Florida MD July 2015

JULY 2015 • COVERING THE I-4 CORRIDOR

Cardiovascular Surgeons, P.A. Passion for Excellence, Innovation and Personalized Care

The promise of innovation.

Pediatric interventional radiology allows us to reach new frontiers in treating children with serious illness. Used as an alternative to traditional surgery — or in combination with it — this hybrid “diagnostics-meets-treatment” specialty delivers life-changing outcomes for patients with vascular anomalies of the blood and lymphatic system, developmental structural problems, tumors and other complex conditions.

With our commitment to innovation and the least invasive pediatric treatments possible, Nemours Children’s Hospital offers the only dual-trained, board-certified pediatric diagnostic and interventional radiologists in Florida — and the region’s only dedicated pediatric interventional suite.

Because of its precision, image-guided therapies greatly reduce the chance of collateral damage to tissue. Even targeted chemotherapy is now possible. And with our Clarity IQ technology, procedures offer dramatically reduced X-ray doses.

Equipped with advanced 3-D tools that produce real-time images, applications of pediatric IR include: • • • • •

insertion of central lines (in even the tiniest newborns) draining difficult-to-reach abscesses gastrostomy tube placement tumor or organ biopsies treating venous, lymphatic or arteriovenous malformations and certain types of hemangiomas • using radiofrequency ablation, cryoablation and lasers to destroy tumors

For questions about pediatric interventional radiology at Nemours Children’s Hospital, contact us at (407) 567-3427.

To refer a patient, call (407) 650-7715 or visit Nemours.org/PatientReferrals.

Craig Johnson, DO Division Chief

Fabiola Weber-Guzman, MD Interventional Radiologist

Your child. Our promise.

contents 4

JULY 2015 COVERING THE I-4 CORRIDOR

 COVER STORY

Cardiovascular Surgeons, PA, (CVS) is recognized as a premiere practice for specialized and technologically advanced treatment of complex cardiac, thoracic and vascular diseases.

PHOTO: DONALD RAUHOFER / FLORIDA MD

“Patients come to CVS for routine cardiovascular problems, as well as for first and second opinions from throughout the state of Florida,” says Kevin D. Accola, MD, president of CVS. Throughout its 44-year history, the Orlando-based group has performed more than 86,000 cardiac procedures. The group performs more than 2,200 surgeries annually. CVS currently consists of six board certified surgeons having a collective 180 years of surgical experience.

“Our volume and results underscore the world-class care provided. There is no need to travel far distances for cardiac surgical care,” Dr. Accola says. He describes the “ripple effect” of a broadening awareness that is bringing patients to CVS in Orlando from throughout Florida and the southeastern United States.

ON THE COVER: Standing left to right.

Dr. Jorge E. Suarez-Cavelier, Dr. Bradley S. Litke; Dr. Kevin D. Accola, Dr. George J. Palmer, III and Dr. Tomas D. Martin Missing is Dr. Clay Burnett

PHOTO: DONALD RAUHOFER / FLORIDA MD

17 CIN SOUND TO GOOD TO BE TRUE? BEWARE THE TROJAN HORSE 22 ADVANCED PEDIATRIC INTERVENTIONAL RADIOLOGY AT NEMOURS CHILDREN’S HEALTH SYSTEM

DEPARTMENTS 2

FROM THE PUBLISHER

3

HEALTHCARE LAW

10 PULMONARY & SLEEP DISORDERS 12 CANCER 14 MARKETING YOUR PRACTICE 16 ORTHOPAEDIC UPDATE 18 BEHAVIORAL HEALTH

20 DIGESTIVE AND LIVER UPDATE

FLORIDA MD - JULY 2015

1

FROM THE PUBLISHER

I

am pleased to bring you another issue of Florida MD. When I was a boy, I used to love to play outside and get dirty. God bless my poor mother, may she rest in peace. I guess that boy still lives

on inside the man because that’s still what I like to do. If there’s a boy or girl inside of you too that likes to play hard and doesn’t mind getting a little messy, there’s an incredibly fun event coming up that you should consider. It’s called Mud Volleyball and it benefits the March of Dimes. What could be better?

Form a team with your friends, your family or your co-workers and come out August 22nd for some down and dirty fun and good times for a great cause. I hope to see some of you there.

Best regards,

Donald B. Rauhofer Publisher

FOR MORE INFORMATION ON THE MUD VOLLEYBALL EVENT OR THE MARCH OF DIMES PLEASE CALL: Phone: (407) 599-5077 Fax: (407) 599-5870 Central Florida Division 555 Winderley Place, Suite 105 Maitland, FL 32751 Volunteers or call (407) 876-6699 ext. 233 COMING UP NEXT MONTH: The cover story is about Dr. Gharagozloo and the new Thoracic Surgery Program at Celebration Health. Editorial focus is on Sports Medicine and Robotic Surgery.

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Reprints of cover articles or feature stories in Florida MD are ideal for promoting your company, practice, services and medical products. Increase your brand exposure with high quality, 4-color reprints to use as brochure inserts, promotional flyers, direct mail pieces, and trade show handouts. Call Florida MD for printing estimates.

Email press releases and all other related information to: info@floridamd.com

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Publisher: Donald Rauhofer Photographer: Donald Rauhofer / Florida MD Contributing Writers: Heidi Ketler, Daniel T. Layish MD, Sergio Larach, MD, Sajid Hafeez ,MD, Smitha Pabbathi, MD, Mary Ann Morgan, PhD, Bryan Bognar, MD, Fabiola C. Weber-Guzman, MD, David Doyle, Julie Tyk, Marni Jameson, Jennifer Thompson, Corey Gehrold 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 2012, Sea Notes Media. All rights reserved. Reproduction in whole or in part without written permission is prohibited. Annual subscription rate $45.

HEALTHCARE LAW

Anatomy of a Florida Department of Health Complaint

By David Doyle and Julie Tyk Department of Health (Department) Complaints are common and originate from a wide variety of sources. Complaints come from patients, family members, Notices of Intent in medical malpractice claims and Code 15 Reports hospitals are required to submit to the Department.

Typically, a physician receives a letter from the Department including a copy of the complaint. The physician has 45 days to submit a written response to the complaint. Upon receipt of the letter, a physician should contact their professional liability carrier as insurance policies often provide coverage for administrative actions. Under no circumstances should a physician submit a response to the Department or speak with its investigator without seeking legal advice.

A physician, with the assistance of counsel, should submit a written response to the complaint. This initial response, if done properly and thoroughly, is the physician’s best chance to, in the immortal words of Deputy Barney Fife, “nip it in the bud.” The response should provide all relevant information and records for the Department in an easily understandable manner since investigators usually have no medical training. Counsel can also submit a summary of the physician’s defense, as well as an expert affidavit in support of the physician’s treatment.

During the investigation, the investigator may request an interview. Physicians under investigation are not required to submit to an interview. However, if a physician agrees to an interview, he should only do so with counsel present.

Once the initial investigation is complete, the investigator prepares a report for The Probable Cause Panel (the Panel). The Panel reviews the investigator’s report and any information the physician submitted to determine if probable cause exists that the physician violated any Florida Statute or rules.

If the Panel finds no probable cause, the case is dismissed, and the matter is not a public record. The Panel may also elect to issue a Letter of Guidance, which is neither public record nor considered formal discipline. The case will be dismissed after the Letter of Guidance is issued.

If the Panel finds probable cause, a formal Administrative Complaint is prepared by the Department. The Administrative Complaint outlines the charges against the physician. A physician typically has three options: 1) dispute the charges and request a formal hearing; 2) stipulate to the Department’s proposed settlement; or 3) attempt to negotiate a settlement with the Department’s attorney.

If a physician elects a formal administrative hearing, an admin-

istrative judge will hear the case. Both sides can call witnesses, experts and submit evidence. The judge will prepare a written decision called a recommended order. The order is submitted to the Board of Medicine where a final order is entered. The final order may be appealed.

A Department Complaint can have far reaching implications on a physician’s medical license. The Health Care Practice Group at GrayRobinson is committed to assisting Clients in navigating and defending Department Complaints. For more information and assistance, please contact David Doyle and Julie Tyk at GrayRobinson.

