Florida md march 2015

MARCH 2015 • COVERING THE I-4 CORRIDOR

Orlando Regional Medical Center North Tower’s 21st Century Art and Science Enhances Patient Care

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contents Photo: PROVIDED BY ORLANDO REGIONALMEDICAL CENTER

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MARCH 2015 COVERING THE I-4 CORRIDOR

 COVER STORY

The opening of the 345,000-square-foot, 245-bed patient tower in January marked Orlando Regional Medical Center’s emergence into a new era of patient care experience.

Standing 10-stories high, the North Tower’s curving architectural façade is like an ocean wave. Within it is a secure environment infused with natural light and color and a multitude of qualities that create the optimum conditions for healing.

“The North Tower represents a transformation in our health care story that redefines how we care for our patients,” says Mark A. Jones, ORMC president. “One advantage of the new patient tower is that we will be converting all of ORMC to a private-room facility, which allows patients to rest better, feel more at ease and have more privacy as they recover. Also, advanced patient care units are specially designed with features within the room to bring clinicians and technology closer to patients and families for improved interaction and medical care delivery.”

11 U.S. Appeals Court Says Merger of Hospital and Large Medical Group Breaks the Law 25 Advances in Colorectal Care 27 LIMB DEFORMITY CASE STUDIES 28 FECAL INCONTINENCE

Photo: PROVIDED BY ORLANDO REGIONALMEDICAL CENTER

ON THE COVER: The 245-bed, 10-story, 345,000-square foot north tower is designed to enhance the quality of care, reinforce safety for patients and caregivers, and heighten patient satisfaction. It features all private rooms, centralized registration, in-room computers to enable caregivers to chart at patients’ bedside, safety “red lines” that are integrated into acutecare rooms to identify isolation boundaries, and a host of concierge-style amenities; all nestled in a building that reflects the natural beauty of Florida – blending medicine and art for a unique healing environment. Brasfield & Gorrie served as the general contractor for the project. The architectural firm was HKS Architects, Inc.

DEPARTMENTS 2 FROM THE PUBLISHER 3

FINANCIAL UPDATE: Insurance•Benefits•Wealth MGMT.

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HEALTHCARE LAW

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

20 SURGERY 22 DIGESTIVE AND LIVER UPDATE FLORIDA MD - MARCH 2015

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FROM THE PUBLISHER

I

am pleased to bring you another issue of Florida MD. It’s hard to imagine anyone who is not familiar with the March of Dimes and the work they do to address the problems of premature births and babies born with birth defects. They are always searching for results and services that will help families have healthier babies. April 25, 2015 is the annual March for Babies. It’s a wonderful team-building opportunity for your staff and their families and a great time for a great cause. Listed below are instructions on how you and your family can join the march or how to form a team for your whole practice. I hope to see some of you there.

Best regards, Donald B. Rauhofer Publisher

Coming UP Next Month: The cover story focuses on The Spine & Scoliosis Center in Orlando. Editorial focus is on Surgery and Scoliosis.

Join more than a million people walking in March of Dimes, March for Babies and raising money to help give every baby a healthy start! Invite your family and friends to join you in March for Babies, or even form a Family Team. You can also join with your practice and become a team captain. Together you’ll raise more money and share a meaningful experience.

When: Saturday, April 25th • 7:00am Registration • 8am Walk S Where: Lake Eola, Downtown Orlando Steps for New Users: 1. Go to marchforbabies.org 2. Click START NOW 5. Sign up by filling out your personal profile. Record your username and password for future reference.

Steps for Returning Users: 1. Go to marchforbabies.org 2. Click SIGN IN

Some keys to success: Ask your friends, family and colleagues to support you by donating to the March of Dimes. This can help you raise more money.

The main reason why people do not donate is that no one asked them to give (don’t be shy)! Emailing them is an easy way to ask.

You’re done! Your personal page has been created for you and you are ready to begin fundraising!

ADVERTISE IN FLORIDA MD

PREMIUM REPRINTS

For more information on advertising in Florida MD, call Publisher Donald Rauhofer at (407) 417-7400, fax (407) 977-7773 or info@floridamd www.floridamd.com

Reprints of cover articles or feature stories in Florida MD are ideal for promoting your company, practice, services and medical products.

Increase your brand exposure with high quality, 4-color reprints to use as brochure inserts, promotional flyers, direct mail pieces, and trade show handouts. Call Florida MD for printing estimates.

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

2 FLORIDA MD - MARCH 2015

For more information on March for Babies please call: Darren Bungo Phone: (407)-599-5077 Fax: (407) 599-5870 Central Florida Division 555 Winderley Place Suite 105 Maitland, FL 32751

Publisher: Donald Rauhofer Photographer: Donald Rauhofer / Florida MD Contributing Writers: Heidi Ketler, Daniel T. Layish, MD, Srinivas Seela, MD, Sajid Hafeez, MD, Puja Venkat, MD, Louis B. Harrison, MD, Javier F. Torres-Roca, MD, George J. Nassif, DO, Randy S. Schwartzberg, MD, Julie Tyk, JD, Joseph M. Zavatsky, MD, Lucrecia Sta.Ana, MD, Jennifer Thompson, S. Kyle Taylor, Marni Jameson, Christopher Iobst, MD 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.

Financial Update: Insurance • Benefits • Wealth Management

Living with Volatility, Again

By S. Kyle Taylor

Volatility is back. Just as many people were starting to think markets only ever move in one direction, the pendulum has swung the other way. Anxiety is a completely natural response to these events. Acting on those emotions, though, can end up doing us more harm than good.

There are a number of tidy-sounding theories about why markets have become more volatile. Among the issues frequently splashed across newspaper front pages: global growth fears, policy uncertainty, geopolitical risk, and even the Ebola virus.

In many cases, these issues are not new. The US Federal Reserve gave notice it was contemplating its exit from quantitative easing (an unconventional monetary policy used by central banks to stimulate the economy when standard monetary policy has become ineffective). Much of Europe has been struggling with sluggish growth or recession for years, and there are always geopolitical tensions somewhere.

In some ways, the increase in volatility could be just as much a reflection of the fact that volatility has been very low for some time.

Markets do not move in one direction. If they did, there would be no return from investing in stocks and bonds. And if volatility remained low forever, there would probably be more reason to worry.

For those still anxious, here are six simple truths to help you live with volatility: 1. Don’t make presumptions. Remember that markets are unpredictable and do not always react the way the experts predict they will. When central banks relaxed monetary policy during the crisis of 2008-09, many analysts warned of an inflation breakout. If anything, the reverse has been the case with central banks fretting about deflation.

2. Someone is buying. Quitting the equity market when prices are falling is like running away from a sale. While prices have been discounted to reflect higher risk, that’s another way of saying expected returns are higher. And while the media headlines proclaim that “investors are dumping stocks,” remember someone is buying them. Those people are often the long-term investors.

3. Market timing is hard. Recoveries can come just as quickly and just as violently as the prior correction. For instance, in March 2009—when market sentiment was at its worst—the S&P 500 turned and put in seven consecutive months of gains totalling almost 80%. This is a reminder of the dangers for long-term investors of turning paper losses into real ones and paying for the risk without waiting around for the recovery.

markets have turned rocky again, highly rated government bonds have flourished. This helps limit the damage to balanced fund investors. So diversification spreads risk and can lessen the bumps in the road.

5. Nothing lasts forever. Just as loading up on risk when prices are high can leave you exposed to a correction, dumping risk altogether when prices are low means you can miss the turn when it comes. As always in life, moderation is a good policy.

6. Discipline is rewarded. The market volatility is worrisome, no doubt. But through discipline, diversification, and understanding how markets work, the ride can be made bearable.

At some point, value re-emerges, risk appetites reawaken, and for those who acknowledged their emotions without acting on them, relief replaces anxiety. (“Dimensional”) is an investment advisor registered with the Securities and Exchange Commission. Diversification does not eliminate the risk of market loss. There is no guarantee investment strategies will be successful. The S&P 500 Index is not available for direct investment and does not reflect the expenses associated with the management of an actual portfolio. Past performance is no guarantee of future results. All expressions of opinion are subject to change without notice in reaction to shifting market conditions. This content is provided for informational purposes, and it is not to be construed as an offer, solicitation, recommendation, or endorsement of any particular security, products, or services.

Securities and Investment Advisory Services offered through NFP Advisor Services, LLC, Member FINRA/SIPC. NFP Advisor Services, LLC is not affiliated with The Vaughn Group, Inc.or Dimensional,

S. Kyle Taylor is a principal at The Vaughn Group, Inc. and manages the wealth management department. As an independent financial advisor, he focuses on helping his clients understand the importantce of developing a strategic, long-term wealth plan.

Kyle believes that wealth management is a process and a partnership built on trust and integrity. He approaches that process by gaining clarity about a client’s current situation – identifying core values, defining future goals, and developing a flexible strategy that allows them to reach their objectives.

Kyle graduated from the University of Florida with a B.A. in Finance and also attended the College for Financial Planning. He can be reached via email at kyle@vaughngroup.com or by phone at (407) 872-3888. The Vaughn Group, Inc.’s offices are located at 1407 E. Robinson St., Orlando, FL 32801. 

4. Never forget the power of diversification. While equity FLORIDA MD - MARCH 2015

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COVER STORY

Orlando Regional Medical Center North Tower’s 21st Century Art and Science Enhances Patient Care

By Heidi Ketler, APR The opening of the 345,000-square-foot, 245-bed patient tower in January marked Orlando Regional Medical Center’s emergence into a new era of patient care experience.

In the next several weeks the inpatient rehabilitation unit from the Lucerne Pavilion will be moved to the top two floors of the North Tower. When relocated in the North Tower, these inpatients also will regain strength and movement from the use of the Standing 10-stories high, the North Tower’s curving architecnew rehabilitation garden. tural façade is like an ocean wave. Within it is a secure environ“The rehab garden is a beautiful, secure, private area like we ment infused with natural light and color and a multitude of have never had before,” says Brian Wetzel, M.H.A., administrator qualities that create the optimum conditions for healing. of ORMC ancillary services and facility planning. “It’s a wonder“The North Tower represents a transformation in our health ful offering for our patients who usually stay longer with us than care story that redefines how we care for our patients,” says Mark any other to help them get back to independent living.”

