JUNE 2021 • COVERING THE I-4 CORRIDOR
Florida Vein Care & Cosmetic Center
EndoVenous Laser Treatment (EVLT) – A Minimally Invasive Option for Vein Disease
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ON THE COVER: Richard Bragg, MD, medical director for Florida Vein Care and Cosmetic Center in Lake Mary, Florida.
COVERING THE I-4 CORRIDOR
COVER STORY
Since 1999, EndoVenous Laser Treatment (EVLT) has become the therapy of choice for patients with painful and painless varicose veins. Now the standard of care and FDA approved, EVLT is minimally invasive, done in the doctor’s office in under an hour, requires no general anesthesia or stitches and provides immediate relief from symptoms. Patients return to normal activities right away. “Over the past 20 years, the demand for EVLT has skyrocketed 200 percent,” says Richard Bragg, M.D., medical director for Florida Vein Care and Cosmetic Center in Lake Mary, Florida. “The procedure has really directed patients away from stripping and ligation done in the hospital.” According to the American College of Phlebology (ACP), more than 80 million Americans suffer from some form of venous disorders. Phlebology is the field of medicine that treats vein disease such as spider and varicose veins. Varicose veins occur when the one-way valves in the veins don’t function efficiently and the veins become visibly distended with blood. The condition can cause pain, heaviness and/or throbbing in the legs and are often a cosmetic embarrassment for the patient. Nearly 40% of women and 25% of men suffer from varicose veins. Heredity is the primary contributing factor for varicose veins. Other predisposing factors include multiple pregnancies, aging, leg injury and occupations that require standing for many hours. Spider veins are small, thread-like clusters of red, purple, and blue veins that are usually considered an aesthetic annoyance. They most commonly appear on the thighs, calves and ankles.
MORE CANNABIS DISPENSARIES = FEWER OPIOID DEATHS
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JUNE 2021
12 HELPING EMPHYSEMA PATIENTS BREATHE EASIER 16 COSMETIC PROCEDURES AMID THE PANDEMIC
DEPARTMENTS 2
FROM THE PUBLISHER
7 DERMATOLOGY 8 PULMONARY 10 PHARMACY UPDATE
13 MARKETING YOUR PRACTICE 14 PEDIATRICS
FLORIDA MD - JUNE 2021
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FROM THE PUBLISHER
I
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
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: JJohn “Lucky” Meisenheimer, MD, Jason Malone, DO, Omar E. Beidas, MD, Mark A. Vollenweider, MD, MPH, Tabarak Qureshi, MD FCCP, Sonda Eunus, MHA, Michael Patterson NHA, OTR/L, CEAS, Juan Lopez, Pharm D, John Meisenheimer, VII Art Director/Designer: Ana Espinosa Florida MD is published by Sea Notes Media,LLC, P.O. Box 621856, Oviedo, FL 32762. Call (407) 417-7400 for more information. 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 2021, Sea Notes Media. All rights reserved. Reproduction in whole or in part without written permission is prohibited. Annual subscription rate $45.
More Cannabis Dispensaries = Fewer Opioid Deaths By Michael Patterson, NHA, OTR/L, CEAS A recent study in the British Medical Association Journal (BMJ) shows increasing access to marijuana dispensaries is associated with a significant reduction in opioid-related deaths. (link below) Association between county level cannabis dispensary counts and opioid related mortality rates in the United States: panel data study | The BMJ Researchers reviewed opioid mortality and cannabis dispensary prevalence in 23 US states from 2014 to 2018. The study concluded that counties where the number of legal marijuana shops increased from one to two experienced a 17 percent reduction in opioid-related fatalities. Increasing the dispensary count from two to three was linked to an additional 8.5 percent decrease in opioid deaths.
is expected to exceed 70,000 people, and opiates are legal via prescription. Society is tired of being lied to about cannabis. They are tired of politicians protecting the illegality of cannabis, and pharmaceutical companies pitching drugs that have side effects worse than the disease or condition for treatment. As more and more facts and data emerge on the positive benefits to society and health that cannabis offers, the legalization trend of cannabis will continue in the USA and globally. Michael Patterson NHA, OTR/L, CEAS is CEO of US Cannabis Pharmaceutical Research and Development LLC. (uscprd.com). He is a healthcare executive with 25+
“Higher medical and recreational storefront dispensary counts are associated with reduced opioid related death rates, particularly deaths associated with synthetic opioids such as fentanyl.” Per the study, it’s a finding that “holds for both medical and recreational dispensaries.”
years experience in: Cannabis-Hemp investment, Law,
“While the associations documented cannot be assumed to be causal, they suggest a potential association between increased prevalence of medical and recreational cannabis dispensaries and reduced opioid related mortality rates,” the researchers wrote. “This study highlights the importance of considering the complex supply side of related drug markets and how this shapes opioid use and misuse.”
subject matter expert in the Global Cannabis and Hemp
“Our findings suggest that increasing availability of legal cannabis (modeled through the presence of medical and recreational dispensary operations) is associated with a decrease in deaths associated with the T40.4 class of opioids, which include the highly potent synthetic opioid fentanyl. This finding is especially important because fentanyl related deaths have become the most common opioid related cause of death.”
ANALYSIS This study is one of many that continues to demonstrate that cannabis is a benefit to society not a detriment. Most states that have legal medical cannabis programs allow use of cannabis as a substitute for the use of opiates. Opiate addiction and deaths in the USA have destroyed countless lives, families, and communities. The lies regarding the safety of opiate use by Pharmaceutical companies are now coming out in litigation across the country by US States demanding restitution from the many effects of the opioid plague. There has never been a single recorded death in human history associated with the use of cannabis, and it is still illegal based on US federal law. Meanwhile, the opiate death toll for 2020
Regulation, Compliance, Operations, & Management, Skilled Nursing, Pharmacy, Laboratory, Assisted Living, Home Healthcare, & Healthcare Analytics. He is a Industry with Gerson Lehrman Group (glg.it) & Guidepoint. He is an editorial board member of the American Journal of Medical Cannabis, licensed Nursing Home Administrator, & licensed Occupational Therapist in 4 states.
