Florida md june 2016 by FloridaMD

JUNE 2016 â&#x20AC;¢ COVERING THE I-4 CORRIDOR

St. Cloud Regional Medical Center Patient Quality of Life Is Central to Expert, Compassionate Vascular Care

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JUNE 2016 COVERING THE I-4 CORRIDOR

 COVER STORY

PHOTO: PROVIDED BY ST. CLOUD REGIONAL MEDICAL CENTER

The area’s first and only vascular surgeon, Adonis J. Lysandrou, M.D., provides the full spectrum of care for those with arterial and venous disease to help them gain control of their health. Dr. Lysandrou is board certified in vascular surgery. His practice at Vascular Associates of St. Cloud and St. Cloud Regional Medical Center brings to the region more than 10 years of experience in the diagnosis and management of arterial and venous disease. “Vascular surgeons are usually called on to handle vascular conditions outside of the heart and brain that involve blood clots, injuries, trauma, dissection (of the artery walls) and uncontrolled bleeding,” says Dr. Lysandrou. “I treat everything from aneurysms and carotid artery blockages to peripheral vascular and venous diseases.”

3 MEDICAL OFFICE RESOURCES OF FLORIDA SPONSORS IMMERSIVE HIPAA IT RISK ASSESSMENT WORKSHOP 17 CALLING ALL INDEPENDENT DOCTORS TO UNITE AT AID’S FIRST MEETING: INDEPENDENCE IN ACTION 2016

PHOTO: DONALD RAUHOFER / FLORIDA MD

ON THE COVER: Adonis J. Lysandrou, MD

DEPARTMENTS 2

FROM THE PUBLISHER

PULMONARY & SLEEP DISORDERS

10 MARKETING YOUR PRACTICE 11 HEALTHCARE BANKING, FINANCE AND WEALTH

12 HEALTHCARE LAW 13 ORTHOPAEDIC UPDATE 14 ALLERGIES 16 INPATIENT REHABILITATION 18 BEHAVIORAL HEALTH 20 CANCER 23 DIGESTIVE & LIVER UPDATE FLORIDA MD - JUNE 2016 1

FROM THE PUBLISHER

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

Donald B. Rauhofer Publisher

COMING NEXT MONTH: The cover story focuses on Mark A.

Socinski, MD joining the Florida Hospital Cancer Institute as the new Executive Director and his vision for the Institute and Florida Hospital’s approach towards cancer care. Editorial focus is on Imaging Technologies and Interventional Radiology.

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

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Publisher: Donald Rauhofer Photographer: Donald Rauhofer / Florida MD Contributing Writers: Heidi Ketler, Sajid Hafeez, MD, Tabarak Qureshi, MD, Steven Rosenberg, MD, Dana Clark, MD, Jeff Holt, Jennifer Thompson, J. Darin Stewart, Erica G. Burns, Michelle Bilsky, Dorothy Mowbray, Corey Gehrold, Lucien Johnson, Marni Jameson 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.

Medical Office Resources of Florida Sponsors Immersive HIPAA IT Risk Assessment Workshop By Dorothy Mowbray, M.O.R.O.F. Media Committee Chair and Board Member Technology can be an asset but it must be integrated into the practice operations to be effective and efficient. HIPAA is about protecting the patient’s information and this data security doesn’t stop with the hardware of technology. At this Immersive HIPAA IT Risk Assessment Workshop, attendees will experience a HIPAA protected environment and the security protection that is achieved with Managed Security Services and other office requirements. With the assistance of representatives from Microsoft and Fortinet, Karl Muhlbach, President of Eukairos Technology and a MOROF member, will lead this workshop on Friday, July 15, 2016 at the Venue On The Lake at the Maitland Civic Center. The address is 641 South Maitland Ave., Maitland, FL 32751. Attendees can come for the whole day, 8:30 a.m. to 5 p.m., or either the morning or afternoon intercessions. Breakfast and lunch will be included. This is designed to be the first in a series of HIPAA related technology topics. For more details, costs and tickets go to www.mor-of.net. Muhlbach’s passionate about helping, “Practices and their employees must understand and appreciate the Cyber Threat and what is at risk. It’s a paradigm shift in the way they treat patient’s private information. Immersing them in this environment will help them understand what is required and where their current solution might be lacking.” Just because a practice’s EMR software is HIPAA certified, doesn’t mean that the whole practice is. The management of these devices also needs to be compliant. Plus, the staff cannot be careless with patient data nor leave patient information laying around for all to see. Even having the staff talk too loudly about a patient could be a violation. He explained, “True HIPAA compliance is only achieved through a holistic approach with technology and the training within the practice itself. That’s why at Eukairos Technology we refer to the HIPAA acronym more poignantly as Healthcare Information Protected Against Attack!” Topics at the workshop include: • What are my responsibilities under HIPAA? • What’s a HIPAA IT Risk Assessment and Why do I need one? • How to prepare for an IT audit • Benefits of Managed Security Services • Taking your practice mobile • Integrating Office 365 into your practice • See how the Microsoft Surface Pro 4 is mobilizing practices • Updating and maintaining your required Risk Assessment Attendees will be provided with a Microsoft Surface and extra bandwidth will be available so everyone receives a hands-on experience at the workshop. This mobile tablet is designed for physicians and nurses to carry wherever they go. Microsoft claims that the Surface empowers providers with instant access to the

information and resource they need to be more productive and provide better patient care. Plus, it can be sanitized with many standard disinfectants before it travels from patient to patient. After the workshop, attendees will need to return their Microsoft Surface. It’s just a test drive immersive experience, not a gift! Attendees will, however, leave with a workshop certificate of completion that will be a great asset to their HIPAA Risk Assessment file for their practice. To register for the Immersive HIPAA IT Risk Assessment workshop, visit the www.mor-of.net website for more event information and costs. Medical Office Resources of Florida (MOROF) provides educational resources to the healthcare community through monthly presentations, LinkedIn MOROF (open group), MOROForlando YouTube channel. MOROF meets the fourth Thursday of each month from 7:30 a.m. to 9 a.m. at the Venue On The Lake at the Maitland Civic Center. The address is 641 South Maitland Ave., Maitland, FL 32751. Healthcare professionals are always welcome as guests. 

FLORIDA MD - JUNE 2016 3

COVER STORY

St. Cloud Regional Medical Center –

Patient Quality of Life Is Central to Expert, Compassionate Vascular Care By Heidi Ketler as risk factors are present. Consultation with a vascular surgeon often yields new options for patients with chronic and refractory disease. Dr. Lysandrou offers the latest in open and endovascular aneurysm repair, carotid endarterectomy, angioplasty with and without stenting, embolectomy, thrombectomy and vascular bypass grafting, among other procedures. “New technology and advanced endovascular therapy are very nice for treating patients whose health is compromised because of diabetes, high blood pressure and cholesterol and worsened cardiac disease. Endovascular surgery decreases morbidity,” says Dr. Lysandrou. He performs endovascular procedures in St. Cloud Regional Medical Center’s state-of-the-art catheterization lab. Dr. Lysandrou stresses the importance of experience, needed to determine when open or endovascular surgery is best for a patient, given the diagnosis. “As a vascular surgeon, it is very important to know when to do procedures and when not to do them. Dr. Lysandrou reviews a duplex ultrasound, which allows him to determine blood flow through the That’s when you’re going to save people’s veins. This information will help with diagnosis and developing a treatment plan specific to his lives and extremities. Sometimes it’s betpatient. ter to follow the patient, especially when the risks associated with the medical problem are low compared to the risks of surgery.” Dr. Lysandrou’s specialized expertise extends to treatment of chronic venous insufficiency, venous thromboembolism, varicose and spider veins. He implants long-term venous access devices, such as Mediports for oncology and hematology patients and arteriovenous fistulas and catheters for dialysis access. He also works at the St. Cloud Regional Medical Center Wound Care Center once a week and provides hyperbaric oxygen treatments to patients. Equal to his experience is Dr. Lysandrou’s depth of compassion. “My most important job as a physician and surgeon is to do no harm. It is the basis of the Hippocratic oath. And that’s why, when we see patients we take care of them like they are our family members and friends. We do for each patient what we would do for our family,” he says. Dr. Lysandrou was attracted to vascular surgery during his general surgery