A. Jones, ORMC president. “One advantage of the new patient The North Tower’s creation is part of a five-year, $297 million tower is that we will be converting all of ORMC to a privaterenovation and redesign of Orlando Health’s downtown campus. room facility, which allows patients to rest better, feel more at ease Expansion of the existing South Tower includes new space for the and have more privacy as they recover. Also, advanced patient emergency department, new surgical suites and new cardiovascucare units are specially designed with features within the room to lar services areas. Many of these South expansion areas, the emerbring clinicians and technology closer to patients and families for gency department expansion for example, will open in April. improved interaction and medical care delivery.”

“The entire redesign and renovation project represents one of The new ORMC tower is now home to 10 inpatient care units the largest and most significant projects in the organization’s histhat were formerly in ORMC’s South Tower and the Lucerne Patory,” says Mr. Jones. “To see it nearing completion is amazing. vilion. The units are: cardiac progressive care, vascular stepdown, “When we come to work, we are grateful to be able to bring neuroscience intensive care, neurology stepdown, neurology, these great facilities to our community. We’re especially proud of trauma intensive care, trauma stepdown, multisystem intensive the extraordinary care that our frontline teams and medical staff care, intermediate critical care and inpatient rehabilitation. provide to our patients and The new ORMC tower’s first floor areas include Patient Business, Guest Services and Administration. The families.”

Patient Business Department is the first step for patients when they arrive on campus. The new location makes it truly centralized. Previously the department was located in two areas. The new Patient Business area also includes lab services. In the same convenient location, patients will have access basic lab services needed for pre admission testing and outpatient needs

Redefining the Patient Experience The new North Tower and South Tower expansion and redesign project is key to fortifying ORMC’s mission to provide quality patient care, as well as efficiencies for the organization, in the 21st century.

Photo: PROVIDED BY ORLANDO REGIONALMEDICAL CENTER

“Most hospitals today were designed when health care was very different,” says Michael L. Cheatham, M.D., F.A.C.S., F.C.C.M., chief surgical quality officer for ORMC.” Natural light was not a priority. Computer records were not a part of patient care.

Prior to the opening of the North Tower, Lucerne Pavilion had been the newest ORMC inpatient care facility. The patient care wings in the South 4 FLORIDA MD - MARCH 2015

COVER STORY Tower were constructed in the 1960s and 1980s, and 30 percent of non-intensive care beds there were semi-private.

Renovating semi-private rooms to become private rooms that meet current building codes for health care facilities built such a long time ago is a costly endeavor, according to Mr. Wetzel. Practical improvements are limited to aesthetic updates and technology upgrades, such as televisions and enhanced vital signs monitoring.

Photo: PROVIDED BY ORLANDO REGIONALMEDICAL CENTER

“Semi-private” means the patient has a roommate and less control over privacy and noise level. Beyond such distractions as visitors, television and snoring – the challenge for medical staff to protect against infection is far greater.

The Orlando Health Rehabilitation Institute’s Rehabilitation Garden is not a garden in a traditional sense but is a tool to promote rehabilitation and restoration. The Rehab Garden provides challenges for maneuvering across different terrains, and obstacles so patients are better prepared for transitioning to the community. The therapy team can use gardening activities to improve mobility, endurance, muscle strength, and coordination.

The activities can also be used for cognitive benefits such as memory, attention, and sequencing.

So ORMC is “very quickly becoming an entirely all-private facility by this spring,” says Mr. Wetzel.

During the extensive design phase for North Tower construction and South Tower renovation, comprehensive research was conducted to identify patient care advances to support a renewed ORMC enhanced patient care experience. It involved hundreds of medical professionals – with all members of the patient care team represented – as well as patients and family members.

Hospital-design best practices were studied in depth. Focus groups were conducted. Tours of other acclaimed health care facilities were led.

More inspiration came from mock rooms that were constructed for tour and critique by general contractor Brasfield & Gorrie in a warehouse just blocks from the ORMC campus. The full-size prototypes of two patient rooms – one was ICU-level, the other, acute care – and a central nursing station represented the future of patient care.

Working closely with hospital team leaders, HKS Architects Inc. professionals masterfully incorporated the myriad of enhanced patient care elements that are now integral to ORMC’s North Tower. The expansive windows, bringing into each patient room the natural daylight so essential to life and healing, are among them. “Physiologically, natural light is a tremendous help, reducing confusion and delirium in patients and helping them maintain their normal sleep and wake patterns,” says Dr. Cheatham.

“It was a significant undertaking, but the value was apparent.

You couldn’t get the same engagement and feedback by just looking at floorplans,” says Mr. Wetzel. It paid off in “several practical, tangible improvements for enhanced patient, guest and team member experience that might have otherwise been overlooked.”

“When you combine all the qualities of a safe, healing environment with the incredible commitment of our frontline team, it improves outcomes, which makes for a very special place in which to provide great care. We’re very excited about the days to come,” says Mr. Jones.

The Patient Room of the Future Is Here “The entire North Tower was very carefully designed to provide patients all that they will need to recover, from the time they first arrive in the hospital to when they are ready to go home,” says Dr. Cheatham. “We are trying to make patient care as pain free and stress free as possible for both patient and family. The goal is to help them recover as quickly and safely as possible.”

Gone are the days of buzzing-bright fluorescent light. In North Tower patient rooms, adjustable LED lighting at bedside provides several levels of light, small reading light for the patient to full task lights for the clinical staff. There are dimmable task lights at the foot of the bed in the visitors area to provide lighting for guests that does not disturb the patient. The window treatments were designed to provide two levels of natural light, filtered light or complete blackout to aide in the patient’s sleep.

“Lighting is important in patient rooms, so we tried to provide many levels of lighting that can be easily controlled. It is important for a patient to feel they have control of their environment, and lighting is one small way to help provide comfort in their environment,” says Karen Guindi, interior designer and facilities planning senior project manager with Orlando Health Business Development.

All rooms are large to accommodate advanced medical equipment, abundant storage space, seating and space for diverse interactions with the patient. In addition to a sink and separate FLORIDA MD - MARCH 2015

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Photo: PROVIDED BY ORLANDO REGIONALMEDICAL CENTER

COVER STORY “We’re already finding that caregivers are able to respond more quickly to the patient call bell,” says Mr. Wetzel. “Time is saved, because now not every interaction with our patients in isolation requires our caregivers to put on a gown, mask, gloves and protective eye gear every time they check in on the patient.”

Dr. Cheatham adds, “Hospital staff has full visual access to the patient from the hallway, so regardless of whether they are in isolation or not, we are able to see the patient and access the patient more easily.”

Windows on the hallway side of the patient room provide a clear line of sight for nurses The new Orlando Regional Medical Center tower environment also embraces families. The Family Retreat posted at substations directly Room is a place for family members and loved ones to spend time in a calming environment as needed so between every two patient they may continue to provide the love and support needed as their family member or loved one recovers. rooms. Medical monitors that check the patient’s physical condition and intercoms and call bells bathroom, many of the rooms are equipped with a specialized lift also connect the patient to the nursing staff. that safely transports less mobile patients from bed to wheelchair and even into the bathroom.

Patient-inspired amenities include the private family retreat space on each floor. One borrowed from home is the built-in All rooms have a wall-mounted, flat-panel television, windowhampers in each room that replace the metal-frame laundry cart, side recliner and folding guest chair to encourage visitors. The which was known to loiter about and generally be in the way. non-ICU patient rooms have a sleeper sofa and guest chair. The ICU patient rooms have a sleeper bench that open and still proEvidence-based Design Enhances the vides the room of a twin size bed.

Hospital Experience A wall-mounted, hard-wired computer in each patient room The interior design within the North Tower is as enlightened as gives the health care team the ability to interact with the patient the 21st century patient care provided. while using the computer to chart patients and access their test Here, omnipresent natural light plays on Florida-inspired colresults, such as radiographic studies. Caregivers can coordinate ors and textures. More than 760 pieces of artwork by Florida artcare and perform a myriad number of essential operations. ists celebrate native flora and fauna, landscapes and seascapes, and “If the caregiver who is coordinating discharge recognizes that, they greet the eye at every turn. for example, a walker would be beneficial for patient mobility Thoughtfully placed artwork is also in the recovery room. at home, he can order it on the spot rather than waiting until “When you wake up after surgery, it can be very disorienting,” getting to his work station. That might be a nuance that is undersays Ms. Guindi. “Having something familiar for the patient to estimated if you’re not the patient who wants to go home,” Mr. focus on is another way to support them.”

Wetzel says.

Today, there is a far greater awareness of the impact of interior Next-generation inpatient care provides for a safer healing endesign in health care environments. “It has been known for cenvironment. For instance, special consideration was given to surturies that harmonious environments encourage healing,” whethfaces that won’t harbor bacteria and are easy to clean. Rooms also er it be a health spa or a hospital, says Ms. Guindi. include a built-in facility to quickly and safely remove infected “Evidence-based design shows that beautiful views, nice enwaste and linens. vironments and artwork can help lower blood pressure, reduce Integrated into the floor of acute-care rooms is an inlaid “red anxiety and take focus off of pain ” She adds, “Beautiful environline,” an infection control line that reminds caregivers how far ments not only help aide in the healing of patients, but promotes they can safely enter before taking airborne or contact isolation guest and family to be more involved with the patient in the hosprecautions. It’s a timesaver for those who need to simply compital, which again assists with the patient’s healing progress. municate with the patient – the patient transport team before de“Our staff also gains the same benefits of these light-filled, parture, the staff person gathering food trays, the nurse routinely calming environments. We hope to help reduce some of the stress checking in.

6 FLORIDA MD - MARCH 2015

COVER STORY from their very stressful jobs.”

