Florida MD July/August 2022

JULY/AUGUST 2022 • COVERING THE I-4 CORRIDOR

Leading the Wave, One of America’s Best Neurologists; Now Serving Florida and Beyond!

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JULY/AUGUST 2022 COVERING THE I-4 CORRIDOR

 COVER STORY

Epilepsy is one of the most common neurological disorders that causes unprovoked, recurrent seizures. A seizure is a sudden rush of abnormal electrical activity in the brain. Anyone can develop epilepsy, but it’s more common in young children and older adults. In adults aged 65 and older, the most common causes for new-onset epilepsy are ischemic stroke, neurodegenerative conditions such as dementia, tumors, and trauma. Nearly 25% of new-onset epilepsy occurs in the elderly.

With an average prevalence of 1%, sixty-five million people around the world have epilepsy. Three million four hundred thousand of those people are in the United States, and about 224,000 of them are in Florida. In addition, one in 26 people in the United States will develop epilepsy at some point in their lifetime. One-third of epilepsy patients live with uncontrolled seizures despite taking seizure medications. Six out of ten people with epilepsy have been unable to identify the cause of it. There are two main types of epilepsy: generalized epilepsy, which may affect the whole brain at the same time, and focal (or partial) seizures, which originate in one part of the brain and may spread to nearby areas, or even the entire brain.

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CANNABIS IS NOT A GATEWAY DRUG

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CATCHING MULTIPLE SCLEROSIS EARLY

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THE BENEFITS OF COMPREHENSIVE NEUROSCIENCE CARE

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TRENDS IN COMPREHENSIVE ORTHOPEDIC CARE

PHOTO: PROVIDED BY FALCON ADVANCED NEUROLOGY & EPILEPSY FREEDOM CENTER

ON THE COVER: JAIVIR S. RATHORE, MD, FAES, OFFERS COMPREHENSIVE EPILEPSY CARE AT FALCON ADVANCED NEUROLOGY & EPILEPSY FREEDOM CENTER IN ORLANDO, FLORIDA.

DEPARTMENTS 2

FROM THE PUBLISHER

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DERMATOLOGY

10

PULMONARY AND SLEEP DISORDERS

14

PEDIATRICS

16

MARKETING YOUR PRACTICE

FLORIDA MD - JULY/AUGUST 2022

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FROM THE PUBLISHER

I

am pleased to bring you another issue of Florida MD. Human trafficking is one of the horrors in today’s society. It’s modern day slavery and Central Florida is one of the worst places in the country. I have asked Paving the Way, an organization headquartered here in Central Florida that helps physicians spot signs that one of their patients could be a victim. Please check out their website and help put a stop to human trafficking..

Best regards,

Donald B. Rauhofer Publisher

According to Homeland Security, there are over 300,000 children a year trafficked in the United States. In fact, Florida ranks 3rd in the county for calls to the National Trafficking Hotline and right here in Central Florida, Orange county ranks 2nd in the state for child trafficking case. Sadly, the average age of entry is 11-14.

Those facts can be frightening, leaving most people asking, who am I to do anything about this? More importantly, what can I do?

Paving The Way Foundation was created to provide answers to those questions. We’ve educated over 13,000 youth, parents, teachers, and community leaders about human trafficking, the impact it has on families and the actions to take to prevent it.

A surprising statistic is 88% of trafficking victims reported being in a medical setting for various concerns but did not feel safe enough to ask for help. We can prevent that from happening by training our frontline teams to learn the signs of trafficking, understand grooming and recruitment tactics and how to engage with patients about this silent crime to get them to safety.

Here is one action you can take right now: put the National Trafficking Hotline number in your phone, 888-3737888, you can call 24 hours a day, 7 days a week.

To learn more about what you can do or ways to get involved in ending human trafficking we invite you to join in the fight, please go to our website, www.pavingthewayfoundation.org click on programs for information on what’s available to educate you and your staff or download one of our tool kits. Together we can disrupt the cycle of human trafficking.

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Publisher: Donald Rauhofer Photographer: Donald Rauhofer / Florida MD Contributing Writers: John “Lucky” Meisenheimer, MD, Daniel T. Layish, MD, Amy Gutierrez, MD, FAAN, Michael Jablonski, MD, Christian Rosado, MD, Adela Casas-Melley, MD. Omar Cruz-Diaz, MD, Abishek Seth, MD, Sonda Eunus, MHA, Michael Patterson NHA, OTR/L, CEAS, John Meisenheimer, VII Art Director/Designer: Ana Espinosa Florida MD is published by Sea Notes Media,LLC, P.O. Box 621856, Oviedo, FL 32762. Call (407) 417-7400 for more information.

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FLORIDA MD - JULY/AUGUST 2022

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COVER STORY

Leading The Wave, One of America’s Best Neurologists; Now Serving Florida & Beyond!

By Paul J. Watkins

EPILEPSY FREEDOM CENTER AT FALCON ADVANCED NEUROLOGY, A FLORIDIAN CENTER OF EXCELLENCE IN COMPREHENSIVE EPILEPSY CARE. Epilepsy is one of the most common neurological disorders that causes unprovoked, recurrent seizures. A seizure is a sudden rush of abnormal electrical activity in the brain. Anyone can develop epilepsy, but it’s more common in young children and older adults. In adults aged 65 and older, the most common causes for new-onset epilepsy are ischemic stroke, neurodegenerative conditions such as dementia, tumors, and trauma. Nearly 25% of newonset epilepsy occurs in the elderly.

With an average prevalence of 1%, sixty-five million people around the world have epilepsy.Three million four hundred thousand of those people are in the United States, and about 224,000 of them are in Florida. In addition, one in 26 people in the United States will develop epilepsy at some point in their lifetime.

One-third of epilepsy patients live with uncontrolled seizures despite taking seizure medications. Six out of ten people with epilepsy have been unable to identify the cause of it. There are two main types of epilepsy: generalized epilepsy, which may affect the whole brain at the same time, and focal (or partial) seizures, which originate in one part of the brain and may spread to nearby areas, or even the entire brain.

If a seizure doesn’t affect consciousness, it’s called “focal aware,” Dr. Rathore received the prestigious Fellow of the American Epilepsy Society (FAES) designation in 2021.

previously known as “simple partial seizure.” If a seizure affects consciousness, it’s called “focal unaware,” previously known as “complex partial seizure.” Seizures can either be convulsive or non-convulsive, and at times, especially in critically ill ICU patients, seizures may be happening inside the brain without any obvious outward signs except altered mental status or comatose state. These are called “subclinical seizures.” Most seizures last one to two minutes, but sometimes, they may go on for several minutes. One episode of seizure or a cluster of seizures lasting more than five minutes without the patient returning to baseline is a life-threatening condition called “status epilepticus.”

Epilepsy causes people to have repeated seizures, but not everyone who has a seizure has epilepsy. Low blood glucose or sodium level, alcohol withdrawal, illicit drugs, infections, certain medications, or fever (especially in children) can also cause seizures.

Other problems, such as anxiety, conversion disorder/psychogenic non-epileptic seizures (PNES), or fainting spells, can cause events that look like seizures. As a result, patients are sometimes subjected to unnecessary medications and procedures. Therefore, accurate and timely diagnosis and treatment are of paramount importance.