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COVER STORY
Florida Vein Care and Cosmetic Center
EndoVenous Laser Treatment (EVLT) – A Minimally Invasive Option for Vein Disease By Margaret M. Sloane, RN, BSN Since 1999, EndoVenous Laser Treatment (EVLT) has become the therapy of choice for patients with painful and painless varicose veins. Now the standard of care and FDA approved, EVLT is minimally invasive, done in the doctor’s office in under an hour, requires no general anesthesia or stitches and provides immediate relief from symptoms. Patients return to normal activities right away. “Over the past 20 years, the demand for EVLT has skyrocketed 200 percent,” says Richard Bragg, M.D., medical director for Florida Vein Care and Cosmetic Center in Lake Mary, Florida. “The procedure has really directed patients away from stripping and ligation done in the hospital.” According to the American College of Phlebology (ACP), more than 80 million Americans suffer from some form of venous disorders. Phlebology is the field of medicine that treats vein dis-
ease such as spider and varicose veins. Varicose veins occur when the one-way valves in the veins don’t function efficiently and the veins become visibly distended with blood. The condition can cause pain, heaviness and/or throbbing in the legs and are often a cosmetic embarrassment for the patient. Nearly 40% of women and 25% of men suffer from varicose veins. Heredity is the primary contributing factor for varicose veins. Other predisposing factors include multiple pregnancies, aging, leg injury and occupations that require standing for many hours. Spider veins are small, thread-like clusters of red, purple, and blue veins that are usually considered an aesthetic annoyance. They most commonly appear on the thighs, calves and ankles. Patients who come to Florida Vein Care and Cosmetic Center seeking relief for these conditions can expect Dr. Bragg and his
PHOTO : BY TERRY CUFFEL / CORPORATE VISUAL SERVICES
This varicosed anterior thigh circumflex vein was removed by a phlebectomy using 3mm incisions. No sutures are required, and the after picture is 4 weeks post-op.
4 FLORIDA MD - JUNE 2021
COVER STORY
Immediately after endovenous laser treatment, patients walk for 20 minutes in the office on the treadmill. A post-op dressing and compression stocking is worn for 1 week after treatment.
healthcare team to provide a comprehensive three step process that includes consultation, treatment and follow up. Consultation - The consultation phase consists of a careful medical history evaluation followed by an initial vascular exam known as a “Doppler,” a quick, painless, non-invasive test to determine the extent of the problem. During this time, Dr. Bragg enjoys getting to know his patients, answering questions, and exploring the many options available to treat varicose and spider veins. In some cases, additional diagnostic testing using an ultrasound is required in order to create an effective treatment plan. These painless diagnostics are conveniently performed by Dr. Bragg in the office. Treatment - Florida Vein Care and Cosmetic Center offers a personalized treatment plan that includes safe, effective, state of the art procedures for varicose and spider veins. Dr. Bragg notes that he has seen an annual growth of 40% in his office over the past seven years and EVLT accounts for a large portion of that growth. EVLT has the same if not better results than vein stripping and ligation, once considered the gold standard for treatment of varicose veins. Clinical studies indicate that EVLT has a 95% initial success rate and excellent long term outcomes. Candidates for EVLT usually fall between the ages of 20-60 and must be able to walk immediately following the procedure. Typically, EVLT uses laser energy to target a faulty valve at the saphenous femoral junction located in the groin. The saphenous vein runs up the inside of the leg. A small laser fiber is inserted at the knee and advanced up the leg to the groin using non-invasive ultrasound for accurate placement. As the laser is withdrawn, pulses of light cause the vein to heat up, collapse, and then seal itself. During the process, local anesthetic is delivered inside the vein so the patient doesn’t feel the heat. When the laser tip is withdrawn back to the knee, the
PHOTO : BY TERRY CUFFEL / CORPORATE VISUAL SERVICES
All patients are screened with the bi-directional doppler to rule out saphenopopliteal junction incompetence prior to any treatment.
FLORIDA MD - JUNE 2021
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COVER STORY
PR OO Bragg. A Sigvaris support stocking should be worn for one week
one week the treatment patientsmust mustschedule schedule aa brief brief follow-up after after the treatment andand patients follow-up appointment to evaluate the results of the procedure. appointment to evaluate the results of the procedure. 4 | REPRINTED FROM CENTRAL FLORIDA M.D. NEWS MAY 2007 6 FLORIDA MD - JUNE 2021
407.805.8989 Office • 407.805.8833 Fax www.floridaveincare.com www.floridaveincare.com
PHOTO BY TERRY CUFFEL / CORPORATE VISUAL SERVICES
F
PHOTO : BY TERRY CUFFEL / CORPORATE VISUAL SERVICES
and then seal itself. During the process, local anesthetic is delivered inside the vein so physician removes fromWhen the vein, the patient doesn’t feel theit heat. the applies a of tapeback along a Sigvaris lasersmall tip ispiece withdrawn to with the knee, the graduated compression stocking. The patient physician removes it from the vein, applies is asked to get upofand in the office to a small piece tapebegin alongwalking with a Sigvaris check for bleeding and reduce the risk of clots. graduated compression stocking. The patient “With EVLT, there is reduced risk of anestheis asked to get up and begin walking in the sia, reduced risk of infection, reduced office to check for bleeding and reduce the cost and a oneEVLT, inch scar as isisthe case with vein risk instead of clots.of“With there reduced stripping, the patient has a tiny three risk of anesthesia, reduced risk of infection, millimeter incision the knee,” remarks Dr. Bragg. reduced cost and at instead of a one inch scar they canthefinally wear skirts as is “Female the case patients with veinsay stripping, patient without being embarrassed and teachers are has a tiny three millimeter incision at the amazed that their legs feel fine at the end of a knee,” remarks Dr. Bragg. “Female patients long day on their feet.” Dr. Bragg has done over say they can finally wear skirts without being 1500 EVLT procedures since 2002. embarrassed and teachers are amazed that After procedure, Dr. their legs feelnearly fine at every the endEVLT of a long day Bragg points out that it is usually necessary on their feet.” Dr. Bragg has done over 1500 Dr. Bragg sees all patients in consultation. He explains venous anatomy, pathology and to have an ambulatory phlebectomy on the treatment options. EVLT procedures since 2002. remaining bulging veins. “This is a micro-surThe consultation, the in-office diagnostic ultrasound, and the After nearly every EVLT procedure, Dr. gical removal of surface varicose veins using aBragg smallsees veinallhook,” Dr. patients in consultation. He explains venous anatomy, pathology and procedure is covered by most insurance plans. Bragg points out that it is usually necessary says Dr. Bragg. “Phlebectomy is also done in the options. center under treatment to have an ambulatory phlebectomy on the Laser treatment holds great promise in the field of phlebology, local anesthesia through tiny incisions that require no stitches remaining bulging veins. “This is a microsays Dr. Bragg. Today, EVLT can be used on the greater sapheand leave nearly imperceptible scars.” After the vein has been reThe consultation, the in-officevein diagnostic ultrasound, and the procedure surgical removal of surface varicose veins nous vein, short saphenous and perforator veins. These three moved, a bandage and stocking is worn for one week. is covered by most using a small vein hook,” says Dr. Bragg. “Phlebectomy is also done in the areas cause mostinsurance varicose plans. veins seen in the legs. Sclerotherapy is used in treatment for spider and varicose veins Laser treatment holds great promise in theBachelor’s field of phlebology, says center under local anesthesia through tiny incisions that require no stitches Dr. Bragg received his pre-medical degree from and has been developed and refined by experts since its introducDr.Louisiana Bragg. Today, EVLT can be used on the greater saphenous vein, and leave nearly imperceptible scars.” After the vein has been removed, a State University in 1988. After graduating from Louition in Europe nearly a century ago. It’s become popular in the short saphenous vein and perforator veins. These threehe areas most bandage and stocking is worn for one week. siana State University Medical School in 1992, wascause selected United States in the past decade. Once diseased veins are identivaricose veins seen in the legs. at Florida Hospital’s Family Practice Sclerotherapy is used in treatment for spider and varicose veins and for internship and residency fied, a sterile solution of “sclerosing” material is injected microDr. Braggprogram. received