That’s why health care organizations are increasingly employing interior designers, like Ms. Guindi, and why she was an integral part of North Tower planning. Supported by HKS, the architecture and interior design team, she orchestrated such interior design aspects as unique color palettes and floor patterns, furnishings, lighting, spatial configurations and artwork selection and placement.

A focus of North Tower interior design was creating comfort for families, which also supports the clinical staff. “Supporting families is very important for everyone at Orlando Health. If the family is happy that makes the staff happier.” And that ultimately leads to less staff turnover.

The interior design also addresses visitor comfort, such as sufficient seating. “The nurse should be taking care of the clinical aspects of patients, rather than worrying about finding more chairs,” Ms. Guindi says.

Ample storage directly outside of the patient rooms for essential supplies, like gloves and masks, is another example of thoughtful design that helps nurses make the best use of their time. It also makes ergonomic sense, saving nurses unnecessary trips down the hall.

Patients and visitors first experience Ms. Guindi’s hospitality interior design background when they enter the North Tower lobby and two-story atrium. It looks a lot like an upscale hotel lobby, and some may wonder if they’ve come to the right place.

Within this voluminous, light-filled space, contemporary styling and colors are complemented by a collection of three, magnificent lily pad paintings that occupy an entire wall. An artful column of blown-glass bubbles rises to the ceiling nearby. A variety of seating options include a continuous high-backed sofa along the wall below the lily pads and cushioned chairs that are grouped with tables throughout the atrium.

“In the atrium space I wanted something dramatic but comfortable, so people feel they can relax in a calm environment,” Ms. Guindi says.

She acknowledges a trend in which hospital design borrows from the hospitality industry, as well as residential applications. “Hospitals and hotels have a lot in common.” Both require furnishings and fabrics that are durable for high-traffic use and easy to clean. Hotels also specialize in design that incorporates the comforts of home and functionality usually in compact space.

“We want to create an environment that’s comforting and nurturing, and incorporate elements from hospitality that make sense for the North Tower patient care environment,” Ms. Guindi says.

“It is a fact that people feel most comfortable at home. If we can bring some elements of the home environment to the hospital, patients are more apt to heal quicker,” says Ms. Guindi. The hospital gardens, the artwork and the chandelier in the main lobby

Photo: PROVIDED BY ORLANDO REGIONALMEDICAL CENTER

Each patient care floor has a central nurse’s station equipped with computers, and other electronics and systems to help care for patients.

Each unit also has a sub-nurse’s stations located in alcoves between rooms. With computers between every two patient rooms, nurses at the new ORMC tower always have a workstation within reach.

FLORIDA MD - MARCH 2015

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COVER STORY

Ms. Guindi also was instrumental in designing the way-finding cues that help guide patients and visitors to their North Tower destination. “A lot of cues have been incorporated into the design to make it easier for guests and patients to get where there they need to go, which helps especially in stressful situations,” says Ms. Guindi.

Photo: PROVIDED BY ORLANDO REGIONALMEDICAL CENTER

are examples of “positive distractions” that can be associated with home.

Even the distinctive floor patterns around central nursing stations bring to mind beautiful area rugs.

Each room includes a wall mounted computer for clinicians to use, bringing caregivers closer to patients to provide care, communicate testing results and other updates, and improve engagement. Each acute care room has a “red line” integrated into the floor that indicates where a caregiver can enter the room without needing personal protective equipment for patients requiring isolation. If the caregiver needs to cross the red line, protective wear is necessary. One unique feature to this room is the patient lift which helps safely transport patients in and out of bed with greater ease to patients and caregivers.

They start in the atrium, where tableaus of different colors of terrazzo tile guide patients and visitors to the guest elevators. Each floor has a sub-lobby with a distinct wall color that offers a visual cue as soon as the elevator doors open.

Nature is another calming force that is carried throughout. It’s seen in nursing stations, which each have a vibrant macro-graphic mural of a nature scene – like a field of sunflowers – on the back wall. Orchids and other live plants throughout the hospital interior add to the natural beauty while helping to purify the indoor air.

Healthier Indoor and Outdoor Environment

• Stone, porcelain, Corian and glass are a few of the materials selected for their sustainable qualities, resulting in lowered operating costs, reduced energy use and increased building efficiency.

• Recycling building materials were used whenever possible.

“We take a lot of pride in the final product and the team that helped us to bring it to operation,” says Mr. Wetzel. “It’s such a pleasure to have this facility to offer the community, and I believe this new patient tower will allow us to continue to improve patient care for many decades to come.” 

ORMC has submitted an application to meet silver-level Leadership in Energy and Environmental Design (LEED) certification. The rigorous LEED review aims for the highest standards for air quality and energy-efficiency.

Key green building features of the North Tower include the angle of the building to capture the best lighting. Greenscape methods and materials used in the creation of outdoor green spaces – the parks and gardens – include native plants that require less watering, fertilizers and pesticides.

Other green building features include: • Light filtering through expansion windows maximizes natural light and reduces the need for artificial lighting.

• Light sensors and electronic eyes on faucets assist with energy efficiency.

• Low–water-flow fixtures are used in bathrooms and other areas.

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CONTACT INFORMATION

Orlando Regional Medical Center 1414 Kuhl Avenue Orlando, FL 32806 321.841.5111 myormc.com

Healthcare Law

HIPAA 2015: Attacks, Enforcement and Compliance

By Julie Tyk, JD Since September 2011, when mandatory reporting of breaches began, over 1,170 breaches involving 31 million records have been reported to the Department of Health and Human Services (HHS). According to research from the Ponemon Institute, the top four causes of healthcare data breaches are: • Lost or stolen device; • Unintentional employee action; • Third-party snafu; and • Criminal attacks.

Major data breaches at retailers like Target and Home Depot have increased pressure to improve security across industries, including healthcare. The Office for Civil Rights (OCR), the department responsible for enforcing HIPAA, expects HIPAA complaints to reach 17,000 in 2015, up from 13,000 in 2013. The OCR’s HIPAA enforcement priorities highlight criminal cyber threats. On January 13, 2015, Jocelyn Samuels, director of the Office of Civil Rights (OCR) at the U.S. Department of Health and Human Services, briefed reporters on the agency’s HIPAA enforcement priorities, noting a focus on threats to electronic health information, or ePHI. As a result, you can expect that the OCR is likely to increase investigations in 2015.

From 2009 – 2013 (data for 2014 is still being compiled), there have been 49,375 complaints lodged with OCR regarding HIPAA violations. Of these, roughly 30% led to fines. These fines amounted to $25,980,500.00. HIPAA violations may result in penalties of $100 to $50,000 per violation, depending on the conduct at issue. If the violation results from “willful neglect” the party is subject to mandatory fines of $10,000 to $50,000 per violation. Additional penalties may be assessed if the breach resulted from failure to implement required policies or practices.

Covered entities must self-report breaches of unsecured protected health information (PHI) to the affected individual and HHS. A covered entity may avoid HIPAA penalties if the violation was not the result of “willful neglect” and it corrects the violation within 30 days.

In 2015, the OCR will begin enforcing the requirements of HIPAA and the Health Information Technology for Economic and Clinical Health Act (the “HITECH Act”) through random audits. Last year the OCR delayed its second round of compliance audits. It originally planned to audit 350 randomly selected covered entities between October 2014 and June 2015. The audits are now planned for some time in 2015.

Below are several ways to you can prepare for the upcoming

audits and potentially avoid “willful neglect” penalties: 1. Review electronic protected health information systems for vulnerabilities and unsupported software.

2. Conduct or update your security risk assessment required by the security rules.

3. Implement the administrative, technical, and physical safeguards required by the HIPAA security rule.

4. Execute business associate agreements with all entities considered a business associate that reflect the changes under the HIPAA Omnibus Rule provisions.

5. Update the form for Notice of Privacy Practices to reflect the changes under the HITECH Act Omnibus Final Rule and provide to every patient.

6. Train employees and monitor performance.

7. Respond immediately to any suspected breach.

8. Report breaches in a timely manner.

9. Document your actions.

To ensure that your privacy and security policies and procedures, Notice of Privacy Practices, and Business Associate Agreement form are fully up-to-date and in compliance with the Final Rules, please contact the Healthcare Team here at GrayRobinson.

Julie A. Tyk, JD, is an attorney in the Health Care Practice and Litigation Practice Groups with GrayRobinson, P.A. Julie concentrates her practice in peer review, medical malpractice, transportation litigation and insurance defense. She has represented physicians, hospitals, ambulatory surgical centers, nurses and other health care providers across the state of Florida. Call her at (407) 244-5694; julie.tyk@gray-robinson.com or visit www.gray-robinson.com. 

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

FLORIDA MD - MARCH 2015

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PULMONARY AND SLEEP DISORDERS

Pulmonary Rehabilitation

By Daniel T. Layish, MD, FACP, FCCP, FAASM Pulmonary rehabilitation can benefit patients with a wide variety of lung diseases including COPD, pulmonary fibrosis, cystic fibrosis, and sarcoidosis (among other chronic respiratory illnesses). Pulmonary rehabilitation does not replace standard medical and/or surgical treatments for these lung diseases. Rather, it supplements and complements standard therapy.

Patients with COPD (and other chronic lung diseases) develop shortness of breath with activity. This leads to the tendency to avoid activity, which in turn leads to deconditioning. It is felt that one of the main benefits of pulmonary rehabilitation is to break the cycle of deconditioning. Pulmonary rehabilitation programs typically include two or three outpatient sessions per week for 10 to 12 weeks. Typically, a pulmonary rehab program will include aerobic exercise, strength training, patient education in management of lung disease - including nutrition, energy conservation, medication compliance, bronchial hygiene, and breathing strategies. The component of group support is also felt to be a significant contributor to the success of these programs. The group support motivates the patient to attend the pulmonary rehab sessions. It also allows the patient to realize that there are other people suffering from chronic respiratory illness and to see how they are able to overcome these obstacles. Pulmonary rehabilitation is considered to be critical both before and after lung transplantation. Occasionally, a patient will have such a significant functional and symptomatic improvement after pulmonary rehab that transplant can be delayed.