STATE-OF-THE-ART CARE Since 2007, Epilepsy Freedom Center at Falcon Advanced Neurology in Orlando has been providing leading-edge diagnosis and treatment of all types of epilepsy and sleep disorders.

PHOTO: PROVIDED BY FALCON ADVANCED NEUROLOGY & EPILEPSY FREEDOM CENTER

“Epilepsy can be due to a variety of reasons across the age spectrum, starting from newborn babies to elderly adults,” says Falcon Epilepsy Freedom Center’s medical director and neurologist-in-chief Jaivir S. Rathore, MD, FAES. “DocJ,” as he’s known, is triple board certified in neurology, epilepsy, and clinical neurophysiology.

He’s among the select few neurologists in the entire state of Florida to have received the prestigious Fellow of the American Epilepsy Society (FAES) designation in 2021 for his distinguished career and more than a decade of clinical, research, and leadership contribution to the field of epilepsy and neurology. Dr. Rathore is a Member of the American Academy of Neurology (AAN) and the Continuing Medical Education (CME) Committee for the American Epilepsy Society (AES), a Former Vice-Chairman of the Clinical Fellows Council, and Chief Fellow of the prestigious Johns Hopkins Hospital in Baltimore, Maryland, which has been ranked the number one hospital for neurology and the most number one ranked hospital in the United States by U.S. News & World Report.

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PHOTOS: PROVIDED BY FALCON ADVANCED NEUROLOGY & EPILEPSY FREEDOM CENTER

COVER STORY

Sub-dural grid electrodes on a human brain in an operative room to map vital brain functions and record seizures for precise localization of seizure onset zone before surgery.

SYMPTOMS OF EPILEPSY

DIAGNOSIS AND TREATMENT

Seizures may present in a variety of ways, some of which may be difficult to recognize, especially for patients or their families, and in some cases, even for healthcare providers other than trained epilepsy specialist neurologists. Most physicians know seizures as generalized tonic-clonic, often called “grand mal seizures,” in which a person has shaking, eye-rolling, foaming at the mouth, tongue biting, bowel/bladder incontinence, falling, and becoming unconscious. Many times, though, epilepsy can have subtle presentations, including abnormal taste or smell, déjà vu sensation; abnormal visual or auditory phenomenon, including hallucinations; headaches, altered mental status like staring spells or loss of consciousness episodes, “roller coaster” feeling, gastric rising sensations, palpitations, nausea; and decline in cognitive abilities, including memory deficits. Another possible presentation is outof-context smiling or laughing (gelastic seizures) or crying (dacrystic seizures).

Sometimes, seizures can cause an intense sense of impending doom or fear, which may be labeled as “psychiatric conditions” or “panic attacks” and may cause several years of delay in diagnosis and appropriate treatment. Seizures can cause labile mood, more commonly depression, anxiety, acute psychosis, and suicidal ideations. “My paper in Harvard journal ‘Epilepsy & Behavior,’ grant funded by the National Institutes of Health (NIH), on depression screening using PHQ-9 as a screening tool is one of the most commonly used tests worldwide,” informs Dr. Rathore. The paper can be found at: https://pubmed.ncbi.nlm.nih.gov/25064739/.

“Epilepsy can worsen a variety of other medical conditions.

In patients with or without cardiac arrhythmias, it increases the risk of sudden death due to cardiac arrest in 1% of cases. This phenomenon is called ‘Sudden Unexpected Death in Epilepsy,’ or ‘SUDEP,’ the risk of which is higher in convulsive seizures and seizures that originate from sleep stages,” states Dr. Rathore, an Alumnus Fellow of the Cleveland Clinic Epilepsy Center. Find more information about the Center at The Charles Shor Epilepsy Center | Cleveland Clinic.

Diagnosis of epilepsy starts with a comprehensive history taking and meticulous neurological examination by an experienced neurologist, followed by a brain wave test (video EEG) and a brain MRI with epilepsy protocol. In addition, the neurologist may order lab work to rule out an electrolyte disturbance, metabolic cause, infection, or drug abuse as the cause. In some pediatric cases, the neurologist may order a genetic panel as well.

There’s a series of other imaging studies that can be done if a patient needs exact localization of the seizure focus if surgery is planned (which may include FDG-PET, Ictal SPECT, fMRI, or magnetoencephalogram (MEG) and neuropsychological evaluation). For more accurate localization of seizure focus and functional brain mapping before surgery, stereotactic intracranial electrode placement for SEEG or sub-dural grid electrodes for electrocorticography/ECoG can be done. Dr. Rathore collaborates with functional neurosurgery at some of the leading tertiary care hospitals for surgical care of his patients.

“Robotic SEEG started in North America at the Cleveland Clinic in Ohio in 2010,” shares Dr. Rathore, “and I was one of the first fellows to learn that revolutionary technique during my fellowship with the world-renowned first neurosurgeon to do it, Dr. Jorge González-Martínez.”

There are more than 30 antiepileptic medications available to control seizures in nearly two-thirds of patients. Special precautions need to be taken in selecting the medications, especially in pregnant patients due to the risk of fetal abnormalities (teratogenicity) of certain medications like valproic acid, topiramate, phenytoin, etc. Unfortunately, despite trying multiple medications, nearly 36% of patients continue to have recurrent seizures, either due to not being able to take these medications because of side effects or due to the medications being ineffective in controlling the seizures. In such patients, neuromodulation, diet therapy (such as ketogenic or Modified Atkins Diet), or surgery are options.

FLORIDA MD - JULY/AUGUST 2022

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COVER STORY

The majority of patients do very well on medications, and most of them can be seizure free, are at lower risk of sudden death, and enjoy a significantly improved quality of life.

Per literature, the reported rates of excellent surgical outcome for non-lesional partial epilepsy range from 41% to 65% for the temporal lobe, 37% for mixed mesial temporal and neocortical sites, and 29% to 56% for extratemporal epilepsy. In the lesional group, seizure freedom rates were significantly better when patients underwent surgery early in the course of the disease.

In appropriate cases, laser interstitial thermotherapy (LiTT) may be an option for people whose epilepsy is caused by a visible abnormality in one area of the brain. Some patients who either do not want surgery or are not surgery can- The responsive neurostimulation (RNS) system to diagnose and treat seizures is one of the didates may be offered neuromodulation (brain breakthrough advances in epilepsy care. stimulation, or a so-called “seizure pacemaker”) with responsive cases, can avert an ER visit or hospitalization.” neurostimulation (RNS® Therapy). RNS uses an implanted device to help prevent seizures before they begin or abort them in RESOURCE FOR PATIENTS AND THE the early stages, similar to how a pacemaker detects and treats COMMUNITY abnormal heart rhythms. Other neuromodulation devices inEpilepsy Freedom Center at Falcon Advanced Neurology in clude deep brain stimulation (DBS) and/or vagus nerve stimulaOrlando, FL provides comprehensive epilepsy care, encompasstion (VNS). Dr. Rathore did a neurostimulation “J. Kiffin Penry” ing medications, surgery, and neuromodulation. “We also ofmini-fellowship at the Wake Forest University School of Medifer the ‘Epilepsy Monitoring Unit’ (EMU) diagnostic aspect of cine in Winston-Salem, NC. Dr. Rathore did the first ever case of epilepsy at Falcon Advanced Neurology,” Dr. Rathore informs.

