall well-being of the patient. Insufficient or inappropriate care given to the patient in a regular urgent care facility or in an ER may cause additional medical issues that can cost more for the insurance company and very negatively affect the patient’s health. The insurance people are realizing those facts once they see our infrastructure and physical facility.”

ONE OF ONLY FOUR IN THE COUNTRY GI Urgent Care Center of Florida is one of only four such GIfocused urgent care centers in the U.S. Dr. Seela says the other three centers are attached to big healthcare systems in hospital settings. GI Urgent Care Center of Florida, however, is an independent facility in a unique community setting. If the concept of a GI-dedicated urgent care center is so effective and so beneficial for patients, PCPs, and insurance companies, why aren’t more such centers opening? “One big reason is that implementing the idea is full of challenges, just as any other startup company faces challenges,” offers Dr. Seela. “There’s still a shortage of GI doctors in the county, so that could be one of the contributing factors. In addition, not everyone has the same vision for helping patients, so that might be why so few other centers have been started. Finally, there’s a financial investment involved, and the risk that goes with it, and not all physicians are willing to take that step.”

WHAT REFERRING PHYSICIANS SHOULD KNOW “The main thing referring physicians should know is that we have the knowledge, experience, staffing, and resources to address acute and chronic GI issues in a timely fashion,” says Dr. Sheela. “We’re also able to reduce the cost for the patients as well as for the insurance companies. Lastly, we offer efficiency in terms of

PHOTO: DONALD RAUHOFER / FLORIDA MD

At the heart of care: Our clinical support staff orchestrating seamless patient support at the nurses’ station, embodying dedication and compassion at G.I. Urgent Care of Florida.

6 FLORIDA MD - JANUARY/FEBRUARY 2024

Behind the scenes at GI Urgent Care of Florida: Our meticulous lab team diligently processes samples, ensuring precision and excellence in digestive health diagnostics.

getting a patient an appointment right away, getting a diagnosis right away, and treating the patient accordingly.” “We’ve combined the three essential elements – financial incentive, physical infrastructure, and appropriate staffing,” concludes Dr. Seela. “Now, we’re looking for patients and local doctors who will support this concept.”

For more information or to refer a patient, please call (407) 900-7184 or visit www.GIUrgentCare. com. GI Urgent Care is located at 206 N. Dean Rd., Suite 110, in Orlando. 

OFFERING TREATMENT FOR GASTROENTEROLOGY INCLUDING, BUT NOT LIMITED TO: Abdominal Pain • Abnormal Liver Tests • Anemia • Barret’s Esophagus • Belching, Bloating, Flatulence • Bile Duct Stricture • Celiac Disease • Non-Cardiac Chest Pain • Cirrhosis • Colon, Liver, Stomach, Esophageal and Pancreatic Cancer • Constipation• Colon Polyps • Crohn’s Disease • Diarrhea • Diverticulitis • Duodenal Ulcer, or Duodenitis • Esophageal Stricture • Esophagitis • Gallstones • Gastroenteritis • Gastroesophageal Reflux Disease (GERD) • Gastric(Stomach) Ulcers, or Gastritis • Gastrointestinal or Rectal Bleeding • Gastroparesis • Heartburn, Indigestion • Hiccough • Helicobacter Pylori • Hemorrhoids • Hiatal Hernia • Hidden (Occult)blood in stool • Intestinal Malabsorption • Irritable Bowel Syndrome • Jaundice • Lactose Intolerance • Liver Tumors • Nausea and Vomiting • Pancreatic Tumors • Pancreatitis • Peptic Ulcer Disease • Post-cholecystectomy Syndrome • Primary Biliary Cirrhosis • Primary Sclerosing Cholangitis • Rectal or Anal Pain, Itching • Rectal Urgency/Incontinence • Trouble Swallowing • Ulcerative Colitis • Weight Loss, Poor Appetite • On-site Lab • Diagnostic Services

Advanced Care: Before, During and After High-Risk Pregnancy Appointments: 407.567.3000

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FLORIDA MD - JANUARY/FEBRUARY 2024

DERMATOLOGY

Not All Basal Cell Carcinomas Are Created Equal

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 an MD practicing in Orlando.  8 FLORIDA MD - JANUARY/FEBRUARY 2024