David Doyle

Julie Tyk

David O. Doyle, Jr. is a shareholder and civil trial lawyer, concentrating his practice in medical malpractice defense litigation, insurance defense litigation and health care law.

He can be reached at david.doyle@gray-robinson.com or 407-244-5651.

Julie A. Tyk, JD, is an attorney in the Health Care Practice and Litigation Practice Groups with GrayRobinson, P.A. 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. She may be contacted by calling (407) 244-5694; julie.tyk@gray-robinson.com or by visiting www. gray-robinson.com. 

Be sure and check out our website at www.floridamd.com!

COMING UP NEXT MONTH: The cover story is about Dr. Gharagozloo and the new Thoracic Surgery Program at Celebration Health. Editorial focus is on Sports Medicine and Robotic Surgery.

FLORIDA MD - JULY 2015 3

COVER STORY

Cardiovascular Surgeons, P.A. – Staying Ahead of the Curve with Passion for Excellence, Innovation and Personalized Care

By Heidi Ketler Cardiovascular Surgeons, PA, (CVS) is recognized as a premiere practice for specialized and technologically advanced treatment of complex cardiac, thoracic and vascular diseases.

“Patients come to CVS for routine cardiovascular problems, as well as for first and second opinions from throughout the state of Florida,” says Kevin D. Accola, MD, president of CVS. Throughout its 44-year history, the Orlando-based group has performed more than 86,000 cardiac procedures. The group performs more than 2,200 surgeries annually. CVS currently consists of six board certified surgeons having a collective 180 years of surgical experience.

“Our volume and results underscore the world-class care provided. There is no need to travel far distances for cardiac surgical care,” Dr. Accola says. He describes the “ripple effect” of a broadening awareness that is bringing patients to CVS in Orlando from throughout Florida and the southeastern United States.

CVS began as a progressive, cutting-edge practice in 1970, performing the region’s first coronary artery bypass surgery. “At

PHOTO: DONALD RAUHOFER / FLORIDA MD

Dr. Accola and Mike Butkus, PA discuss upcoming TAVR case.

4 FLORIDA MD - JULY 2015

the time, there were very few cardiac surgeons, and there was an enormous backlog of patients who would benefit from the relatively new bypass procedure,” says George J. Palmer III, MD, who joined the practice in 1995.

Additionally, CVS surgeons introduced the region’s first mitral valve repair and replacement program, pioneered minimally invasive rapid-deployment aortic valve replacements and ushered in the first heart transplantation and mechanical cardiac-assist program in central Florida. More recently, CVS began utilizing advanced percutaneous and minimally invasive techniques for aortic valve replacement in high-risk or medically inoperable patients using transcatheter aortic valve replacement (TAVR).

CVS has been involved in state-of-the-art clinical research for innovative valve and mechanical cardiac assistance devices for decades, and the physicians all participate in ground-breaking research, serving as recognized experts for up-to-date presentations, both regionally as well as internationally. As such, CVS physicians have served as primary investigators on numerous United States

COVER STORY Food and Drug Administration (FDA) and continue to be active in research and teaching for new techniques and devices for cardiac and thoracic procedures. “Research is integral to our group culture. It improves the medical care available to our patients, and helps in training new physicians. Each of us works to advance the science and knowledge base of our specialty,” Dr. Accola says.

SPECIALIZED SURGEONS COLLABORATE AND EDUCATE PHOTO: DONALD RAUHOFER / FLORIDA MD

Kevin D. Accola, MD Dr. Accola specializes in treating patients with degenerative valve diseases through performing mitral and aortic valve repairs and replacements, tricuspid valve repairs and replacements and transcatheter aortic valve replacement (TAVR). He performs more than 500 valve surgeries annually.

To stimulate ongoing innovation, Dr. Accola led development of the Valve Center of Excellence in conjunction with Florida Hospital Cardiovascular Institute. He has since served as its medical director. “With more than 270 transcatheter aortic valve replacements per year, Florida Hospital Valve Center of Excellence has one of the highest volumes in the state, with exceptional results,” says Dr. Accola, who leads the way.

Dr. Burnett and patient discuss complexities of CABG to be performed.

Dr. Palmer’s practice is one of the busiest laser lead extraction programs in the southeastern United States, with referrals coming from throughout the regions. “Consider that there are two million active lead patients in the United States and several thousand procedures being done on a monthly basis. Add to that the rapid growth of central Florida, especially with the expanding retiree population, and the need is great for implantable cardiac devices, like pacemakers, and the management of their complex lead issues,” says Dr. Palmer.

failures, is in high demand. As the volume of patients with lead complications rose, “many in our local community had leads that needed attention, but they weren’t sure where to turn for good, safe care. That’s where CVS has thrived,” says Dr. Palmer.

Recognizing the need, Dr. Palmer “developed a collegial effort from the electrophysiology cardiology, infectious disease and cardiovascular surgery experts, with enhanced outcomes for a team approach to these vexing and complex clinical problems,” he says.

Jorge E. Suarez-Cavelier, MD Dr. Suarez-Cavelier, a native of Columbia, trained in Houston, Texas, and Charlotte, N.C., before joining CVS in 1998. He was instrumental in developing the open-heart surgery program at Osceola Regional Medical Center, in Kissimmee. He is now centered at Florida Hospital in Orlando and has been a foundational member of the TAVR team at Florida Hospital along with Dr. Accola. In addition to TAVR expertise, he specializes in cardiac, vascular, valvular and thoracic procedures.

Dr. Suarez’ breadth of experience and outstanding outcomes are instrumental in his high-visibility and extraordinary patient satisfaction within the Florida Hospital community. In addition to his busy clinical practice, he serves as chairman of the Department of Cardiac Surgery at Florida Hospital, providing strong leadership for the highest-volume cardiac surgery program in the state of Florida.

Bradley S. Litke, MD

Given the growing complexity of the electronic devices and their widespread use, expertise in handling the complications of these devices, such as industry recalls, lead infections and device

Dr. Litke joined CVS in 2014 after more than 15 years of cardiac surgery practice in Volusia County. In addition to cardiac and valvular procedures, Dr. Litke brings specialized minimally

Not only does the center work to bring new technology to the region, but it is a vibrant educational venue for visiting surgeons from around the world to observe new valvular applications. Dr. Accola takes his expertise across country and abroad, lecturing and performing surgeries as a visiting professor in institutions as far away as South America, India and Asia, among other places.

George J. Palmer III, MD Dr. Palmer is an expert in the clinical management of cardiovascular implantable electronic devices, transvenous lead extraction and electrophysiology. His cardiovascular practice also encompasses valvular, coronary and thoracic surgeries.

FLORIDA MD - JULY 2015

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COVER STORY invasive expertise, with both video-assisted thoracic surgery (VATS) and robotic thoracic procedures, such as lung resections, mediastinal explorations and less-invasive thymectomy operations. The value of video and robotic thoracic operations is still evolving, with early studies demonstrating less post-surgical pain, faster recovery time, shorter hospital stays, reduced blood loss and excellent outcomes.

Dr. Litke is the director of cardiac surgery at Central Florida Regional Medical Center in Sanford and has quickly accelerated both the volume and quality metrics at the center. Additionally, he is an active consultant for the newly established Trauma Program at Sanford, providing the expertise for patients suffering from thoracic injuries.

Clay M. Burnett, MD Dr. Burnett completed his general surgery training nearby at the University of South Florida in Tampa, before joining the prestigious cardiovascular surgery-training program at The Texas Heart Institute (THI) under the direction of Denton A. Cooley, MD. In addition to the cardiac surgery residency program, Dr. Burnett completed a Cardiac Transplantation and Mechanical Assist Device Fellowship at THI. During his intensive training at MD Anderson Cancer Center in Houston, Dr. Burnett developed a strong interest in the surgical treatment of lung cancer. After his training, Dr. Burnett returned to his undergraduate alma mater to become the director of transplantation at East Carolina University Medical Center in Greenville, N.C.