PHOTO: DONALD RAUHOFER / FLORIDA MD

4 FLORIDA MD - JUNE 2016

COVER STORY residency because of the typically rapid results. “After a procedure, the difference is like day and night. Once healing occurs, patients are very happy and grateful to be able to do the activities of daily living that they used to,” he says. The general public is not widely aware of the processes at work in cardiovascular disease beyond the heart and in other parts of the body that rely on oxygen- and nutrient-rich blood, such as the legs, feet and arms, kidneys, lungs and brain. One of these processes is atherosclerosis. A form of arteriosclerosis, it is a slowly progressive Dr. Lysandrou uses diagrams and an enlarged 3D model to discuss with his patient what an abdominal disease that may begin as early as aortic aneurysm is and how it relates to her health. He ensures his patients truly understand their vaschildhood. cular health. The exact cause of atherosclerosis is unknown and thought to 8 million people in the United States have PAD, including 12-20 start with damage to the inner layer of the artery as a result of percent who are older than age 60. Individuals with PAD have high blood pressure, cholesterol and/or triglycerides, smoking or a higher risk of developing CAD and cerebrovascular disease, other tobacco sources, insulin resistance or diabetes, obesity and/ which can lead to a heart attack or stroke. or inflammation as a result of such diseases as lupus or infections Since PAD prevents muscles and organs from receiving the oxor unknown causes. Age and unhealthy diet also are risk factors. ygen and nutrients to work properly, blockages can cause crampThe accumulation of fatty deposits and other cellular products ing, pain and tiredness in the affected area during activity. The at the site of injury is usually accompanied by hardening, and pain resolves with rest. Left untreated, PAD can result in foot stenotic narrowing, of the artery. Plaque formations can grow ulcers, infections and gangrene, which requires amputation. large enough to significantly reduce the blood’s flow through an In patients with symptoms of PAD in the legs, the ankle-braartery. When a plague formation becomes brittle or inflamed, it chial index is a non-invasive test to measure blood pressure in the can rupture, producing a blood clot that can travel to other parts ankles. Imaging tests such as ultrasound, magnetic resonance anof the body. giography and computed tomographic angiography can provide Complications of atherosclerosis depend on the location of the additional diagnostic information. affected arteries. Symptoms usually don’t occur until the artery is Most cases of PAD can be managed with lifestyle changes and so narrowed or clogged it can’t supply adequate blood to organs medication. Severe cases may require surgery to bypass blocked and tissues. arteries. Atherosclerosis is a major cause of aneurysms. Symptoms deARTERIAL DISEASE: PREVALENCE AND RISKS pend on location and can result in life-threatening complications Coronary artery disease (CAD) is an effect of atherosclerosis. if left untreated. Often there are no noticeable symptoms, and It is the most common form of heart disease and the leading cause the aneurysm is found incidentally to an imaging study for other of death in both men and women in the United States, according medical reasons. Aneurysms may cause pain and throbbing at its to the Centers for Disease Control and Prevention. Symptoms location. often include chest pain. Aortic aneurysms, those that occur anywhere along the aorta, Those with CAD are at a higher risk for heart attack. Over time were the primary cause of 10,597 deaths and a contributing cause CAD can weaken the heart muscle and contribute to heart failure in more than 17,215 deaths in the United States in 2009, accordand arrhythmias. Individuals with CAD have a higher risk for ing to the Centers for Disease Control and Prevention. other vascular diseases. Treatment may include lifestyle changes and medications to lowAbdominal aneurysms are the most common along the aorta in er heart attack risk. For those whose angina worsens, angioplasty people age 65 and older. In addition to atherosclerosis, risk facwith or without stenting and/or bypass surgery may be advised. tors include injury or infection, emphysema, family history, high blood pressure, high cholesterol, obesity and smoking. Less than Peripheral arterial disease (PAD) is caused by atherosclerotic 80 percent of patients survive a ruptured abdominal aneurysm, plaque that impedes blood flow in the legs, arms, abdomen, neck according to the American Heart Association (AHA) and brain. It is most common in the leg arteries. Approximately FLORIDA MD - JUNE 2016

PHOTO: DONALD RAUHOFER / FLORIDA MD

VASCULAR HEALTH

COVER STORY When symptoms are present, they usually include throbbing or deep pain in the back or side and/or pain in the buttocks, groin or legs. The United States Preventive Services Task Force recommends that men age 65-75 who have ever smoked get an ultrasound screening for abdominal aortic aneurysms, even if they have no symptoms. Thoracic aortic aneurysms are life threatening and cause significant short- and long-term mortality due to rupture and dissection. Fortunately they are rare, affecting approximately 6-10 out of 100,000 people. About 20 percent of those cases are linked to genetic syndromes, such as Marfan syndrome and Ehlers-Danlos syndrome. Symptoms, such as a sharp, sudden pain in the chest or upper back, shortness of breath and/or trouble breathing or swallowing, are subtle or non-existent. Peripheral artery aneurysms commonly occur in the neck (carotid), groin (femoral) or behind the knees (popliteal). About 85 percent are popliteal, and most peripheral aneurysms occur in men older than 50. Risk factors include age, gender and diabetes. It is estimated that about half of peripheral aneurysms are bilateral. Among these cases, about one-third of those with a popliteal aneurysm and one-half with a femoral aneurysm have an associated aortoiliac aneurysm. While peripheral aneurysms are less likely to rupture or dissect than aortic aneurysms, they can form blood clots that break away and possibly block blood flow in an artery. Arterial thrombosis can be limb threatening when all outflow vessels are occluded. This can lead to amputation in up to 30 percent of patients. Often peripheral aneurysm is asymptomatic. Disabling claudication and/or acute limb ischemia are often the result of arterial thrombosis, peripheral embolization or compression of adjacent structures with resultant venous thrombosis or neuropathy. Surgery is recommended for all asymptomatic popliteal aneurysms larger than 2 centimeters and for all that are symptomatic regardless of size. Large aneurysms that compress the popliteal vein or nerve are resected in addition to grafting.

AORTIC ANEURYSM: DIAGNOSIS & TREATMENT Life-threatening internal bleeding is likely when aneurysms rupture or dissect. As a result, timely diagnosis and treatment, including open or endovascular surgery to replace or repair the damaged artery, are critical. Medication to lower blood pressure may be prescribed for those whose aneurysm doesn’t appear to be at imminent risk of rupture. Studies have shown likelihood of rupture is directly related to the size of the aneurysm. A small aneurysm may be monitored by ultrasound every six months or annually. The standard surgical treatment for aneurysms has been open surgery. In 2003, endovascular aneurism repair (EVAR) surpassed open aorta surgery as the most common repair of abdominal aortic aneurysms. Symptomatic aneurysms mandate endovascular or open repair regardless of size. During EVAR, long, thin catheters are inserted through small incisions in the femoral artery. Using X-ray guidance, the stent graft, or “scaffold,” is delivered to the aneurysm site. The stent graft provides a snug, new artery lining, relieving the diseased tissue from direct stress of blood pressure. This often results in the 6 FLORIDA MD - JUNE 2016

aneurysm shrinking over time. The benefits of endovascular repair are generally less pain, a shorter hospital stay, lower risk of complications and speedier recovery than traditional surgery. Potential risks include endoleak around the graft, migration of the graft and stent fracturing. Other complications that are serious but rare include paralysis, delayed aneurysm rupture and infection. The long-term durability of endovascular stent grafting is not yet known, because it is a fairly new procedure. For this reason, patients who have endovascular repair should be monitored on a regular basis.

VENOUS DISEASE: DIAGNOSIS & TREATMENT Leg health problems and vein disease affect approximately 80 million Americans. A properly functioning vein relies on tiny valves that open and close to move oxygen-depleted blood up from the feet and back toward the heart. While the exact cause of vein disease is unknown, the following factors may contribute to chronic inflammation that results in overstretched and dilated veins, functional valvular failure and reflux: • Heredity, which includes congenital absence of venous valves • Excess weight • Female gender • Standing occupations • Previous damage or inflammation of the venous system • Pregnancy Venous thrombosis includes superficial thrombophlebitis, which does not pose as much health threat as deep-vein thrombosis, which is life threatening. Superficial thrombophlebitis can occur after an injury, in a varicose vein or after the introduction of irritating fluids into the vein. It responds well to warm, moist heat, non-steroidal antiinflammatory medication and elevation. Deep-vein thrombosis (DVT) can occlude one or more of the major leg veins, impairing blood return to the heart and causing significant leg swelling. There also is a risk that the blood clot or a piece of it will break loose and travel to the heart and lungs, where it can cause a fatal pulmonary embolism. Factors that cause blood flow to become sluggish and clot include smoking, use of female hormones, prolonged bed rest, surgical procedures, injuries and prior episodes of DVT, to name a few. If DVT is suspected, anticoagulation therapy is promptly initiated and aggressively managed. Post-thrombotic syndrome is the result of scarred valves and vein linings that prevent the valves from closing properly, causing blood to leak into surrounding tissue. Swelling, heaviness and aching in the leg tends to increase by day when the patient is upright. There is no cure and lifelong use of elastic stockings may be required to control symptoms. Untreated venous insufficiency in the deep or superficial system causes chronic venous insufficiency (CVI). This complex, progressive condition affects 2-5 percent of the population and comes with a high potential for serious complications, such as phlebitis, deep-vein thrombosis and venous stasis ulcers. CVI’s earliest manifestation may include lower-extremity edema, lipodermatosclerosis and/or discomfort, such as the signature

COVER STORY pain that comes with ambulation. Varicose or spider veins and ulceration may occur above the superficial fascia. Diagnosis is often performed on an outpatient basis. The most common noninvasive test is a venous duplex scan that assesses reflux, venous valve function and venous clot formation. Magnetic resonance angiography is often used if venous clots or vessel narrowing is suspected in the pelvis or abdomen. A contrast venogram, using X-ray fluoroscopy, is an invasive examination that is occasionally necessary to investigate venous disease more thoroughly. Intravascular ultrasound uses a catheter with an ultrasound probe in the vein to obtain the most accurate measurement of venous obstruction. Once venous insufficiency syndromes begin, the damage cannot be reversed, only treated. Treatment is designed to alleviate the symptoms and correct the underlying abnormality when possible. Graduated compression is the cornerstone of treatment, as oral medication has not proven useful. Surgical and endovenous therapy is commonly reserved for those with discomfort or ulcers that are refractory to medical management. Valvuloplasty is occasionally successful, but the risk of postoperative deep-venous thrombosis is high. Venous bypass is successful in select patients. About 1 percent of the population in developing countries suffers from venous ulcers, which may be caused by inflammatory Inside St. Cloud Regional Medical Center’s Multipurpose Cardiac Catheterization Lab, Dr. Lysandrou prepares to perform angiogram, which enables him to evaluate blockages in the arterial system. An angiogram detects blockages using X-rays taken during the injection of a contrast agent.

processes associated with leukocyte activation, endothelial damage, platelet aggregation and intracellular edema. Many patients with venous ulcers have had a history of deep-vein thrombosis. The ulcers are generally irregular in shape, shallow and located over bony prominences. Venous ulcers are often recurrent and can persist for weeks to many years, significantly impacting patient quality of life. Severe complications include cellulitis, osteomyelitis and malignant change. Antibiotics won’t heal ulcers and should only be used for short courses in cases of clinical infection. Large ulcers that are refractory to conservative measures may benefit from surgical management. In addition to advanced expertise in valvular dysfunction, Dr. Lysandrou provides a coordinated multidisciplinary approach that is critical to effective treatment and prevention. Varicose veins affect at least 15 percent of the population in the United States. Varicose veins do not pose a serious health threat, so therapy for asymptomatic varicose veins is unnecessary unless removal is for cosmetic purposes. While elevating the legs and/or wearing elastic compression stockings usually control discomfort, Dr. Lysandrou offers more aggressive therapy. Most spider veins can be treated in the office using sclerotherapy, in which a very thin needle is used to inject a sclerosant directly into the veins. This causes the vein lining to seal. Nonsurgical endovascular laser therapy (EVLT) uses heat under ultrasound guidance to close varicose veins. The body then naturally reroutes the blood to healthy veins. After the office procedure, patients notice an immediate and significant improvement in appearance, and there is little-to-no recovery time. Vein stripping is a more invasive procedure in which the saphenous veins are removed and the major side branches are ligated. The outpatient surgical procedure is performed under general anesthesia. The incisions are not sutured and elastic compression is applied. Recovery varies from two to four weeks, depending on the number of veins removed and their location. Radiofrequency ablation is a minimally invasive alternative to vein stripping. Under ultrasound guidance, a radiofrequency catheter inserted into the abnormal vein emits heat to close the vein. This procedure can be performed in the office using local anesthesia and a mild sedative. Recovery is in a matter of days, with strenuous activity restricted for two weeks.