PHOTO: JOHN MEISENHEIMER, VII, MD

Occasionally a patient will tell me their “doctor friend” recommended that they don’t need treatment for a basal cell carcinoma because it will never hurt you. “Doc, he said it’s only a basal cell carcinoma.” Dermatologists fully recognize this as a genuinely cringe-worthy statement. You don’t need to see too many people missing various parts of their facial anatomy to know this advice is blatantly wrong. Even in this modern time of medical miracles, people still die from neglected basal cell carcinomas. When pressed for the name of their “doctor friend,” it usually comes up as I don’t remember their name, or it ends up being “Doctor Google.” It is true a superficial basal cell carcinoma on the torso probably would take years and years for it to cause any sort of significant morbidity to a patient. But, on the other hand, even a small basal cell on the torso will continue to grow if left untreated slowly. What might have been a simple, inexpensive procedure now, a decade later, has turned into a monster of aggravation, discomfort, and cost. Although metastatic disease risk is low with basal cell carcinomas, it is certainly not zero. Several people die each year from basal cell carcinoma. Even more, patients can have disfiguring bouts with cancer losing various parts of anatomy such as nose, ears, eyes, etc. What a lot of patients and even some physicians are not aware of is that not all basal cell carcinomas are created equal. There are several different histologic growth patterns. These varying histologic types can each behave Infiltrative Basal Cell carcinoma of the forehead. differently and require different treatment plans. As mentioned before, a superficial basal cell carcinoma is probably not going to cause a great deal of physical damage unless neglected for long periods. There are other types of basal cell carcinomas; morpheaform and sclerosing basal cell carcinomas with infiltrating growth patterns. These cancers left untreated can cause a significant amount of morbidity in shorter periods measured in months, not years. Aggressive basal cell cancers can also become neurotropic, meaning that they “wrap” around a nerve and can track down its length. Neurotropism can be particularly dangerous, especially if this is on the face and affecting a nerve that happens to pass through a foramen into the brain. Clearly, not a good scenario. Basal cell carcinomas, limited to the skin, tend to be very amePathology of an infiltrative Superficial Multifocal BCC. basal cell carcinoma. nable to treatment in a variety of different ways. Even as a Mohs surgeon I can think of at least half a dozen different ways that I have treated basal cell carcinomas. Not all basal cell carcinomas need Mohs surgery. Each case of basal cell carcinoma should be evaluated individually and in consideration as to the best method of treatment based on its histologic growth pattern, location, and physical condition of the patient. The great news about basal cell carcinoma, even though it is the most common type of skin cancer and millions are treated each year, only a tiny percentage of these end up causing death in patients. When someone says I would much rather have a basal cell Neurotropic basal cell carcinoma. carcinoma than a melanoma, there is a caveat; if you die from a basal cell carcinoma, you are just as dead as if you were to die from melaSclerosing basal cell noma. Happily, most of the time, with early diagnosis and treatcarcinoma. ment, you don’t have to die from either. Basal cell carcinoma is called cancer for a reason. Give it its respect that it is due, or otherwise, you may regret saying, “oh, you don’t have to worry about it, it’s only a basal cell carcinoma.”

PHOTO: JOHN MEISENHEIMER, VII, MD

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

Nodular basal cell carcinoma.

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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FLORIDA MD - JANUARY/FEBRUARY 2024

PULMONARY AND SLEEP DISORDERS

Chronic Thromboembolic Pulmonary Hypertension By Daniel T. Layish, MD There are several categories of pulmonary hypertension. WHO Group I includes patients with idiopathic pulmonary hypertension, familial pulmonary hypertension, drug and toxin related (fen-phen) portopulmonary hypertension, HIV related pulmonary hypertension and pulmonary arterial hypertension associated with connective tissue disorders (such as scleroderma). WHO Group II pulmonary hypertension is often referred to as pulmonary venous hypertension. This includes patients with left ventricular systolic or diastolic dysfunction or valvular heart disease. Essentially, the WHO Group II category includes patients who have an elevated pulmonary capillary wedge pressure and/ or elevated left ventricular end diastolic pressure. WHO Group III pulmonary hypertension consists of patients with COPD, interstitial lung disease, or other conditions in which hypoxia causes vasoconstriction. The remainder of this article will focus on WHO Group IV pulmonary hypertension (chronic thromboembolic pulmonary hypertension or CTEPH). Although WHO Group IV patients are relatively rare, it is crucial to identify them because this is the only type of pulmonary hypertension which is potentially surgically curable. After acute pulmonary embolism, most patients will recover and have normal pulmonary hemodynamics, gas exchange, and exercise tolerance. It is believed that 1-4% of patients with acute pulmonary embolism will go on to develop CTEPH within two years. It is not clear why some patients with acute pulmonary embolism develop CTEPH. Risk factors include hypercoagulable states, myeloproliferative syndromes, splenectomy and chronic indwelling central venous catheters. Patients with CTEPH present with dyspnea, which can have a gradual onset. Many patients with CTEPH will not have a known previous diagnosis of acute pulmonary embolism. As with other patients with pulmonary hypertension, patients with CTEPH may not show findings on physical exam until pulmonary hypertension is in the late stages. Findings include a right ventricular lift, jugular venous distention, fixed splitting of the second heart sound, hepatomegaly, ascites, and peripheral edema. Patients with CTEPH may have “flow murmurs” heard over the lung fields because of turbulent flow through partially obstructed or recanalized pulmonary arteries. These tend to be accentuated during inspiration. Acute pulmonary embolism is the trigger for CTEPH. In some patients this triggers a small vessel vasculopathy (for unclear reasons) that contributes to the extent of pulmonary hypertension. This may explain why up to 35 percent of patients who undergo succesful pulmonary thromoendarterectomy can have some degree of postoperative pulmonary hypertension. Although VQ scanning has become less commonly used for diagnosis of acute pulmonary embolism this remains the initial imaging study of choice in patients with pulmonary hyperten10 FLORIDA MD - JANUARY/FEBRUARY 2024