Pulmonary rehabilitation programs are typically multidisciplinary in nature and may include a respiratory therapist, registered nurse, exercise physiologist, nutritionist, physical and/ or occupational therapists. The staff is trained to encourage the patient’s self management and coach them to adopt healthier habits through lifestyle modification. To enroll in a pulmonary rehabilitation program requires a medical referral. Pulmonary rehabilitation is covered by most third party payors. Pulmonary rehabilitation is appropriate for any stable patient with a chronic lung disease who is disabled by respiratory symptoms.

The pulmonary rehab program should involve assessment of the patient’s individual needs and creation of a treatment plan that incorporates realistic goals tailored to each patient. Evidence based analysis consistently reveals improvement in health related quality of life after pulmonary rehabilitation as well as improved exercise tolerance. Pulmonary rehabilitation has been shown to improve the symptom of dyspnea and increase the ability to perform activities of daily living. Pulmonary rehabilitation has also been shown to reduce health care utilization (including frequency of hospitalization) and decreases length of stay (when hospitalization is required). Pulmonary rehabilitation has not been demonstrated to improve survival.

10 FLORIDA MD - MARCH 2015

The benefit from a pulmonary rehabilitation program may decline over time if the individual does not maintain their conditioning. Some pulmonary rehabilitation programs will therefore include a “graduate” or maintenance program after the patient finishes the initial program.

Patients who develop shortness of breath often become anxious which in turn exacerbates the sensation of dyspnea and this can become a vicious cycle. Pulmonary rehabilitation can be very helpful in addressing this problem. Sometimes pulmonary rehabilitation will require supplemental oxygen with exercise.

Although the strongest evidence regarding pulmonary rehabilitation programs is in the setting of COPD, it has been shown to be beneficial in a variety of disease states. Pulmonary rehabilitation has been shown to be a cost effective tool in the fight against chronic lung disease. It is currently felt to be underutilized.

Daniel Layish, MD, graduated magna cum laude from Boston University Medical School in 1990. He then completed an Internal Medicine Residency at Barnes Hospital (Washington University) in St.Louis, Missouri and a Pulmonary/Critical Care/Sleep Medicine Fellowship at Duke University in Durham, North Carolina. Since 1997, he has been a member of the Central Florida Pulmonary Group in Orlando. He serves as Co-director of the Adult Cystic Fibrosis Program in Orlando. Dr. Layish may be contacted at 407-841-1100 or by visiting www.cfpulmonary.com. 

Coming UP Next Month: The cover story focuses on The Spine & Scoliosis Center in Orlando. Editorial focus is on Surgery and Scoliosis.

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U.S. Appeals Court Says Merger of Hospital and Large Medical Group Breaks the Law Orlando Doctors’ Association Contributes to Ruling that Puts Hospitals on Notice

In a striking victory for independent doctors, competition and the future of the nation’s health care, the U.S. Court of Appeals for the Ninth Circuit ruled Feb. 10 that a lower district court was correct when it found the 2012 acquisition of a large medical group by a major hospital system in Idaho violated federal antitrust laws, and ordered the merger to be dissolved.

“This is a case the nation has been watching, because it will have a wide ripple effect,” said Tommy Thomas, a Winter Park CPA, and founding member of the Association of Independent Doctors, a national nonprofit that played a role in the decision.

“Today’s ruling puts hospitals on notice,” Thomas said: “Buying up market share to the point of creating a monopoly in the community is against the law.” He hopes the decision will spur more lawsuits to unwind similar hospital-doctor mergers. The doctors’ association filed an amicus brief last August asking the Ninth Circuit panel of judges to uphold the lower court’s decision, which it did on all counts.

Antitrust attorneys around the country took note of the decision, the Idaho Statesman reported.

Many felt the ruling sets a precedent that might slow merger activity in the health-care industry, where consolidation has increased in recent years.

“It certainly puts a spotlight on any hospital looking to acquire physicians,” Jonathan Lewis, a partner and antitrust lawyer at Baker Hostetler in Washington, D.C., told the Statesman.

The purchase of independent medical groups by hospitals is a national trend. Hospitals claim the mergers help integrate care, but analysts say it’s a way for hospitals to capture market share and higher revenues. Studies show such mergers dramatically increase health-care costs, and do not improve outcomes.

The new ruling involves St. Luke’s Health System’s acquisition of Saltzer Medical Group and its 34 doctors. The Nampa County practice was Idaho’s largest independent medical group before it sold to the hospital system, for just under $30 million, according to court documents.

St Luke’s claimed that the merger would be better for the patient community as it would help “integrate care” and “enhance efficiencies.”

However, nearby St. Alphonsus Medical Center disagreed and said that the merger created a monopoly that reduced competition, increased costs and was not in the best interest of patients.

The purchase gave St. Luke’s 80 percent of the primary care doctors in Nampa and significant bargaining leverage over health insurers, according the Idaho Statesman.

By Marni Jameson The Federal Trade Commission joined St. Alphonsus and filed suit against St. Luke’s claiming that the merger violated antitrust laws.

The U.S. District Court for Idaho agreed and ordered the parties to unwind the merger.

St. Luke’s instead appealed the decision to the Ninth Circuit Court of Appeals.

Shortly after, the Winter Park-based doctors’ association retained Washington law firm Mayer Brown to write an amicus brief affirming the district court’s decision. Robert E. Bloch, an attorney from Mayer Brown who helped write the brief, said, “The association’s brief provided its unique perspective to the Court of Appeals and described the significant challenges independent physicians face. The association’s fight to provide the best, most cost effective care is an important part of this case.”

In addition to AID, four other groups -- attorneys general from 16 states, a group of economics professors, America’s Health Insurance Plans, and Catalyst for Payment Reform -- also filed amicus briefs asking the Ninth Circuit to affirm the lower court ruling.

Orlando has a vested interest in this ruling, said Thomas. “All Americans, but especially those in Central Florida, have felt firsthand the negative impacts these mergers have on costs, care and communities.”

Central Florida has two of the nation’s largest health systems, which are rapidly buying up medical groups to secure market share.

Florida Hospital and Orlando Health are respectively the No.2 and No.6 largest nonprofit health systems in the country, according to Becker’s Healthcare, yet Orlando is only the 26th largest metro.

“Most metros don’t have one system this big, and Central Florida has two,” said Thomas. “It will be up to the community, and its independent doctors, to keep the systems in check.”

AID, which has members coast to coast, is the only national trade association that solely represents the interests of independent doctors on the national stage. To continue fighting this fight for Americans, we need independent doctor everywhere to join our cause www.aid-us.org.

Marni Jameson is the executive director for the Association of Independent Doctors. You may reach her at 407865-4110 or marni@aid-us.org.  FLORIDA MD - MARCH 2015 11

CANCER

Frontiers in Radiation Oncology

By Puja Venkat, MD, Louis B. Harrison, MD and Javier F. Torres-Roca, MD Technological advances in imaging and radiation oncology over the last three decades have led to the implementation of radiation therapy based multidisciplinary approaches which allow for organ and function preservation in multiple anatomical sites. In early stage breast cancer, for example, women now have the option for breast conservation therapy (partial mastectomy, or lumpectomy, followed by whole breast radiation therapy) as opposed to mastectomy1. For prostate cancer, radiation therapy has equivalent oncologic outcomes as compared to radical prostatectomy2. Similar strides have been made in anal cancer, where surgical management alone left patients with a permanent colostomy. Now with a combination of radiation and sensitizing chemotherapy (chemoradiation), we are able to definitively treat anal cancers without surgery, leaving the gastrointestinal tract intact and functional3. Similarly, locally advanced laryngeal cancer was historically treated with total laryngectomy. We are now able to offer patients concomitant radiation and chemotherapy, preserving their voice4.

However, organ preservation is not enough. The high, curative doses of radiation that we now use have the potential to permanently damage normal tissues leaving them functionally impaired.

With cancers of the head and neck region, for example, many patients, although cured of their cancer after radiation therapy, were left with permanent dry mouth and dysphagia5. Advancements in radiation therapy planning and delivery have allowed us to deliver these high doses of radiation therapy to the areas of disease while preserving salivary glands and muscles intrinsic to swallowing, thus preserving optimal function.

Intensity modulated radiation therapy (IMRT), in particular, has allowed us to shape our radiation fields with extreme precision. IMRT utilizes multiple beams and smaller beamlets that can be varied in their intensity. This allows a 3D computer planning system to create complex treatment shapes with rapid dose fall off outside the desired target area. IMRT allows us to sculpt the dose away from critical normal structures, such as the parotid and submandibular glands, for example, decreasing the risk of permanent dry mouth and dysphagia6.

As we shrink and shape our fields, however, we incur the risk of missing our target. The development of image guided radiation therapy (IGRT) has allowed us to visualize our target and surrounding structures prior to each treatment. As patients lose weight or organs fill and empty, internal structures move considerably. We now have treatment machines that can take x-ray, CT, and, more recently, MRI images of the patient in the treatment position just prior to delivery. Furthermore, 4D planning addresses movement during treatment as seen with breathing.

These technical advancements give radiation oncologists greater control over daily treatments and allow higher precision therapy.

These improvements in imaging, planning and delivery have 12 FLORIDA MD - MARCH 2015

all contributed to the development of stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT). These techniques use highly targeted 3D planning to deliver very high, ablative doses to small areas in one to five treatments. SRS targets lesions in the brain or spine, while SBRT treats lesions in the rest of the body. These ablative doses, in a sense, provide surgical outcomes through a non-invasive technique. For example, standard of care for early stage lung cancer remains surgical resection. We, however, routinely use SBRT to treat these lesions with control rates similar to surgical series7.

The treatment is delivered in 3 to 5 sessions with very few side effects6. This is an ideal option for patients who are either non-surgical candidates due to comorbidities, or for patients who prefer a non-invasive approach. SBRT has opened new doors to the opportunities for curative radiation therapy.