In addition to cardiac surgery, Dr. Burnett has continued his strong interest in thoracic oncology, with experience developing several multidisciplinary thoracic tumor boards at prior hospitals, and he is involved in the Thoracic Tumor Conference already in place at Florida Hospital.

Tomas D. Martin, MD Dr. Martin trained at the prestigious Baylor College of Medicine Medical Center in Houston, spending additional training time with the renowned cardiovascular pioneer, E. Stanley Crawford, MD, before completing his thoracic training at the University of Florida in Gainesville. After his training he began the Aortic Surgery program at Emory University in Atlanta for several years before being lured back to Gainesville to lead a new aortic surgery center of excellence at UF. He spent the next 25 years developing and growing the center into a regionally and nationally recognized center specializing in complex cardiovascular and thoracic diseases, performing more than 300 complex aortic surgeries annually.

Dr. Martin is recognized for aneurysm repair, and open and endovascular approaches for complex thoracic and thoracoabdominal aneurysms, with an emphasis on the entire spectrum of aortic disease states. His innovative practice includes the largest experience with the most difficult cases, such as connective tissue disorders like Ehler-Danlos and Loeys-Dietz syndromes

Dr. Martin recently joined CVS merging his complex practice with the extraordinary team of nurses, physicians and specialDr. Burnett joined CVS in 2014 after nearly 25 years of experiists already within the Florida Hospital Orlando family. “Florida ence and brings with him a strong interest in adult cardiac surHospital Orlando is one of a few hospitals in the state capable of gery, including aortic aneurysm repair, valve replacement and retaking care of our patients who are among the most complicated pair procedures and complex coronary artery bypass operations. in any system. Here, we have the expertise and resources in place to continue producing outstandDr. Suarez and Dr. Martin review and discuss an ascending aortic aneurysm. ing outcomes, and adding expertise to the CVS program has helped complete all levels of care found in premier national centers of cardiovascular surgery,� Dr. Martin says.

ADVANCED COMPLEX CARDIOVASCULAR PROCEDURES

PHOTO: DONALD RAUHOFER / FLORIDA MD

Studies have shown that technically advanced cardiovascular surgeries are more likely to be successful when performed by specialized surgeons in experienced referral medical centers. Cardiovascular Surgeons, PA has kept pace with the advances and often leads as principal investigators in groundbreaking medical devices, such as ventricular assist devices, electrophysiological pacing and defibrillator devices and innovative rapidly deployed valve replacements.

6 FLORIDA MD - JULY 2015

COVER STORY

Aortic stenosis is the most common heart valve disorder in the developed world, primarily affecting those older than 65 years old. The cause is usually calcification and fibrosis of a previously normal tricuspid aortic valve or a congenital bicuspid valve.

The symptoms are progressive, usually starting as a loss of exercise endurance, with more severe valvular stenosis leading to chest pain (angina), loss of consciousness (syncope) and congestive heart failure (CHF) when the valve becomes critically stenosed.

Conventional surgery to replace diseased valves is the most commonly employed approach, but, with an aging and more complex patient population, surgical risks can be prohibitively high for frail elderly patients with multiple medical problems.

In 2011, the FDA approved TAVR as an option for these frail patients.

In this procedure, the valve is replaced from either the groin or through a small chest incision, without the use of a heart-lung machine for temporary support. Eliminating the need for a sternotomy incision and use of a heart-lung machine allows for faster recovery and less complications in selected patients. Though short-term TAVR outcomes and survival rates are comparable to conventional approaches, complications still occur, including higher rates of stroke, vascular complications and perivalvular leak as compared to traditional valve operations.

PHOTO: DONALD RAUHOFER / FLORIDA MD

TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR)

CVS Staff prepare for daily clinic.

ENDOVASCULAR CARDIAC LEAD MANAGEMENT With more cardiovascular implantable electronic devices in use in older patients with more complex medical comorbidities, safe removal of complicated leads has become a critical component of specialized care. The primary reason for removal is infections.

“We see infections almost every day,” says Dr. Palmer.

Lead failure or recall for industry reasons is another reason for extraction. Despite the rapidly improving technology, design flaws can shorten the device lifespan, with some failure from deteriorating electronics nearing 20 percent during a 10-year period.

Lead extraction, particularly for older leads with significant endovascular scar tissue, can be difficult and risky and requires considerable skill and experience, as well as a complete team to care for these technically complicated procedures.

MITRAL VALVE REPAIR TO TREATMENT MITRAL INSUFFICIENCY

EARLY ANEURISM DETECTION AND TREATMENT

Longstanding mitral insufficiency (MI) is a significant cause of cardiovascular morbidity and mortality. It is now recognized that mitral valve repair is generally favored over mitral valve replacement for patients with degenerative mitral valve disorders, yielding excellent long-term outcomes with preservation of heart function and avoidance of long-term anticoagulation.

Abdominal aortic aneurysm is a common condition and the most common type of aneurysm, occurring in approximately one in 20 men over the age of 60 who have ever smoked. Rupture of these aneurysms has a mortality rate of 80 percent and causes 9,000 deaths per year in the United States.

“Patients with mitral valve insufficiency need to be evaluated by an experienced surgeon with training in all repair techniques who also is an expert in precisely interpreting echocardiograms that are the basis of determining successful repair. In those cases, in the hands of an experienced repair surgeon, patients can expect successful repair of 98 percent of all degenerative valves, with freedom from re-operation within 20 years at more than 90 percent. Here at Florida Hospital, we are proud of our regionally recognized superior outcomes,” says Dr. Accola.

The aortic diameter to consider elective surgical therapy varies depending on the cause of the aneurysm, the presence of a connective tissue disorder, age and other medical conditions and associated aortic valve problems. For aneurysms that are 5.5 centimeters and greater, it is generally accepted that the risk of rupture exceeds the risk of surgery, so elective surgery may be advised.

Regardless of size, surgical repair is warranted for aneurysms that have ruptured, those that rapidly enlarge (1 centimeter per year), those that are the source of emboli or those that cause pain and tenderness, which may indicate impending rupture.

FLORIDA MD - JULY 2015

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COVER STORY Open surgical repair is well established as a definitive treatment, having been in use for more than 50 years. In recent years, however, endograft therapy has overtaken open repair in frequency of use, particularly in older, high-risk patients or patients unfit for open surgery.

PHOTO: DONALD RAUHOFER / FLORIDA MD

Open surgery continues to be preferred, especially for young patients. “In an open operation, once the aorta is fixed (using the patient’s native tissue), it’s fixed,” says Dr. Martin. “In young patients, endovascular procedures require follow up for a long time, and some worry about the radiation exposure of multiple CTs.”

ROBOTIC SURGERY Minimally invasive cardiothoracic surgical techniques are reducing the impact of traditional surgery approaches and can return patients to their active lives more quickly. These innovative techniques also are giving some patients who otherwise might have no surgical options a chance at surgery with the hope of improved life expectancy.

In particular, robotic surgery for non-cardiac thoracic disease, such as lung cancer, biopsies and thymectomy, is a growing field and CVS, under the leadership of Dr. Litke, has added this option for patients. “For tumors less than 3 centimeters and for removal of diseased thymus glands, robotic surgery is ideal. For less ideal circumstances, other minimally invasive tools, such as videoscopy-assisted thoracoscopy using miniature cameras and incisions, can often be used,” says Dr. Litke.

“All in all, there are more tools utilizing minimal incisions that are available, and CVS is committed to helping develop the optimal use of these exciting new options for patients referred to our practice,” says Dr. Litke.

ADVANCED CARE WITH A PERSONAL TOUCH In the clinic and in the surgical suite, the professional confidence of CVS surgeons to improve – and save – lives is delivered with a personal touch. Dr. Accola calls it “compassionate cardiac care on a person-to-person basis.”

It is evident from the first patient contact, when a staff person rather than a digital voice recording answers the phone. “We have such an awesome team of people. I think that the strength of our group is the many years of experience and cohesiveness of the partners, physician assistants, mid-level providers and nurses,” says Dr. Palmer. “The administrative and support staff members are not only exemplary individuals, but they are hard-working professionals who have been with us for many years. They are an extension of our surgical philosophy of compassionate care,” echoes Dr. Accola.