sion to separate “small vessel” variants (Idiopathic pulmonary arterial hypertension) from “large vessel” disease (CTEPH) A normal VQ scan essentially excludes the diagnosis of CTEPH. A scan with one or more mismatched segmental defects is suggestive of the diagnosis. However, it is important to note that VQ scan can often understate the extent of central pulmonary vascular obstruction. Once the VQ scan is found to be abnormal then further testing should be undertaken (such as CT angiogram and/or pulmonary angiography). The angiographic findings in CTEPH are distinct from those of acute pulmonary embolism. They can include pouch defects and pulmonary artery webs. Patients with severe pulmonary hypertension have been found to tolerate performance of angiography as well as VQ scan without significant complication rate. The surgery for CTEPH is quite different from surgical intervention for an acute pulmonary embolism. Surgery for CTEPH is called a pulmonary thromboendarterectomy (PTE), which requires median sternotomy and cardiopulmonary bypass. It requires an often tedious intimal dissection of fibrotic recannalized thrombus from the native pulmonary arterial wall. IVC filter placement is usually recommended before pulmonary thromboendarterectomy. These patients can have a complicated postoperative course and this type of surgery is only done at a few specialized centers in the country. The center which is best known for this type of surgery is the University of California (San Diego). Patients who have undergone PTE are typically maintained on lifelong anticoagulation. To be a candidate for this surgery, a patients must have central, surgically accesible chronic thromboemboli. A significant postoperative complication is pulmonary artery steal, which refers to redistribution of pulmonary arterial blood flow from well-perfused segments into the newly opened segments resulting in ventilation perfusion mismatch and hypoxia. This redistribution of flow resolves over time. Approximately, 30% of PTE patients can develop reperfusion pulmonary edema. The perioperative mortality of pulmonary thromboendarterectomy can be in the range of 2-3% in experienced centers. Outcome is clearly better in high voluime centers (more than fifty PTE surgeries/year). Approximately 5000 thromboendarterectomy procedures have been performed worldwide, 3000 at UCSD alone. Surgery for CTEPH is clearly the best therapeutic option. However, there are some patients with CTEPH who are inoperable or who have persistent or recurrent pulmonary hypertension after undergoing pulmonary thromboendarterectomy. There is now a medical therapy available for these patients. Riociguat (Adempas) was approved by the FDA in October 2013. It is a member of a new class of compounds-soluble guanylate cyclase stimulators. In the multicenter study by Ghofrani et al that was published in the New England Journal of Medicine in July 2013,

PULMONARY AND SLEEP DISORDERS 261 patients were randomized prospectively to receive riociguat versus placebo. Riociguat was shown to significantly improve exercise capacity and pulmonary vascular resistance. Side effects include systemic hypotension. Prior smaller studies have also shown some benefits to medical therapy in CTEPH (inoperable or with post-operative PH) with oral agents such as bosentan and sildanefil, inhaled iloprost and subcutaneous treprostinil. Medical therapy has also been used as a “bridge” before PTE. Although relatively rare, CTEPH is an important cause of PH since it is potentially curable with pulmonary endarterectomy. This surgery should only be performed in very experienced, specialized centers. PTE surgery should always be the treatment of choice for CTEPH. However, medical therapy can have a role as a bridge to PTE,in patients who are not surgical candidates or in those who have persistent pulmonary hypertension despite undergoing PTE. I would like to express my gratitude to Dr. Peter Fedullo (University California San Diego) for his review of this manuscript and providing the photographs.

Pulmonary angiogram showing lack of blood flow to the right middle lobe and the right lower lobe from CTEPH.

Example of chronic clots removed during pulmonary thromboendarterectomy.

Example of the large perfusion defects seen on V/Q scan in a patient with CTEPH.

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 407-841-1100 or by visiting www.cfpulmonary.com. 

FLORIDA MD - JANUARY/FEBRUARY 2024 11

HEALTHCARE LAW

Social Media – Five Things Physicians Should Never Post By Julie A. Tyk, JD As an example, Alaska dentist, Seth Lookhart, made national headlines for filming a video of himself riding a hoverboard while extracting a patient’s tooth. Dr. Lookhart filmed the procedure on a sedated patient without authorization and forwarded the video to several people. A lawsuit was filed by the State of Alaska in 2017 charging Dr. Lookhart with “unlawful dental acts”, saying his patient care did not meet professional standards. The lawsuit goes on to further allege Dr. Lookhart joked that performing oral surgery on a hoverboard was a “new standard of care,” citing phone records that were obtained. Dr. Lookhart has also been charged with medical assistance fraud for billing Medicaid for procedures that were not justified, unnecessary, and theft of $25,000 or more by diverting funds from Alaska Dental Arts. On Friday, January 17, 2020, Dr. Lookhart was convicted on 46 counts of felony medical assistance fraud, scheming to defraud, misdemeanor counts of illegally practicing dentistry and reckless endangerment. Dr. Lookhart was sentenced to serve 20 years with eight suspended, leaving 12 years of active time. A doctor in Rhode Island was fired from a hospital and reprimanded by the state medical board. The hospital took away her privileges to work in the emergency room for posting information online about a trauma patient. The doctor’s post did not include the patient’s name, but she wrote enough that others in the community could identify the patient, according to a board filing. The popularity of social media has exploded in recent years. According to a recent PEW report, 70% of Americans use social media. Before jumping on the bandwagon, healthcare professionals are advised to be mindful of the possible ramifications of posting information on social media sites. There are numerous legal issues that can arise when healthcare providers use social media, including issues related to patient privacy, fraud and abuse, tax-exempt status, and physician licensing. The Federation of State Medical Boards has issued the Model Guidelines for the Appropriate Use of Social Media and Social Networking in Medical Practice, which contains the “industry standards” for cyber security, online behavior, and patient privacy. Physicians should familiarize themselves with these guidelines. Five things which physicians should never post to social media. 1. Inaccurate Medical Information: Medical professionals should avoid republishing, sharing, “liking,” or “retweeting” news stories about medical treatments unless they have completely read the story and have verified its accuracy. If a user finds inaccurate medical information through your social media channel, it can reflect very poorly upon you and your practice. Healthcare professionals also need to be careful about providing medical advice to patients using social media. If a patient receiving the medical advice from a doctor through social media is located in a state in which the doctor is not licensed, the doctor giving the advice risks liability under state licensing laws. 2. Do Not Post Anything that Violates Patient Confidentiality: Friending patients on social media sites may pose risks under Health Insurance Portability and Accountability Act (HIPAA) and state privacy laws. The fact that an individual is a patient of a healthcare provider falls within the types of health information that these laws are designed to protect. As a rule, healthcare providers should not use so12 FLORIDA MD - JANUARY/FEBRUARY 2024