PHOTO: DONALD RAUHOFER / FLORIDA MD

EARLY INTERVENTION Recognizing that many vascular diseases go undiagnosed or misdiagnosed, Dr. Lysandrou urges early intervention with a specialist at the earliest signs. “If you see anything in the feet or legs – discoloration or ulcerations that are not healing – leg pain or numbness, that’s when it’s really important to think about a vascular cause and a bigger problem,” he says. Prevention is always better than treatment after a medical emergency. “Once an artery closes in the leg, it can be difficult to open it up again, and irreversible damage may already be done.” For more information on Vascular Associates of St. Cloud visit StCloudPhysicians.com. To schedule an appointment with Dr. Lysandrou, call (407) 891-2930.  FLORIDA MD - JUNE 2016

PULMONARY AND SLEEP DISORDERS

Bronchial Thermoplasty By Tabarak Qureshi, MD

ASTHMA OVERVIEW: Approximately 25 million people have asthma in the United States and 5-7 % of them have severe persistent asthma. This group of asthmatics continue to have symptoms despite using multiple inhaled medications, which leads to a increased burden on health care expenditure. A severe persistent asthmatic spends roughly > $12,000/yr as compared to a mild asthmatic who may spend $2,000/yr. Poorly controlled asthma leads to increased health care use and has negative effects on a patients quality of life.

after the BT treatment period (day of first BT procedure until 6 weeks after the last bronchoscopy, approximately 12 weeks). This was noted by an improvement in symptoms reflected on the Asthma Quality of Life Questionnaire (AQLQ), at 6,9 and 12 months after bronchial thermoplasty.

Although recent advances in medicines have helped in customizing bronchodilators and antiinflammatory therapies, there are no treatments that have targeted airway remodeling. These changes are more prominent in severe persistent asthma.

BRONCHIAL THERMOPLASTY: This is a procedure that targets the smooth muscle in the airways. Through the direct application of heat the smooth muscle in the airways is reduced. This has dual benefits toward the lumen of the airway, firstly reduces the accumulation of excess airway smooth muscle that leads to narrowing of the airways and secondly helps reduce the intensity of constriction of the airways. This is a non-pharmacological treatment of asthma that has shown to improve asthma control in the severe persistent asthmatic. Multiple trials have been done, including randomized control trials that have shown improvement of asthma control in Moderate-severe persistent asthmatics. Bronchial thermoplasty (BT) (delivered by the Alair Bronchial Thermoplasty System; Asthmatx Inc, Sunnyvale, California) is a new treatment option for patients with severe persistent asthma. Bronchial Thermoplasty is preformed through a regular flexible bronchoscope. It is done in three sessions, each separated by three week intervals. In the first procedure, the right lower lobe is treated, followed by the left lower lobe and then bilateral upper lobes. The right middle lobe is not treated secondary to a possibility of developing right middle lobe syndrome. The patient is followed closely during the treatment cycles as exacerbation of asthma is common during the treatment stage.

CLINICAL TRIALS: ASTHMA INTERVENTION RESEARCH 2 (AIR2) TRIAL: The Asthma Intervention Research 2 (AIR2) trial, a doubleblind, sham-controlled, randomized clinical trial of BT in patients with severe asthma, showed a 32% reduction in severe exacerbations, an 84% reduction in emergency department (ED) visits caused by respiratory symptoms, a 73% reduction in hospitalizations for respiratory symptoms, and a 66% reduction in time lost from work/school/other daily activities because of asthma symptoms compared with a sham-treated group in the year 8 FLORIDA MD - JUNE 2016

Alair Catheter: a flexible tube with an expandable wire array at the tip to deliver therapeutic RF energy to the airway walls via a standard bronchoscope.

5 YEAR SAFETY OF BRONCHIAL THERMOPLASTY (BT) DEMONSTRATED IN MODERATE TO SEVERE PERSISTENT ASTHMA: One hundred sixty-two (85.3%) of 190 BT-treated subjects from the Asthma Intervention Research 2 trial completed 5 years of follow-up. The proportion of subjects experiencing severe exacerbations and emergency department (ED) visits and the rates of events in each of years 1 to 5 remained low and were less than those observed in the 12 months before BT treatment (average 5-year reduction in proportions: 44% for exacerbations and 78% for ED visits). Alair Radio Frequency Controller: designed to safely and accurately deliver precise, controlled RF energy through the Catheter to the airway walls.

PULMONARY AND SLEEP DISORDERS

Bronchial Thermoplasty completed in 3 outpatient procedures.

Respiratory adverse events and respiratory-related hospitalizations remained unchanged in years 2 through 5 compared with the first year after BT. Prebronchodilator FEV1 values remained stable between years 1 and 5 after BT, despite a 18% reduction in average daily inhaled corticosteroid dose. High-resolution computed tomographic scans from baseline to 5 years after BT showed no structural abnormalities that could be attributed to BT.

CONCLUSIONS: With the development of improved medical therapies and understanding the mechanisms of asthma, there still remains a number of frustrations for patients with severe persistent asthma. These include persistent symptoms with daily treatments of exacerbations and risk associated with escalating dose of steroids. Bronchial Thermoplasty is a novel treatment that targets structural changes in airways smooth muscle, in turn effecting airway remodeling and has long lasting effects. This is unlike any available treatment and compliments standard medical treatment. Recommendation for options for treatment with bronchial thermoplastic were made by Global Initative for Asthma (GINA) and the American College of Chest Physicians (CHEST), in the sub group of patients with severe persistent asthma. Bronchial thermoplastic helps down stage asthma, in turn improving quality of life and reduction in over all health care costs associated with severe persistent asthma.

Dr Tabarak Qureshi completed his Pulmonary, Critical Care and Sleep Medicine fellowship at Wayne State University/Detroit Medical Center. He has been at the Central Florida Pulmonary Group since 2009 and is a Clinical Assistant Professor at the University of Central Florida School of Medicine. He Leads the Bronchial Thermoplasty program at the Central Florida Pulmonary Group. He is involved in training physician at Florida Hospital Altamonte, which is one of the four Centers of Excellence for bronchial thermoplasty in the United States. . î Ž

COMING UP NEXT MONTH: The cover story focuses on Mark A. Socinski, MD joining the Florida Hospital Cancer Institute as the new Executive Director and his vision for the Institute and Florida Hospitalâ&#x20AC;&#x2122;s approach towards cancer care. Editorial focus is on Imaging Technologies and Interventional Radiology.

FLORIDA MD - JUNE 2016

MARKETING YOUR PRACTICE

The Secret to Immediately Differentiating Your Practice From Your Competitors: Part 1 By Jennifer Thompson All things being equal, why would a patient choose your practice over the one around the corner? Here’s a hint: it’s not your doctor’s credentials. Traditionally, and even until recently, doctors’ and physicians’ approaches to marketing and generating new patients were centered around the doctors themselves, their

can you as a doctor differentiate yourself from the rest of the pack? Most prospective patients who visit a doctor’s website already assume the physician has proper credentials; so what sets the doctor apart from the rest is the experience they offer to the patient. Physicians need to understand in today’s medical market, it’s not about YOU the doctor, it’s about the patients, their stories, and their outcomes. That is what creates authority, connection and interest to drive potential patients into the office. It’s all about trust and accountability. The patients are the ones who will do the marketing, through word of mouth, from friend to friend, and from network to network.

PATIENT TESTIMONIALS

credentials, their qualifications, and the level of the technology they offered. However, the internet and social media have radically changed the way people communicate, and have revolutionized how patients now search for, and choose, their doctors. So, how can you differentiate your practice immediately from your competitors?

PATIENT-FIRST MARKETING Old modes of patient marketing are becoming less and less effective, to the point of becoming obsolete. The most successful doctors and clinics in America today are using what’s known as a patient-first approach to marketing; a strategy developed by Insight Marketing Group, a medical marketing agency for independent physicians based in Orlando, Florida. Today’s consumers of medical care are more refined and discerning than ever before. They need more than to see a billboard or a brochure, plastered with the faces of a clinic’s twenty physicians and their credentials; potential patients now seek an emotional connection with their doctor, and they want to know about other people’s experiences with that physician. Many turn to internet review sites such as Vitals.com and Healthgrade.com as well as social media for reviews and recommendations from their peers, in order to make an informed decision about their healthcare provider. Assuming most, if not all, physicians are board certified, how 10 FLORIDA MD - JUNE 2016

One of the key aspects of patient-first marketing is sharing the outcome and the benefits right from the patient’s mouth. This has proven to be the most effective means of communication to prospective clients than any other message you can send out. In a recent industry report by tech resource Software Advice, 62% of surveyed respondents said that they use patient reviews and testimonials to start their search for a new doctor. And 19% use online reviews to validate their choice of a physician before making an appointment. That’s huge! And, as technology and social media begin to play a larger role in our daily lives (and the future lives of those household decision makers) it is imperative to make sure physician offices are proactive in putting their best foot forward and presenting their practice as a patient-first, highly successful and well reviewed business. If someone declares to their network and their community that a particular doctor changed their life, that physician now has a personal testimonial of great power and impact. That proclamation creates an immediate connection with potential patients; something that will serve as a key differentiator for the physician’s practice. Leading with the patient’s positive experience and turning it into a marketing strategy can pay great dividends in the long run. Testimonials also give doctors the opportunity to better manage their online reputation. If there’s a negative google review floating out there about you, you can change that by overwhelming the search engine with positive reviews. Can’t wait until next month for Part 2? Check out www.InsightMG.com for early access to the complete resource. 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. 