his Bachelor’s degree from Louisiana has been developed and refined by experts since its introduction in Europe residency Hepre-medical remains board certified in family practice scopically into the vein altering the walls of the vein causing them State University inBragg 1988.isAfter graduatingwith fromthe Louisiana State University nearly a century ago. It’s become popular in the United States in the past medicine. Dr. an instructor National Procedures to collapse and dissolve. The simple procedure is safe and virtually Medical School 1992, physicians he was selected internship residency decade. Once diseased veins are identified, a sterile solution of “sclerosing” Institute and inteaches whofor come to himand from aroundat painless and essentially improves the circulation in the legs by diFlorida Hospital’s Family Practice residency program. He remains material is injected microscopically into the vein altering the walls of the the world injection sclerotherapy, ambulatory phlebectomy board and verting blood flow into nearby healthy veins. Treatment does not certified intechniques. family practice medicine. Dr. Bragg isAmerican an instructor with of the vein causing them to collapse and dissolve. The simple procedure is safe EVLT An active member of the College prevent the development of more spider veins, but the removal National Procedures Institute and teaches physicians who come to him and virtually painless and essentially improves the circulation in the legs Phlebology, he volunteers many hours a year to educate physiof existing spider veins can dramatically improve the appearance from around the and worldlayinjection sclerotherapy, by diverting blood flow into nearby healthy veins. Treatment does not cians, nurses, people about venous ambulatory disease. phlebectomy of the area. Often, two or more sessions are required to achieve and EVLT techniques. An active member of the American prevent the development of more spider veins, but the removal of existing Dr. Bragg’s main office is located at 580 Rinehart RoadCollege in Lakeof optimum results. Phlebology, he volunteers many hours a year to educate physicians, nurses, spider veins can dramatically improve the appearance of the area. Often, Mary, Florida. His other locations are at 7009 Dr. Phillips Blvd. For tiny veins on the legs, face or chest, a laser procedure usand lay people about venous disease. two or more sessions are required to achieve optimum results. and at 10902 Dylan Loren Circle in Orlando. ing a high energy light source can be used. The laser light passes Dr. Bragg’s main office is located at 580 Rinehart Road in Lake Mary, For tiny veins on the legs, face or chest, a laser procedure using a high For more information log on to www.floridaveincare.com through the skin without damaging it and selectively targets the Florida. His second office is at 7009 Dr. Phillips Blvd. in Orlando. For energy light source can be used. The laser light passes through the skin or to schedule an appointment, call the office at (407) 805spider vein. The light is absorbed by the red blood cells in the information log on to www.floridaveincare.com or to schedule an without damaging it and selectively targets the spider vein. The light is 8989. vein. The resulting heat causes the walls of the vein to seal to- more appointment, call the office at (407) 805-8989. absorbed by the red blood cells in the vein. The resulting heat causes the gether and disappear. Laser light treatment may be used in conwallsjunction of the vein to seal together and disappear. Laser light treatment may with sclerotherapy. be used in conjunction with sclerotherapy. When considering treatment options, Dr. Bragg ensures that When considering treatment options, Dr. Bragg ensures that his his patients understand the risk and limitations and that patients patients the risk and limitations and that patients have realistic haveunderstand realistic expectations for outcomes. expectations for outcomes. Follow-Up - Follow-up is an important component of Dr. Follow-Up - Follow-up is an important component of Dr. Bragg’s Bragg’s care management plan. Unlike with vein stripping and 580580 Rinehart LakeDr.Mary, 32746 RinehartRoad, Road, Suite 110 •7009 PhillipsFL Blvd., care management plan. Unlike with vein stripping and ligation which ligation which requires bed rest and limited activities, patients 110 Suite 240 requires rest andnon-surgical limited activities, patients are whoexpected undergo non-surgical 7009 Dr.Suite Phillips Blvd., Suite 240 • Orlando, FL 32819 whobed undergo treatments to get movLake Mary, FL 32746 Orlando, FL 32819 treatments are expected to get moving. “We want our patients to walk 30ing. “We want our patients to walk 30-40 minutes a day for up to 10902 DylanOffice Loren Circle • Orlando, FL Office 32825 407.805.8989 407.352.9877 40 minutes a day for to threeresolution weeks to facilitate resolution of thesays treated three weeks to up facilitate of the treated veins,” Dr. 407.805.8833 Fax 407.351.0755 Fax veins,” says Dr. Bragg. A Sigvaris support stocking should be worn for
DERMATOLOGY
Not All Basal Cell Carcinomas Are Created Equal
Lucky Meisenheimer, M.D. is a board-certified dermatologist specializing in Mohs Surgery. He is the director of the Meisenheimer Clinic – Dermatology and Mohs Surgery. John Meisenheimer, VII is a medical student at USF.
Nodular basal cell carcinoma. FLORIDA MD - JUNE 2021
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PHOTO: JOHN MEISENHEIMER, VII PHOTO: JOHN MEISENHEIMER, VII
Occasionally a patient will tell me their “doctor friend” recommended that they don’t need treatment for a basal cell carcinoma because it will never hurt you. “Doc, he said it’s only a basal cell carcinoma.” Dermatologists fully recognize this as a genuinely cringe-worthy statement. You don’t need to see too many people missing various parts of their facial anatomy to know this advice is blatantly wrong. Even in this modern time of medical miracles, people still die from neglected basal cell carcinomas. When pressed for the name of their “doctor friend,” it usually comes up as I don’t remember their name, or it ends up being “Doctor Google.” It is true a superficial basal cell carcinoma on the torso probably would take years and years for it to cause any sort of significant morbidity to a patient. But, on the other hand, even a small basal cell on the torso will continue to grow if left untreated slowly. What might have been a simple, inexpensive procedure now, a decade later, has turned into a monster of aggravation, discomfort, and cost. Although metastatic disease risk is low with basal cell carcinomas, it is certainly not zero. Several people die each year from basal cell carcinoma. Even more, patients can have disfiguring bouts with cancer losing various parts of anatomy such as nose, ears, eyes, etc. What a lot of patients and even some physicians are not aware of is that not all basal cell carcinomas are created equal. There are several different histologic growth patterns. These Infiltrative Basal Cell carcinoma of the forehead. varying histologic types can each behave differently and require different treatment plans. As mentioned before, a superficial basal cell carcinoma is probably not going to cause a great deal of physical damage unless neglected for long periods. There are other types of basal cell carcinomas; morpheaform and sclerosing basal cell carcinomas with infiltrating growth patterns. These cancers left untreated can cause a significant amount of morbidity in shorter periods measured in months, not years. Aggressive basal cell cancers can also become neurotropic, meaning that they “wrap” around a nerve and can track down its length. Neurotropism can be particularly dangerous, especially if Pathology of an infiltrative this is on the face and affecting a nerve that happens to pass through basal cell carcinoma. a foramen into the brain. Clearly, not a good scenario. Superficial Multifocal BCC. Basal cell carcinomas, limited to the skin, tend to be very amenable to treatment in a variety of different ways. Even as a Mohs surgeon I can think of at least half a dozen different ways that I have treated basal cell carcinomas. Not all basal cell carcinomas need Mohs surgery. Each case of basal cell carcinoma should be evaluated individually and in consideration as to the best method of treatment based on its histologic growth pattern, location, and physical condition of the patient. The great news about basal cell carcinoma, even though it is the most common type of skin cancer and millions are treated each year, only a tiny percentage of these end up causing death in paNeurotropic basal cell carcinoma. tients. When someone says I would much rather have a basal cell Sclerosing basal cell carcinoma. carcinoma than a melanoma, there is a caveat; if you die from a basal cell carcinoma, you are just as dead as if you were to die from melanoma. Happily, most of the time, with early diagnosis and treatment, you don’t have to die from either. Basal cell carcinoma is called cancer for a reason. Give it its respect that it is due, or otherwise, you may regret saying, “oh, you don’t have to worry about it, it’s only a basal cell carcinoma.”