cial media to share any health information that could be linked to an individual patient, such as names, pictures, and physical descriptions, without the patient’s consent. The American College of Physicians recommends that doctors be especially aware of the implications for patient confidentiality when using social media. There have been cases of physicians losing their medical license after posting an image on social media that violated patient confidentiality. Always obtain permission from the patient in writing if you intend to use an image featuring any body part. Avoid talking about specific patients at all on social media unless you have permission to do so. Even if there is no chance that a patient could be identified by what you write on social media, it is considered unprofessional to discuss the specifics of their condition. Also be careful when taking photographs of yourself while in your practice. There have been cases where medical professionals have accidentally included the image of the patient behind them while taking a ‘selfie’. Make sure there are no patient health records on display when taking photos in the medical practice and no patients are included in photographs unless they want to be. 3. Your Personal Information: The American College of Physicians (ACP) and the Federation of State Medical Boards (FSMB) recommend that doctors create separate social media accounts for their professional and personal lives. They also suggest that the professional profile be more visible than any personal one. 4. Opinions on Controversial Issues: Any controversial topic or “hot button” topic should be avoided as much as possible, including anything to do with religion, politics, racism, abortion, and gun control. Moreover, healthcare providers that are exempt from taxation under Section 501(c)(3) of the Internal Revenue Code are prohibited from intervening in political campaigns and from seeking to influence legislation as a substantial part of their activities. This restriction may extend to advertising on or sponsoring social media sites that support a political candidate or particular pieces of legislation. 5. Complaints or Rants: It is unprofessional to use social media platforms to complain or rant about your professional situation. Everything you write on social media may one day come back to haunt you. A patient might realize that you were complaining about them on social media. A medical malpractice claim can have far reaching implications. The Health Care Practice Group at Pearson Doyle Mohre and Pastis, LLP, is committed to assisting Clients in navigating and defending medical malpractice claims. For more information and assistance, please contact David Doyle and Julie Tyk at Pearson Doyle Mohre & Pastis, LLP. Julie A. Tyk, JD, is a Partner with Pearson Doyle Mohre & Pastis, LLP. Julie concentrates her practice in medical practice defense litigation, insurance defense litigation and health care law. She has represented physicians, hospitals, ambulatory surgical centers, nurses and other health care providers across the state of Florida, and may be contacted by calling (407) 951-8523; jtyk@pdmplaw.com. 

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ORTHOPEDICS

AI Technology Improving Patient Outcomes, Recovery and Satisfaction in Hip Replacements By Dr. George Haidukewych/Orlando Health Jewett Orthopedic Institute In the ever-evolving landscape of medical technology, artificial intelligence (AI) continues to push the boundaries of what is possible in the field of surgery. One groundbreaking development that has captured the attention of the orthopedic community is the integration of AI into hip replacement surgeries, promising enhanced outcomes, reduced recovery times, and improved overall patient satisfaction.

This level of precision has never been available until now. Some of the most common reasons for dissatisfaction with a hip replacement include getting the leg lengths wrong, and poor implant placement resulting in dislocation or premature failure. These are all issues which are prevented by the simulation modeling.

Orlando Health Jewett Orthopedic Institute is one of the first in the nation to offer artificial intelligence assistance in hip replacement procedures. I was introduced to the technology by virtue of working with a leading orthopedic company that is developing hip planning simulation and navigated, robotic execution methods. I am part of an international team of experienced hip surgeons working on developing the next generation of hip replacement implants and techniques.

At Orlando Health, artificial intelligence has entered other aspects of care throughout the system. At the Orlando Health Jewett Orthopedic Institute, AI enables us to complete MRI scans rapidly – only taking a few minutes in some cases - and provides sharper images for our radiologists to read. It’s also utilized at the Orlando Health Digestive Health Institute during colonoscopies.