RNS in Lakeland, FL area in May 2021.

“It’s the oldest and one of only two private independent diagSEIZURE SAFETY PRECAUTIONS & nostic facilities with EMU in the entire state of Florida. Usually, EMU is found only in the large tertiary care hospitals, and the PREVENTIONS waiting period to get an appointment at such a facility is several “It’s very important that patients with uncontrolled seizures months. This waiting period is a major cause for care deficit have a detailed discussion with their neurologist about safety preand, unfortunately, it sometimes causes ER visits for seizure pacautions,” says Dr. Rathore. tients.

“Another important aspect is that of seizure trigger identifica“We also collaborate with various clinical trials, and we offer tion and its avoidance for seizure prevention,” adds Dr. Rathore. clinical trial participation to our patients across various neu“Many patients may have their personal seizure trigger factors, rological conditions. Also, we’re a research center for our pasuch as peri-menstrual ‘catamenial’ seizures, but for most, the tients,” says Dr. Rathore. common ones are missing antiseizure medications for any reason (forgetting it or not being compliant), sleep deprivation, excess The Epilepsy Foundation of America is the largest epilepsy stress, sunlight or flickering light exposure in photosensitive epiorganization in the country, and Dr. Rathore is the co-chairman lepsies; certain medications, such as bupropion, tramadol, stimuof the Florida chapter. He leads educational sessions for varilants, and some antibiotics, such as penicillin, fluoroquinolones, ous school districts in Central Florida on seizure first aid and cephalosporins, carbapenems, etc. All epilepsy patients with freoffers free consultations for patients who are underinsured or quent seizures and/or generalized tonic-clonic seizures must dishave no insurance or ability to pay. In addition, Dr. Rathore has cuss ‘seizure rescue’ medication options with their neurologist. co-sponsored and led Walk to END EPILEPSY®. The Epilepsy These have evolved from inconvenient, and at times embarrassFoundation of America honored Dr. Rathore in 2021 with its ing, rectal diazepam of years ago to today’s diazepam or midazolprestigious Volunteer Appreciation Award and the American am nasal sprays, which are convenient, quick to administer, faster College of Physicians (ACP) also honored Dr. Rathore as one of acting, and very effective. These rescue medications can play a the Young Achievers at its annual meeting in Orlando in 2014. vital role in preventing a serious seizure episode or shorten the “The Doctor Is In” on NBC Bloom TV featured Dr. Rathore in duration of a seizure and hence can be lifesaving and, in many October 2019 to raise awareness about epilepsy.

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PHOTOS: PROVIDED BY FALCON ADVANCED NEUROLOGY & EPILEPSY FREEDOM CENTER

SUCCESSFUL OUTCOMES

COVER STORY The Florida chapter’s advocacy group works with the state legislature in the capital city of Tallahassee to bring about several changes to help patients. Most recently, the state of Florida passed House Bill 173 into law on March 25, 2022, thereby protecting children and teens living with epilepsies in the state.

“The most rewarding part of my co-chairmanship is reaching out to patients statewide, increasing the awareness of epilepsy, finding out the challenges that patients are facing, and identifying what we can do to help them, as well as the family members and the schools,” says Dr. Rathore, who is a Member of the Reviewer’s Panel for Neurology®, The Official Journal of the American Academy of Neurology.

“As epilepsy is a worldwide disease, I also provide global econsultations, worldwide webinars, and in-person educational lectures at some of the leading medical centers in the US, India, and multiple other countries,” says Dr. Rathore.

The epileptologist is passionate about his work and taking care of his patients. This is evident in his #1 national ranking among all neurologists in web-based, pooled patient reviews on Healthgrades, U.S. News & World Report, and WebMD’s Preferred Provider for 2022. Dr. Rathore was also included in “The America’s Best” neurologist in 2020-2022, as well as being designated the best-rated neurologist in Orlando, FL: https://threebestrated.com/neurologists-in-orlando-fl

FULL RANGE OF NEUROLOGICAL SERVICES Although a substantial portion of Dr. Rathore’s practice is devoted to caring for epilepsy patients, he offers the full spectrum of neurology services at Falcon Advanced Neurology in Orlando, FL, as well as at two additional clinics in The Villages area of Central Florida in collaboration with TriCounty

Health, LLC. [see Services sidebar] “I feel a great sense of responsibility to care for my elderly patients, especially those with seizure disorder, given one of my practice areas is The Villages, Florida, which is the largest retirement community in the world, and me being the only boardcertified adult epileptologist in this large catchment area of central to north Florida, in between big cities like Orlando, Tampa, Gainesville, and Jacksonville,” says Dr. Rathore.

“I’m the regional medical director for the southeast US – including Florida – for one of the largest home video EEG companies, called NeuLine Health. We provide home video EEG services across twenty-three states so these patients are not deprived of this testing only because they cannot go to centers or hospitals due to mobility or transportation issues,” says Dr. Rathore.

“Human brain is an enigma containing around 86 billion interconnected neurons, which makes it one of the most complex objects in the universe, which fascinates me,” says the epileptologist. This interest guided him through his medical studies.

“I ended up doing an epilepsy research fellowship at Cleveland Clinic for two years and then I did a two-year epilepsy clinical fellowship at Johns Hopkins Medicine. It’s a great honor and privilege to work for the Epilepsy Foundation of America at that level, do research, serve the patients, and offer them the latest, cutting-edge technology in the field of epilepsy. I believe it’s the calling of my life, and I am truly grateful to my family, teachers/ mentors, and friends who have helped me reach this stage of my career.”

DR. RATHORE WELCOMES REFERRALS FROM ALL HEALTHCARE PROVIDERS. Continued on page 8

PHOTOS: PROVIDED BY FALCON ADVANCED NEUROLOGY & EPILEPSY FREEDOM CENTER

Dr. Rathore testing high-density electrode (in the image on left) and wireless dry electrode (in the image on right) video EEG technology at the annual meeting of the American Epilepsy Society.

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COVER STORY

For more information about Falcon Advanced Neurology & Epilepsy Freedom Center, located at 6000 Metrowest Blvd., Suite 104-105, in Orlando, Florida, 32835, please call (407) 365-3033, or visit www.fsneuro.com. Dr. Rathore has collaborated with TriCounty Health to provide neurology clinic services in The Villages area at 17190 SE 109th Terrace Rd., Summerfield, FL 34491, and at 3990 E. FL-44 in Wildwood, FL 34785 (Suite 4056 in Freedom Plaza). Please call (352) 268-0003 to reach either clinic, or visit www.tricountyhealthllc.com for more information. 

PHOTO: PROVIDED BY FALCON ADVANCED NEUROLOGY & EPILEPSY FREEDOM CENTER

SERVICES AVAILABLE AT FALCON ADVANCED NEUROLOGY & EPILEPSY FREEDOM CENTER INCLUDE, BUT ARE NOT LIMITED TO: Routine and long-term monitoring video EEG (inpatient and at home) Stroke/TIA Dizzy spells/syncope Various headache syndromes (including chronic migraines) and BOTOX® therapy Concussion/traumatic brain injury (TBI)

Dr. Rathore at his alma mater Cleveland Clinic main campus in Ohio during his fellowship days 2011–13.

Movement disorders, including Parkinson’s Disease, Tardive dyskinesia, Dystonia etc.