“We’ve created a group structure that is – even from an administrative standpoint – very advanced. Our staff ‘goes the extra mile’ for our patients by proving a personal touch when scheduling procedures, obtaining insurance authorization, and answering questions they may have about their upcoming surgery.

“It is our practice commitment to continue to provide up world-class cardiothoracic surgery, while endeavoring to maintain a family-oriented community practice that truly cares about our patients and their families,” says Dr. Accola.

8 FLORIDA MD - JULY 2015

The docs left to right are: Dr. Jorge E. Suarez-Cavelier, Dr. Bradley S. Litke; Dr. Kevin D. Accola, Dr. George J. Palmer, III and Dr. Tomas D. Martin. Missing is Dr. Clay Burnett.

To speak with one of the CVS surgeons or staff and to refer a patient, call (407) 425-1566. More information also is available online at www.cvsorlando.com. 

COMPLEX ADULT CARDIOVASCULAR AND THORACIC PROCEDURES INCLUDING: • Coronary Artery Bypass Graft • Aortic Valve Repair and Replacement • Mitral Valve Repair and Replacement • Tricuspid Valve Repair and Replacement • Aortic Aneurysm Resection • Aortic Dissection Repair • Redo Cardia Procedures • Laser Lead Extraction • Robotic Thoracic Surgeries • Transcatheter Aortic Valve Replacements (TAVR) • Mitral Clip Procedures • Mediastinoscopy/Lung Biopsy • Pacemaker/AICD implantation • Pulmonary/Lung Resection

CARDIOVASCULAR SURGEONS, P.A. 217 Hillcrest Street, Orlando, FL 32801 407-425-1566 • www.cvsorlando.com

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FLORIDA MD - JULY 2015

9

PULMONARY AND SLEEP DISORDERS

Halotherapy

By Daniel T. Layish, MD, FACP, FCCP, FAASM

The word Halotherapy comes from the Greek word “halos” meaning salt. While the potential benefits and therapeutic nature of salt has been known for centuries, it was not until the early 1800’s that the underground salt mines throughout Eastern Europe were noted to benefit various respiratory conditions. As the workers were mining the salt in these climate-enriched chambers, dry salt particles would be inhaled into the respiratory system.

The dry salt was discovered to be super absorbent, anti-bacterial and anti-inflammatory. Soon people with various conditions were spending time in these salt mines. In the mid-1900’s the Russians began working on a technology to replicate the dry salt particles in the air and developed the first halogenerator, a device that grinds pure sodium chloride into precise particles (several microns in diameter) and disperses the dry salt into a climate controlled room or chamber. This was the start of modern Halotherapy, which has been utilized for several decades throughout Eastern Europe and has begun to expand into many other countries including the United States and Canada. The small particle size is felt to be important to allow penetration deep into the lungs, since larger particles will simply be deposited in the nose, throat or large airways. The air in a halotherapy chamber is also filtered to remove contaminants and the temperature and humidity are well controlled.

As a pulmonologist, I initially became familiar with halotherapy through my care of individuals with Cystic Fibrosis. Cystic Fibrosis is a genetic disorder characterized by dehydration of the respiratory epithelial surface, resulting in impaired mucociliary clearance. In this disorder, thick tenacious secretions obstruct the lower airway and sinuses and provide an environment for chronic infection. Nebulized hypertonic saline has been shown (in well done randomized clinical trials) to improve pulmonary function and respiratory symptoms as well as reduce pulmonary exacerbation rate in individuals with cystic fibrosis. This may be referred to as “wet” salt therapy as opposed to halotherapy which is “dry” salt therapy. Nebulized hypertonic saline can sometimes cause bronchospasm, and not all patients can tolerate this therapy even when premedicated with a bronchodilator. In cystic fibrosis, halotherapy has some theoretical advantages over nebulized hypertonic saline. The prolonged duration of therapy (typically a 45-minute session) appears to be associated with a much lower incidence of bronchospasm then is seen in the setting of nebulized hypertonic saline. In addition, in the halotherapy mode of administration the salt particles are delivered to both the sinuses and the lower respiratory tract. After seeing anecdotal benefit in our patients with cystic fibrosis, we performed a clinical study, which confirmed that this therapy was well tolerated and the patients derived symptomatic benefit in terms of their sinus complaints. Other studies are planned to study this therapy further in individuals with cystic fibrosis.

The fundamental defect in cystic fibrosis is related to chloride transport and therefore there is a strong rationale for halotherapy in this particular disease. Anecdotally, I have seen patients with other respiratory diseases derive significant benefit from Halo10 FLORIDA MD - JULY 2015

therapy including bronchiectasis, chronic bronchitis, chronic sinusitis and allergic rhinitis. The hypothesis is that Halotherapy may help with respiratory illnesses by liquefaction of airway secretions thereby enhancing expectoration. There seems to be very little risk to this therapy other than the financial and time investment. There is certainly a theoretical basis for the possible benefit of halotherapy, given the known antiinflammatory and anti-infective properties of salt.

Currently, halotherapy is not covered by medical insurance companies. However, it is hoped that this may change as research is planned to try to prove the benefits that many patients have reported. Many halotherapy institutions offer a monthly pass that can make therapy more affordable than purchasing individual sessions. There is also an effort to develop systems that can deliver halotherapy in the home setting, avoiding the need to travel to a salt room. This is important since many people do not live close to a halotherapy center. It is worth noting that many patients have also noticed benefits in non-respiratory conditions, particularly dermatalogic conditions such as acne and psoriasis and research is planned in this area as well.

References available upon request. I would like to thank Leo Tonkin and Ulle Pukk for reviewing this manuscript.

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. Dr. Layish serves as the medical advisor for the Salt Room Orlando and also sits on the board of the Salt Therapy Association. He may be contacted at 407-841-1100 or by visiting www.cfpulmonary.com. 

FLORIDA MD - JULY 2015 11

CANCER

Focusing on Cancer Survivorship: How Moffitt Leads the Way in Care for Those Transitioning from Patient to Survivor

By Smitha Pabbathi, MD, Mary Ann Morgan, PhD and Bryan Bognar, MD There are more than 14 million cancer survivors in the United States. As that number continues to grow, the need for programs that provide resources and assistance for adult cancer survivorship has become particularly important. Survivorship is a significant milestone for cancer patients and should be a reason for rejoicing.

The Survivorship Program at Moffitt Cancer Center honors this passage but acknowledges survivors have unique needs after they have successfully completed treatment. Many questions regarding their future care begin to surface. Patients fear the path forward with regards to ongoing surveillance and the re-integration with the primary care physician. They want to be sure they are followed correctly for their cancer history. Moffitt’s Survivorship Program understands this complexity and focuses on delivering patient centered survivorship care.

Moffitt’s Survivorship Program began in 2010 and focuses on four pillars of survivorship care identified by the Institute of Medicine in the 2006 report, From Cancer Patient to Cancer Survivor: Lost in Transition. Those pillars are: • Prevention of recurrent and new cancers, and other late effects; • Surveillance for cancer spread, recurrence or second cancers; assessment of medical and psycho-social late effects; • Intervention for consequences of cancer and its treatment, including physical and psychological/social distress for survivors and caregivers; • Coordination or bridging care between specialists and primary care providers so all health needs are met.

The Survivorship Clinic providers work collaboratively with

the medical and radiation oncologists and surgeons. The clinic follows patients who have no evidence of disease after they have completed their treatment. When the oncologist or surgeon feels the patient has a low risk for recurrence, he or she is referred to survivorship clinic. The patient can then be followed when he or she feels it is appropriate to transition. Consultation with the oncologists and surgeon occurs following this transition, as indicated. The majority of the patients followed in the Survivorship Clinic are survivors of breast, prostate, gastrointestinal and genitourinary malignancies, but the clinic also sees patients who have had lymphomas and other types of cancers.

When patients transition to the survivorship clinic, they are provided with a personalized Survivorship Care Plan. This document, which includes a treatment summary and an individualized care plan, empowers the patient and their families to better understand their diagnosis, treatment and surveillance needs in the future. It also gives them all the information necessary to update their community physicians, so together they can be vigilant at monitoring for potential long-term or late effects of their treatment. The Survivorship Care Plan is a new standard set by the Commission on Cancer. Moffitt is accredited by the Commission for its delivery of quality care.