The new simulation modeling allows the orthopedic surgeons to put the hip replacement in with accuracy to the degree and millimeter that is appropriate for the individual patient. We can then apply artificial intelligence to the X-rays taken in the operating room to confirm the placement. The technology provides immediate feedback in the operating room about whether the surgeon hit the target, allowing us unprecedented accuracy and efficiency during surgery. It’s beautiful technology that we’re excited to have at our disposal. According to the American Joint Replacement Registry 2023 report, more than 3.1 million primary and revision hip and knee arthroplasty procedures have been performed between 2012 and 2022. The data also shows there are 42,228 procedural cases reported by ambulatory surgery centers, which is an 84% increase since 2022. We are seeing more patients, including a younger population, seeking these procedures to improve their daily lives. When I started operating 25 years ago, patients were sometimes in the hospital for a week after undergoing a hip replacement. With new implant technology and surgical techniques such as robots, as well as advancements in patient care, the length of stay for our patients has continued to decline. The AI technology continues this trend by shortening the procedure and decreasing the amount of time our patient is under anesthesia. Now, our patients can undergo hip replacement surgery in the morning and be home before lunchtime. We do pre-operative planning to make the hip very specific to patients’ activities, such as yoga or golf. We use computer simulation to tell us where to put the hip, computer-aided navigation to hit our target to the degree, and artificial intelligence in our X-rays on the patient’s anatomy to get their leg lengths just right. 14 FLORIDA MD - JANUARY/FEBRUARY 2024

Learning the methods takes professional instruction. Courses are available for interested surgeons. I expect more physicians across the country will begin incorporating AI technology into their practices in the future, though it does not replace our training. We must be able to confirm the information the AI technology produces with our own surgical experience. Used in this fashion, the AI technology is a game changing tool for us to explore and incorporate for the benefit of our patients.

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ORTHOPEDICS

Internationally recognized for joint replacement surgery and trauma, George J. Haidukewych, MD, serves as director of orthopedic trauma, chief of complex joint replacement, academic chairman for the Orthopedic Faculty Practice and professor at the University of Central Florida College of Medicine. He trained at the prestigious Mayo Clinic in Rochester, Minn. Dr. Haidukewych specializes in total hip and total knee replacements as well as orthopedic trauma. He brings extensive experience in the management of failed and infected total hip and total knee replacements and in reconstruction of the joints after trauma. In the Fall of 2017, Dr. Haidukewych was inducted into the International Hip Society, an exclusive association of joint surgeons from all over the globe that have demonstrated excellence in hip surgery. The society is comprised of top surgeons from various countries who specialize in hip replacement surgery. Members convene at multiple times throughout the year to discuss difficult cases and share best practices. New members must be voted in by current society members. Dr. Haidukewych is the only surgeon in Orlando in the society. He is also an award-winning researcher, published more than 100 peer reviewed publications and book chapters and has presented hundreds of educational lectures on trauma and hip and knee replacement. Dr. Haidukewych holds several patents and developed multiple innovative implants for fracture fixation and joint replacement. 

FLORIDA MD - JANUARY/FEBRUARY 2024 15

PEDIATRICS

Navigating Pregnancy Beyond the Norm: A Journey Through Advanced Maternal Age By: Staff Writer

BAILEY AND BRAXTON’S STORY After dating for 10 years and recently married, Brandi and Brian were ready to have children. They had always dreamed of having twins — hoping for a “one and done” pregnancy — although multiples were not part of their family history. Both knew it wouldn’t be easy. Brandi had been diagnosed with polycystic ovarian syndrome (PCOS), which could make it challenging to get pregnant. To assess her fertility, Brandi’s obstetrician (OB) suggested she get an ovulation test. No one was more surprised than Brandi herself when the test revealed her ovulation levels were off the charts. Her OB confirmed she was pregnant. They soon began regular visits with their OB. At a routine ultrasound, two weeks later, Brian and Brandi got another surprise; they were having twins!

THEN THERE WERE TWINS Their OB advised them to see a maternal-fetal medicine (MFM) specialist, as Brandi’s pregnancy was considered “highrisk” because she was having multiples and would be 35 years old on the expected due date. Brandi researched a list of possible MFMs in the area and selected Claudia Taboada, DO. “From the first time we met Dr. Taboada, I knew we were in good hands,” says Brandi. “We immediately had a bond between us. We trusted her.” Brandi’s pregnancy continued to progress without incident. But at 35 and half weeks, her blood pressure skyrocketed unexpectedly. They went to the emergency room and were encouraged by the OB physician to have a C-section to deliver the babies immediately. Brandi and Brian were understandably shaken, anxious and unsure what to do. This wasn’t part of their Bailey and Braxton at 6 months old.

plan. Just then, the phone rang. It was Dr. Taboada. As Brandi recalled, “She somehow knew that we needed to hear from her.” Dr. Taboada listened to their concerns and reassured Brandi and Brian that having a C-section would be a good decision for Brandi and her babies. “I really can’t thank her enough. She will forever be a part of our family.” Bailey and Braxton were born just 10 seconds apart. They are healthy, happy fraternal twins. Bailey is the talker, waking up every morning around 5 a.m., cooing in her crib, while Braxton prefers to sleep in.