Speech/language disorders Sleep disorders Memory and dementia disorders, such as Alzheimer’s Disease Multiple sclerosis and its diagnosis with lumbar puncture for CSF analysis Neuropathy

FALCON ADVANCED NEUROLOGY & EPILEPSY FREEDOM CENTER 6000 Metrowest Blvd. • Suite 104-105 Orlando, FL 32835• 407-365-3033 www.fsneuro.com #JohnsHopkins #ClevelandClinic #Harvard #UIChicago #NIH #TopDoctor #EpilepsyFoundation 8 FLORIDA MD - JULY/AUGUST 2022

Sciatica pain Restless legs syndrome Spinal cord disorders Myasthenia gravis (MG) and other autoimmune neurological conditions

DERMATOLOGY

Melanoma Makes Me a Real Doctor

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

Melanomas come in all different shapes and sizes. They are rarely the archetypal jet black, nodular mole-like growth, in which even a first-year medical student could make the diagnosis.

Melanomas may appear elevated, they can be flat, they can be multicolored, and they do not have to have pigment. Some melanomas can persist for very long periods before being discovered, such as lentigo maligna melanoma. Others can grow rapidly and deadly in a few weeks. Melanomas can develop beneath the nails, and even in non-skin areas such as the eye, oral cavity, nasal sinuses, even rectally.

The best guidance for identifying melanomas for non-dermatologists is using the mnemonic ABCDEs of melanoma evaluation, Asymmetry of the lesion, Border irregularity, Color variation, Diameter greater than 6mm and Evolution. However, dermatologists rarely use the ABCDE guide, as most of us know by looking because of intuitive expertise. When a dermatologist observes a suspicious lesion, in our mind, it pops up, “that looks suspicious.” Intuitive expertise is ubiquitous throughout all specialties and comes with experience. The ER doc that walks into a patient room and immediately diagnoses congestive heart failure with only a glance is demonstrating intuitive expertise. Intuitive expertise can be confounding to medical students who need to look up everything online. Still, it is this intuitive expertise we all gain through training and experience that makes us “real” doctors.

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

PHOTO: JOHN MEISENHEIMER, VII

Lentigo maligna melanoma.

PHOTO: JOHN MEISENHEIMER, VII

As a Mohs surgeon, I rarely “pop” pimples anymore, not that there is anything disgraceful about helping a patient with a disfiguring skin disease that can leave them permanently scarred.

As the Seinfield episode would suggest, laypeople might seem to think unless you are saving lives, you are not a “real” doctor. So, I guess in a sense, melanomas make dermatologists “real” doctors (and let’s not forget squamous cell carcinomas and basal cell carcinomas can also kill you).

I know in my practice over the last 30 years, I have found hundreds of melanomas. Even to this day, when I see a melanoma, I quietly give myself a high five. When you catch melanoma in time, you have changed a person’s life for the better, even if they may not realize it. At the same time, I am also grateful that I did not miss that melanoma. There is always a degree of stress when doing a “routine skin exam” there is nothing routine about melanoma or the potential for missing a melanoma.

A superficial spreading melanoma.

Nodular melanoma.

PHOTO: JOHN MEISENHEIMER, VII

Jerry was having dinner at a restaurant with his dermatologist girlfriend.

Seinfield - “How’s the life-saving business?

Dermatologist girlfriend - “It’s fine.”

Seinfield - “It must take a really, really big zit to kill a man.”

Dermatologist girlfriend - “What is with you?”

Seinfield - “You called yourself lifesaver. I call you pimple popper M.D.” A restaurant patron walks up to their table and says, “Dr. Sitarides?”

Dermatologist girlfriend - “Mr. Perry, how are you?”

Mr. Perry - “I just want to thank you again for saving my life.”

Seinfield - “She saved your life?” Jerry has a shocked look on his face.

Mr. Perry - “I had skin cancer.”

Seinfield - “Skin cancer, damn.” Jerry’s face twists in the agony of defeat.

PHOTO: JOHN MEISENHEIMER, VII

When I was in medical school and revealed to my classmates that I wanted to be a dermatologist, they usually gave me a flabbergasted look and said, “You want to pop zits for a living?” Immediately followed by, “You don’t want to be a real doctor?” I wish the Seinfeld episode, when Jerry was dating a dermatologist, had been released so that I could refer them to it. The Seinfeld episode went something like this:

Pathology of a melanoma.

FLORIDA MD - JULY/AUGUST 2022

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PULMONARY AND SLEEP DISORDERS

Shift Work Sleep Disorder

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

Optimal sleep and wakefulness requires proper alignment between an individual’s intrinsic circadian rhythm and their desired sleep wake schedule. The word circadian comes from the Latin “circa” meaning “about” and “dian” meaning “day”. Our intrinsic circadian rhythm is controlled by an internal clock in the hypothalamus (suprachiasmatic nucleus). The hypothalamus receives signals from the retina that entrain the circadian rhythm to the light dark cycle. The circadian rhythm affects the timing of sleep.

There is also a homeostatic sleep drive, which controls sleep intensity, and it is determined by how long an individual has been awake.

Shift work sleep disorder is a recurrent or persistent mismatch between a person’s habitual sleep wake schedule and their endogenous circadian rhythm. Shift work sleep disorder can be associated with insomnia or excessive sleepiness (or both). The conventional time cues (zeitgeber = “time giver” in German) of sunlight and social activities are frequently out of phase with the altered sleep schedule in an individual with shift work sleep disorder. Many shift workers revert back to their traditional daytime schedule during non-work days. By definition, the course of shift work sleep disorder parallels the period of the shift work and remits with termination of shift work. An individual SLEEP FACTORS with shift work sleep disorder may use a large portion of their free time for recovery of sleep, which may have negative social consequences such as marital discord and impaired social relationships. Shift work sleep disorder tends to be more common after age 50. Between 5 and 8% of the population is exposed to night work on a regular or periodic basis.

Shift work sleep disorder is usually a clinical diagnosis. A formal sleep study (polysomnogram) may be helpful to exclude other etiologies of a patient’s symptoms. The sleep study should ideally be performed during the regular hours of sleep of the individual having the study. To diagnose shift work sleep disorder one must exclude any other medical or psychiatric conditions which could account for the symptoms. In addition, the symptoms should not meet criteria for any other sleep disorder which can produce insomnia or excessive daytime sleepiness (such as Jet-lag syndrome). Women appear to be slightly more prone to developing shift work sleep disorder. Interestingly, women tend to quit their shift work less often than men. The occurrence of shift work sleep disorder may vary depending upon the speed and direction 10 FLORIDA MD - JULY/AUGUST 2022

of shift rotation. It may also vary depending upon a patient’s diurnal preference. It appears to be less common in individuals who identify themselves as “night owls”. Individuals with shift work sleep disorder have been found to have higher rates of peptic ulcer disease as well as more sleepiness related motor vehicle accidents. Other consequences of this disorder include absenteeism from work, higher rates of depression and missed family and social activities as well as chronic fatigue and poor work performance. There have also been studies which link shift work sleep disorder to glucose intolerance as well as higher risk for alcohol and substance use. Sleep CIRCADIAN FACTORS

SHIFT WORK COPING ABILITY

ENVIRONMENTAL FACTORS

diaries can be helpful in assessing patients with shift work sleep disorder. Actigraphy can be useful as an adjunct to history, physical exam and sleep diary. Actigraphy recording should consist of at least three consecutive 24-hour periods. Circadian rhythm markers (such as core body temperature monitoring or timing of melatonin secretion) are more difficult and typically are not used in routine clinical settings.