Moffitt’s Survivorship Clinic and its providers want to maximize the quality of life of survivors. They have discussions with each survivor about overall wellness, including nutrition, weight and exercise, cancer prevention, screenings for cancers and genetic counseling. They also assess for distress and psychosocial needs, and provide patients with resources and tools to successful manage any issues.

For more information on Moffitt’s Survivorship Clinic, please call 813-745-4630.

12 FLORIDA MD - JULY 2015

CANCER The providers of the Survivorship program are:

Survivorship Clinic Staff (pictured left to right): Smitha Pabbathi, MD, FACP; Samantha Roberts, MA; Mary Ann Morgan, PhD, FNP-BC; Bryan Bognar, MD, MPH, FACP; and Lucy Adkins, RN.

Dr. Mary Ann Morgan is a nurse practitioner and serves on the National Comprehensive Cancer Network (NCCN) Survivorship Guidelines Committee. She recently presented to the Nurses Program at the annual NCCN conference March 2015. She is published in cancer survivorship.

Dr. Smitha R. Pabbathi is the new medical director for our Survivorship Program and is rapidly developing expertise in survivorship care. She in an Oncology Hospitalist Physician at Moffitt and has cared for patients across their cancer trajectory.

Dr. Bryan Bognar was our former medical director and he continues to follow Survivorship patients in the clinic. He is the current Vice Dean of Educational Affairs at Morsani College of Medicine. He has been appointed to the steering committee for a three-year term, beginning with the 2016 Cancer Survivorship Symposium: Advancing Care and Research and ending after the 2018 Symposium. This steering committee is made up of representatives from the American Society of Oncologists, American College of Physicians, and the American Family Practice Physicians. 

COMING UP NEXT MONTH: The cover story is about Dr. Gharagozloo and the new Thoracic Surgery Program at Celebration Health. Editorial focus is on Sports Medicine and Robotic Surgery.

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FLORIDA MD - JULY 2015 13

MARKETING YOUR PRACTICE

Healthgrades Introduces Data License Agreement for Provider Profile Management

By Jennifer Thompson The world of online reputation management is ever-changing and requires constant updates and attention. Well, here’s the latest change to be aware of.

While managing your physicians on sites like Vitals, Healthgrades and RateMDs it is important to be aware when big changes are coming to prevent your doctors from falling through the cracks. The last thing you want is to be caught on the outside looking in when someone posts a negative review about you.

Healthgrades recently implemented a new strategy to protect your physicians’ information by limiting who has access to it.

In other words, it’s becoming tougher and tougher for you or a third party to go into Healthgrades and claim or update your physician’s profile. You may have noticed this if you recently tried to log into your Healthgrades account and saw the pop-up that states “Our User Agreement and Privacy Policy Have Changed.” as denoted here by the obnoxious pink arrow on the screenshot.

update their information on Healthgrades. We’re pretty certain it’s also a contract to protect Healthgrades from possible litigation for posting information about physicians online without actually getting permission from the physicians themselves.

Previously, Healthgrades requested not only NPI numbers but also license numbers, birthdays and DEA numbers in order to claim the physicians.

WHAT YOU NEED TO KNOW This new Data License Agreement needs to be signed by an office manager at your practice and then counter-signed by a Healthgrades representative. When you send the signed version back to them, don’t try sending only the signature page. The lawyers want all 10 pages of the agreement.

Once the practice has signed on the dotted line and been counter signed, you can now send Healthgrades a spreadsheet of your providers and your account will be created or updated. This part is kind of nice because you no longer have to go in one-byone to update profiles.

WHY DID HEALTHGRADES UPGRADE THEIR USER AGREEMENT? Healthgrades claims that this is to protect physician (and so do their lawyers and to some extent… and we like the idea of increased protection too). However, the reality of it is that we now have yet another step in the process for doing our job of maintaining physician profiles on these websites that nobody even asked to be on in the first place.

The latest hurdle is the implementation of a Data License Agreement (downloadable at DrMarketingTips.com for your convenience). Essentially, it’s a contract used to verify your affiliation with the physician and give you permission to access and 14 FLORIDA MD - JULY 2015

You may be thinking to yourself, ‘Phew, I’m covered because all of my physicians are already claimed on Healthgrades.”

Not so quick. We work with a lot of physicians and private practices and just because you were claimed and all verified last week, doesn’t meant that’s the case this week. In fact, we’ve no-

MARKETING YOUR PRACTICE ticed quite a few physicians who were deleted from rosters because they were not verified (or because they haven’t signed the new Data License Agreement with Healthgrades).

Your next step is to schedule a meeting with your office manager to go over the new agreement. If you are the office manager, go ahead and download the agreement below so you can sign it and get it to your Healthgrades representative as soon as possible. In no time you will have access to all of your physicians under one account. Then you can sit back and wait for the next change, which is sure to be coming soon.

Looking for more ways to attract and retain more patients? Check out DrMarketingTips.com for free articles, webinars, ebooks, audio blogs and more for your practice.

Jennifer Thompson is co-founder and chief strategist for DrMarketingTips.com, a website designed to help medical marketing professionals market their practice easier, faster and better.

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ORTHOPAEDIC UPDATE

Live Surgery Event Offers Glimpse Into Operating Room

By Corey Gehrold Attendees of this year’s Workers’ Compensation Educational Conference are invited to attend the 8th Annual Orlando Orthopaedic Center Live Surgery Event on Tuesday, August 25 from 8:45 - 9:45 a.m.

WHAT IS THE LIVE SURGERY EVENT? The Live Surgery Event is a live, interactive look into an operating room with two of Orlando Orthopaedic Center’s surgeons, Lawrence S. Halperin, M.D., and Bradd G. Burkhart, M.D. Orlando Orthopaedic Center’s Steven E. Weber, D.O., will moderate the procedures and provide step-by-step explanations dissecting what’s taking place on-screen. Attendees will even be able to ask questions to the surgeons live as they complete their respective procedures. Everyone at the conference is encouraged to attend.

WHAT PROCEDURES WILL BE PERFORMED? This year’s live surgery event will showcase two very different, but relatively common, workers’ compensation surgeries: De Quervain’s tendinosis and rotator cuff repair. Dr. Halperin, a hand and upper extremity specialist, will perform the De Quervain’s tendinosis surgery followed by Dr. Burkhart, a sports medicine, knee and shoulder specialist, performing the rotator cuff repair.

To complete the procedures, Dr. Halperin and Dr. Burkhart will use the latest techniques to ensure each patient experiences: • Less pain • Faster recovery time • Shortened rehabilitation schedules • Smaller scars De Quervain’s tendinosis - When the tendons around the base of the thumb become irritated or constricted, a diagnosis of De Quervain’s tendinosis may be administered by a hand and upper extremity specialist. This swelling of the tendons often creates pain and tenderness along the thumb side of the wrist, which is particularly noticeable when forming a fist or attempting to grip an object.

Once all nonsurgical methods have been exhausted, surgery to cut the tendon sheet, and thus create more room for irritated tendons, is recommended. This is an outpatient procedure and the patient goes home later the same day. Once healed, full function of the hand can resume once comfort and strength levels have returned.

Rotator cuff repair - A rotator cuff repair involves reattaching the head of the humerus to the shoulder tendon when all nonsurgical methods of treatment have been prescribed and failed.

During the Live Surgery Event, Dr. Burkhart will use a minimally 16 FLORIDA MD - JULY 2015

invasive all-arthroscopic method to repair the rotator cuff.

This method of surgery involves inserting an arthroscope into the shoulder joint. The images returned from the camera are used to guide small surgical instruments to complete the procedure. This is an outpatient procedure and the patient goes home later the same day. Once rehabilitation is complete, shoulder strength and motion should return to what they were prior to injury.