HEALTHCARE BANKING, FINANCE AND WEALTH

Handling Unexpected Profits – Secure your practice’s future!

By Jeff Holt, CMPE, VP, Senior Healthcare Business Banker with PNC Bank When your practice has a banner quarter or year resulting in a significant profit, congratulate yourself—but don’t rest on your laurels. An occasional bounty is an excellent opportunity to strengthen your practice’s financial underpinnings for years to come. Here’s how:

DETERMINE HOW MUCH YOU SPEND Take a look at the last 12 months of expenses, and break them down into two categories: fixed and variable. Fixed costs are those that are independent of your patient volume, such as rent or mortgage payments, equipment leases, loan installments, payroll services, malpractice and other insurance payments and so on. Variable costs generally rise and fall depending on how many patients you see. These include laundry, consumables, stationery and some purchased services. To further fine-tune your analysis, you might break down certain costs, such as payroll, into a fixed component—necessary whether you see patients or not—and a variable one, that increases the busier you are.1

CALCULATE YOUR WORKING CAPITAL This is defined as current assets (bank balances, cash, accounts receivable) minus current liabilities (taxes due, accounts payable, short-term loans and the portion of long-term loans due in the next 12 months). Divide this number by 365 to determine your daily operating (working) capital.2

FUND MONTHLY OPERATIONS By separating the cash necessary to operate on a daily basis from that used for unexpected events, you’ll have a clearer sense of how much is available for each. Consider maintaining a minimum balance sufficient to cover the fixed and variable costs of your last cash-inflow month of the year in a monthly operating account, such as your primary business checking account.

ESTABLISH A CONTINGENCY FUND In addition to your operating account, it’s helpful to maintain a separate fund that can be accessed immediately as needed. This might hold three to six months of operating cash, calculated as your daily operating capital multiplied by 90 to 180 days. Your contingency account can serve not only as a safety net but also as an investment; consider placing the funds in a liquid, interestbearing account, such as a money market fund.3

AUTOMATE THE PROCESS As conditions change, your contingency and operational accounts might need occasional rebalancing. When you have more than you need in your operating account, transfer the excess into the contingency fund. If you anticipate a cash flow crunch, transfer money in the other direction. Setting up your

contingency fund as a sweep account can make this happen automatically by establishing minimum and maximum daily balances on your primary checking account, with any excess automatically transferred to the interest bearing account and vice versa.4 Once you’ve built a buffer to protect your practice from seasonal or unexpected downturns, you’ll have a far better sense of what resources you can direct toward strategic growth, capital investment and increased personal income—all built on a solid foundation. Important Legal Disclosures and Information: 1 http://www.ahrq.gov/research/findings/final-reports/costpqids/costpqids2a. html 2 http://www.sba.gov/content/working-capital 3 http://www.entrepreneur.com/article/230204 4 https://www.pnc.com/webapp/unsec/ProductsAndService.do?siteArea=/ p n c c o r p / P N C / Ho m e / Sm a l l + Bu s i n e s s / Sa v i n g s + a n d + L i q u i d i t y / Sweep+Accounts/Business+Sweep+Checking The third-party trademarks referenced in these articles are owned by and are the registered trademarks of their respective third-party owners. There is no affiliation, sponsorship or endorsement relationship between PNC or its affiliates and any such third party. PNC is a registered mark of The PNC Financial Services Group, Inc. (‘‘PNC’’)

Jeff Holt is a Senior Healthcare Business Banker and V.P. with PNC Bank’s Healthcare Business Banking and is a Certified Medical Practice Executive. He can be reached at (352) 385-3800 or Jeffrey.Holt@pnc.com.

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

4O7-417-74OO FLORIDA MD - JUNE 2016 11

HEALTHCARE LAW

Nondiscrimination in Health Programs and Activities By J. Darin Stewart, J.D., C.P.A., Erica G. Burns, J.D., and Lucien Johnson In September 2015, the Department of Health and Human Services Office of Civil Rights (“OCR”) proposed a rule which affected physicians and health care programs. The rule entitled “Nondiscrimination in Health Programs and Activities” implements Section 1557 of the Affordable Care Act (“ACA”). Section 1557 prohibits discrimination on the basis of race, color, national origin, sex, age, or disability in certain health programs and activities. The OCR invited comment by all interested parties, including women’s organizations, organizations serving lesbian, gay, bisexual, or transgender (“LGBT”) individuals, health care providers, religious organizations, consumer groups, and state and local agencies, among many others. After the comment period closed, and taking those comments into consideration, the OCR published a final version of the rule that clarifies and codifies existing nondiscrimination requirements and sets forth new standards to implement Section 1557 of the ACA (the “Final Rule”).

prohibited from discriminating on the basis of sex.

The Final Rule expands the definition of “gender identity” to include male, female, neither, or a combination of male and female, in order to reinforce the fact that individuals with nonbinary gender identities are protected from discrimination on the basis of sex. This new Final Rule adopts the standard established by the Supreme Court in United States v. Virginia, under which a sex-specific health program or activity classification is unlawful unless the covered entity can show an “exceedingly persuasive justification” for it, meaning that the program or designation is substantially related to the achievement of an important healthrelated or scientific objective. 518 U.S. 515 (1996).

tions, individuals, and indi-

How does this new Final Rule affect physicians, healthcare providers, and other related organizations? Section 1557 restates many of the existing requirements of federal civil rights laws already in effect. It is not expected that covered entities will have to undertake any significant new costs or burdens outside of the minimal changes necessary to comply with the new prohibition of sex discrimination, which include training and familiarization, enforcement, posting of the nondiscrimination notice and taglines, and revisions in policies and procedures. The Final Rule also establishes a program for voluntary development of language access plans to provide services to individuals with limited English proficiency that the covered entities might serve or encounter. Those programs are not required by the Final Rule, but covered entities are still required to take reasonable steps to provide meaningful access to services. Medical schools, nursing programs, and other health education programs are already prohibited from discriminating on the basis of sex under Title IX. With the enactment of the Final Rule to Section 1557, health insurance providers receiving federal assistance, hospitals, clinics, other health facilities, Health and Human Services programs, and Title I entities, along with the staff and practitioners working in these health programs, are now also 12 FLORIDA MD - JUNE 2016

In summary, schools and employers are already prohibited from discriminating on the basis of sex under Title IX and Title VII. Under the Final Rule to Section 1557, those protections against discrimination are extended to the healthcare field.

J. Darin Stewart, JD, CPA

J. Darin Stewart, J.D., C.P.A. is a shareholder with GrayRobinson. He represents organizavidual medical providers whose needs include solutions to federal

Erica G. Burns, JD

and state health care regulatory compliance issues, complex financing vehicles, establishing corporate structures through which to transact business enterprises, leasing issues, and numerous corporate law issues. Darin can be reached at 407244-5639 or darin.stewart@gray-robinson.com. Erica G. Burns, J.D. is an attorney with GrayRobinson and also a member of the health care and corporate practice groups. She represents medical facilities, providers, and corporate entities on federal and state statutory and regulatory compliance issues, contract review and analysis, and complex business transactions. She can be reached at 407-843-8880 or erica.burns@gray-robinson.com. Lucien Johnson is a Summer Associate with GrayRobinson and is currently a law school student at the University of Florida.

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

ORTHOPAEDIC UPDATE

The Quest to Live Pain Free: One Man’s Cervical Fusion Testimonial By Corey Gehrold Serious neck discomfort, injuries and complications can be debilitating and seriously hinder one’s ability to enjoy all life has to offer. Just ask Bob, a recent patient of Stephen R. Goll, M.D., at Orlando Orthopaedic Center. He had been battling neck pain for a long time and he began losing strength in his left arm. After Dr. Goll requested an MRI, Bob found out he had two herniated discs in his cervical spine. Together, Dr. Goll and Bob discussed treatment options and the pros and cons to each. “I was very pleased with his mannerisms,” Bob says. “How he explained certain things to me, my options, I just felt very very comfortable. He has a great bedside manner; he says it like it is and doesn’t sugar coat anything.” When nonsurgical treatment, such as physical therapy and epidural injections proved unsuccessful, Dr. Goll and Bob began to explore the possibility of surgery. Together, they decided that cervical fusion surgery was Bob’s best option to relieve his pain and get him back to where he wanted to be. “I am so happy to be pain-free. The most beneficial and successful part of the surgery is that I can now actually sleep at night,”

Bob says he is 100 percent pain-free following recovery from his cervical fusion surgery with Dr. Goll.

Bob says. “Prior to the surgery, I’d put my head on the pillow, and I was in such pain, it was unbelievable. On top of that, I started losing strength in my left arm, and it started to limit some of the things I could do for work.”

WHAT IS CERVICAL FUSION SURGERY? During cervical fusion surgery, damaged portions of the neck (cervical) area of the spine are joined together. The procedure is normally needed when the discs between each vertebrae of the neck have been damaged from an injury or long term wear and tear. The surgeon will remove (take out) the discs, or disc fragments between the vertebrae, to relieve pressure on one or more nerve roots, or on the spinal cord, and will encourage bone growth in order to link adjacent vertebrae together. A metal plate or screw is often used to temporarily stabilize the fusion until the bones permanently fuse together.