Treatment for shift work sleep disorder can include exposure to bright light in the work place as well as administration of wake promoting agents during evening work hours. Other treatments include scheduled napping as well as hypnotic agents to improve daytime sleep. Maintaining a regular sleep wake schedule during both work and non-work days is also recommended (as well as minimizing light or noise in the bedroom and allowing sufficient time in bed for sleep during the daytime). Other recommendations include limiting light exposure by using dark sunglasses during the morning trip home from work. The timing of

PULMONARY AND SLEEP DISORDERS

FLORIDA MD - JULY/AUGUST 2022 11

PULMONARY AND SLEEP DISORDERS light therapy is critical. The American Academy of Sleep Medicine recommends light exposure before the core temperature is reached in an individual with a morning/evening/night schedule (versus administrating light therapy after core temperature in an individual with a night/evening/morning schedule). Studies have utilized various light intensities from 2350 to 12,000 lux. Some but not all studies of bright light therapy have also restricted daytime light exposure. Different schedules of light exposure have also been used. Melatonin has both sleep promoting (hypnotic) and phase shifting properties. Melatonin (when given to night workers before their daytime sleep) may enhance daytime sleep and appears to have no effect on subsequent nighttime alertness.

In a study published by Czeisler in The New England Journal of Medicine in 2005, modafinil resulted in decreased accidents/ near accidents during the commute home (versus placebo). Treatments for shift work sleep disorder can include modafinil (Provigil) as well as armodafinil (Nuvigil). These medications are nonamphetamine stimulants believed to act on the hypothalamus, although their exact mechanism of action is unknown.

more difficulty coping with shift work than men).

In general, the circadian clock adjusts better to clockwise rotation because it is naturally easier to delay sleep to a later hour.

Typically, longer shifts (such as 10-12 hours) cause more sleepiness than eight hour shifts. Women doing shift work tend to get less sleep than men when they are not working because of their persistent family and social obligations. Overall, night and rotating shift workers comprise approximately 6% of all workers. About 1% of the working population in the United States is believed to suffer from shift work disorder. Increased awareness of this disorder should allow more individuals to receive proper diagnosis and therapy.

Shifts can be permanent, fixed or rotating. Shift can rotate forward (clockwise) (from morning to evening to nighttime) or backward (from night to afternoon to early morning shift). Rotating shifts seem to cause more sleep difficulties than permanent shifts and counter clockwise rotation affects sleep wake activities more than clockwise rotation. The speed of rotation and the length of the shift may also impact an individual’s symptoms.

University in Durham, North Carolina. Since 1997, he has

It appears that workers on permanent night shifts sleep one to four hours less than day workers and individuals on rotating shifts sleep about two hours less than day workers. There are several factors involved in this. Shift workers must try to sleep at a time when their circadian/ wakefulness drive is exerting pressure on them to remain awake. The desire to spend time with family or take care of household or social obligations is also a factor. Environmental factors such as noise and light may also be obstacles to sleep quality for shift workers.

TABLE 1: FACTORS INFLUENCING THE EFFECT OF SHIFT WORK ON SLEEP AND WAKEFULNESS • • • • • • • • •

Type of shifts (permanent, rotating).

Duration of shifts.

Speed of rotation (slow or fast).

Direction of rotation (clockwise or counter clockwise).

Social and family disruption.

Exposure to natural or artificial light.

Existing health problems.

Age (over 50 is more adversely affected than younger individuals) Gender (female shift workers seem to have

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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 been a member of the Central Florida Pulmonary Group in Orlando. He serves as Co-director of the Adult Cystic Fibrosis Program in Orlando. He may be contacted at 407841-1100 or by visiting www.cfpulmonary.com. 

Study- Cannabis is not a Gateway Drug

By Michael Patterson, NHA, OTR/L, CEAS For decades, prohibitionists have lived and died by the claim that cannabis is a “gateway” drug that will lead people onto harder drugs. However, there has not been widely accepted objective data to backup those claims. Now, based on a recent study published in April 2021 in the Journal of Experimental Criminology, claims that the initiation of marijuana use is independently linked to the later use of other controlled substances are not supported by longitudinal data. A link to the study is below.

Is marijuana really a gateway drug? A nationally representative test of the marijuana gateway hypothesis using a propensity score matching design | SpringerLink Researchers affiliated with Boise State University analyzed the relationship between self-reported marijuana use in late-adolescence and the use of other illicit substances later in life in a nationally representative sample. Using three waves of data from the National Longitudinal Study of Adolescent to Adult Health (1994–2002), eighteen propensity score-matching tests of the marijuana gateway hypothesis were conducted. Six of the eighteen tests were statistically significant; however, only three were substantively meaningful. These three tests found weak effects of frequent marijuana use on illicit drug use but they were also sensitive to hidden bias.

The researchers reported, “Political discourse advocating marijuana prohibition commonly hinges on the assumption that marijuana causes hard drug use. The MGH [marijuana gateway hypothesis] is by far the most common justification for prohibiting the use of cannabis. However, the current study provides further evidence that common liability arguments are more in line with substance use patterns observed in the USA.” Results from this study indicate that marijuana use is not a reliable gateway cause of illicit drug use. As such, prohibition policies are unlikely to reduce illicit drug use.

They concluded: “In sum, the findings from the current study … provide further support of previous research questioning the causal claims of the MGH. While there is strong support for correlation and sequencing in marijuana and hard drug use, correlation and sequencing alone cannot provide sufficient evidence for causality. Factors other than marijuana use such as genetic predisposition, peer associations, or access to the illicit drug market could be the primary causes of hard drug use instead of marijuana use itself. As such, any public policy that prohibits the use of marijuana in an attempt to curb hard drug use is unlikely to succeed.”

ANALYSIS This study is based on objective data analysis. The Marijuana Gateway Theory is based on lies and fear. Lies and fear have been used by prohibitionists for almost 100 years to keep cannabis illegal and away from people who need this life saving medication.

This study is just the beginning of objective, clinical data coming out about the benefits of cannabis in our society and proving the claims of the prohibitionists of cannabis being bad for society as

false and misleading.

With the US Government recently approving over ten new research licenses to allow cultivation of cannabis for research purposes, more and more quality studies and data will continue to be published.

These studies will prove that cannabis is beneficial to patients and our society. With more objective and clear-cut data, prohibitionists will have to think of other lies and fearmongering techniques to keep cannabis illegal. Cannabis has been a part of human history for thousands of years. No matter what prohibitionists do, cannabis legalization is coming to the USA and most of the planet. It is not a matter of “if ”, but “when”.

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

Sea Notes Photography Donald Rauhofer – Photographer Head Shots • Brochures • Meetings Events • Portraits • Arcitectural

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PEDIATRICS

Robotic Surgery in Pediatrics By: Pamela I. Ellsworth, MD, Adela Casas-Melley, MD, Omar Cruz-Diaz, MD, Abishek Seth, MD WHAT IS ROBOTIC SURGERY?