Puja Venkat, MD

Louis B. Harrison, MD

Advancements in brachytherapy (placement of radioactive sources adjacent to or within the tumor) have also Javier F. Torres-Roca, allowed us to deliver high doses of raMD diation in a convenient and safe fashion. In locally advanced cervical cancer, dose escalation achieved through brachytherapy, has significantly improved disease free survival8. For low to intermediate risk prostate cancer, we can now offer patients definitive treatment with brachytherapy alone in one to two minimally invasive procedures9. For high risk prostate cancer, the addition of brachytherapy to IMRT allows for the omission of hormonal therapy, significantly improving quality of life10. Intraoperative radiation therapy (IORT) for breast cancer delivers one treatment at time of lumpectomy. In a select group of patients, this appears to be sufficient allowing some women to avoid the 3 to 6 weeks of whole breast radiation therapy11.

These advances allow us to personalize treatment plans to a patientâ&#x20AC;&#x2122;s individual anatomy, tumor size and location, and personal preferences. We hope to take personalized medicine even further, using a patientâ&#x20AC;&#x2122;s individual tumor biology and genetic profile to determine radiation treatment parameters. We currently prescribe radiation doses without consideration of the potential differences in tumor and patient radiosensitivity. For example, we know oropharyngeal cancers caused by human papillomavirus (HPV) have more favorable clinical outcomes after chemoradiation as compared to HPV negative cancers12. Potentially, HPV related

CANCER cancers are intrinsically more radiosensitive, allowing us to de-escalate treatment13. Taking this a step further, can we characterize every tumor’s radiosensitivity? Moffitt Cancer Center has been researching this question for the last decade. We have found that gene expression can predict cellular radiosensitivity14. Ten genes in particular have been identified to create a multigene expression model of intrinsic tumor radiosensitivity15. This model predicts a radiosensitivity index (RSI) that has now been prospectively validated in multiple disease sites15. This model not only has the potential to lower radiation doses for radiosensitive tumors, decreasing side effects, but also to raise doses for radioresisitant tumors, increasing cure rates. We believe this model may play a key role in individualizing radiation oncology therapy as we continue to advance cancer care. References available upon request Puja S Venkat, MD, received her MD degree in 2012 from the University of Toledo College of Medicine. She completed a Transitional year internship at St. Joseph Mercy Hospital Ann Arbor in 2013. She is currently completing her Radiation Oncology residency at Moffitt Cancer Center/University of South Florida.

Javier F. Torres-Roca, M.D., a board certified radiation oncologist, is an Associate Member at Moffitt Cancer Center in the Department of Radiation Oncology, the Chemical Biology & Molecular Medicine Program, and the Department of Biomedical Informatics, and an Associate Professor of Oncologic Sciences at the University of South Florida. Dr. Torres-Roca earned his medical degree from the University of Puerto Rico and subsequently performed post-doctoral training in immunology and molecular biology in the laboratories of Nobel Laureate Professor Luc Montagnier at the Institut Pasteur and Dr. Irving Weismann and Dr. Leonard Herzenberg at Stanford University. Dr. Torres-Roca completed his clinical training in radiation oncology at the University of California. Since 2002 Dr. Torres-Roca has been clinical faculty at Moffitt Cancer Center with a sub-specialty in urological malignancies. He is also the founder and chief scientific officer of Cvergenx, Inc, a personalized medicine company that is commercializing the first genomic molecular diagnostic to predict a tumor’s radiosensitivity.

Louis B. Harrison, MD , FASTRO received his MD degree from the SUNY Downstate Medical Center College of Medicine.

He completed a Radiation Oncology residency at Yale University School of Medicine, Yale-New Haven Hospital; where he also served as Chief Resident. Following his residency, Dr. Harrison joined the faculty at Memorial Sloan Kettering Cancer Center in New York, in 1986. While at Memorial, he assumed increasing responsibilities over his 11-year tenure and was the Chief of the Brachytherapy Service in the Department of Radiation Oncology as well as the Institutional Program Leader of the multidisciplinary Head and Neck Cancer Disease Management Team. Dr. Harrison was also appointed to the faculty of Cornell University School of Medicine; Assistant Professor (1987-1991); and Associate Professor (1991-1997). He joined the Continuum Health Partners (Beth Israel Medical Center, St. Luke’s-Roosevelt Hospitals and NY Eye and Ear Infirmary) in 1997.

At Continuum, Dr. Harrison served as Chairman and Gerald J. Friedman Endowed Chair of Radiation Oncology and Physician-in-Chief of Continuum Cancer Centers of New York. He was also appointed as Professor of Radiation Oncology and Otorhinolaryngology-Head and Neck Surgery at the Albert Einstein College of Medicine. When Continuum merged with Mount Sinai in 2013, his academic appointment moved to the Icahn School of Medicine at Mount Sinai, where he was Professor of Radiation Oncology as well as Otolaryngology.

Dr. Harrison has served in numerous positions with the nation’s the leading radiation oncology professional society, the American Society for Radiation Oncology (ASTRO), before being elected as Chairman of the Board and President.

He has also been elected President of the American Brachytherapy Society and President of the International Society of Intraoperative Radiation Therapy. 

FLORIDA MD - MARCH 2015 13

Marketing Your Practice

Getting the Most Out of Every Phone Call to Your Practice By Jennifer Thompson We recently conducted a survey for one of our clients about overall patient satisfaction. Everything was rated relatively well... except one issue. Patients said phone calls were the worst part about the office experience.

So, we thought, “How can we make phone calls better for our client and their patients?” Now that it’s not just about insurance anymore, patient satisfaction is front and center for medical practices.

night and over the weekend. Instead of having a staff member dedicate an entire morning to deciphering voicemails and calling patients back, she will have an inbox (or spreadsheet) with data neatly filled out. She can then mow down a list and

Below you’ll find a few tips and strategies you can use at your office to increase efficiency on the phone and improve patient satisfaction during phone calls.

Remind Staff How Important the Patient Is We’re all guilty of it.

Sometimes we got lost in the day-to-day-mark-offtask-one-and-move-to-task-two mentality and we forget why we went into healthcare in the first place (it was to help people in case you need a reminder).

Every phone call is a life choosing your office for help, and it’s up to you to make a difference for them. Call a quick meeting and remind staff answering the phones that we’re here to help, these people matter and they need us to improve their life.

It’s often said you can hear someone smile through the phone; so take a few minutes and remind your phone operators that patients are listening for that smile and they deserve to hear it.

Every. Time.

Incentivize Staff When the phone rings at your practice, do you have a goal in response time or are you just hoping it doesn’t go to voicemail?

Set a goal and then incentivize staff to meet and exceed it. We suggest 80 percent of calls answered within 30 seconds or less.

As a motivator, create a contest for front desk staff, appointment schedulers or whomever is responsible for answering your phones. Those that meet or exceed the goal should be recognized among their peers and rewarded. Take them out to lunch once a month or pick up a gift card the next time you’re at Target - anything to show their efforts matter.

Oh, and be sure to be consistent with your rewards. If you start an incentive program, you can’t stop without good reason (and “I forgot” is not good reason).

Tweak Operations There are a few ways you can easily increase efficiency when it comes to phone calls from an operational standpoint. Consider: • Adding an appointment request form to your website to cut down on new patients calling in. This is especially handy at 14 FLORIDA MD - MARCH 2015

confirm appointments much faster than checking a few dozen voicemails on the office line. We’ve seen this form work for our clients, even generating 300+ appointments month over month that would have either been phone calls or folks that wouldn’t have scheduled at all.

• Answer the phone with, “Hello, when would you like to be seen?” This surprises the patient, but it gets the conversation rolling right away. Sure, sometimes the caller may not need to be seen, but about 90% of your calls are for appointments or follow ups, so you may as well jump right in.

• Stagger staff members in the front so one is managing patients at the office and one is on the phone. This way, no one is left unattended and your team can work together to increase patient flow efficiency and get patients back to see their doctor as soon as possible.

Break Down What Your Medical Staff Should be Saying We hear it far too often. Physicians, especially those who tend to have a few more gray hairs, like to tell patients to call the office and let us know how you’re doing. Ugh. This creates a bottleneck at the front, which takes staff away from getting new patients scheduled and can lead to a negative experience from the patient on the line because of how much they have to wait just to let someone know how they feel.

Continued on page 16

Marketing Your Practice Instead, schedule a training session (or two) for your medical staff and explain why it’s important for them to tell patients to use the patient portal for messaging. Talk about how it slows the office down and may be hurting the bottom line. Present any hard numbers you can so the physicians can clearly see how they’re costing themselves money by creating inefficiencies - that should get them to do what you need right away.

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

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

Coming UP Next Month: The cover story focuses on The Spine & Scoliosis Center in Orlando. Editorial focus is on Surgery and Scoliosis.

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Shortness of Breath Cough Lung Cancer Lung Nodules

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Our physicians are Board Certified in Internal Medicine, Pulmonary Disease, Critical Care Medicine, and Sleep Medicine Daniel Haim, MD, FCCP

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Mahmood Ali, MD, FCCP

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Downtown Orlando:1115 East Ridgewood Street East Orlando:10916 Dylan Loren Circle Altamonte Springs: 610 Jasmine Road

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Behavioral Health

The Nature of The Affliction STORY

By COVER Sajid Hafeez, MD “So… How long do I have to take the medication?” If a psychiatrist had a dollar for every time he has been asked this question, he’d be set to retire a few years after med school. It is a question that bears investigation in a larger context of how psychiatric care is understood by the general patient.

Generally speaking, the shorter the duration of a medication, the higher the compliance on behalf of the patient. When medications are required to treat chronic issues, the patient is less likely to see them as a cure and more as a burden. Antibiotics to treat an infection have a finite conclusion when the infection is cleared.

Yet, illnesses such as diabetes or hypertension are afflictions that will likely persist through the rest of most patient’s lives.