HOW LONG WILL IT TAKE TO RECOVER FROM A CERVICAL FUSION? Stephen R. Goll, MD Everyone heals at a different rate and the speed at which a patient will recover depends on several factors, including: • General level of health • Overall physical fitness • Mental attitude • Use of tobacco “In most cases, cervical fusion only involves a one night stay in the hospital, with patients able to go home the morning after the surgery,” says Dr. Goll, a board certified orthopaedic surgeon, specializing in spine surgeries and spinal disorders of the back and neck. “The surgeon may want their patient to wear a cervical collar or brace to help immobilize the neck for a period of time, to let that fusion start to heal.” Recovery time for most patients generally lasts four to six weeks. On follow up visits, the patient will undergo examinations and have X-rays taken, to make sure that fusion is occurring and that the bone has healed through the fused vertebrae. The fusion process generally takes two to three months. Surgeons may provide their patients with neck stretches and/or strengthening exercises once the neck has fully healed. The doctor will determine when the patient is able to return to work. “Since the surgery, I’m 100% pain free,” Bob continues. “I’m very pleased with the results. My [general practitioner] recommended Dr. Goll, and I’m so pleased that he did because it worked out so so well.”

WHAT ARE THE RESULTS OF CERVICAL FUSION SURGERY?

Following surgery and recovery, a vast majority of patients report pain reduction in the neck and arm, improvements in neurological activity, and a fast return to normal functioning. Research has shown that cervical fusion surgery is successful in alleviating arm pain in ninety-two percent of patients, and neck pain relieved in 73 to 83 percent of patients. With a successful cervical fusion surgery, Bob is thankful for being pain-free and for a new lease on life. “I would absolutely recommend Dr. Goll to anyone suffering with neck or lower back pain,” he says. “His skills are phenomenal, his follow up is excellent, and his staff is superb.” 

FLORIDA MD - JUNE 2016 13

ALLERGIES

Treatment of the Person with Nasal Allergies

By Steven Rosenberg, MD, FAAP, FAAAAI

Maimonides wrote the first papers on the treatment of asthma. But it wasn’t until the early part of the 20th century that physicians realized that many individuals develop symptoms including head and chest congestion after exposure to pollens, animal dander, dust, and molds. These individuals were classified as being allergic. Allergic Rhinitis is known by many other terms including Pollinosis, Hay Fever, and Rose Fever. Approximately 40 million Americans experience allergic disease with a large number of them being children. Allergies unlike many other illnesses tend to be most severe in late childhood and early adult life -- times when individuals are expected to be the most productive. Because of this, the economic costs of allergies are quite high, exceeding five billion dollars each year. Rhinitis is the inflammation of the nasal membranes. Individuals who have inflammation caused by allergies are diagnosed as having Allergic Rhinitis. Individuals with seasonal allergic rhinitis experience symptoms when the outdoor pollens are most elevated -- usually during spring and fall. Others will have their symptoms year around and are known as having Perennial Allergic Rhinitis. Seasonal allergens include trees, weeds, and grasses. Perennial allergies include animal dander, molds, and dust. Symptoms of Allergic Rhinitis include nasal irritation and itching, rhinorrhea or nasal discharge, nasal congestion, and post nasal drip. Other symptoms seen with allergic rhinitis in  cludes sinusitis, headaches, eye irritation, and pharyngitis as well as asthma. Walt Disney World Environmental control in which the paSwan & Dolphin Resort, tient attempts to avoid exposure to those alOrlando, FL lergens which lead to a flare-up of symptoms Saturday, Nov.5, 2016 is of paramount importance. Such measures include avoiding yard work and even staying Register at   indoors when the outdoor pollens are high. www.aid-us.org/ Indoors, a thorough house cleaning may be of benefit. Other preventative measures include conference the removal of old pillows which may be dust collectors, replacing the air-conditioning filter, and the purchase of an air-filtration device. If the individual with allergies is allergic to animal dander, the removal of the family pet from the (407) 571-9316 family sleeping quarters may also be beneficial. Patients with severe allergies will not have

Every year millions of Americans, both children and adults, develop cold-like symptoms during the spring and fall. Many of these individuals think that these symptoms are secondary to a “head cold,” but in reality, they are caused by allergies. Allergies have plagued man throughout recorded history. Archeologists have unearthed a report of an Egyptian Pharaoh who died from an allergic reaction after being bitten by an insect in ancient Egypt. In medieval Spain, the philosopher/physician

Don’t miss AID’s ﬁrst member meeting. At Independence in Action 2016, you will hear dynamic, nationally regarded speakers, and meet other independent doctors and sponsors dedicated to keeping doctors independent -- all while enjoying the magic of Orlando’s Walt Disney World theme parks and attractions.

14 FLORIDA MD - JUNE 2016

ALLERGIES their symptoms adequately controlled by these measures. These individuals may benefit from the use of medications. The drugs of choice for the treatment of allergic rhinitis are antihistamines. In the past, antihistamines would cause undesirable side effects such as sedation. The newest classes of antihistamines such as loratadine, desloratadine, fexofenadine, and certirizine are quite effective for the control of allergies, yet cause minimal if any negative side effects. Nasal steroids may be the most effective medications for the treatment of the patient with allergic nasal symptoms. New preparations on the market include mometasone, fluticasone, budesonide, and triamcinolone. Other medications which may be helpful include nasal cromonlyn, nasal decongestants, and topical eye drops for the individual with allergic eye disease. Unfortunately, many people with allergic disease will require more aggressive therapy than environmental control measures and medications. These patients may benefit from immunotherapy or allergy injections. Immunotherapy is the administration in small doses of those allergens to which the patient is sensitive. By administration of such allergens, the person will then build up a tolerance resulting in a reduction of symptoms. The Allergist can perform a series of tests including skin test and RAST analysis which will enable the physician to determine to which allergens the patient is sensitive. The Allergist can then prescribe those medications which will best control the patients’ symptoms and set up a treatment plan which will include environmental control measures. If allergy injections are indicated, the Allergist’s office is skilled in the preparation and administration of immunotherapy. Allergies, especially allergic rhinitis, can result in a significant amount of misery and loss of school and work time. But with proper recognition and treatment, people who suffer from allergies can have their symptoms brought under excellent control.

Better Outcomes. Quality Care.

Stroke. Trauma. Brain Injury.

Steven Rosenberg, MD, FAAP, FAAAAI, has been practicing medicine in the Central Florida area for over 20 years, specializing in the area of Allergy, Asthma, and Immunology. He received the Doctor of Medicine from the State University of New York, Downstate Medical Center. Dr. Rosenberg completed a residency in Pediatrics at the State University of New York at Buffalo and a Fellowship in Allergy, Asthma, and Immunology at the University of Pittsburgh. Dr. Rosenberg has held positions as President of the Central Florida Pediatric Society, at the Florida Allergy, Asthma, and Immunology Society, and on the medical staff at Florida Hospital. In addition, Dr. Rosenberg has held the position of Chairman, Department of Pediatrics at Florida Hospital and is a member of many local and national societies which include the American Academy of Allergy & Immunology, the Florida Allergy and Immunology Society, Florida Hospital Kid’s Docs and the Central Florida Pediatric Society. He holds faculty appointments at the University of Central Florida Medical School and the Florida State University School of Medicine. For additional information please contact him at 407.678.4040 or aaaofcf@gmail.com. 

To learn more, call 407 587-8600. A Higher Level of Care®

FLORIDA MD - JUNE 2016 15

INPATIENT REHABILITATION

Understanding Autonomic Dysreflexia By Dana Clark, MD There are not many emergencies that occur as a direct result of a rehabilitation diagnosis, however the emergencies that occur can be difficult to diagnose and deadly. In the spinal cord injury (SCI) population, one such medical emergency is called Autonomic dysreflexia (AD). AD is clinically characterized by elevated blood pressure and bradycardia. Patients can also experience headache, flushing, sweating above the level of injury, goose bumps below the level of injury, nasal congestion and anxiety. AD occurs only in the SCI population and mostly with neurologic injuries at, or above the T6 spinal cord level. Patients with more complete injuries (meaning less sparing of motor or sensory) are at higher risk of developing AD during their lifetime. Upwards of 48 percent (Linden et al) of patients with SCI at, or above T6 develop AD during the first year post-injury. However, patients can also develop AD years after their initial injury. Important to note, the definition of AD includes elevated blood pressure (BP) from the patientâ&#x20AC;&#x2122;s baseline. In the SCI population, baseline BP can be lower than the able-bodied population. For this reason, elevated BP is defined as systolic BP 2040 mmHg above baseline or 20 percent elevation of systolic BP above baseline. AD is due to an uninhibited sympathetic surge from a noxious

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stimuli below the level of injury. This stimuli excites the sympathetic nervous system causing severe vasoconstriction of arterial vasculature below the level of injury, and in turn, elevated blood pressure. In the able-bodied population, the nervous system responds to this sympathetic surge via the parasympathetic system, thereby preventing prolonged constriction of the vasculature. However, in the SCI population, the injury to the spinal cord prevents this inhibitory parasympathetic response from reaching the splanchnic vascular bed. Baroreceptors identify elevations in BP and respond via the vagus nerve and cause a relative slowing of the heart. The only way to definitively treat AD is to identify and remove the noxious stimuli. Bladder distention and fecal impaction account for most causes of AD. Non-pharmacologic interventions to remove the inciting stimuli are recommended prior to pharmacologic intervention for hypertension if possible. It is important to identify AD in the SCI population as it can be difficult to treat and can increase morbidity and mortality in this population. For a full review of treatment of AD, please refer to the Clinical Practice Guideline released by the Consortium for Spinal Cord Injury Medicine Dana Clark attended college at Johns Hopkins University where she majored in Neuroscience and participated on the track team. She completed a year of volunteer work with the National AIDS fund through Americorps prior to starting Medical School at Rutgers New Jersey Medical School. She graduated from Physical Medicine and Rehabilitation Residency from Harvard University and went on to