Robotic assisted surgery is an advanced technology that allow surgeons to perform surgical procedures in hard-to-reach areas through small incisions. The specialized technology provides more dexterity and precise movements than the human hand and allows for enhanced magnification.

Instead of working at the bedside, the surgeon sits at a console and controls every movement of the robotics arms and the camera. The camera allows for enhanced magnified 3-dimensional views of the surgical area.

To perform robotic surgery, A surgical console provides surgeons complete specialprecise movements and enhanced magnification of the surgical area. ized training.

WHAT MAKES ROBOTIC-ASSISTED SURGERY BETTER THAN TRADITIONAL SURGERY?

One of the major differences between robotic surgery and open surgery is the size of the incision. Many of the robotic-assisted surgical procedures have traditionally required larger, more uncomfortable incisions when performed via an open surgical approach.

Also, the smaller instrumentation and mobility afforded by the robotic instrumentation allows for less pulling and tension on the tissues. These differences result in less postoperative pain and a lower risk of infection and bleeding. The improved pain control results in less use of opioids and allows children to return to school and activities sooner. The smaller incisions provide improved cosmesis, less pain and less risk of infection. Outcomes Comparison of robotic incisions with left with robotic surgery flank incision for pyeloplasty are comparable and often better than with open surgical procedures, related to greater precision and visualization when compared to open surgery and greater than open surgery with respect to parent satisfaction regarding cosmesis and recovery. The robotic arm’s movements have a greater range of motion and can rotate 370 degrees. The robotic camera provides for magnified, high-definition visualization of the surgical area and has three dimensional capabilities that are superior to the human eye.

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ARE THERE DISADVANTAGES OF ROBOTIC SURGERY IN PEDIATRICS?

Robots may not be available in all children’s hospitals which can limit access. In infants or smaller children, the use of the robot may be limited by body habitus and size. Uncommonly the robot may malfunction.

Pamela I. Ellsworth, MD

WHY ROBOTIC SURGERY OVER LAPAROSCOPY?

Both robotic surgery and laparoscopic surgery are considered “minimally invasive procedures.” With laparoscopy, mobility is limited by the size of the instruments, limited hand motion of the surgeon and places a greater torque on the incisions as well as lack of 3-dimensional visualization. Not all laparoscopically performed procedures need to be performed robotically such as laparoscopic orchidopexy, laparoscopic hernia repair, and laparoscopic varicocelectomy which are quick procedures that do not require the dexterity associated with pyeloplasty and other procedures.

WHAT IS THE ROLE OF ROBOTIC-ASSISTED SURGERY IN CHILDREN/ADOLESCENTS?

Adela Casas-Melley, MD

Omar Cruz-Diaz, MD

Abishek Seth, MD

The role of robotic-assisted surgery continues to expand in pediatrics. In pediatric urology, trends in the United States over the past 10 years demonstrate that pyeloplasty is the most performed robotic reconstructive urological procedure in children and has surpassed open surgery as the preferred approach. Has the robot caught up? National trends in utilization, perioperative outcomes, and cost for open, laparoscopic, and robotic pediatric pyeloplasty in the United States from 2003 to 2015. Nemours Children’s Hospital offers Although initially reserved robotic assisted surgery for a variety of procedures. for adolescents, robotic-as-

PEDIATRICS sisted pyeloplasty is more commonly performed for young children and, in some centers, infants. Robotic assisted ureteral reimplantation and robotic-assisted ipsilateral ureteroureterostomy are other more commonly performed procedures. Complex urologic reconstructions are also being performed robotically including robotic-assisted appendicovesicostomy, bladder neck reconstruction and bladder augmentation. In pediatric surgery more commonly performed robotic-assisted procedures include fundoplication, cholecystectomy, choledochal cyst resection, and complex bowel resections. Robotic-assisted hepatobiliary surgery, diaphragmatic hernia repair, repair of duodenal atresia and anorectal pull through procedures have been reported in children.

DO ALL HOSPITALS HAVE A ROBOT?

Many adult hospitals have one or more robots given widespread use of the robot in adult surgical specialties. Often, pediatric surgical

posterior mediastinal mass soon after her visit. The procedure went without difficulty. She spent 24 hours in the hospital and was discharged. She recovered quickly with minimal issues with pain or activity. She was able to proceed with her scoliosis surgery as preCase Study Image 2 viously scheduled 14 days after her robotic thoracoscopy and has already been seen in the office. She is doing well and recovering from her spinal fusion. Although her procedure could have been completed thorascopically, the use the robotic-assisted approach allowed for quicker and less painful recovery and allowed her to proceed with her previously scheduled spinal fusion.

Dr. Ellsworth, who is a graduate of the UMass Medical School, completed a residency in urology at DartmouthHitchcock Medical Center in New Hampshire and then specialized in pediatric urology with a fellowship at the University of Florida. Dr. Ellsworth is certified in urology and pediatric urology by the American Board of Urology.

Nemours Children’s Hospital has a dedicated team of robotic surgeons and staff.

specialists will utilize the robot in the adult hospital. Nemours Children’s Hospital is committed to providing the standard of care for children and is proud to be one of a few free-standing children’s hospital with its own robot.

CASE STUDY

15-year-old female who was referred to our pediatric surgery office for evaluation of a “lung cyst.” She had been followed for scoliosis for several years and completed treatment with a spine brace in 2020. About a Case Study Image 1 year later, she was noted to have progression of her scoliosis and was referred to her orthopedic surgeon for further evaluation. Due to the unusual rapid progression, a spine MRI was obtained. An incidental finding of a pleural base cyst prompted a chest CT. She is otherwise healthy and has never had any surgeries but is scheduled to have a spinal fusion pending the evaluation of the posterior mediastinal cyst.

Dr. Adela Casas-Melley is the chair of the department of surgery at Nemours Children’s Hospital and professor of surgery at UCF College of Medicine. She is a skilled laparoscopic and robotic pediatric surgeon. Dr. CasasMelley has been responsible for the development of multiple multidisciplinary clinics and is the lead for the pediatric surgical robotic program.

Dr. Omar Cruz-Diaz is the director of pediatric urology robotic surgery at Nemours Children’s Hospital.

He completed his pediatric urology fellowship at the University of Miami and is an accomplished robotic surgeon.

Dr. Abishek Seth is an associate professor of urology at UCF College of Medicine and the director of the Spina Bifida Clinic at Nemours Children’s Hospital.

He completed his pediatric urology fellowship at Boston Children’s Hospital and is a skilled scientist-surgeon with an NIH funded grant. Dr. Seth is working alongside Dr. Cruz-Diaz to develop the urology robotic program at Nemours Children’s Hospital.

Call 407.650.7715 or visit Nemours.org/robotics for more information about the pediatric robotic surgery program at Nemours or to refer a patient. 

The patient had a robotic thoracoscopy with resection of the FLORIDA MD - JULY/AUGUST 2022 15

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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Catching Multiple Sclerosis Early

By Amy Gutierrez, MD, FAAN Multiple sclerosis (MS) is a disease of the nervous system that affects the brain, optic nerves and spinal cord. Early signs of MS are varied and can be similar to other illnesses, however, those symptoms are important to know since early detection and treatment of MS can help delay the progression of MS. Nearly one million adults in the U.S. have been diagnosed with MS, and most are diagnosed between the ages of 20 and 50. In MS, the immune system becomes misdirected and attacks the fatty tissue around nerve cells in the central nervous system. Scar tissue form, making it difficult for the nerve cells to communicate between the brain and the rest of the body.