Often times the public naively see mental illness as a transient problem. At some point in life, every person will know sadness in one form or another. More often than not, most people will recover and move on. When a person struggles from depression, this mirrors what they experienced when they were sad, but with lasting effects. The hope is that psychotropic meds act like an antibiotic to “cure the blues,” and once that sickness is cured, life will continue as normal. Part of the explanation to this could be explained by linguistics

As a society, “depressed” and “sad” are often used interchangeably. A person may say that he or she is “depressed because the Denver Broncos lost the Super Bowl,” whereas another may say that he or she is “sad because the Denver Broncos lost the Super Bowl.

A large part of mental health care is in educating the patient that sadness is a temporal emotion that relates to situational and environmental factors. Depression is a lasting condition that persists independent of situational and environmental context, which is related to the physiological make-up of the bodies’ chemistry.

It is because of this chemical origin, that it can be treated with medications that adjust the levels of chemistry or how the body absorbs them.

Unfortunately, there is no dipstick in the back of the head that the doctor can check to measure the serotonin levels and top them off with a quart when needed. Patients are educated that rather these levels must be discerned by the clinical presentation of the patient, his affect, mood, and own subjective self-assessment of these. When set against lab values, history of recurrence, and environmental context the doctor is then best able to hone in on the issue and treat it accordingly.

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16 FLORIDA MD - MARCH 2015

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Behavioral Health Some patients will be diagnosed with an Adjustment Disorder or Stress Response Syndrome, which is essentially a sadness caused by a specific event. A doctor may or may not choose to start a medication to help the patient through the event, in conjunction with therapy that will help the patient to deal with the psychological aspects of the event. These are the patients who may not need to stay on medication once appropriate coping skills and philosophies are established which allow them a certain level of mental resilience against future stressors.

However for those whose afflictions are the results of the body’s physical biochemistry, therapy and coping skills are typically not enough to overcome the chemical imbalance. It is through medication that these levels are corrected and that patient begins to feel the depression lifting. Unfortunately, this point of “feeling better” is what is responsible for much of the relapse in patients.

Often, once a patient begins to feel better, he or she incorrectly assumes that the affliction has been cured and medication is no longer needed. Inevitably some will attempt to wean themselves off the medication. However because the root of the affliction is chemical and not psychological, no matter how mentally stable and prepared he or she may feel, without the medication to maintain the stable chemistry, these patients will drift back into the affliction.

Ultimately a large part of treating the patient is educating him or her as to what is causing the issue and teaching that psychiatric medications are not cures to a sickness, but rather stabilizers of a chronic condition. In much the same way that a patient with hypertension requires beta blockers so too do those with mental illness need their medication to function at an optimal level. When a patient truly understands why the medications are important and how they work, the compliance ultimately increases, which as a result will improve the patient’s overall quality of life.

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

Dr. Hafeez received his adult Psychiatry and Residency Training at the University of Kansas Medical Center in Kansas City. He received his Child and Adolescent Psychiatry fellowship training at the New York Medical College New York and at Children’s National Medical Center of George Washington University in Washington, DC. Dr. Hafeez can be reached at 407-281-7000 or by visiting www. universitybehavioral.com. 

FLORIDA MD - MARCH 2015 17

ORTHOPAEDIC UPDATE

Youth Baseball Throwing Injuries

By Randy S. Schwartzberg, MD An increasing number of shoulder and elbow injuries have been seen in youth baseball pitchers for the past several decades. These young athletes are at particular risk because of their developing bones, muscles, tendons, ligaments and open growth plates.

Some of the more serious injuries include growth plate (physeal) fractures that may require surgery and elbow ulnar collateral ligament injuries that may require reconstructive surgery (the Tommy John procedure).

Several culprits have been implicated for these injuries in youth pitchers including pitching mechanics, pitching quantity and pitch types.

Common examples of common pitching motion mistakes include not having the throwing elbow at its maximum height by the time of stride foot contact and the lead shoulder being in an open position Randy S. Schwartzberg, at the time of stride foot contact. It is MD advisable for young pitchers to learn proper pitching skills at an early age to minimize risks of injury due to improper pitching mechanics.

What Causes Injuries in Youth Baseball Players?

Although there exists a variety of pitching motions, core prin-

Table 3 - Recommended rest days based on pitching amounts.

Table 1 - Recommended pitch limits.

ciples have been identified that are considered proper. Biomechanical studies have identified a handful of common mistakes in the pitching motion that increase stresses seen by the elbow and shoulder. Such increased stresses may increase the risk of injury.

Table 2 - Recommended pitch limits.

18 FLORIDA MD - MARCH 2015

Although pitching mechanics are important, the greatest reason for shoulder and elbow problems in youth pitchers is overuse.

Pitching amounts have been examined in a handful of studies published in the sports medicine literature. It is clear that young pitchers who throw greater than specified amounts are at a significantly greater risk of injury. Discreet recommendations have been garnered to minimize injury risk.

Tracking the amount of pitches that young players throw is the Table 4 - Recommended rest days based on pitching amounts.

ORTHOPAEDIC UPDATE cornerstone of overuse prevention. Traditional attempts have revolved around placing limits on numbers of innings pitched. This is a flawed method because the number of pitches thrown can vary substantially in any given inning. Based on valuable research performed at American Sports Medicine Institute in Birmingham, Alabama, pitching limits for various ages have been developed. In fact, Little League Baseball has adopted these pitching limits.

Since the stresses of pitching on the shoulder and elbow are cumulative, pitch limits have been developed on a daily, weekly, season and yearly basis. It is recommended that such pitching limits be adhered to for youth pitchers. The recommended pitch limits are outlined in Tables 1 and 2. Recommended rest days based on pitching amounts are outlined in Table 3 and 4.

Do Pitch Types Matter?

A more controversial area in youth pitching revolves around pitch types. Specifically, the curveball has been implicated for decades as a causative factor for injury in the young throwing athlete.

Recommendations by coaches, parents and physicians have often been to avoid throwing curveballs until puberty. Interestingly, biomechanical research does not support this concern. In biomechanical studies of young pitchers, it has been demonstrated that fastballs place greater stresses on the elbow and shoulder than curveballs. Further, changeups place lower stresses on the elbow and shoulder than fastballs and curveballs. However, it is likely that young pitchers lack the neuromuscular development and mechanics to throw curveballs properly.

When youth pitchers have multiple pitches, it is likely that they will practice pitching more to become accomplished with their expanded repertoire of pitches. This increase in pitching quantity would be great concern for overuse injuries; thus, it is recommended that young pitchers delay throwing curveballs and other breaking pitches until the ages of 13 and 14.

Other research-based recommendations to minimize injury risk to youth pitchers have been noted. It is recommended that youth pitchers not play catcher due to the increased volume of throws that would be made at the position. It is also recommended that youth baseball players not pitch on multiple teams with overlapping seasons. Additional recommendations include not throwing for three months each year and not continuing to pitch when they experience elbow or shoulder pain. Arm pain while pitching should be evaluated by physicians who specialize in sports medicine.

It is hoped that adhering to these principles will optimize injury prevention in the vulnerable arms of the physically developing youth baseball pitchers.

To learn more about these injuries and to view our full infographic on youth baseball pitching injuries, visit OrlandoOrtho. com. î Ž

FLORIDA MD - MARCH 2015 19

SURGERY

Minimally Invasive Surgery (MIS) for the Treatment of Adult Spinal Deformity (ASD) By Joseph M. Zavatsky, MD With the increasing aging patient population, the incidence of advanced degenerative spinal disease and Adult Spinal Deformity (ASD) is increasing. ASD is a common problem with a prevalence of greater than 60% in the elderly population.

ASD can cause significant disability affecting a patientâ&#x20AC;&#x2122;s quality of life. Conservative treatment options often fail to return this

many advantages over traditional open techniques. MIS surgery can result in smaller incisions; less soft tissue damage and blood loss; decreased infection rates;

Figure 1 - Open technique.

Figure 2 - MIS technique.

aging patient population to their normal activities of daily living (ADLs). Surgical deformity correction and stabilization has been advocated in patients who qualify for surgery and has been shown to decrease pain and improve quality of life. This aging patient population is often deconditioned and can have multiple medical comorbidities including osteoporosis. These additional factors can present challenges often complicating the surgical treatment of their spinal condition. As a consequence, the surgical treatment of patients with ASD is fraught with hazards, which can increase the risk of peri-operative complications. Reported complication rates in traditional open complex spinal deformity surgery have been reported to be as high as 40 â&#x20AC;&#x201C; 75%. Over the past several decades, the surgical treatment options for ASD have expanded in both traditional open and MIS surgical techniques.

Recent advances in spinal surgery including MIS techniques have 20 FLORIDA MD - MARCH 2015

Figure 3 - Pre-op X-ray.

and decreased immediate post-operative pain, which can result in shorter hospital stays and quicker recovery. This can potentially result in lowering complication rates and ultimately improving patient outcomes. Technological advances in MIS spinal surgery may provide surgeons a safer solution to patients who would

SURGERY have otherwise not qualified or been offered surgery, particularly is larger more complex and risky spinal procedures.

Multiple studies have proven the benefits of MIS techniques in a host of surgical procedures including microdiscectomies, laminectomies, spinal fusions, and spinal trauma. There have also been multiple studies demonstrating the benefits of MIS surgery in adult spinal deformity surgery. As a member of the International Spine Study Group (ISSG), I have been fortunate to contribute data to a multi-center database analyzing the benefits of MIS surgery vs. open techniques in ASD. In a recent study comparing MIS vs. open techniques, radiographic and patient

Figure 3 - Post-op MIS X-ray.

reported outcomes data were similar regardless of technique.

But there were certain benefits observed in patients in the MIS cohort. Similar to previous reports in other less complex spinal surgical procedures, the ISSG demonstrated benefits in utilizing MIS techniques in ASD patients including decreased blood loss

and a decreased rate of peri-operative complications. The spine team at Florida Orthopaedic Institute and Florida Hospital Carrollwood will be integral parts of the ISSGâ&#x20AC;&#x2122;s prospective study to further analyze the benefits of treating complex spinal deformity patients with MIS techniques.