PHOTO: JOHN MEISENHEIMER, VII
PHOTO: JOHN MEISENHEIMER, VII
By John “Lucky” Meisenheimer, MD and John Meisenheimer, VII
PULMONARY
What’s New in the Treatment of Mild Obstructive Sleep Apnea and Primary Snoring? By Tabarak Qureshi, MD FCCP
THE FIRST FDA-AUTHORIZED DAYTIME THERAPY: EXCITEOSA® SNORE... SNORE… SNORE… We all know of someone who snores, but when people are informed of their snoring, the typical response is denial and disbelief. The truth of the matter is that snoring is extremely common, but most people don’t understand why it happens. Snoring is generated when the upper airway/pharyngeal muscles relax and as air flows through a relaxed posterior airway. In some people with a crowded posterior airway, these sounds and vibrations result in mild obstructive sleep apnea (OSA), which is identified by having an AHI (apnea hypopnea index) between 5-15 events/hour. The repeated airway obstructions result in sleep disruption, blood pressure swings, and recurrent nocturnal asphyxia and hypoxia resulting in increased sympathetic nervous system activation during sleep. Traditionally, there has not been any significant treatment modality for primary snoring. Mild OSA has been treated primarily with auto-CPAP/PAP or mandibular advancement devices along with lifestyle modifications (weight loss, drinking, and smoking cessation). The most notable change is noted in the upper airway and the genioglossus muscle. This collapsibility is higher in mild OSA compared to primary snoring. In non-snorers, there is an ability to prevent collapsibility of the upper airway and have functional mechanisms that prevent collapse. The genioglossus is considered the largest muscle of the airway and the most important dilatory muscles during sleep onset. With sleep onset, there is rapid reduction in pharyngeal and tongue muscle contractility. Over time the respiratory stimulus and genioglossus activity progressively increase during stable non-REM sleep. However, a notable number of individuals fail to effectively increase genioglossus activity or achieve inadequate tongue muscle activation to overcome the obstruction prior to the arousal. Therefore, there is a failure of the tongue muscles to generate an appropriate protective response from a neural drive or responsiveness perspective. The first proof of concept of daytime stimulation of the tongue was presented by Wiltfang in 1999 (28). He demonstrated using a TENS like stimulation during daytime for two weeks resulted in a significantly reduced respiratory disturbance index (RDI), from 13.2/hour to 3.9/hour, oxygen desaturation index improved as did minimum oxygen saturation from 75% to 88%. In another prospective placebo controlled randomized trial of daytime tongue stimulation vs TENS type stimulation the number of snoring epochs decreased significantly (from 63.9±23.1 epochs per hour to 47.5±31.2; P<.05). 8 FLORIDA MD - JUNE 2021
EXCITEOSA®: The eXciteOSA device targets the intrinsic and extrinsic pharyngeal and tongue muscles by delivering neuromuscular electrical stimulation to the tongue with the purpose of increasing muscle responsiveness and preventing excessive relaxation. The device has three components: 1. Washable flexible electrode mouthpiece with an electrode array that fits onto the tongue. 2. Rechargeable control unit that attaches to the mouthpiece via a USB connection. 3. Smartphone App that manages the functions of the device. The mouthpiece is placed in the mouth, on the tongue with the two electrodes located above and two below the tongue. Therapy consists of a series of pulse bursts with rest periods for 20 minutes during the wakefulness state for a period of 6 weeks. With daily use of eXciteOSA, the tongue muscle function improves to prevent the backward collapse of the tongue and hence obstruction of the airway.
CLINICAL TRIALS DATA The original trial was a prospective multicenter trial of individuals with primary snoring or mild OSA. Snoring was assessed by the bed partner reporting on a visual analog scale-VAS (ranging from 1-10, 10=unbearable snoring). The snorers sleep quality was recording using the Pittsburgh Sleep Quality Index (PSQI) pretreatment (2 weeks before start of therapy), during treatment phase (6 weeks recorded in last two weeks) and post treatment (2 weeks after stopping therapy). 27 individuals completed the trial (8 women and 19 men), average age 44 years (age range 2568 years), BMI 29.7 (range 20.7-35) and AHI 9 (range 2.5-15).