HOW MATERNAL FETAL MEDICINE CAN SUPPORT YOUR PATIENT’S PREGNANCY A MFM specialist will review your patient’s medical and obstetrical history to improve the future pregnancy before it even begins. This includes discussing potential risk factors and developing plans for exercise, nutrition, medication, and prenatal vitamins. If there is a history of hypertension or diabetes, the patient and MFM specialist will set specific goals for managing these conditions prior to pregnancy. For patients currently pregnant at an advanced maternal age, the MFM specialist and obstetrician can co-create a plan of care, review baseline bloodwork to assess and track any inconsistencies, schedule ultrasounds to monitor the baby’s growth, and plan weekly fetal assessments through nonstress tests and/ or a biophysical profile (BPP) test (combines a nonstress test with ultrasound to measure the health of the baby) during the third trimester. In addition to the review of the individual’s medical history, genetic screening is also recommended. The Center for Fetal Care at Nemours Children’s Hospital, Florida employs three board-certified MFM specialists, with two, Claudia Taboada, DO, FACOOG, and Melanie Mitta, MD, FACOG, based in the Lake Nona area and Thinh Nguyen, MD, in Lakeland. Also on staff is Cheryl Kubas, CGC, a full-time certified genetic counselor with 30 years of prenatal guidance experience. She reviews the family history and genetic screenings for potential inherited disorders. This can help determine if the baby needs care immediately after birth or if there are conditions and symptoms the parents should be aware of as their child grows. The Nemours MFM specialists and genetic 13 counselor tailor these insights to empower patients with the best information, collaboratively develop a plan and support them throughout their pregnancy journey.

16 FLORIDA MD - JANUARY/FEBRUARY 2024

PEDIATRICS WHAT YOU SHOULD KNOW ABOUT PREGNANCY & ADVANCED MATERNAL AGE PREGNANCY AT 35 OR LATER: TIME TO SEE A MATERNAL FETAL MEDICINE SPECIALIST? Many people have successful pregnancies and healthy babies later in life. In fact, more people than ever before are waiting to have children. This includes parents who fall into a category called “advanced maternal age” — a parent who is 35 years or older at the time of their baby’s due date. Advanced maternal age by itself, in an otherwise healthy person free of chronic illnesses like diabetes, obesity, and heart disease, has a good prognosis. However, there are associated risk factors that people of advanced maternal age should be aware of, including: • Spontaneous loss (typically due to diminished egg quality) • Stillbirth • Preeclampsia (dangerously high blood pressure that develops during pregnancy) • Increased likelihood of cesarean delivery (typically due to slow or lengthy delivery) If you have a patient contemplating a pregnancy or is pregnant during an advanced maternal age, you may consider referring them for a consult with a maternal fetal medicine (MFM) specialist. MFM specialists offer guidance from preconception through pregnancy. Some individuals are referred to a MFM specialist by their obstetrician due to: • Advanced maternal age • Maternal history of chronic disease (e.g., lupus, autoimmune disorders, hypertension, diabetes or obesity) • Multiple gestation (twins, triplets) • Prior or recurrent pregnancy loss • Abnormal chromosomes in a prior pregnancy • Abnormal ultrasound findings in current or prior pregnancy To learn more or to refer a patient, call 407.567.3000.  Dr. Taboada with the Brian, Brandi, Braxton and Bailey Jones.

Thinh Nguyen, MD, is chief of the Maternal-Fetal Medicine division. He is board-certified in obstetrics and gynecology and maternal-fetal medicine by the American Board of Obstetrics and Gynecology. He earned his medical degree at the University of Miami School of Medicine. Dr. Nguyen completed a residency in obstetrics and gynecology at the University of Toledo College of Medicine in Ohio and a fellowship in maternal-fetal medicine at St. Louis University School of Medicine. Dr. Nguyen is fluent in English and Vietnamese. Claudia Taboada, DO, FACOOG, is a board-certified maternal fetal medicine specialist. She joined Nemours Children’s from the University of Pittsburgh Medical Center Pinnacle Health where she was the medical director for the department of maternal-fetal medicine. She earned her degree in osteopathic medicine from New York College of Osteopathic Medicine and completed a residency in obstetrics and gynecology at the University of Medicine and Dentistry of New Jersey. Dr. Taboada is fluent in English and Spanish. Melanie Mitta, MD, FACOG, is a board-certified obstetrician-gynecologist and fellow of the American College of Obstetricians and Gynecologists (FACOG). She earned her medical degree at the University of Florida (UF) College of Medicine in Gainesville and continued with a residency in obstetrics and gynecology at UF in Jacksonville, Florida. Dr. Mitta’s fellowship in maternalfetal medicine was completed in Atlanta at Emory University of Medicine. Dr. Mitta is fluent in English and Spanish. Cheryl Kubas, MS, LCGC, is board-certified by the American Board of Genetic Counseling and provides prenatal genetic counseling to families at Lake Nona Medical City and Lakeland Regional Health. She earned a master’s degree in genetic counseling at the University of South Carolina and holds a state license in genetic counseling. Ms. Kubas also has experience in cancer and pediatric genetic counseling. FLORIDA MD - JANUARY/FEBRUARY 2024 17

INFECTIOUS DISEASES

Eat S***...and Live By Akshay Manohar, MD Do you remember that sweet, pungent odor that pierced through your skull as a resident? You wandered through the hallways wondering who on earth managed to convince admin that a skunk qualified as an emotional support animal.