Why the immune system attacks the nerve cells is unknown.

Some evidence connects exposure to the Epstein Barr virus with an increased risk of MS, but some experts dispute this. Being of northern European descent puts Americans at higher risk, and women are more likely to develop MS than men. While the disease is chronic, it is usually mild in most case at the beginning.

However, some people may become unable to walk, have normal sensation and balance and it may affect memory as the disease progresses. Treatment with MS medications has repeatedly shown to stop this progression.

EARLY SIGNS OF MS Symptoms of MS can come and go, so particularly in the early stages, it’s easy to dismiss these signs or attribute them to other causes. MS symptoms usually begin and get worse over a 24- to 48-hour period.

They include: • Blurred vision • Double vision • Fatigue • Muscle weakness • Difficulty with coordination and balance • Numbness, prickling or tingling • Thinking and memory problems • Pain • Depression • Slurred speech • Dizziness • Problems with sexual, bowel and bladder function • Tremors • Paralysis • Partial or complete loss of vision in one eye (especially with pain)

not MS, it is important to find out the underlying causes of your symptoms.

HOW IS MS DIAGNOSED AND TREATED? MS is best detected by a neurological examination and painless imaging studies of the brain and spinal cord using magnetic resonance testing (MRI). An ophthalmologist also can use a test called an optical coherence tomography (OCT) to determine if the optic nerve has been affected

by MS. In some cases, a lumbar puncture is needed to make the diagnosis of MS. Based on your symptoms, history, neurological exam and findings on the MRI, your doctor may make the diagnosis of MS. Although there is not currently a cure for MS, more than 25 different medications — ranging from injections to pills to intravenous infusions — are available to treat MS. Physical, occupational and speech therapy can help manage the disease symptoms. Even if you are newly diagnosed or have few symptoms, therapy along with nutrition, exercise and lifestyle changes can help you maintain your health.

The most important goal in MS treatment is to stop the disease from attacking your brain and spinal cord as these structures control everything in your body. By preventing new lesions from forming, we delay and potentially prevent future disability and people with MS can live normal lives.

To make an appointment, call (407) 352-5434 Amy Gutierrez, MD, FAAN, is a neurologist with the Orlando Health Neuroscience and Rehabilitation Institute Neurology Group. She is a Diplomat of the American Board of Psychiatry and Neurology, American Board of Electrodiagnostic Medicine, and American Board of Neuromuscular Medicine. She also is a fellow of the American Association of Neurological Surgeons and American Academy of Neurology.

In 2010 Dr. Gutierrez was a founding member of the ALS Multidisciplinary Clinic at LSU Health Science Center. She worked collaboratively with the Muscular Dystrophy Association and ALS Association providing care to patients and their families. In addition, she was involved in research with the North Eastern ALS Society and as a member of the ALS Clinic at the New Orleans VA Clinic.

Dr. Gutierrez has been the principal investigator for many research trials related to MS. She has more than 20 years of clinical experience with MS and has held leadership roles with the National Multiple Sclerosis Society. 

If you have any of these symptoms, see your doctor. Even if it’s FLORIDA MD - JULY/AUGUST 2022 17

The Benefits of Comprehensive Neuroscience Care

By Christian Rosado, MD Conditions that affect the nervous system are often complex and debilitating. Any patient with a neurological condition is most likely going to have other associated medical conditions and may face psychological, emotional and social challenges as well.

As neurologists, we always work on that premise, because when it comes to the brain and nervous system, it’s unavoidable. These patients will reap the greatest benefit from subspecialty care in a multidisciplinary setting.

This is the basis of the structure of the Orlando Health Neuroscience Institute as a comprehensive neuroscience center offering high quality, accessible, true subspecialty care and fostering multidisciplinary collaboration. The focus is on treating patients holistically across the care spectrum, leveraging expertise in all areas we know a person will need help.

Comprehensive neuroscience care overlaps multiple domains including neurology, neuropsychology, neurosurgery, pain management, rehabilitation and behavioral health with numerous interrelated specialty centers and programs. Under neurology, centers and programs include epilepsy and seizure disorders, movement disorders, neuromuscular and peripheral nerve disorders, memory disorders, cognitive and behavioral neurology, multiple sclerosis and demyelinating disorders, headache and facial pain, stroke and vascular neurology and inpatient neurologic care. Within each of these specific areas, highly trained and experienced experts — many from the academic setting with subspecialty board certifications — leverage advanced technologies, collaboration within the multidisciplinary system and participation in research studies to ensure access to the highest level of complete care.

While all of the subspecialty centers and programs offer exceptional and innovative care, I have chosen a few that are certainly worth highlighting.

EPILEPSY AND SEIZURE DISORDERS CENTER The Orlando Health Neuroscience Institute has a world-class group of epilepsy physicians, including epileptologists and neurosurgeons, working together to provide a level of epilepsy care as high as any in the nation. A patient is able to see a board-certified and fellowship-trained epileptologist and neurosurgeon on the same campus, where they can easily communicate and collaborate to create the best outcome for each individual patient. An expanding inpatient Epilepsy Monitoring Unit offers advanced evaluation with state-of-the-art testing to determine what is causing the epilepsy or seizures and where in the brain it is originating. That can then lead to a collaborative decision as to what the best surgical treatment may be among a variety of treatment options currently available. In addition to resective surgeries, alternative and less invasive surgical methods, including vagus nerve stimulation (VNS), deep brain stimulation (DBS), responsive neurostimulation (RNS) and laser interstitial thermal therapy (LITT), enable the team to coordinate the highest level of epilepsy surgical care available.

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DEMENTIA AND MEMORY DISORDERS CENTER Florida has a high population of people afflicted by dementia, but there are not many places in the region where people can go for proper evaluation and vital resources. So, unfortunately, many people in our communities experience forgetfulness and memory loss but don’t get an actual diagnosis. What is the condition? Is it Alzheimer’s disease? Frontal temporal dementia? Vascular dementia? The Orlando Health Neuroscience Institute has a dedicated dementia and memory disorders center with specialty-trained neurologists and neuropsychologists who are top experts in their fields. They are first able to offer a high level of care in terms of diagnosis. And that is crucial, because without the correct diagnosis, proper treatment cannot be leveraged. In addition to medical diagnostics and treatment, dedicated social workers work hand in hand with our neurologists and behavioral and cognitive neurology specialists to assist patients and families with all their needs. Someone with confirmed Alzheimer’s disease has a very different path to navigate than someone with vascular dementia. We also address caregiver needs, helping guide them through medical decision-making as well as home safety, education and crisis intervention. This is a rapidly growing program with many different means to help these patients.

NEUROMUSCULAR AND MOVEMENT DISORDERS PROGRAMS In neuroscience, there are some very rare diseases that can have extremely debilitating effects, even shortened lifespan. These rare diseases require true experts in the field. One such condition is amyotrophic lateral sclerosis, or ALS. Once called Lou Gehrig’s disease, this very rare condition causes muscles to stop working, and a person loses the ability to walk, eat, breathe. Our dedicated ALS program is led by a specialist with a vast amount of experience in the proper diagnosis and management of ALS. Muscular dystrophy also causes devastating muscle weakness and disability. Many patients diagnosed with muscular dystrophy are then told they must travel long distances to receive care, and that’s very difficult or impossible for many. Our muscular dystrophy program is something new for the community, and something that we see being able to reach and help a lot of people. Parkinson’s disease also falls into this same category. The ability to see a specialist, receive an accurate diagnosis, understand the prognosis and treatment options, and receive the best medical and surgical treatment for these conditions is something that is not possible outside of a comprehensive neuroscience center such as the Orlando Health Neuroscience Institute.