PULMONARY Eight primary snorers and 19 had mild OSA. Results revealed bed partner reported snoring reduced by 52% (p<0.001) with over 80% declaring a reduction of >40%. The change remained statically significant for primary snores and mild OSA patients (VAS reduction 6.6 to 3.6 p<0,001). Another multicenter clinical trial was undertaken at London University hospital along with other sites in Europe. The objective was to validate the objective measures and assess the reproducibility of the subjective outcomes of the previous study. This was cohort of mild OSA (HST using WatchPAT®) and primary snorers. Two consecutive night studies were conducted before and after the 6-week period. This was supplemented with partner VAS, Epworth Sleepiness Scale (ESS), and PSQI. 125 patients were recruited and 115 (50 primary snorers and 65 mild OSA patients) completed the trial. The average age was 46 (range 24-79 years), 73 males and 42 females, average BMI 27 (range 20-34). For the study population the mean objective percentage of sleep time snoring at >40dB, reduced significantly by 41% (p<0.001). 90% of the participants recorded an objective reduction in their snoring. Clinically significant reduction in snoring time was also reported at snoring intensities of 45dB and 50dB with an improvement of 52% (p<0.001) and 54% (p<0.001) respectively. In mild OSA, 79% showed an average reduction in AHI of 52% (p<0.001) and the post therapy AHI normalized to 4.95. Statistically significant improvements were noted in ESS and PSQI scores as well (p<0.001). Oral pooling of saliva was most common side effect, with a
been known to activate motor units that are not otherwise activated. NMES has been shown to change the myofibrillar protein expression to induce a phenotype shift from fatigue prone to fatigue resistant with the strengthening of the cytoskeleton. NMES has been shown to result in metabolic shift from glycolytic to oxidative profiles, increasing intracellular defense against harmful oxygen species, reverse the degeneration of pre and postsynaptic tongue neural morphology associated with ageing and a shift to a higher contractile tension. eXciteOSA offers a simple and effective method of addressing the above-mentioned process and has been shown to benefit individuals with primary snoring and mild OSA. eXciteOSA provides a targeted retraining tool to stimulate the tongue and the biggest dilatory muscle of the airway – the genioglossus muscle. The clinical trial demonstrated significant reductions in all of the relevant objective measures, 90% of the study population showed reduction in snoring, 79% of the mild OSA population showed a 50% reduction in AHI and ODI resulting in reduction in ESS and PSQI. Tongue muscle training using eXciteOSA has proven to be effective in reducing multiple indices associated with sleep disordered breathing. Additional studies have been published and accepted for publication and currently underway. eXciteOSA provides a “no nighttime wearable” safe option of therapy for patients and overcomes many of the risks and disadvantages of currently available treatment options. For more information on this novel daytime therapy option, visit the eXciteOSA website: eXciteOSA.com or email info@signifiermedical.com. Bibliography available upon request. Tabarak Qureshi, MD FCCP practices at Central Florida Pulmonary Group. He is Chairman-Division of Pulmonary Medicine at AdventHealth, Director of ICU AdventHealth Altamonte Springs and Director of the Sleep Lab at Central Florida Pulmonary Group.
small percentage reported tongue discomfort, tooth discomfort, filling sensitivity, gagging, metallic taste and jaw tightness. Prevalence of these symptoms reduced in the six weeks of therapy.
DISCUSSION AND CONCLUSION Daytime neuromuscular electrical stimulation (NMES) therapy for correction of nighttime airway obstruction is a novel, innovative and probably unconventional therapeutic strategy. The ability to control nighttime sleep disordered breathing without wearing a nighttime device makes this an attractive treatment modality. NMES involves the application of electrical current to induce muscle contractions and has been shown to activate the muscle to a greater extent than voluntary muscle actions. It has
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9
PHARMACY UPDATE
Still Having Problems Finding Midrin®? By Juan Lopez, PharmD, FAPC Since the discontinuation of Midrin®, compounding pharmacists have been able to prepare and fulfill headache patients’ need for this therapy. Recently, however, one of the active ingredients of this preparation, dichloralphenazone, has become unavailable and placed on an indefinite backorder by one of the few suppliers that still provided the chemical. Prescribers and patients have been desperate to find an alternative for this ingredient in their medication.
Chloral hydrate and hydroxyzine HCL have been used as alternatives to dichloralphenazone for some of these patients. Chloral hydrate is a component of dichloralphenazone’s molecular complex and is a sedative and hypnotic agent. For prescribers and patients that would like to avoid the use of chloral hydrate, hydroxyzine HCl has been considered as an option. Hydroxyzine HCl could provide a sedative effect and may help with anxiety. A pharmacist skilled in preparing personalized medication can discuss using these alternative ingredient options and the appropriate substitution dosing changes with patients and their healthcare practitioner.
BACKGROUND Midrin® was a multiple ingredient medication typically prescribed for use in patients suffering from tension and migraine headaches.
10 FLORIDA MD - JUNE 2021
COVERPHARMACY STORY UPDATE The Food and Drug Administration (FDA) notified manufacturers and labelers to stop distributing drug products that contained isometheptene mucate, one of the active ingredients found in Midrin®. Isometheptene mucate was originally approved for safety in 1948, before the current FDA drug approval process. For this reason, the FDA considers isometheptene-containing products unapproved new drugs, requiring pharmaceutical companies to submit a new drug application and perform clinical trials proving effectiveness before these products can be manufactured again. As of January 1, 2018, all companies producing isometheptene-containing drugs have agreed to cease distribution. Midrin® is composed of acetaminophen, isometheptene mucate and dichloralphenazone. Acetaminophen acts as a pain reliever by raising the body’s threshold to painful stimuli. Isometheptene mucate constricts certain blood vessels to reduce stimuli leading to vascular headaches. Dichloralphenazone is a mild sedative that helps reduce a patient’s emotional response to painful stimuli. Another commercial product, Prodrin®, which has also been discontinued, is a similar medication that contains two of the three ingredients found in Midrin®, plus caffeine. Following various shortages and the eventual discontinuation of products like Midrin® and Prodrin®, patients have been forced to find new therapies to manage their headaches. Patients using Midrin® for several years to successfully manage their migraine episodes may experience a less than satisfactory response to alternative therapies. What can these patients do?
Headache patients may be at risk for suboptimal or nonexistent therapy following the previous discontinuation of Midrin® and now with the indefinite backorder of dichloralphenazone. Our goal as personalized medicine pharmacists is to meet the individual needs and circumstances of patients and practitioners. DISCLAIMER: These statements are provided for educational purposes only. They have not been evaluated by the Food and Drug Administration, and are not to be interpreted as a promise, guarantee or claim of therapeutic efficacy or safety. The information contained herein is not intended to replace or substitute for conventional medical care, or encourage its abandonment. For more information on how our pharmacists can help, please call 407-260-7002. Juan Lopez, PharmD, FAPC is a personalized medicine pharmacist with Pharmacy Specialists Compounding Pharmacy in Altamonte Springs, FL. For more information on how personalized medicine can help you, please call 407260-7002 or email us at Info@MakeRx.com.
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Fortunately, a pharmacist skilled in the science and art of compounding can prepare therapy containing the same active ingredients found in the commercially discontinued Midrin® and Prodrin® capsules. As is the case now, if there is a shortage in one of the active ingredients, the pharmacist can recommend suitable alternatives that patients and practitioners may want to use. A medication prescribed by a doctor for a specific patient is exempt from the new drug application process if certain criteria are met. The formulation prepared by the pharmacist must not contain ingredients that were discontinued due to safety reasons or appear on an FDA published “Do Not Compound List”. The active ingredients for the formulation must either be found in an already FDA approved drug product, a published positive formulary list or have a United States Pharmacopeia (USP) monograph. Isometheptene mucate, acetaminophen, chloral hydrate and hydroxyzine HCl are available as USP (United States Pharmacopeia) grade chemicals and can be ordered as a compounded medication by a prescriber for a patient seeking this therapy. FLORIDA MD - JUNE 2021 11
Helping Emphysema Patients Breathe Easier By Mark A. Vollenweider, MD, MPH More than 15 million Americans have some form of chronic obstructive pulmonary disease (COPD). And for the 3.5 million who suffer from emphysema — COPD’s more severe, progressive form — simply taking a breath can be a painful challenge. Emphysema weakens and ruptures the tiny air sacs in the lungs, creating larger air spaces. When this occurs, old air becomes trapped in these damaged pockets, putting pressure on the healthy parts of the lung and on the diaphragm — making it difficult to take deep breaths. Patients may struggle with normal daily activities like bathing, getting dressed, walking or even eating without feeling breathless and tired. Emphysema is life-threatening and currently has no cure. Initial treatments include medications such as bronchodilators, antibiotics and inhaled steroids. Pulmonary rehabilitation, nutrition therapy and supplemental oxygen are other approaches. For those with more serious cases of emphysema, highly invasive treatments such as lung volume reduction surgery or lung transplantation have been the traditional options.