Barely a decade ago, the recommendation was a round or two of treatment with metronidazole. While oral therapy was considered superior, the advantage of this drug is that in an ileus, it can be given intravenously.

Just then, a seasoned nurse stopped you. The person from the nursing home that was put on “Vanc and Zosyn” for the past six days needed an order for a rectal tube for explosive diarrhea. Standing outside the door, you heard the echo of a strong stream of water filling a plastic basin, and the chatter of three techs in disposable gowns changing the robes and the sheets of the poor individual.

Then, the guidelines changed. Oral vancomycin became firstline. The interesting thing about vancomycin is that it does not pass the blood-gut barrier. IV Vancomycin does not enter the gut. Oral vancomycin does not get into the blood. It can a little, but for practical/clinically relevant purposes, let’s say it doesn’t.

That intense smell wafting off the soiled linen burned itself into your memory. The nurse interrupted your thoughts with her diagnosis that she had come up with using only her olfactory senses. You ordered the test to confirm, praying that the patient’s hospital stay had not been long enough to set off alarms in the C-suite. “The hospital will be dinged for this! There has never ever been a nosocomial transmission of C. diff here.” Never. They put up a sign on the door saying, “Soap and Water”. The convenient alcohol pump lost its power to the hardy spores. You cowered when the result came back positive, but thankfully, nobody came to criticize your decision to test. You were able to practice medicine. It’s one of the perks of working on a Sunday. Clostridium difficle is now called Clostridioides difficle. In 2016, a 16S rRNA gene sequence analysis differentiated it from other bacteria in that genus. It was great news for infectious disease doctors like me years before COVID because changing the names of bacteria you read about in school keeps us relevant. Despite our best efforts, the popular abbreviation ‘C. diff’, has not changed, and we still use the term for this gram-positive, spore-forming anaerobic bacillus, cousin of terrible maladies like tetanus, botulism, and the flesh-eating, food-poisoning terror Clostridium perfringens. I like to think of C. diff as a cowardly school bully whose evil lays hidden only due to fears of standing out in front of the bigger kids (gut bacteria). Most carriers of the bacteria are asymptomatic and it is part of the “normal” flora. When the competition is wiped out by an antibiotic, however, C. diff rears its head and reproduces at alarming rates, releasing damaging toxins in the colon. If severe enough, it can cause a dangerous condition called toxic megacolon, where sometimes the only chance of survival is a complete resection of the bowel. A less severe, yet complicated scenario is an ileus where oral therapy cannot reach the site of infection. Most people, however, just have diarrhea. Lots of it. Enough to cause dehydration and the need for admission to administer intravenous fluids. 18 FLORIDA MD - JANUARY/FEBRUARY 2024

More recently, the recommendation for the first line drug was changed to fidaxomicin. This was the cause of much grievance for people involved in budgeting and finances of hospital pharmacies and insurance companies since fidaxomicin was appallingly expensive compared to compounded vancomycin which (depending on the negotiated rate) cost a few cents to a few dollars per dose. The advantage of fidaxomicin over vancomycin (and the reason for its promotion) was that the rate of recurrence was lower than vancomycin and in 2021 the recommendation was made to give fidaxomicin first for the initial mild to moderate infection. For fulminant/severe disease where the serum white blood cell count exceeds 15,000/microL, there is a 50% rise in creatinine, or when a “Zar score” that uses factors like ICU admission, age, presence of pseudomembranes, etc., is equal to or greater than 2, vancomycin becomes first line and is sometimes combined with intravenous metronidazole, especially when there is an ileus. Bezlotoxumab a monoclonal antibody was developed against C. diff Toxin B and it was shown to prevent recurrence. There is one other way to fight C. diff: biological warfare. Many years ago, a hospital I was familiar with came up with a protocol. It involved a kitchen blender and a nasogastric (or preferably an extending deep into the jejunum Dobbhoff) tube through which another person’s stool would be administered to the patient. The biggest hurdle I sensed was getting past the fear of litigation. Stool carries live bacteria, viruses, and parasites. For ID doctors, there is an additional concern of transferring multi-drug resistant bacteria from one person to another. While everyone was fretting about this, there was a lady with cancer who had debilitating diarrhea from recurrent infection. She was so fed up and miserable that when her daughter made a concoction using her own stool heavily masked in something edible, she drank it out of desperation. That fixed the problem better than everything else her providers had done. According to OpenBiome, a stool bank that manufactures an FDA approved “poop pill”, the effectiveness of fecal microbiota transplant is 89% compared to 40% with standard antibiotic therapy.

INFECTIOUS DISEASES The biggest limitation of transplanting stool is our fear of the unknown, and lack of thorough understanding of the human-microbiome relationship. We clearly have an ability to determine their fate, but they too have a significant impact in our survival, and perhaps also our personalities. There were two studies where they took stool from people with depression and transplanted it into mice. The mice developed anxiety and depression. The opposite was seen in a case report where a 79-year-old woman with depression showed improvement and was able to stop antidepressants after receiving the stool of her happygo-lucky grandson. Transplanting microbiota has been shown to cause weight gain, but the golden ticket everyone is trying to find is the bacteria that causes weight loss. Hopefully, it’s cheap. That way you won’t have to fill out another s**tty prior-auth. Akshay Manohar, MD, FIDSA is a board-certified infectious disease physician with 7 years of clinical experience. He is a graduate of Kasturba Medical College, Manipal, India, Capital Health’s internal medicine residency in NJ, and the infectious disease fellowship program at SUNY Buffalo, NY, where he did research on a novel drug target for Acinetobacter baumanii and hypervirulent Klebsiella. In his new clinic, Centaur Medical Center, in Orlando, he strives to create a space for people to be comfortable in what can be an intimidating situation. He is fluent in English, Tamil, Hindi, Kannada and has an intermediate proficiency in Spanish. 