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Trends in Comprehensive Orthopedic Care

By Michael Jablonski, MD As holds true for many specialty areas of medicine, orthopedic patients gain the greatest benefit in a setting that is allinclusive of the expertise, technology and services that span the whole continuum of care, from prevention and diagnostics, to therapeutic and surgical treatment options, to physical therapy and rehabilitation.

The Orlando Health Jewett Orthopedic Institute is built on that foundation, and, upon completion, its new physical space will bring together a medical office building, an inpatient hospital and an outpatient surgery center, as well as pharmacy, physical therapy and imaging services — providing comprehensive orthopedic care with everything a patient may need under one roof.

The patient experience is an integral component of overall quality healthcare and includes several aspects of the delivery of care — including convenience, patient involvement and the highest level of expertise — that must be addressed to provide the best possible care, outcomes and satisfaction. As an orthopedic surgeon, I see how surgery can be very stressful, not only for patients, but for the families as well. With special attention to finding ways to reduce anxiety, through design, services and education, we can provide a unique, positive experience. A couple examples the institute will incorporate are an education showcase in the form of a mock operating room in the lobby area to familiarize patients and families with what surgery looks like, and a special platform that allows families to record messages for their loved one to hear before they go into surgery.

A positive patient experience, coupled with leading-edge expertise and technology, is the best recipe for successful outcomes. That’s something that a comprehensive institute offers by providing an academic and research setting that attracts the best professionals in their respective fields and equips them to perform at their highest level.

From the technology perspective, surgical excellence is a key factor. In addition to my specialization in robotic knee replacement, our highly skilled group of physicians perform hip, elbow, shoulder, hand and finger joint replacements and even spine surgery using advanced robotic techniques. One example is MAKO®plasty, which uses robotic-arm assisted technology to perform knee and hip replacements. These minimally invasive approaches can prevent unnecessary trauma to healthy tissue and bone, which can mean quicker recovery and better joint usage post-surgery for patients and have allowed us to expand the outpatient joint placement option for appropriate patients. For example, knee replacements can be done under spinal anesthesia with regional nerve blocks. Using a robotic technique without the need for general anesthesia, together with multidisciplinary care in pain management and physical therapy, many patients are able to go home the same day of surgery. Compared to even 10 years ago, the number of outpa-

tient joint replacement procedures has grown tremendously. What used to be, when I started over 20 years ago, a four- to six-day hospital stay, is now almost always next-day, with up to 25 percent to 30 percent of patients going home the same day.

In sports medicine, arthroscopic surgery has become the norm for many procedures and offers many surgeon and patient benefits. Improved reach and precision can in turn allow us to treat more complex conditions.

Smaller incisions and a reduced need for general anesthesia can enhance recovery for patients. One exciting new technology is the NanoScope™ operative arthroscopy system. This state-ofthe-art technology offers arthroscopic surgery through a needle with precise, direct image-guided visualization. A surgeon can insert a needle with an attached camera, under local anesthesia, and look at any area of concern for a quicker and more accurate diagnosis. Patients can stay awake and even watch the procedure on the screen. The Orlando Health Jewett Orthopedic Institute will house a designated nanotechnology suite offering leadingedge diagnostic and treatments capabilities not widely available in the region.

At the forefront of ever-advancing technology, the institute offers 3D technology that enables our surgeons to perform even more complex surgeries by being able to print different bone deformities for repair or joints for better implant fit. A bioskills lab will used for teaching residents as well as for innovation, such as for our physicians who help design implants. A 118-seat auditorium will provide space for our physicians to showcase what we do and then utilize the bioskills lab to teach new techniques to other orthopedic surgeons and specialists.

Nonsurgical treatment, both in sports injuries as well as arthritic conditions, is an area that’s always advancing. Anytime we can treat an injury or condition conservatively through different medical or physical therapy modalities, that’s a worthwhile approach. Platelet rich plasma (PRP) injections and hyaluronic acid (HA) injections are current nonoperative sports medicine treatments that produce successful outcomes. Over the next several years, the use of stem cells will become more refined and effective in orthopedic care. Therapy and rehabilitation also play a vital role, and we work hand in hand with our physical and occupational therapists on-site as well as at Orlando Health Jewett Orthopedic Institute community-based clinics.

As healthcare providers, we value the provider-patient relationship and consider our patients partners in their success. The Continued on page 20 FLORIDA MD - JULY/AUGUST 2022 19

Continued from page 18

For these devastating conditions for which there are no known cures, we have a responsibility to mobilize every avenue for new therapies and research opportunities. Orlando Health is committed to participating in medical research as well as training and educating the next generation of neurologists. At the institute, we are expanding our research programs. Just one example is becoming a site for two national investigational studies for new multiple sclerosis therapies. These research protocols offer patients with many different neurological conditions treatment options outside what is conventionally available. New advances like this will further enhance care for an even broader range of patients throughout Central Florida and beyond.

Christian Rosado, MD, is a board-certified vascular neurologist and medical director of neurology with the Orlando Health Neuroscience Institute. Dr. Rosado works within a multidisciplinary team that includes specialists in neurology, neurosurgery, interventional pain management, rehabilitation and neuropsychology as well as neuroradiology, lung and sleep medicine, cardiology and oncology. This collaborative approach enables the institute to offer the most comprehensive, advanced treatment and management options to patients with neurological conditions. Dr. Rosado earned his medical degree from Indiana University in Indianapolis and completed all of his specialty training at the University of Florida in Gainesville, which included an internship in internal medicine followed by a neurology residency and a vascular neurology fellowship. 

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Orlando Health Jewett Orthopedic Institute philosophy and facility allow us to best achieve that desired outcome for our patients.

Michael V. Jablonski, MD, is a board-certified orthopedic surgeon and the physician leader of Orlando Health Jewett Orthopedic Institute. He specializes in knee joint replacement, using Mako® Robotic Arm Assisted Surgery, as well as in sports medicine. Dr. Jablonski completed medical school and residency training at the University of Florida College of Medicine, followed by a fellowship with the renowned Dr. James Andrews at the American Sports Medicine Institute. He served as the chief medical officer for 2022 USA Special Olympics, an immensely rewarding experience that fostered a strong interest in advocating for inclusive, quality orthopedic care for people with intellectual disabilities. Dr. Jablonski grew up in Central Florida and has enjoyed practicing in the area for more than 20 years. 

20 FLORIDA MD - JULY/AUGUST 2022

2022

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.

JANUARY –

Digestive Disorders Diabetes

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Cardiology Heart Disease & Stroke

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Surgery Scoliosis

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Women’s Health Advances in Cosmetic Surgery

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Allergies Pulmonary & Sleep Disorders

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Neurology / Neuroscience Advances in Rehabilitation

AUGUST –

Sports Medicine Robotic Surgery

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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/AUGUST 2022 21

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