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16 FLORIDA MD - JUNE 2016

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Calling All Independent Doctors to Unite at AID’s First Meeting: Independence in Action 2016 By Marni Jameson One of the most common questions doctors ask me when they join the Association of Independent Doctors is “Do you have an annual meeting?” Up till now the answer has been, “We plan to -- someday.” Someday when we’re bigger, and have more members, have a solid core of sponsors and are well-enough established. Well, I am delighted to announce, some day has come. Our three-year-old association will host its first member meeting, Independence in Action 2016, Saturday, Nov. 5, at the Walt Disney Swan & Dolphin Resorts in Orlando. While the one-day event is open to all doctors interested in preserving their independence, AID members will enjoy a discounted registration rate. Since AID was established in April 2013 to create a voice for independent doctors who did not want to be acquired by a hospital, but who felt alone in their fight for autonomy, the national non-profit has grown to represent nearly 1,000 members in 14 states coast to coast. Now these far-flung members from Maine to Los Angeles can meet other like-minded doctors, while hearing from nationally recognized speakers who will share their insights into the future of independent practices, dynamics in the marketplace, and survival tactics. Here are some of the renown speakers who will be presenting at Independence in Action 2016. • Gerard Anderson, PhD FOLLOW THE MONEY A professor of health policy and management at Bloomberg School of Public Health, John Hopkins University, and director of the Center for Hospital Finance and Management, Dr. Anderson a leading authority on health-care payment reform. He will discuss how price decisions made by physicians and hospitals influence profits, revenue and quality of care. He will also examine the characteristics that allow doctors and hospitals to have the greatest bargaining power, reveal who is most likely to use the power to their advantage and how, and reasons behind his findings that nonprofit hospitals are actually among the nation’s most profitable.

questions he has tackled for The Atlantic: Should doctors work for hospitals? Should hospitals make a profit or a difference? Do drugstore clinics hurt or hinder the doctor-patient relationship? And why physicians are burning out young? • Michael Reilly, MD GAMES HOSPITALS PLAY Orthopedic surgeon and whistle blower, Dr. Reilly is the force behind the second largest hospital false claims settlement in U.S. History. The case Michael T. Reilly, MD vs Broward Health culminated in a landmark $70 million Stark Law settlement last year. In his talk, Dr. Reilly will share his 12-year journey as he battled the ninth largest health-care system in the country – and won. He will discuss what lay behind the fight: the detrimental dynamic created by hospital-physician employee contracts, and their local and national ramifications. Dr. Reilly will cover not only the salient points of Federal Stark Law and the Anti-kickback law, but also how to mount a challenge when violations occur. • Marlan Wilbanks. Esq. THE FIGHT AGAINST FRAUD Widely recognized for his work on Stark Law violations and false claims, attorney Wilbanks has championed cases that have resulted in more than $2 billion in settlements being returned to the U.S. Treasury. Sharing lessons learned from fighting fraudulent claims on behalf of the American taxpayer, Mr. Wilbanks will discuss recent settlements he’s won, how these cases impact providers, and the scope and potential impact of current cases. He will also discuss the vital and courageous role of the whistle blower. If you’re an independent doctor, and care about staying that way, you don’t want to miss this conference. To take advantage of early bird rates, sign up before Aug. 15 at www.aid-us.org/conference. • Member Registration before Aug. 15 – $100; after Aug 15 -- $175 • Non-Member Registration before Aug. 15 – $150.00; after Aug 15 -- $225 Join AID today and save.

• Richard Gunderman, MD THE CASE FOR AUTONOMY Professor of radiology, pediatrics, medical education, philosophy, liberal arts, and philanthropy, and vice-chair of the radiology department at Indiana University, Dr. Gunderman is also a contributing writer to The Atlantic, where his views as both a philosopher and physician are both relevant and profound. At AID’s conference, Dr. Gunderman will make the case for doctor independence with his trademark grace, humanity, authority and reason. He will address some of the many thought-provoking

Marni Jameson is the executive director of the Association of Independent Doctors, a national nonprofit dedicated to helping reduce health-care costs by helping consumers, businesses and lawmakers understand the value of keeping America’s doctors independent www.aid-us. org. You may reach her at marni@aid-us.org. 

FLORIDA MD - JUNE 2016 17

BEHAVIORAL HEALTH

The Mental and Health Issues of Substance Abuse By Sajid Hafeez, MD According to the National Alliance on Mental Illness, 50% of those affected with severe mental disorders will also struggle with issues of substance abuse. When working in mental health, it is an ever present factor to be considered when deciding how best to treat the patient. The question is, what came first, the chicken or the egg? In truth there is no definitive answer. Some patients may turn to illegal drugs to manage the symptoms of substance abuse. Others may develop mental illness from the use of illegal drugs. Regardless of how it began, it is important to understand that they are linked and as such treat both. When a patient is initially admitted, substance abuse habits are questioned by the admissions therapists as well as the nurse. Because of the nature of substance abuse, it is important for these professionals to establish a good rapport and convey a nonjudgmental attitude in order to elicit a truthful response to these questions. The majority of patients will be forthright about their habits, but some will attempt to Serving Central Florida Since 1982 hide their habits. Knowing this, the treatment team must remain conscious of the idea that a patient’s behaviors could effectively be the Our physicians are Board Certified in Internal Medicine, result of substances in the system or withdraw Pulmonary Disease, Critical Care Medicine, and Sleep Medicine symptoms. This can also be confirmed with Specializing in: a routine urine drug test. Depending on the • Asthma/COPD substances ingested, a patient can present with • Sleep Disorders any variety of classic mental illness symptoms • Pulmonary Hypertension from depression, to mania, to psychosis. • Pulmonary Fibrosis As stated, many will turn to substance abuse • Shortness of Breath to manage their symptoms. This type of sub• Cough stance abuse happens significantly in those • Lung Cancer who are unable to afford medical insurance • Lung Nodules or treatment to manage underlying issues • Low Dose CT - On Site of mental illness. Marijuana is commonly • Clinical Research abused to manage anxiety. Alcohol can be Daniel Haim, M.D., F.C.C.P. used to calm someone potentially manic or Daniel T. Layish, M.D., F.A.C.P., F.C.C.P. high strung. Those who are depressed may use Francisco J. Calimano, M.D., F.C.C.P. uppers to make them feel better. For many, it Francisco J. Remy, M.D., F.C.C.P. will distract them from these mental illnesses Ahmed Masood, M.D., F.C.C.P. or other stressors of life. A large risk of these Syed Mobin, M.D., F.C.C.P. behaviors is that many of these substances can Eugene Go, M.D., F.C.C.P. exacerbate the symptoms of the underlying Mahmood Ali, M.D., F.C.C.P. mental illness, making it harder to manage Steven Vu, M.D., F.C.C.P. until the illness and the abuse both spiral out Ruel B. Garcia, M.D., F.C.C.P. of control to the point that the patient ends Tabarak Qureshi, M.D., F.C.C.P. Kevin De Boer, D.O., F.C.C.P. up being admitted to a mental health facility. Jorge E. Guerrero, M.D., F.C.C.P. So too, are there the recreational users who Roberto Santos, M.D., F.C.C.P. are using the drugs not to manage symptoms, Hadi Chohan, M.D. but simply because they enjoy the induced efJean Go, M.D. fects. Many will discount the usage as someGuillermo Arias, M.D. thing casual and benign without realizing how Erick Lu, D.O. concurrent drug usage may eventually lead to long term cognitive and psychological damDowntown Orlando East Orlando Altamonte Springs age. A way to explain it to them is in terms 1115 East Ridgewood Street 10916 Dylan Loren Circle 610 Jasmine Road of the brain’s ability to rebound from being 407.841.1100 | www.cfpulmonary.com | Most Insurance Plans Accepted exposed to external chemicals. Every chemi-

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18 FLORIDA MD - JUNE 2016

BEHAVIORAL HEALTH cal that we ingest affects the brains chemical balance in some way or another. This includes drugs both legal and illegal: caffeine, alcohol, THC, Cocaine. The body will naturally always try to adjust itself back to what is known to be as its natural state. Tolerances are developed that cause the user to use a larger quantity to maintain the desired effect. Each time a substance is used, it pushes a little further on the brain’s ability to rebound from the exposure. Often times the ability to rebound is damaged. This is why some substance abusers can do the same drug time and time again, and eventually have a permanently altered behavior. The trouble is that there is no way for a person to know what this tolerance limitation is. Some patients may smoke marijuana daily for years and have minimal lasting damage. Other patients may react adversely on a 2nd or 3rd usage. This is compounded in the fact that in procuring drugs illegally, the casual user has no way to verify the composition or purity of the substance. Many times patients will unwittingly be pushed over that rebound limit from a laced substance and will be faced with a difficult return path to wellness. Given a high enough quantity, just about any substance can alter the mind, pushing it into a state of psychosis. When treating these patients, the team must be prepared to address both issues, the mental health and the substance abuse. A doctor will prescribe the patient different medications to help abate the physical symptoms of withdraw in the form of a medical stepdown. While the doctor is able to attempt to return a certain level of lucidity or control with medication, it falls upon the therapist to address the mental dependency of substance abuse. Because of this, inpatient stays commonly include drug group therapy where patients are able to address their issues and investigate the link between their habit and their mental wellness. Due to the addictive nature of substance abuse, this is a disease that may have more incidences of relapse and failure when compared to a mental health issue that is primarily about chemical balance such as depression. As such, the discharge planner must anticipate the need for secondary substance abuse outpatient care in addition to a standard therapist and psychiatrist, and may refer to groups such as Alcoholics Anonymous or Narcotics Anonymous. Because of the prevalence of substance abuse within the realm of mental health, those who treat any issues of mental health should stay well versed in the signs and symptoms of substance abuse. What are the physical symptoms? What are the psychological symptoms? In addressing these concerns, a treatment team is better able to manage the mental health as well. Ultimately it doesn’t matter which came first, the chicken or the egg. What is important is that both are addressed and cooked up in the kitchen of mental wellness. 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 Often times the stress of everyday life can be overwhelming. A particuPsychiatry Unit, an Attending Psychilarly traumatic event can change your life in an instant. We are here. atrist of the Comprehensive Psychiatry Let us help you navigate through life’s sometimes unpredictable turns. Emergency Program and of the Mobile UBC is a 112 bed psychiatric inpatient and substance abuse/detox hosCrisis Team at the Westchester Medipital. UBC offers children, adolescents, and adult programs and accepts cal College. At Vassar Brother’s Medimost insurances including Medicare and Tricare. We offer specialized cal Center in New York. Dr. Hafeez treatment based on the individual and treat the following common diwas the Director of Outpatient Child agnoses as well as others: & Adolescent and Adult Psychiatric PLEASE PLACE STAMP HERE

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 407-281-7000 or by visiting www. universitybehavioral.com. 