Lawrence S. Halperin, MD

Bradd G. Burkhart, MD

ABOUT ORLANDO ORTHOPAEDIC CENTER This is the eighth year Orlando Orthopaedic Center has presented the Live Surgery Event. Since 1972 the practice has grown to include six locations, a state-of-the-art outpatient surgery center and 20 board certified physicians across multiple orthopaedic subspecialties. To learn more about Orlando Orthopaedic Center, visit OrlandoOrtho.com. 

CIN Sound to Good to Be True?

Beware the Trojan Horse

By Marni Jameson Many of you will be approached, if you haven’t already been, by one or more hospitals inviting you to join their Clinically Integrated Network Though not new ventures, CINs have become more popular as a result of Obamacare, which fuels the alignment of doctors and hospitals in ways that allegedly reduce cost, waste and inefficiencies. How that gets achieved is debatable, but CINs are an attempt.

These networks include both hospital-employed doctors, and independent ones who don’t want to work for the hospital.

At the Association of Independent Doctors, we have had an opportunity to review privileged documents that list the terms of agreement for several networks, and urge caution. What may sound like a great deal on the surface bears closer inspection.

Before you agree to participate in any CIN, consider these 10 points.

1. Who benefits? Ask what is in this for the hospital? Clearly, the hospital can negotiate very effectively for themselves and their employed physicians. So why now does the hospital want independent doctors to enroll? What is in it for you? If you think the hospital is going to negotiate better rates for you, jump to No. 5.

2. History and track record. When was the last time an arrangement the hospital presented truly benefited independent doctors in the long run? Why is this any different? Be suspicious.

3. Who controls the decisions? A CIN board will make every decision, action, and determination for the network, including terms and conditions of contracts with payors. Look closely at the agreement to see how this board is formed, and who appoints its members. Although this board must be “physician led” by definition, the CIN will likely remain under the hospital’s control.

4. How do independent doctors get protected? The hospital will likely make sure employed doctors dominate the CIN board, and thus influence the decisions and votes of those employed board members. Sure, a few token independent doctors may be on the board, but they won’t form a majority.

5. What about your existing contracts? A close reading of the agreements reveals that, theoretically, the CIN could force doctors to terminate contracts they have with payors, and prohibit doctors from negotiating future payor contracts, especially if those existing contracts include beneficiaries covered by the CIN’s contracts. Independent doctors may not have the option to get paid at the more favorable rates they have negotiated on their own. Again, the CIN negotiates these contracts, not you.

6. How could joining impact your fees? The CIN Board could also negotiate higher reimbursement rates for the hospital and the hospital’s employed physicians, and pay for that by lowering reimbursement rates to independent physicians.

7. What’s the payoff if you’re more efficient than the pool? When has a hospital ever gotten more efficient as it grew? Just as hospitals’ bundled payment programs neutralize doctors’ efficiencies by combining them with hospitals’ inefficiencies, which independent doctors can’t control, the new dynamic also dilutes any gains independent doctors realize by becoming more efficient.

8. How will joining the CIN impact your overhead? Your overhead costs will likely go up. As an independent provider, you will still pay for your current overhead – such as electronic medical records, administrative, billing and collection costs -- plus you will subsidize the same costs for the CIN. 9. Who owns your patients’ data? Once you join a CIN, the hospital will have access to your patients’ demographics and health information, and could data mine the records. Even if you leave the network, they will have your patients’ information.

10. Show me the papers. Be wary of hospitals that arrange lots of meetings for doctors telling them why they should join the CIN, but have no operating agreements available for review.

Without the paperwork, the agreement is just talk. That talk likely portrays the CIN as a win-win for doctors and hospitals alike, but the devil is in the details. Be highly suspicious of any agreement that the hospital wants you to “hurry up” and sign without allowing time for your attorney or CPA to review it. In short, beware the Trojan horse.

Marni Jameson is the executive director for the Association of Independent Doctors. You may reach her at 407865-4110 or marni@aid-us.org. 

FLORIDA MD - JULY 2015 17

BEHAVIORAL HEALTH

Planning for Psychiatric Care

By Sajid Hafeez, MD Author Alan Lakein once said, “Planning is bringing the future into the present so that you can do something about it now.”

When it comes to acute psychiatric care, all members of the treatment team know their roles; they are experienced and are able to quickly assess and adapt general treatment plans to a wide assortment of clinical admitting diagnoses. In a perfect world, every patient could be admitted, stabilized, and sent home with no fear or relapse in 3 days time. However, the world is not perfect and no matter how well-thought out the basic plan of treatment, there will always be unforeseen factors and limitations that must be taken into consideration to create the best possible outcome for the patient.

Limitations to ideal treatment come in many regularly seen forms: intellectual, emotional, chronological, financial, and environmental. A truly experienced treatment team has encountered these limitations time and time again and has developed their own preferred methods to help the patients navigate around these road blocks, as well as teaching them how to navigate them on their own once they discharge.

While some patients may be highly intelligent and function-

ing, it may not necessarily be the case for all patients. Unfortunately, there are many who have not developed the expanded reasoning so that they are adequately equipped to manage the stressors of life. For some this might be educational, for others it might be in relation to IQ level, or emotional readiness. It becomes important for the therapists to understand the nature of these limits so that they are able to adapt different therapeutic strategies to help the patients develop coping skills to manage these stresses. It might be a treatment plan that is more basic and focuses on simple skills like expressing feelings in a different way, or using a context that the patient is more familiar with in order to draw a parallel by example. In group therapy, this patient may also benefit from sessions with an alternative group rather than a main group who may be talking about concepts over that person’s head.

A frequent limitation is the outside environment. Some patients, when admitted, seem perfectly stable and adjusted because they are living in a highly controlled environment and able to leave the stressors of the real world on the other side of the door.

Without preparing them on how to handle these stressors, they may become rapid readmissions quickly after being discharged.

While the treatment team has an influence of the patient, they typically have no influence over the patient’s outside factors. So it is vitally important for the team to keep this into consideration when developing a ORTHOPAEDIC lasting plan. If patients lack transportation, SUBSPECIALTIES they are unable to make appointments. If • SPINE patients are being abused, and that situa• ELBOW tion is not dealt with appropriately, then • FOOT & ANKLE nothing has changed. The treatment team • HAND & WRIST will work with outside agencies such as • HIP protective services and caseworkers to en• KNEE act a plan of action to manage these exter• ONCOLOGY nal influences.

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On a long enough time scale, any team could take a patient from unstable to stable. The trick is discerning what is most therapeutically needed into the reduced time frame that is covered by insurance.

Many patients have limited funds or are lacking them all together. If finances are the impetus for their admission, adding to that debt in exchange for services becomes a risky gambit. The treatment team understands that accurate documentation allows

BEHAVIORAL HEALTH the doctor more options to negotiate for coverage on behalf of the patient. In expressing the dire need of acute care and the likelihood of failure if cut short, the team is able to advocate for coverage and time, allowing the patient more opportunities to gain tools for success.

Many times, the doctor may know that for the patient’s condition, a specific medication has a high degree of success. Yet, there is no purpose for the doctor to start the patient on a medication that he or she could not afford after discharge. So the doctor must have a general idea of which medications are covered by which insurance companies. Some will only authorize generic while others will only authorize brand medications. In truth, the generics and brand medications are not always the same as there are often different standards in clinical efficacy. So it isn’t as simple as saying “if not this, than that will work.” So the doctor must stay educated on the most recent studies and data of all medications if he or she is to provide the best care within the limitations.

While there are times that many of these limiting factors can seem insurmountable, there is always a way around them. It just takes a seasoned team to know the hidden paths and tricks to help deliver the best route around them. So too does this experience in dealing with these limitations further allow the health care professionals further refine what is most appropriate for a successful stabilization.