Akshay Manohar, MD, FIDSA • Centaur Medical Center 100 W Gore St, Suite 605•Orlando, FL 32806 (407) 271-4731 • www.CentaurMedical.org

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FLORIDA MD - JANUARY/FEBRUARY 2024 19

Important Criteria for Selecting Medical Office Space By Frank Ricci, Healthcare Realty & Development Services LLC One of the most important investments your practice will ever make is the location of your medical practice. In this article, we will discuss several key elements to consider when selecting medical office space and some of the tools the experts use. In assessing possible locations, it is important to consider the following factors: 1. Accessibility: The location should be easily accessible to patients, staff, and emergency services. This includes convenient access via major roads, public transportation, and ample parking. Building accessibility for people with disabilities is also important as is a covered drop off area, especially here in Florida. In evaluating a potential location, we utilize maps, site plans, and a visual inspection. 2. Visibility and Signage: Depending on your practice, a highly visible location with good signage might attract more patients. High visibility areas are typically those with high foot or vehicle traffic. We use Google Maps and Florida Department of Transportation data to analyze traffic and traffic patterns and Placer AI to analyze foot traffic. 3. Demographics of the Surrounding Area: A thorough understanding of your patients is crucial and matching that information with the markets available is the key to optimizing your decisions. The age, income levels, and healthcare needs of the local community need to align with the services you provide. We use tools like ESRI to research demographic data including age distribution, income levels, and health profiles of a region which we use to identify locations with a high potential patient base. 4. Proximity to Hospitals and Other Providers: Being near hospitals, other medical facilities and other providers can be beneficial for referrals, shared services, and patient convenience, especially for specialists. You should complete an internal survey of your key referral patterns and identify those practices and specialties with which you have symbiosis Use this information in your search and analysis. 5. Competition and Market Saturation: Understanding the level of competition and market saturation in the area is just as important as knowing which referral patterns benefit your practice. A market with too much competition may offer fewer opportunities for growth. Using state health records, you can plot these providers on a map to help delineate areas with the greatest opportunities. 6. Size and Layout: Your space should be sized to accommodate current needs and allow for future growth. The layout should adhere to the principles of Evidence Based Design for comfort, staff & patient flow, privacy and infection control. Complete a space program analysis to identify required spaces and sizes to determine your space requirements. 7. Infrastructure and Technological Capabilities: Today’s medical offices are able to provide services in-house unheard of even 20 FLORIDA MD - JANUARY/FEBRUARY 2024

a decade ago due to advancing technology but in order to use these technologies, adequate infrastructure is required. This will include structural integrity, ample and steady power, reliable internet connectivity and adequate mechanical systems. 8. Building Amenities and Local Services: Facilities such as elevators, security, maintenance, and janitorial services can impact the functionality and perception of your office. Additionally, amenities such as a gift or coffee shop, restaurant, grocery store, personal services, etc. as part of the building or in close proximity offer benefits to both patients and staff. 9. Environment and Atmosphere: A location that offers a pleasant and professional environment can significantly enhance the patient experience. This includes considerations like natural light, noise levels, furnishings and overall aesthetics. 10. Space Terms and Cost: The ownership and financial aspects must be carefully analyzed, including whether to own or lease. Financial details such as sales price, down payment, tax impact, utilities, lease cost, lease terms and the potential for rent increases must be carefully evaluated to ensure they align with your financial plans. A detailed cost/benefit analysis should be performed to determine the financial parameters and risks. 11. Available Properties: A thorough inventory of available properties must be conducted for evaluation. There are a multitude of online searchable databases that list available properties, including Loopnet, CoStar, Crexi, TotalCommercial and many others. Use this as a base from which to start your search but not all property that is available or might be available is accessible through these sites. Actual site and location visits are required to provide an accurate and thorough inventory of prospective sites. In summary, the selection of medical office space is a multifaceted decision that requires balancing important practical considerations, market opportunities, patient and staff convenience and financial viability. Due to the many variables involved and the tools required, it is often in your best interest to enlist a specialist to help evaluate your needs, analyze the various market opportunities and to help you select the best possible location for your specific practice. Frank Ricci is a licensed real estate broker and Managing Partner of Healthcare Realty & Development Services LLC based in Winter Park, Florida. Frank has specialized in medical real estate for over 30 years and been involved in the leasing and sales of over $200 million worth of properties. For more information, contact Frank at 407-947-5074, FrankR@healthcarerealtyonline.com or visit healthcarerealtyonline.com. 

2024

EDITORIAL CALENDAR

Florida MD is a monthly medical/business digital magazine for physicians.. Florida MD is emailed directly to healthcare providers in Orange, Seminole, Flagler, Volusia, Osceola, Polk, Brevard, Lake and Indian River 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.

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