AN ALTERNATIVE TO LUNG SURGERY With no surgical cutting or incisions needed, the Zephyr® Valve System is the first procedure approved by the U.S. Food and Drug Administration (FDA) to treat severe cases of emphysema that is minimally invasive. The valve is effective for adults who have little or no collateral ventilation (where ventilation bypasses obstructed airways through other channels) in the lobes where valves will be placed. People who have breathlessness even though they are taking emphysema or COPD medicines are candidates. Other health factors also may be taken into account. Since 2007, more than 20,000 patients have been treated with the Zephyr Valve worldwide. In June 2018, it was approved by the FDA for use in the United States. The Zephyr Valve was granted Breakthrough Device Designation by the FDA based on positive data from clinical trials, including the pivotal LIBERATE trial. Orlando Health Orlando Regional Medical Center (ORMC) was the only hospital in Florida that participated in the LIBERATE clinical trial to evaluate the effectiveness and safety of the Zephyr Endobronchial Valve in emphysema patients with little to no collateral ventilation. During the procedure, a bronchoscope — a small, flexible tube with a camera — is inserted through the nose or mouth and down into the lungs. The Zephyr system’s one-way valves are implanted to prevent airflow into the lungs’ diseased areas while allowing trapped air and fluids to escape. By reducing the lung volume, the healthy portions of the lungs can expand, and the diaphragm has less pressure, enabling deeper breaths, less shortness of breath and increased energy levels. While the Zephyr Valve does not cure emphysema and may not eliminate all symptoms of the disease, it does provide a revo12 FLORIDA MD - JUNE 2021
lutionary approach for improving the health and quality of life for patients with emphysema. Orlando Health ORMC was the first hospital in Florida to offer the Zephyr valve treatment and continues to be one of only about a dozen in Florida approved by Pulmonx, maker of the Zephyr Valve, to perform the procedure.
OPENING THE LUNGS’ AIRWAYS Prior to being approved for the Zephyr Valve procedure, patients will receive a CT scan. Using the StratX® Lung Analysis Platform, a cloud-based CT analysis service, the surgeon is provided information on where the dense portions of the lung are and where the damaged portions are. The damaged portions of the lung are where valves need to be placed to obstruct airflow to those areas. Once the 30- to 60-minute bronchoscopy procedure is underway, the StratX® findings are confirmed using the Chartis® Pulmonary Assessment System. Before any valves are put in place, catheters with balloons are inserted to obstruct the targeted lobes. The Chartis System provides precise flow and pressure readings for each specific lobe to assess the absence of collateral ventilation. For example, if I am trying to obstruct the left upper lobe, when the Chartis balloon is placed in that airway I want the air flow to go down and the pressure to go up to make sure that there are no backflow leaks, or collateral lateral ventilation. This process is an important predictor of response to the valve treatment and puts the patient’s needs at the forefront before the procedure continues. During the procedure, anywhere from two to six one-way valves are placed in the designated airways to block off the diseased parts of the lungs, preventing air from entering those areas and becoming trapped. Keeping air from getting trapped in the diseased parts of the lung allows the healthier parts of the lungs to be more efficient — able to expand and take in more air. As with any medical procedure some risks exist, including pneumothorax, worsening of COPD symptoms, bleeding in the airway, pneumonia and, in rare cases, death. Patients will stay in the hospital for five days for observation following the procedure. Patients who have had the Zephyr Valve procedure may experience immediate relief. It improves quality of life by allowing patients to breathe easier, have less shortness of breath, and be more active and energetic. Whether returning to work, enjoying retirement, or celebrations in between, the outcomes can be life changing. continued on page 13
MARKETING YOUR PRACTICE
Is Your Online Reputation Costing You Patients? By Sonda Eunus, MHA, CMPE What does your online reputation say about your practice? If you have a negative online reputation, you are missing out on new patients every day. Most medical practices now get the majority of their new patients through Google and other search engine queries, such as “Pediatrician in Orlando”. If your practice appears in these searches, the most common next step for a potential new patient would be to check out your reviews – what are other patients saying about your practice? It has been reported that 90% of consumers read online reviews before visiting a business and that online reviews influence 67% of purchasing decisions (Bright Local). For this reason, it is incredibly important to pay attention to the rating and reviews that your practice has on search engines, social media platforms, and local online business directories. However, despite the importance of cultivating a positive online reputation, only 33% of businesses report actively collecting and asking for reviews (1). One great process to set in place at your practice is asking for patient reviews after each patient visit. It can be as simple as training your front office staff to ask each patient how their visit went while checking them out, and if they receive favorable feedback then they can ask the patient to please leave a review on Google or Facebook about their experience. If they receive negative feedback, this feedback should be taken very seriously, and management should be notified as soon as possible so that the issue can be mitigated before the patient decides to post a negative review. Setting up an automated text or email campaign that asks each patient for their feedback after their appointment is also a great way to improve your online reputation as well as to correct any issues that may be occurring at your practice. When you receive feedback from patients, you are then able to prompt them to leave a public review on Facebook, Google, Yelp, Healthgrades, or other applicable review platforms. However, you must be aware that legally, you are not allowed to only direct people with favorable feedback to leave reviews, which is known as review-gating – so if you are implementing an automated system like this, just make sure that you are aware of this limitation. There are online reputation management platforms which allow you to customize the
messages that people see when they leave negative feedback as opposed to positive feedback, but both of those messages must still offer the option to leave a public review. However, if you create your message in such a way as to communicate to the patient who may leave negative feedback that you are working hard on resolving the issue and that someone will be in touch shortly, that may prevent them from leaving a public negative review. When you receive a public review on Google, Facebook, or other review sites, make sure that you respond to it – either by thanking them for a good review or by asking them to contact you to discuss how you can improve their experience. Do not argue or try to defend yourself online – try to speak about it with them privately, fix the issue, and ask them to remove the review if possible. When you receive great reviews, make sure to cross-share them on your various social media platforms. You should also create a “Reviews” page on your website and add all great reviews to this page. This instantly adds credibility to your website. Finally, make sure that when you look over the feedback and reviews that you receive, you are paying attention to what the negative reviews are saying – this is a great opportunity to identify current process challenges and improve your patients’ experience at your practice. Need help managing your practice’s online reputation? Visit www.lms-plus.com to see how Leading Marketing Solutions can help. Sonda Eunus is the CEO of Leading Marketing Solutions, a Marketing Agency working with Medical Practices and other Businesses to help them identify the best marketing strategies for their business, create a strong online presence, and automate their marketing processes for a better return on their Marketing budget. Learn more about Leading Marketing Solutions at www.lms-plus.com.