Years of experience as the Director of the Spine, Scoliosis & Deformity Institute at the Ochsner Medical Center in New Orleans, LA has been integral in the successful development of the Spine Destination Program at Florida Hospital Carrollwood.

Through a collaborative effort between the orthopaedic spine surgeons, neurosurgeons, anesthesiologists, ICU intensivists, pain management physicians, chiropractors, physical therapists, nurses, and the rest of the support team, safe complex spine care utilizing the most advanced surgical techniques, including MIS, can now be offered to patients locally, regionally, nationally, and internationally.

Joseph M. Zavatsky, M.D. is a board-certified orthopaedic spine surgeon. He is joining the Florida Orthopaedic Institute here in Tampa, FL after practicing at Ochsner Medical Center in New Orleans, LA from 2008 to 2014, where he was the Director of the Scoliosis & Deformity Institute, Co-Director of the Spine Center, and Section Chief of Orthopaedic Spine. He was also the Surgical Clerkship Director for the University of Queensland Australia School of Medicine at Ochsner Medical Center. Additionally, he served as the team spine consultant for the NBA New Orleans Pelicans and the NFL New Orleans Saints.

He earned his M.D. degree from the University of Pittsburgh School of Medicine. He completed his surgical internship and Orthopaedic Surgery training at Albert Einstein Medical Center in Philadelphia, PA. At NYU / Hospital for Joint Disease he completed his Spine Fellowship. Additionally, he completed an International AO Traveling Spine Fellowship at the Instituto Ortopedico Galeazzi in Milan, Italy. Dr. Zavatsky is currently the Director of the Spine, Scoliosis & Deformity Institute and serves as the Director of the Spine Fellowship Program. He specializes in patients of all ages, from newborns to adolescents to seniors, with all spinal disorders. In addition to performing more common degenerative cervical, thoracic, and lumbar surgical procedures, he also has a special interest in minimally invasive surgery (MIS), motion preservation surgery including total disc replacement, along with adult and pediatric complex deformity and spinal reconstructive surgery.

He has numerous peer-reviewed publications and has authored multiple book chapters. He has presented at a multitude of national and international spine meetings and Dr. Zavatsky has been listed as one of the top spine surgeon leaders in the nation performing MIS surgery in patients for the correction of spinal deformity. He is a faculty instructor and has been an invited lecturer and surgical proctor both nationally and internationally, teaching both MIS and deformity techniques to spine surgeons from around the world. Dr. Zavatsky may be contacted at (813) 978-9700 or by visiting www.floridaortho.com. î Ž

FLORIDA MD - MARCH 2015 21

Digestive and Liver Update

Lower GI Bleeding: Etiology, Risk Factors

By Srinivas Seela, MD

Lower GI Bleeding Lower gastrointestinal bleeding (LGIB) is a frequent cause of hospital admission and is a factor in hospital morbidity and mortality. LGIB is distinct from upper GI bleeding in epidemiology, management, and prognosis. Lower GI bleeding (LGIB) is diagnosed in 20% to 30% of all patients presenting with major GI bleeding. The annual incidence of LGIB is 0.03%, and it increases 200-fold from the second to eighth decades of life. The mean age at presentation ranges from 63 to 77 years. Approximately 35.7 per 100,000 adults in the United States are hospitalized for LGIB annually, and a full-time gastroenterologist manages more than 10 cases per year. Although blood loss from LGIB can range from trivial to massive and life-threatening, the majority of patients have self-limited bleeding and an uncomplicated hospitalization.

Compared with acute upper GI bleeding (UGIB), patients with LGIB tend to present with a higher hemoglobin level and are less likely to develop hypotensive shock or require blood transfusions. The mortality rate ranges from 2% to 4%8 and usually results from comorbidities and nosocomial infections.15 A recent epidemiologic study reported a decreased incidence of LGIB (41.8/100,000 in 2001 vs 35.7/100,000 in 2009; P Z .02) and a lower age adjusted and sex-adjusted case fatality rate (1.93% in 2001 vs 1.47% in 2009; P Z .003) over the past decade.

LGIB historically has been defined as bleeding that emanates from a source distal to the ligament of Treitz.After the advent of deep enteroscopy, small-bowel sources have been placed in the category of midgut bleeding, and a new definition of LGIB has been proposed as bleeding from a source distal to the ileocecal valve. Acute LGIB is defined as bleeding of recent duration (<3 days) that may result in that may result in hemodynamic instability, anemia, and/or the need for blood transfusions. Chronic LGIB is the passage of blood per rectum over a period of several days or longer and usually implies intermittent or slow loss of blood. Patients with chronic LGIB present with occult fecal blood, intermittent melena or maroon stools, or scant amounts of bright red blood per rectum, hemodynamic instability, anemia, and/or the need for blood transfusion.

The most common causes of lower GI bleeding include: • • • • • • • • • • •

Diverticular disease Gastrointestinal cancers Inflammatory bowel disease (IBD) Infectious diarrhea Angiodysplasia Polyps Hemorrhoids and anal fissures Ischemic colitis Angioectasia Hemorrhoids Colorectal neoplasia

22 FLORIDA MD - MARCH 2015

• • • • • • • • •

Postpolypectomy bleeding Inflammatory bowel disease Infectious colitis NSAID colopathy Radiation proctopathy Stercoral ulcer Rectal varices Dieulafoy lesion NSAID, nonsteroidal anti-inflammatory drug.

Signs and Symptoms The clinical presentation of LGIB varies with the anatomical source of the bleeding, as follows: • Maroon stools, with LGIB from the right side of the colon • Bright red blood per rectum with LGIB from the left side of the colon • Melena with cecal bleeding In practice, however, patients with upper GI bleeding and rightsided colonic bleeding may also present with bright red blood per rectum if the bleeding is brisk and massive.

The presentation of LGIB can also vary depending on the etiology. A young patient with infectious or noninfectious (idiopathic) colitis may present with the following: • • • •

Fever Dehydration Abdominal cramps Hematochezia

An older patient with diverticular bleeding or angiodysplasia may present with painless bleeding and minimal symptoms. Ischemic colitis, abdominal pain, and varying degrees of bleeding are usually observed in patients with multiple comorbidities such as congestive heart failure (CHF), atrial fibrillation, or chronic renal failure (CRF). LGIB can be mild and intermittent, as often is the case of angiodysplasia and colon carcinoma, or moderate or severe, as may be the situation in diverticula-related bleeding.

Colon carcinoma rarely causes significant LGIB. Massive lower GI bleeding usually occurs in patients aged 65 years and older who have multiple medical problems, and produces the following manifestations: • Systolic blood pressure of less than 90 mm Hg • Hemoglobin (Hb) level of 6 g/dL or less • The passage of maroon stools or bright red blood from the rectum

Diagnosis Nonsurgical modalities used to diagnose LGIB include the following: • Colonoscopy

Digestive and Liver Update • Radionuclide scans • Angiography

Resuscitation and initial assessment

Fiberoptic flexible colonoscopy is the initial diagnostic method of choice in most patients who are hemodynamically stable.

Colonoscopy should be performed following a rapid bowel preparation (“prep”) with volume cathartic agents. Rapid bowel prep colonoscopy has higher diagnostic and therapeutic yields compared to unprepped colonoscopic evaluation. In hemodynamically unstable patients and in those with brisk ongoing LGIB, angiography with or without a preceding radionuclide scan can be performed. Angiography is also performed if colonoscopy has failed to identify a bleeding site. Rarely, exploratory laparotomy and intraoperative push enteroscopy can be performed in truly hemodynamically unstable patients owing to the speed and the volume of the bleeding.

Appropriate routine blood tests include the following: • Complete blood cell (CBC) count • Serum electrolytes levels (eg, sequential multiple analysis 7 [SMA7]) • Coagulation profile, including activated partial thromboplastin time (aPTT), prothrombin time (PT), platelet count, and/ or bleeding time (bleeding time is only recommended in patients with bleeding disorders and use of antiplatelet agents) Helical CT scanning of the abdomen and pelvis can be used when a routine workup fails to determine the cause of active GI bleeding. Multiple criteria are used for establishing the bleeding site, including the following[1, 2] : • Vascular extravasation of the contrast medium • Contrast enhancement of the bowel wall • Thickening of the bowel wall • Spontaneous hyperdensity of the periintestinal fat • Vascular dilatations Patients who have experienced multiple episodes of LGIB without a known source or diagnosis should undergo the following: • • • • •

Elective mesenteric angiography Upper and lower endoscopy Meckel scanning Upper GI series with small bowel Enteroclysis See Workup for more detail.

Initial resuscitation involves establishing large-bore IV access and administration of normal saline. The patient’s blood loss and hemodynamic status should be ascertained, and in cases of severe bleeding, the patient may require invasive hemodynamic monitoring to direct therapy.

Hemostasis Once the bleeding site is localized, nonsurgical therapeutic options that may be considered include the following: Diverticular bleeding: Colonoscopy with bipolar probe coagulation, epinephrine injection, or metallic clips. Thermal contact modalities, including heater probe and bipolar coagulation, can be used alone or in combination with epinephrine injection for the treatment of bleeding colon diverticula. Epinephrine solution in a dilution of 1:10,000 or 1:20,000 is injected in aliquots of 1 mL to 2 mL at the site of active bleeding or around a nonbleeding visible vessel. An adherent clot, if present, may be guillotined by using a polypectomy snare. The visible vessel can be treated effectively by using a heater probe (10 J- 15 J) or bipolar coagulation (10 W-16 W) with 2 to 3–second pulse applications and application of mild contact pressure. Perforation has been reported with contact thermal coagulation in the thin-walled right side of the colon in up to 2.5% of patients, so higher settings or repeated applications should be avoided to prevent transmural injury. Endoscopic clip placement is an alternative treatment to

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Management The management of LGIB has 3 components, as follows: • Resuscitation and initial assessment • Localization of the bleeding site • Therapeutic intervention to stop bleeding at the site

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Digestive and Liver Update thermal coagulation and has the advantage of quick and easy application. Clips can be deployed over a bleeding vessel at the neck of the diverticulum or to oppose the walls and close the diverticular orifice, thereby tamponading a vessel within the dome. The use of an endocap has been described to evert the diverticulum and facilitate clipping of bleeding vessels within the dome of a diverticulum. There are no reports of early rebleeding after endoscopic treatment with clips.Endoscopic band ligation for treatment of diverticular bleeding has been described in some small series of patients.