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CANCER

Why Colonoscopies are Still the Standard for Early Colon Cancer Detection By Omar Kayaleh, MD There’s been ongoing debate about whether colonoscopy is the most effective way to screen for colon cancer and its disadvantages compared to other screening methods. There’s also the question of who should get one and when. As section chief for gastrointestinal medical oncology at UF Health Cancer Center - Orlando Health, I see a whole spectrum of patients who have gastrointestinal primary malignancy, including esophagus, pancreas, rectal, small intestine and anal cancer. I understand that as medicine evolves, we must look for ways to improve how we detect and treat disease, but I’ve seen firsthand how colonoscopy can lead to earlier detection that improves patient outcomes.

WHY COLONOSCOPY: WHO SHOULD GET ONE & WHEN Colon cancer is the second-leading cause of death in the country. This year, there will be more than 95,000 new cases in the U.S., according to the American Cancer Society. With these statistics, it’s still surprising that more people don’t

get screened for colon cancer, especially those over age 50. The fear surrounding this procedure and preparing for it keeps too many people from taking a step that is potentially lifesaving. According to the American College of Gastroenterology, the main reason many patients say they don’t get a colonoscopy is because they never discussed the procedure with their doctor. Patient education is critical with this disease, and we should begin conversations with patients about colonoscopy as they near or enter middle-age. Colonoscopy screening should start at 50 in patients with no polyps, no family history of colon cancer or apparent risk. After the initial test, screening should take place every five to 10 years thereafter. Those with a first-degree relative with colon cancer or multiple people with colon cancer in their family are considered high risk and should have their first colonoscopy beginning at age 40. There also are higher-risk entities, such as people with hereditary non-polyposis (HNPCC) or Lynch Syndrome. These patients tend to have an increased risk of colon cancer and other malignancies. Though there are only a few polyps present with Lynch Syndrome, if this entity is diagnosed in a family there could be an early onset of colon cancer. Another less common condition called familial adenomatous polyposis ORTHOPAEDIC (FAP) also may put someone at very high SUBSPECIALTIES risk for colon cancer. These individuals can • SPINE have thousands of polyps, similar to a ber• ELBOW ber carpet. I’ve seen a 13-year-old patient • FOOT & ANKLE with colon cancer because of this condi• HAND & WRIST tion. These patients should be screened in • HIP their early teens because they are at such • KNEE high risk. However, if a patient is unsure of • ONCOLOGY or doesn’t know his or her family history, • PEDIATRICS • SHOULDER the standard screening recommendations • SPORTS MEDICINE apply.

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While all polyps may not lead to colon cancer, in enough time the majority well. Direct visualization and sampling can give us detailed insight into how these cancers develop. Colon cancer is one of the best documented evolutions of how a normal cell transforms into a cancerous growth, we can visualize all stages of transformation from normal colonic lining cells to cancer. Scientists have been able to document the

CANCER presence of dysplasia and see how the cells change in appearance and function. Eventually they progress into a non-invasive carcinoma, before invading into the wall of the colon, spreading to the lymph nodes, and eventually the liver and other organs. So, by utilizing colonoscopies we are able to not only removed malignancies of the form but rather remove polyps before they even become malignant. Knowing all this it becomes more evident that colonoscopies can save lives. It’s misguided to use social stigmas about the pain or embarrassment surrounding this procedure as reasons not to do a colonoscopy.

UNDERSTANDING THE RISK OF COLONOSCOPY Compared to sigmoidoscopy, a more limited method for screening colon cancer, colonoscopy does come with certain risks, such as bleeding from the site where we’ve removed a polyp or taken a biopsy. Although uncommon, perforation in the rectum or colon may also occur, and this could require surgical intervention. Very rarely, a patient also may experience a negative reaction to a sedative. There are certain patients who can’t tolerate colonoscopies due to ongoing medical issues. For those we do a barium enema or use other methods such as fecal occult blood testing. A stool guaiac test also can tell us whether there is blood in any place in the gastrointestinal tract and newer tests can identify this occurrence in the lower intestinal tract. The newer immunologic testing for blood in the stool can also reduce the chance of developing colon cancer or detect early malignancies in the colon. Still, for average and high-risk patients, the benefits of colonoscopy far outweigh the risks. The simple fact is that before colonoscopies became the standard, the incidence of colon cancer had steadily increased. Studies have shown that routine colonoscopies can reduce colon cancer mortality rates. For example, long-term results from the National Polyp Study found that removing adenomatous polyps during colonoscopies improved patient outcomes, resulting in a nearly 50-percent reduction in colon cancer deaths normally expected in the sample size tested. In many cases, we’re preventing polyps from becoming colon cancer, thereby reducing the incidence of this disease. Unfortunately, there are some patients who do not get to us until the disease is far advanced. With metastatic colon cancer, the median survival is about 27 months. We hope that we can convert what used to be an acutely deadly disease into a chronic condition. We’re making headway in terms of treatment and improving quality of life, even if the disease is incurable. Many patients can now see their grandkids and kids graduate, watch them get married and can do more with their lives because they’ve survived longer.

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Still, it’s a battle. The research and oncological communities are beginning to get a lot smarter in what we do with smart molecules and targeting of cellular mechanisms. FLORIDA MD - JUNE 2016 21

CANCER Antibody and Immunotherapy are some examples of this, and we’re just starting to see what these modalities due for other disease entities. However, it’s still the Holy Grail — getting the body to heal itself. Until these treatment approach realize their full potential, we need to focus on prevention. Colonoscopy and fecal occult blood testing have been life savers for many people, despite its social stigma. I’ve seen the difference colon cancer screening has made and know that it will continue to have an impact if we can better educate patients and remove some of the myths surrounding these lifesaving procedures. Omar Kayaleh, MD, serves as the medical oncology team leader for the Gastrointestinal Cancers Specialty Section at UF Health Cancer Center — Orlando Health. He also served as chairman of the Department of Internal Medicine as well as chief of the Hematology/ Oncology Specialty Section at UF Health Cancer Center — Orlando Health. Dr. Kayaleh received his medical degree from the University of Florida, completed a residency in internal medicine at Franklin Square Hospital in Baltimore and fulfilled a fellowship at the Medical University of South Carolina. Dr. Kayaleh is board-certified in internal medicine and in the specialties of medical oncology and hematology. He has held many offices and memberships on numerous medical staff committees, including Pharmacy and Therapeutics. He is a member of the Orange County Medical Society, Florida Medical Association, American Medical Association, American Society of Hematology, and the American Society of Clinical Oncology.

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COMING NEXT MONTH: The cover story focuses on Mark A. Socinski,

MD joining the Florida Hospital Cancer Institute as the new Executive Director and his vision for the Institute and Florida Hospital’s approach towards cancer care. Editorial focus is on Imaging Technologies and Interventional Radiology.

Compassionate, Caring & Sophisticated Medical Care

• Radiofrequency Ablation (for Patients with Barrett's Esophagus) • Colonoscopy

22 FLORIDA MD - JUNE 2016

DIGESTIVE AND LIVER UPDATE

Nonalcoholic Fatty Liver Disease (NAFLD) Part 1 By Harinath Sheela, MD Nonalcoholic fatty liver disease (NAFLD) refers to the presence of hepatic steatosis when no other causes for secondary hepatic fat accumulation (eg, heavy alcohol consumption) are present. NAFLD may progress to cirrhosis and is likely an important cause of cryptogenic cirrhosis. DEFINITIONS — Patients with nonalcoholic fatty liver disease (NAFLD) have hepatic steatosis, with or without inflammation and fibrosis. In addition, no secondary causes of hepatic steatosis are present. NAFLD is subdivided into nonalcoholic fatty liver (NAFL) and nonalcoholic steatohepatitis (NASH). In NAFL, hepatic steatosis is present without evidence of significant inflammation, whereas in NASH, hepatic steatosis is associated with hepatic inflammation that may be histologically indistinguishable from alcoholic steatohepatitis . Other terms that have been used to describe NASH include pseudoalcoholic hepatitis, alcohol-like hepatitis, fatty liver hepatitis, steatonecrosis, and diabetic hepatitis.