Continued from page 12
Mark A. Vollenweider, MD, MPH, is a board-certified interventional pulmonologist with Orlando Health Medical Group Pulmonary and Sleep Medicine. His research interests include complicated airway management and pleural malignancies, and he is skilled in the use of several innovative technologies to diagnose and treat benign and malignant airway and pulmonary lesions. Dr. Vollenweider was the Principal Investigator in Orlando Health Orlando Regional Medical Center’s participation in the LIBERATE clinical trial to evaluate the effectiveness and safety of the Zephyr® Endobronchial Valve and co-authored the study published in the American Journal of Respiratory and Critical Care Medicine.
FLORIDA MD - JUNE 2021 13
PEDIATRICS
Pediatric Limb Length Discrepancies By: Jason Malone, DO Q: HOW COMMON ARE PEDIATRIC LIMB LENGTH DISCREPANCIES?
done for leg difference of 2-5 cm.
A: Limb length discrepancies are very common. Up to twothirds of the population have a leg length difference of less than 2 cm (0.79 inch). Luckily, most people do not have symptoms unless the difference is greater than 2 cm.
Q: HOW LONG DOES THE PROCESS TAKE?
Q: WHAT ARE CAUSES OF LIMB LENGTH DISCREPANCIES?
A: Limb length discrepancies can be categorized into two major groups: congenital and acquired. Congenital causes range from longitudinal deficiencies such as congenital short femurs, proximal focal femoral deficiencies, tibia hemimelia, fibular hemimelia, hemihypertrophy, unilateral clubfoot, skeletal dysplasias, and hip dysplasia. Acquired causes range from idiopathic, paralytic disorders such as cerebral palsy or polio and physeal injury from trauma, infection or tumors. Q: WHAT TECHNIQUES DO YOU USE TO TREAT THESE PATIENTS?
A: Symptomatic leg length differences less than 1 cm can be treated with a shoe insert. A difference greater than 1 cm can be addressed with nonsurgical treatment with a customized shoe lift. However, some patients or families do not wish to use a brace or shoe insert for the rest of their life. Leg differences can be treated with a shortening procedure on the long side or a lengthening procedure on the short side or a combination of the two. Shortening procedures are smaller surgeries that are quicker to recover from but do lead shorter stature. Lengthening procedures are classically done for differences greater than 5 cm but many deformity specialists are now treating smaller leg length differences down to 3 cm in skeletally mature patients. Q: HOW DOES THE PROCESS WORK?
A: Limb Lengthening procedures were first described by Dr. Gavriil Ilizarov in the 1950s. He called the process distraction osteogenesis. The process entails making a fracture in a bone, having the patient rest for 5-7 days, then distracting the bone ends about 1 mm per day. The bones can be distracted with an external fixator, a mechanical intramedullary nail, and soon with an expanding plate. We can safely lengthen a bone about 5 cm per treatment. External fixators are better for legs that have an associated large deformity or children with open growth plates. Intramedullary nails are better tolerated but can only be placed in the femur of children at least 8 years old once the growth plate is closed in the tibia. The new lengthening plates that should be out in the summer of 2021 will allow us to lengthen internally even when a child has an open growth plate. Shortening procedures usually are done in growing children. This is done through a timed epiphysiodesis. I prefer to perform a percutaneous epiphysiodesis as it leaves small scars and is associated with less complications than other techniques. This is 14 FLORIDA MD - JUNE 2021
A: Distraction osteogenesis is a long process. After the initial surgery we wait about a week for the bony callus or regenerate to develop. We then lengthen 1 mm per day. Then the bone takes about 8-12 weeks to fully heal the regenerate. A large 5 cm lengthening can take about 100 days to fully heal. Q: WHAT ARE THE POTENTIAL COMPLICATIONS INVOLVED?
A: Distraction osteogenesis is safe if performed and monitored by an experienced physician, but it can also be associated with multitude problems. The bones, tendons, muscles and neurovascular structures are growing faster than the body is used to growing, so patients can develop joint contractures, joint dislocations and nerve stretch. We combat this by using nighttime braces, starting physical therapy right away, and stopping the lengthening process if any major complication develops. We can also lengthen more in the future. You also have your standard complication that can happen with any orthopedic procedure such as infection, nonunion, malunion or hardware failure. An epiphysiodesis can also have its complications such as fracture at the physis, continue growth, angular deformity if the entire growth plate is not fully removed and continues to grow, not timing the surgery right and not achieving the desired correction or even overcorrecting and needing to perform an epiphysiodesis on the contralateral side. Q: WHEN SHOULD A CHILD SEE A SPECIALIST TO ADDRESS THE DISCREPANCY?
A: A child should see a pediatric orthopedic surgeon specialized in deformity correction when they have a congenital leg length difference, when they have a physeal injury, or an idiopathic leg length difference that is symptomatic or over 2 cm. Q: ARE YOU CURRENTLY DOING ANY RESEARCH IN THE FIELD?
A: I just finished a research paper looking through a nationwide database from 1997-2016 on trends in femoral lengthenings in pediatric patients. What we found are that most of the surgeries are performed in large urban teaching hospitals. The South does more lengthenings than any other region in the country. The surgery has become safer over the years with shorter hospital stays but like most of medicine, the costs have risen substantially through the years. We currently have the paper submit for publication. Jason Malone, DO, is a fellowship-trained pediatric orthopedic surgeon at Nemours Children’s Health who specializes in treating limb length discrepancies and deformities. Call (407) 650-7715 for more information.
PEDIATRICS
9-year-old boy had a physeal injury to his left tibia. He sustained a 5 cm leg length difference with a flexion deformity of his knee. He had a projected leg length difference 9.6 cm.
He was treated with a hexapod external fixator to lengthen his leg 5 cm and correct his deformity.
16-year-old boy with an idiopathic 4 cm leg length difference, right genu valgum and an osteochondroma.
He was treated with a lengthening intramedullary nail, acute correction of his knee dormity and excision of his osteochondroma.
The tibia is now healed right before the external fixator is removed.