Sajid Hafeez, M.D., is a child and adolescent psychiatrist who is serving as a Medical Director of the Acute Care Baker Act Unit at the University Behavioral Center. He also served as the Center’s Medical Director of the long term Residential Units: ASAPP Unit (for adolescent boys with inappropriate sexual behaviors), Solutions Unit (for adolescent boys with behavior problems), Promises and Stars Unit (for adolescent females with behavioral problems as well as victims of sexual abuse), and Discovery Unit (for children ages 5-13 with behavioral as well as inappropriate sexual problems). In addition, Dr. Hafeez also Served as an Assistant Professor of Psychiatry at the University of Central Florida (Voluntary Position). He was also the Chief of the Adolescent Psychiatry Unit, an Attending Psychiatrist of the Comprehensive Psychiatry Emergency Program and of the Mobile Crisis Team at the Westchester Medical College. At Vassar Brother’s Medical Center in New York. Dr. Hafeez was the Director of Outpatient Child & Adolescent and Adult Psychiatric Clinic as well as Director of Consultation and Liaison Psychiatry. Dr. Hafeez received his adult Psychiatry and Residency Training at the University of Kansas Medical Center in Kansas City. He received his Child and Adolescent Psychiatry fellowship training at the New York Medical College New York and at Children’s National Medical Center of George Washington University in Washington, DC. Dr. Hafeez can be reached at 407-2817000 or by visiting www.universitybehavioral.com.

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FLORIDA MD - JULY 2015 19

DIGESTIVE AND LIVER UPDATE

Pelvic Floor Dysfunction-Part 2

By Sergio Larach, MD This article was written in two parts. Part one covered Pelvic Floor Dysfunction: Definition, Diagnosis, and Treatment. And it was published in the May edition. Part two is published here and will cover Bowel Incontinence: Definition, Cause, and Treatment Options.

BOWEL INCONTINENCE WHAT IS INCONTINENCE? Incontinence is the impaired ability to control gas or stool. Its severity ranges from mild difficulty with gas control to severe loss of control over liquid and formed stools. Incontinence to stool is a common problem, but often it is not discussed due to embarrassment.

WHAT CAUSES INCONTINENCE? There are many causes of incontinence. Injury during childbirth is one of the most common causes. These injuries may cause a tear in the anal muscles. The nerves supplying the anal muscles may also be injured. While some injuries may be recognized immediately following childbirth, many others may go unnoticed and not become a problem until later in life. In these ¬situations, a prior childbirth may not be recognized as the cause of incontinence.

Anal operations or traumatic injury to the tissue surrounding the anal region similarly can damage the anal muscles and hinder bowel control. Some individuals experience loss of strength in the anal muscles as they age. As a result, a minor control problem in a younger person may become more significant later in life.

Diarrhea may be associated with a feeling of urgency or stool leakage due to the frequent ¬liquid stools passing through the anal opening, If bleeding accompanies lack of bowel control, this may indicate inflammation within the colon (colitis), a rectal tumor, or rectal prolapse - all conditions that require prompt evaluation by a physician.

HOW IS THE CAUSE OF INCONTINENCE DETERMINED? An initial discussion of the problem with your physician will help establish the degree of control difficulty and its impact on your lifestyle. Many clues to the origin of incontinence may be found in patient histories. For example, a woman’s history of past childbirths is very important. Multiple pregnancies, large weight babies, forceps deliveries, or episiotomies may contribute to muscle or nerve injury at the time of childbirth. In some cases, medical illnesses and medications play a role in problems with control.

A physical exam of the anal region should be performed. It may readily identify an obvious injury to the anal muscles. In addition, an ultrasound probe can be used within the anal area to provide a picture of the muscles and show areas in which the anal muscles have been injured.

20 FLORIDA MD - JULY 2015

Frequently, additional studies are required to define the anal area more completely. In a test called anal manometry, a small catheter is placed into the anus to record pressure as patients relax and tighten the anal muscles. This test can demonstrate how weak or strong the muscle really is. A separate test may also be conducted to determine if the nerves that go to the anal muscles are functioning properly.

WHAT CAN BE DONE TO CORRECT THE PROBLEM? Treatment of incontinence may include: • Dietary changes • Constipating medications • Muscle strengthening exercises • Biofeedback • Surgical muscle repair • Artificial anal sphincter.

Sacral Neuromodulation ( Interstim), injectables (Solesta) After a careful history, physical examination and testing to determine the cause and severity of the problem, treatment can be addressed. Mild problems may be treated very simply with dietary changes and the use of some constipating medications. Diseases which cause inflammation in the rectum, such as colitis, may contribute to anal control problems. Treating these diseases also may eliminate or improve symptoms of incontinence. Sometimes a change in prescribed medications may help. Your physician also may recommend simple home exercises that may strengthen the anal muscles to help in mild cases. A type of physical therapy called biofeedback can be used to help patients sense when stool is ready to be evacuated and help strengthen the muscles.

Injuries to the anal muscles may be repaired with surgery. Some individuals may benefit from a technique that delivers electrical energy to the skin and muscles surrounding the anus which results in firming and thickening of this area to help with continence.

In certain individuals that have nerve damage or anal muscles that are damaged beyond repair, an artificial sphincter may be implanted. The artificial sphincter is a plastic, fluid filled doughnut that is surgically implanted around the damaged anal sphincter. This artificial sphincter keeps the anal canal closed. When an individual wants to have a bowel movement, the fluid can be pumped out of the doughnut to allow the anal canal to open.

The InterStim® Therapy System is a surgically implanted device used to help a patient reduce the number of bowel accidents (fecal incontinence). The InterStim® Therapy System has several components: a neurostimulator which delivers an electrical pulse to the sacral nerve; an electrical lead that is implanted on a sacral nerve, and a programmer that is used to control the electrical pulse delivered by the neurostimulator. The neurostimulator and the lead are permanent implants.

Solesta is a gel that is given through 4 injections into the wall of

DIGESTIVE AND LIVER UPDATE the anal canal. It helps give more control by bulking up the tissue in the anal canal. The injections do not usually cause pain and anesthesia is not necessary.

In extreme cases, patients may find that a colostomy is the best option for improving their quality of life.

If a patient has pelvic health issue, don’t hesitate to learn more about treatment options, seek out an expert evaluation, at our center, we have state-of-the-art technology for physiologic testing and a multidisciplinary approach to patients with complex pelvic floor disorder REFERENCES

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Jennifer Speranza, MD, FACS, FASCRS, on behalf of the ASCRS Public Relations Committee© 2012 American Society of Colon & Rectal Surgery National Institute of Child Health and Human Development (NICHD) a unit of the National Institutes of Health (NIH).

Sergio Larach, MD completed his fellowship at the University of Texas Medical School. He is board certified in colon and rectal surgery. His interests include the whole spectrum of colorectal issues, and his addition to our practice will involve colonoscopies, anorectal diseases and pelvic floor evaluations. Dr. Larach is fluent in Spanish.

He has held multiple professional appointments through his career, including Program Director of Orlando Health’s and Florida Hospital’s Colon and Rectal Fellowship Programs. Dr. Larach is currently a Clinical Associate Professor at University of Central Florida and Clinical Associate Professor at Florida State University.

Dr. Larach has also published numerous articles on colon and rectal surgery, conducted clinical research, and authored book chapters in his specialty.

He has been instrumental in the development of the TAMIS procedure for the treatment of rectal cancers.

He is the Associate Director of International Advisory Affairs of the International Society of University Colon and Rectal Surgeons and is also a reviewer for the Surgical Endoscopy journal.

To contact Dr. Sergio W. Larach, please call Digestive and Liver Center of Florida at 407-384-7388. 

FLORIDA MD - JULY 2015 21

Advanced Pediatric Interventional Radiology at Nemours Children’s Health System

By Fabiola C. Weber-Guzman, MD When people think of interventional radiology (IR), they often think of tiny tubes snaked into the heart or brain by an interventional radiologist subspecialized in one area or the other.

That’s typical of adult IR, but pediatric IR is a whole-body specialty providing access almost anywhere in the body with minimal trauma, relatively low risk and very short recovery times.

Whether we’re working on an image-based diagnosis, a biopsy or a therapeutic intervention such as blocking the blood supply to a vascular anomaly, IR is usually the least invasive approach available. At times, a pediatric IR procedure will provide so much new information that the working diagnosis must be revised. My experience at Nemours Children’s Hospital (NCH) reinforces the perspective that pediatric IR is a head-to-toe specialty, since it’s common to go from a patient with a vascular malformation in the face to one with an anomaly in the leg.