EPIDEMIOLOGY Prevalence — Nonalcoholic fatty liver disease (NAFLD) is seen worldwide and is the most common liver disorder in Western industrialized countries, where the major risk factors for NAFLD, central obesity, type 2 diabetes mellitus, dyslipidemia, and metabolic syndrome are common ]. In the United States, studies report a prevalence of NAFLD of 10 to 46 percent, with most biopsy-based studies reporting a prevalence of NASH of 3 to 5 percent . Worldwide, NAFLD has a reported prevalence of 6 to 35 percent (median 20 percent). • In a prospective study of 400 US military personnel and their families (mean age 55 years), the prevalence of NAFLD by ultrasound was 46 percent . Factors associated with NAFLD included male sex, increasing age, and the presence of systemic hypertension, obesity, or diabetes. • In a population-based sample that included 2133 subjects from the US who reported moderate or no alcohol intake, hepatic steatosis was present in 30 and 32 percent, respectively. • Estimates of prevalence of NAFLD in Asia-Pacific regions range from 5 to 30 percent, depending upon the population studied. In the US, the prevalence of NAFLD has been increasing over time. This increase was demonstrated in a comparison of three cycles of the National Health and Nutrition Examination Survey (NHANES): • Between 1988 and 1994, the prevalence of NAFLD was 5.5 percent, between 1999 and 2004 it was 9.8 percent, and between 2005 and 2008 it was 11 percent, accounting for 47, 63, and 75 percent of chronic liver disease during those time periods, respectively. However, it should be noted that the definition of NAFLD used in the study (elevated serum aminotransferase levels in the absence of an alternative explanation) could lead to misclassification and likely underestimated

the true prevalence of NAFLD, since patients with NAFLD may have normal serum aminotransferases. This is supported by the findings from a subsequent study from NHANES that used ultrasound data collected from patients between 1988 and 1994. In that study, the age-adjusted prevalence of NAFLD was estimated to be 19 percent. Over the same three time periods, there were also increases in the rates of other components of the metabolic syndrome , including obesity (22, 30, and 33 percent, respectively), type 2 diabetes (6, 8, and 9 percent, respectively), and systemic hypertension (23, 33, and 34 percent, respectively). ( Patient demographics — Most patients are diagnosed with NAFLD in their 40s or 50s ]. Studies vary with regard to the sex distribution of NAFLD, with some suggesting it is more common in women and others suggesting it is more common in men. There appear to be ethnic differences in the prevalence of NASH . A study of hepatic triglyceride content in 2287 subjects from a US multiethnic, population-based sample found a higher prevalence of hepatic steatosis in Hispanics (45 percent) compared with whites (33 percent) or blacks (24 percent). The higher prevalence in Hispanics was explained by a greater prevalence of obesity, although the lower prevalence in blacks persisted after controlling for body mass index and insulin sensitivity. Association with other disorders — Patients with NAFLD (particularly those with NASH) often have one or more components of the metabolic syndrome • Obesity • Systemic hypertension • Dyslipidemia • Insulin resistance or overt diabetes This association was demonstrated in a study of 304 patients with NAFLD but without overt diabetes . Liver biopsies were performed in 163 patients revealed NASH in 120 (74 percent). Metabolic syndrome was seen in 53 percent of patients who did not undergo biopsy, in 67 percent of those with simple steatosis (NAFL) on biopsy, and in 88 percent of those with NASH on biopsy. After correcting for age, sex, and body mass index, metabolic syndrome was associated with an increased risk of severe fibrosis (odds ratio [OR] 3.5, 95% confidence interval [CI] 1.1-11.2). While the metabolic syndrome is a known risk factor for cardiovascular disease and is common in patients with NAFLD, NAFLD may be independently associated with cardiovascular disease. In a study using data from NHANES, NAFLD was associated with cardiovascular disease after controlling for older age, male sex, obesity, type 2 diabetes, smoking, and family history of early myocardial infarction (odds ratio 1.23; 95% CI 1.04-1.44)]. However, the study did not control for dyslipidemia or systemic hypertension, which could act as confounders, since hyperlipidemia is associated with both NAFLD and cardiovascular disease. FLORIDA MD - JUNE 2016 23

DIGESTIVE AND LIVER UPDATE There are also data that suggest NAFLD is associated with cholecystectomy. This was examined using a group of 12,232 participants in a population-based survey from the United States. After controlling for factors such as age, sex, body mass index, diabetes, and cholesterol levels, patients who underwent cholecystectomy were more than twice as likely to have NAFLD than those who had not undergone cholecystectomy (OR 2.4, 95% CI 1.8-3.3). An increased prevalence of NAFLD was not seen in patients with gallstones who had not undergone cholecystectomy.

complain of fatigue, malaise, and vague right upper abdominal discomfort . Patients are more likely to come to attention because laboratory testing revealed elevated liver aminotransferases or hepatic steatosis was detected incidentally on abdominal imaging.

Other conditions that have been associated with NAFLD, independent of their associations with obesity, include polycystic ovary syndrome, hypothyroidism, obstruct sleep apnea, hypopituitarism, and hypogonadism .

• In a population-based study of 1168 participants from Mumbai, NAFLD was detected in 9 percent (19 percent of those older than 20 years of age) Among those with NAFLD, 5 percent had hepatomegaly. • In a study of 12 patients with NASH who underwent CT scanning, 11 had hepatomegaly (defined as a liver span of >18 cm), with a mean liver span for all 12 of 21 cm. • In a study of 144 patients with NASH, 18 percent were noted to have hepatomegaly on examination and/or ultrasound, and there was a trend toward an increased rate of hepatomegaly among those with more advanced fibrosis (28 percent). The population-based study likely provides a better estimate of the prevalence of hepatomegaly in patients with NAFLD since it does not subject to referral bias. However, the study did not differentiate between patients with nonalcoholic fatty liver and those with NASH, and as suggested by the third study, it is possible that hepatomegaly is more prevalent in patients with more advanced disease.

Currently, screening for NAFLD is not recommended for patients at increased risk. PATHOGENESIS — The pathogenesis of nonalcoholic fatty liver disease has not been fully elucidated. The most widely supported theory implicates insulin resistance as the key mechanism leading to hepatic steatosis, and perhaps also to steatohepatitis. Others have proposed that a “second hit”, or additional oxidative injury, is required to manifest the necroinflammatory component of steatohepatitis. Hepatic iron, leptin, antioxidant deficiencies, and intestinal bacteria have all been suggested as potential oxidative stressors. CLINICAL MANIFESTATIONS — Most patients with nonalcoholic fatty liver disease (NAFLD) are asymptomatic, although some patients with nonalcoholic steatohepatitis (NASH) may

Physical findings — Patients with NAFLD may have hepatomegaly on physical examination due to fatty infiltration of the liver . In some patients, hepatomegaly is the presenting sign of NAFLD. The reported prevalence of hepatomegaly in patients with NAFLD is highly variable:

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Florida Hospital is accredited by the Florida Medical Association to provide continuing medical education for physicians. Florida Hospital designates this live activity for a maximum of 8 AMA PRA Category 1 Credit(s)™. Each physician should claim only those hours of credit commensurate with the extent of their participation in the activity. Florida Hospital is committed to making its activities accessible to all individuals. If you have a disability, please submit a description of your needs, along with your registration, to assure that you will be able to participate in the activity. ASCO is not the CME provider for this activity.

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DIGESTIVE AND LIVER UPDATE Patients who have developed cirrhosis may have stigmata of chronic liver disease (eg, palmar erythema, spider angiomata, ascites). Laboratory findings — Patients with NAFLD may have mild or moderate elevations in the aspartate aminotransferase (AST) and alanine aminotransferase (ALT), although normal aminotransferase levels do not exclude NAFLD. The true prevalence of abnormal transaminases among patients with NAFLD is unclear, since many patients with NAFLD are diagnosed because they are noted to have abnormal aminotransferases. When elevated, the AST and ALT are typically two to five times the upper limit of normal, with an AST to ALT ratio of less than one (unlike alcoholic fatty liver disease, which typically has a ratio greater than two). The degree of aminotransferase elevation does not predict the degree of hepatic inflammation or fibrosis, and a normal alanine aminotransferase does not exclude clinically important histologic injury. The alkaline phosphatase may be elevated to two to three times the upper limit of normal. Serum albumin and bilirubin levels are typically within the normal range, but may be abnormal in patients who have developed cirrhosis. Other laboratory abnormalities that may be seen in patients who have developed cirrhosis include a prolonged prothrombin time, thrombocytopenia, and neutropenia. Patients with NAFLD may have an elevated serum ferritin concentration or transferrin saturation. There is evidence that a serum ferritin greater than 1.5 times the upper limit of normal in patients with NAFLD is associated with a higher nonalcoholic fatty liver disease activity score (and thus, NASH) and with advanced hepatic fibrosis. Patients with NAFLD may also have positive serum autoantibodies (antinuclear antigen, antismooth muscle antibody), though the significance of these findings is unclear. Radiographic findings — Radiographic findings in patients with NAFLD include increased echogenicity on ultrasound, decreased hepatic attenuation on computed tomography (CT), and an increased fat signal on magnetic resonance imaging (MRI). Associated disorders — In addition to the findings related to NAFLD, patients often have findings associated with the metabolic syndrome. Part 2 of this article covering Diagnosis of Nonalcoholic Fatty Liver Disease (NAFLD), will follow in the August issue of FloridaMD. Harinath Sheela, MD moved to Orlando, Florida after finishing his fellowship in gastroenterology at Yale University School of Medicine, one of the finest programs in the country. During his training he spent significant amount of time in basic and clinical research and has published articles in gastroenterology literature. His interests include Inflammatory Bowel Diseases (IBD), Irritable Bowel Syndrome (IBS), Hepatitis B, Hepatitis C, Metabolic and other liver disorders. He is a member of the American Gastroenterological Association (AGA), the American Society for Gastrointestinal Endoscopy (ASGE) and the American Association for the Study of Steven Rosenberg, M.D. Liver Diseases (AASHarleen Anderson, M.D. LD) and Crohn’s Colitis foundation ALLERGY, ASTHMA & IMMUNOLOGY ASSOCIATES OF CENTRAL FLORIDA (CCF). Dr. Sheela is a CliniWinter Park Altamonte Springs Orlando cal Assistant Professor 407-678-4040 407-331-6244 407-370-3705 at the University of Central Florida Lindsey Porter Carlos M. Jacinto, M.D. ARNP, FNP-BC School of Medicine. Our physicians are Board Certified He is also a teaching Allergy, Asthma & Immunology & attending physician Board Certified Pediatrics at Florida Hospital Internal Medcine Treating Allergic Diseases of the Ears, Nose & Throat Residency and FamOur physicians hold faculty appointments at the Florida State University School of Medicine and the ily Practice Residence University of Central Florida School of Medicine and are members of Florida Hospital Kid's Doc's (MD and DO) programs.  www.aaacfonline.com

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