The femur is now healed right before the nail was removed. FLORIDA MD - JUNE 2021 15
Cosmetic Procedures Amid the Pandemic By Omar E. Beidas, MD The ripple effects of the pandemic over the past year-plus have indeed been far reaching. One unexpected effect, though perhaps more obvious in hindsight, has been a notable surge in the number of people seeking cosmetic procedures. While masks became the norm in many settings outside the home, inside, many people have been spending a lot of time on various video platforms, whether visiting with family and friends or attending work meetings. All that time seeing your own image looking back at you on screen can lead to increased self-scrutiny, particularly of facial features. Combined with remote working allowing for at-home recovery time, and entertainment and travel shutdowns providing a little extra disposable income for some, plastic surgeons across the country have been reporting significant increases in patient volumes. Once services opened back up to allow elective procedures, the Orlando Health Aesthetic and Reconstructive Surgery Institute plastics group has seen a definite uptick in the number of patients, particularly women, coming in looking for a more youthful, more refreshed appearance.
For patients in their 50s and 60s looking for facial rejuvenation, cosmetic surgery may be the best course of action. A facelift usually is a sameday procedure performed under general anesthesia. Because, as mentioned earlier, we lose fat as we age, these patients also may need volume. So, along with the facelift to stretch the face and smooth the wrinkles, a surgeon can perform a fat transfer, taking fat from an unwanted place on the body and transferring it to the face where it’s deficient. A very small amount of fat makes a big difference in the face. Once transferred, the fat cells will permanently stay in their new location. In the first six weeks after surgery, it is common to lose 30-40 percent of the fat initially transferred, so the surgeon will place extra fat during to account for the initial loss. Facial surgery definitely requires more downtime than Botox or fillers. For our patients, we recommend a gradual increase in activity over six weeks.
For patients in their 30s and 40s, minimally invasive injectables are a very popular and effective treatment. In cosmetics, injectables is a broad term that refers to a class of medications administered via needle that includes Botox® and similar type products and a number of dermal fillers, such as Juvéderm® and Restylane®.
Several other procedures are available for patients looking for more than facial rejuvenation.
Botox, a purified form of botulinum, is injected in very small amounts to relax facial muscles and in turn reduce wrinkles. Most commonly used for forehead lines, crow’s feet and frown lines, Botox lasts three to six months, but may also serve a longer-term preventive role. When started early and used consistently, Botox not only diminishes the dynamic, or active, wrinkles seen when someone frowns or raises their brows, but also can help lessen the deeper static wrinkles seen when the face is at rest, because the muscles causing them are not constantly activating. As the name suggests, fillers are used to add volume. We all lose fat in the face as we age, so fillers are the treatment of choice for hollowing under the eyes, nasal labial folds and sunken cheekbones, returning volume to smooth lines and enhance shape. Fillers can last one to two years, depending on the type of filler used and area treated. Another product on the market is Kybella®, the first FDA-approved injectable treatment to reduce fat under the chin. A type of nonsurgical fat reduction, Kybella contains a man-made form of deoxycholic acid, a naturally occurring material that helps the body absorb fat. Unlike Botox and fillers, the results from Kybella are permanent. Currently approved only for use on the neck, indications may expand in the future. All of these injectables are performed in-office, with minimal downtime. After an initial consultation to review medical history and discuss goals and options, the treatment time can be as little as 15 to 30 minutes. Recovery involves some bruising or redness at the treatment site, and it can take up to two weeks for the results to be noticeable. 16 FLORIDA MD - JUNE 2021
One option offered at Orlando Health Aesthetic and Reconstructive Surgery Institute is a “mommy makeover,” a restorative procedure that includes both breast and abdominal surgeries completed at the same time. Advanced options include breast augmentation with fat transfer, in which fat from liposuction is used to enhance the breasts in place of implants, and a drainless tummy tuck, which involves sealing off any openings left during surgery with more sutures rather than using drains that stay in place for weeks. Body contouring is a surgical process to remove excess skin and fat for people who have lost more than 50 pounds. Not just cosmetic, it also treats functional problems related to excess skin and improves the shape and tone of underlying tissue that supports the skin. Body contouring usually involves a number of surgical procedures and target areas, including the arms, abdomen, buttocks, thighs and back. It’s important for patients to choose a cosmetic surgeon who understands their goals. It can be helpful to provide a photo to give the surgeon a good idea of what the patient is looking for and to allow for discussion on whether those results are achievable. While it seems that many offer these services, the procedures are complex and should be performed by a surgeon who has extensive training and experience. By choosing a member of the American Society of Plastic Surgeons, listed on PlasticSurgery.org, patients can be assured a qualified, board-certified plastic surgeon. At at the end of the day, the goal of plastic surgery is to make the patient happy. So, for me, it’s all about setting expectations and then finding ways to make sure the patient makes the right decision that is going to give them the result they want.
Omar E. Beidas, MD, is a board-certified plastic and reconstructive surgeon with Orlando Health Aesthetic and Reconstructive Surgery Institute. Specializing in body contouring after weight loss, he started the surgery after weight loss (SAWL) program at Orlando Health — the first of its kind in the southeast United States. Other specialties include fat transfer, breast reconstruction following breast cancer, transgender surgery, lipedema surgery and breast revision surgery. He also performs reconstructive surgeries in support of a wide range of specialties as well as general cosmetic procedures.
2021
EDITORIAL CALENDAR
Florida MD is a monthly medical/business digital magazine for physicians.. Florida MD is emailed directly to healthcare providers in Orange, Seminole, Flagler, Volusia, Osceola, Polk, Brevard, Lake and Indian River counties. Cover stories spotlight extraordinary physicians affiliated with local clinics and hospitals. Special feature stories focus on new hospital programs or facilities, and other professional and healthcare related business topics. Local physician specialists and other professionals, affiliated with local businesses and organizations, write all other columns or articles about their respective specialty or profession. This local informative and interesting format is the main reason physicians take the time to read Florida MD. It is hard to be aware of everything happening in the rapidly changing medical profession and doctors want to know more about new medical developments and technology, procedures, techniques, case studies, research, etc. in the different specialties. Especially when the information comes from a local physician specialist who they can call and discuss the column with or refer a patient. They also want to read about wealth management, financial issues, healthcare law, insurance issues and real estate opportunities. Again, they prefer it when that information comes from a local professional they can call and do business with. All advertisers have the opportunity to have a column or article related to their specialty or profession.
JANUARY –
Digestive Disorders Diabetes
FEBRUARY –
Cardiology Heart Disease & Stroke
MARCH –
Orthopaedics Men’s Health
APRIL –
Surgery Scoliosis
MAY –
Women’s Health Advances in Cosmetic Surgery
JUNE –
Allergies Pulmonary & Sleep Disorders
JULY –
Neurology / Neuroscience Advances in Rehabilitation
AUGUST –
Sports Medicine Robotic Surgery
SEPTEMBER – Pediatrics & Advances in NICUs Autism OCTOBER –
Cancer Dermatology
NOVEMBER –
Urology Geriatric Medicine / Glaucoma
DECEMBER –
Pain Management Occupational Therapy
Please call 407.417.7400 for additional materials or information. FLORIDA MD - JUNE 2021 17
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