In pediatric IR we work hand-in-hand with our referring physicians to discuss IR alternatives when there’s a need to collect diagnostic information or apply treatment. Which IR techniques might benefit a pediatric patient may not be immediately obvious; the possibilities vary on a case-by-case basis and change as technology evolves, so we welcome inquiries.

The management of a deep vein thrombosis (DVT) in the leg or thigh of a teenager is a great example. It’s common to treat with anticoagulant drugs only, but while waiting for the drugs to take effect and dissolve the clot, swelling may continue and cause tissue damage. If the clot lasts long enough, it may prompt the development of collateral circulation, which may produce swelling and chronic pain after the clot has dissolved.

IR techniques can improve the chances for a good, long-term outcome. We can place a filter in the inferior vena cava to protect the heart and lungs from clot movement, and then advance a catheter into the clot and perfuse it with a thrombolytic agent, or use a saline jet or ultrasound to disintegrate the clot while suctioning away the debris.

The procedure and equipment costs are greater than anticoagulation therapy alone, but quick removal of the thrombus can reduce the length of hospital stay and the potential for future problems requiring ongoing treatment. Recovery times are negligible, and patients and parents love that! We don’t stop there, though. We work and interact in a multidisciplinary environment. In the case of an unexplained DVT, we’ll work with our colleagues in hematology to determine the cause and the best 22 FLORIDA MD - JULY 2015

practice for prevention.

Even for routine procedures like line placements, the potential for IR techniques to make things easier on patients is very significant.

We frequently use these techniques to insert vascular access ports and tunneled lines, and use similar techniques for lumbar punctures for CNS chemotherapy access. Without pediatric IR, central line placements like those we’ve performed on 900-gram premature babies would be possible only with surgical dissection.

In addition to offering many alternatives, pediatric IR can also change outcomes. For patients with osteoid osteomas, surgical excision often results in considerable pain and weakened bone structure. In IR, we can overheat the osteoma with a radiofrequency ablation tool, or freeze it with a cryogenic one — both modalities kill and shrink the osteoma. The patient typically goes home the same day and has only mild discomfort for a couple of days.

Because pediatric IR can offer advantages in treating many different kinds of tumors, we participate in multidisciplinary tumor board conferences. Even when IR techniques are not curative, they can still be very helpful. For palliative treatment of malignancies in non-surgical candidates, cryoablation is often an effective and much appreciated tool.

We can do a lot for cystic fibrosis patients too. For a patient with a bronchial artery hemorrhage, bleeding can be extensive.

Coughing up blood is especially unsettling to the patient and family. Rather than waiting for the natural clotting process to stop the bleeding, we use IR techniques to locate and plug the bleeding vessel. The treatment offers the patient and family a prompt resolution of the problem and reduces the duration of the patient’s and family’s anxiety and concern.

As the number of options and applications for interventional radiology in children is growing, the associated levels of radiation exposure are falling. We recently upgraded our fluoroscopy equipment so it can support new protocols that reduce radiation doses by 50–75 percent of the previously required exposure. In all of our techniques, we maintain the ALARA principle of radiation dosing: As low as reasonably achievable.

Despite all the great IR technology available, ranging from coils to lasers, we never forget that the equipment is just expensive gear if it’s not used as part of a plan focused on what’s best for the patient. To better answer the questions of what techniques to use,

when to use them and for which patients, we continue research.

I’m interested in sclerotherapy agents and work to determine which of the commonly used agents (doxycycline, metal coils, detergent or cyanoacrylate glue) works best, alone or in combination. Through our research and that of others, we’re always learning. We’ve learned, for example, that a fibro-adipose venous anomaly (FAVA) is particularly resistant to sclerotherapy. Surgical removal of FAVAs requires removal of muscle, so we’re still looking for better IR tools to help treat FAVAs. Recent research indicates some FAVAs may be susceptible to cryoablation, so this offers a new option to consider for our patients who have these complex and often painful vascular anomalies.

NCH has the only two dual-trained board-certified pediatric diagnostic and interventional radiologists in the state. We are leading Central Florida in maximizing the opportunities for better patient care using IR, while reducing the risks of radiation exposure and invasive interventions. Other hospitals in the region have recognized the value of our expertise and have helped us extend our reach to their patients by granting emergency privileges to us. Through sustained teamwork, research and care, we’re improving the lives and futures of children throughout the region.

Fabiola C. Weber-Guzman, MD, is a pediatric interventional radiologist who earned her medical degree at the Ponce School of Medicine and Health Sciences and completed an internship and residency at University Hospitals Richmond Medical Center and a diagnostic radiology residency at the Medical College of Georgia. She completed fellowships in pediatric radiology and pediatric interventional radiology at Boston Children’s Hospital. Dr. Weber-Guzman is board-certified by the American Board of Radiology and is fluent in English and Spanish. She may be contacted by calling (407) 567-4609.

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COMING UP NEXT MONTH: The cover story is about Dr. Gharagozloo and the new Thoracic Surgery Program at Celebration Health. Editorial focus is on Sports Medicine and Robotic Surgery.

Be sure and check out our website at www. floridamd.com!

> WELCOME RITU WALIA, MD < — Pediatric Gastroenterologist — The Digestive and Liver Center of Florida is pleased to announce the addition of a pediatric gastroenterologist to our practice. Dr. Walia is Board-Certified in Pediatrics and specialized in Pediatric Gastroenterology.

Her interests include Acid Reflux, Inflammatory Bowel Disease (IBD), Abdominal Pain, Chronic Constipation/Impaction, Motility Disorders and Irritable Bowel Syndrome (IBS). She also specializes in Fecal Transplants for the treatment of Recurrent C.difficile Infections in Children.

Please join us in welcoming Dr. Ritu Walia to our community.

RAVENHEART GRAPHIC DESIGN • ILLUSTRATION • PHOTOGRAPHY •

407-292-6609 • 407-414-3359

To schedule an appointment, call 407-384-7388.

Accepting New Patients • www.dlcfl.com

Compassionate, Caring, and Sophisticated Medical Care

FLORIDA MD - JULY 2015 23

24 FLORIDA MD - JULY 2015

2015

EDITORIAL CALENDAR

Florida MD is a four-color monthly medical/business magazine for physicians in the Central Florida market.

Florida MD goes to physicians at their offices, in the thirteen-county area of Orange, Seminole, Volusia, Osceola, Polk, Flagler, Lake, Marion, Sumter, Hardee, Highlands, Hillsborough and Pasco counties. Cover stories spotlight extraordinary physicians affiliated with local clinics and hospitals. Special feature stories focus on new hospital programs or facilities, and other professional and healthcare related business topics.

Local physician specialists and other professionals, affiliated with local businesses and organizations, write all other columns or articles about their respective specialty or profession. This local informative and interesting format is the main reason physicians take the time to read Florida MD. It is hard to be aware of everything happening in the rapidly changing medical profession and doctors want to know more about new medical developments and technology, procedures, techniques, case studies, research, etc. in the different specialties. Especially when the information comes from a local physician specialist who they can call and discuss the column with or refer a patient. They also want to read about wealth management, financial issues, healthcare law, insurance issues and real estate opportunities. Again, they prefer it when that information comes from a local professional they can call and do business with. All advertisers have the opportunity to have a column or article related to their specialty or profession.

JANUARY –

Digestive Disorders Diabetes

FebRUARY –

Cardiology Heart Disease & Stroke

MARCH –

Orthopaedics Men’s Health

ApRil –

Surgery Scoliosis

MAY –

Women’s Health Advances in Cosmetic Surgery

JUNe –

Allergies pulmonary & Sleep Disorders

JUlY –

imaging Technologies interventional Radiology

AUgUST –

Sports Medicine Robotic Surgery

SepTeMbeR – pediatrics & Advances in NiCU’s Autism OCTObeR –

Cancer Dermatology

NOveMbeR – Urology geriatric Medicine / glaucoma DeCeMbeR – pain Management Occupational Therapy

Please call 407.417.7400 for additional materials or information.

FLORIDA MD - JULY 2015 33

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Because when you have what it takes to fight to save lives, youâ&#x20AC;&#x2122;re amazing.

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