However, this technique may be limited by inadequate suction of diverticula with small orifices or large domes, and high early rebleeding rates have been observed.

Additional studies are necessary to evaluate this technique before it can be adopted into routine clinical practice.

• A tattoo should be placed adjacent to the bleeding site for future reference • Recurrent bleeding: Resection of the affected bowel segment should be performed • Angiodysplasia: Thermal therapy (eg, electrocoagulation, argon plasma coagulation) can be used to achieve complete hemostasis • Conservative management, including nothing by mouth (NPO) and intravenous (IV) hydration in patients with ischemic colitis

Surgery The indications for surgery include the following: • Active persistent bleeding with hemodynamic instability that is refractory to aggressive resuscitation • Persistent, recurrent bleeding • Transfusion of more than 4 units packed red blood cells in a 24-hour period, with active or recurrent bleeding • Transfusion of more than 6 units of packed red blood cells during the same hospitalization.

Srinivas Seela, 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 a significant amount of time in basic and clinical research, and has published articles in Gastroenterology literature.

His interests include advanced and therapeutic endoscopic procedures, colorectal cancer screening, Gastro Esophageal Reflux Disease (GERD), metabolic and other liver disorders.

Dr. Seela is board certified in both Internal Medicine and Gastroenterology. He is a member of the American Gastroenterological Association (AGA), the American Society for Gastrointestinal Endoscopy (ASGE), the American Association for the Study of Liver Diseases (AASLD), and Crohn’s Colitis Foundation (CCF).

In addition to being an Assistant Professor at the University of Central Florida School of Medicine, he is also a teaching attending physician at both the Florida Hospital Internal Medicine Residency and Family Practice Residence (MD and DO) programs. Dr. Srinivas Seela is a gastroenterologist at Digestive and Liver Center of Florida. Contact information 407-3847388. 

24 FLORIDA MD - MARCH 2015

Advances in Colorectal Care

By George J. Nassif, DO Ideally we would live in a population that has a perfect colorectal cancer screening program in which cancer would be found early and treatment would be simple, but we are still far away from this. As colon and rectal surgeons at The Center for Colon and Rectal Surgery at Florida Hospital, we focus on the treatment of colon and rectal disease. are a five physician group of board certified general surgeons who did further fellowship training in diseases of the colon, rectum and anus. We have gained international recognition in colon and rectal surgery with over 30 publications in 2014. We have 1 international and 2 ACGME fellows in an extremely well sought after training program. Our mission has been to innovate in the field, as well as to give the highest quality of care to our patients, while obtaining excellent measurable quality outcomes. Our team covers all Florida Hospital locations in Central Florida, as well as being Florida’s busiest tertiary referral center for colon and rectal cancer.* A primary clinical focus to the group has been minimally invasive surgery as well as finding new innovative approaches to further expand treatment of cancer. Greater than 90 percent of our oncological cases are performed in a minimally invasive fashion.

Our expertise includes advanced multiport laparoscopy, single incision laparoscopy, robotic assisted colon and rectal surgery and sphincter preserving surgery. These techniques have allowed for enhanced patient recovery, decreased length of hospital stay, and less time off from daily activities for the patient.

A true international advancement in colon and rectal surgery, transanal minimally invasive surgery (TAMIS) has been pioneered and cultivated by the Florida Hospital Center for Colon and Rectal Surgery group. TAMIS was invented by Drs. Albert, Atallah, and Larach in 2009 at Florida Hospital. It is an innovative technique that has allowed for advanced laparoscopic skills to translate into endoluminal surgery of the rectum for select benign and malignant pathology. As TAMIS has continued to gain attention around the world new indications have been explored.

TAMIS has been utilized throughout Europe for performing sphincter preserving surgery for distal rectal cancer normally treated with an abdominal perineal resection and permanent colostomy. Utilizing a simultaneous laparoscopic and TAMIS resection has allowed for excellent oncological outcomes and improved quality of life without a colostomy. Our group has the largest experience with this technique

in the U.S. and among the highest in the world. Florida Hospital is the first and only training center in the nation that teaches colon and rectal surgeons from all over the world this innovative technique.

With medicine in the U.S. focusing on quality outcomes as a marker for excellence of care, we are working to become one of the first accredited Rectal Cancer Centers of Excellence (COE).

Rectal cancer COE will receive accreditation by a board with members from the American College of Surgeons, American Society of Colon and Rectal Surgery, and the Multiple Oncological societies. Once accredited, institutions will then be responsible for the rectal cancers in that geographical area. These institutions and selected surgeons will manage and treat all rectal cancers.

This model has been shown in the past to produce better quality outcomes when selected individuals perform increased volumes of complex surgeries. We are on the front line with programs such as Cleveland Clinic and the University of Rochester incorporating numerous metrics in quality patient care when treating rectal cancers. We have been actively working with leaders from all over the country to set guidelines and databases to track these out-

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FLORIDA MD - MARCH 2015 25

From left to right: Teresa H.deBeche-Adams, MD, FACS; George J. Nassif, DO; Matthew Albert, MD, FACS, FASCRS; Paul A. Mancuso, MD, FACS, FASCRS; Sam Atallah, MD, FACS, FASCRS.

comes for all rectal cancer patients. At Florida Hospital we have been using these guidelines for over a year in preparation for a smooth transition into becoming a Center of Excellence. Some of these guidelines include bimonthly multi-disciplinary tumor board for all rectal cancers to be presented, as well as each surgeon being graded on strict detail of the pathological specimen.

With our special interest in the treatment of rectal cancer and innovation with TAMIS and other minimally invasive surgical techniques, we as a group have been invited to lecture worldwide. This has given us an opportunity to promote not only TAMIS, but also Florida Hospital in the capacity of colon and rectal surgery. We continue to follow our mission of innovation, quality care and education each day as we strive to make Florida Hospital the premier center for colon and rectal cancer treatment in the southern U.S. *Based on MedPar data and applies to Inpatient discharges only.

Our fellowship-trained and board-certified surgeons combine exceptional diagnostic skill and advanced surgical experience to treat a broad range of colon and rectal diseases. With regular participation in multi-disciplinary conferences—such as pelvic floor, pathology and GI tumor board—the physicians bring a true team approach to solving complex problems of the colon and rectum. In addition to patient care, all the physicians are actively involved in surgical innovation. Most notably, the group is the sole pioneer of Transanal Minimally Invasive Surgery (TAMIS) and Robotic Transanal Surgery (RTS)— techniques which have now been adopted worldwide. Research is also an important area of focus for the practice and from 2013-2014 the team has published 21 peer-review articles. With four locations throughout the area, advanced training and minimally invasive procedures, the Center for Colon & Rectal Surgery ensures access to a true continuum of care. The physician team can be contacted at 407-303-2615 or by visiting http://www.centerforcolonandrectalsurgery.com.



Coming UP Next Month: The cover story focuses on The Spine & Scoliosis Center in Orlando. Editorial focus is on Surgery and Scoliosis.

26 FLORIDA MD - MARCH 2015

Limb Deformity Case Studies

By Christopher Iobst, MD The Limb Deformity Center at Nemours Children’s Hospital offers surgical treatments for the correction of upper- and lower-limb deformities and injuries in children and adolescents. Christopher Iobst, MD, is a pediatric orthopedic surgeon who joined Nemours Children’s Hospital in January 2014, specializing in the fields of limb lengthening and limb deformity correction. Dr. Iobst began working with children with limb deformities in 2002. He uses unique, minimally invasive techniques combined with state-of-the-art equipment to provide the best treatments and outcomes for patients with complex orthopedic issues due to trauma, birth defects, infections or short stature.

CASE STUDY GSL, a 12-year-old male, presented with significant bowing of both lower extremities. The family noted that the bowing had been gradually getting worse over time. Since the patient had significant growth potential remaining, guided growth was chosen as the primary method of correction. This outpatient surgery is minimally invasive and allows the child to remain fully weight bearing throughout the treatment.

As he continued to grow over the next few years, the guided growth plates gradually straightened out his deformity. Once he reached complete correction, the plates were removed with another outpatient procedure. As he is now skeletally mature, the correction of his alignment will remain Case study JW

Case study GSL

permanent and he can feel confident that his bowing will never return to affect him in his adult life.

CASE STUDY JW was a seven-year-old male with a diagnosis of congenital short femur who presented with a four-centimeter leg length discrepancy. He was having difficulty walking and running due to the significant difference in his leg lengths. The family decided to pursue a lengthening of his shorter extremity to correct his deformity and improve his ability to function. The lengthening of his femur would occur by carefully cutting the bone and growing new bone at a rate of one millimeter per day. He underwent a “turbo” lengthening procedure that combined an external fixator with internal fixation. This allowed him to have the external fixator removed in six weeks instead of the usual six months. The new bone in his femur healed well and he was able to begin running and playing sports about six months after his surgery.

He has maintained his equal leg lengths and has not required any further treatment.

To refer a patient for evaluation to the Limb Deformity Center at Nemours Children’s Hospital, call (407) 650-7715. 

FLORIDA MD - MARCH 2015 27

Fecal Incontinence

By Lucrecia Sta.Ana, MD Discussing loss of bowel control for patients is difficult and upsetting. Patients will avoid talking about their issue without understanding that this is a common condition that increases with age. It is estimated that more than 18 million adults (1 in 12 people) in the United States suffer from fecal incontinence. This means fecal incontinence is more common than steoporosis and Alzheimer’s disease.

Fecal Incontinence significantly impacts quality of life. Depression, poor self perception, embarrassment and inability to perform daily activities are all amplified with the inability to control stool and/or urine. More than half of patients have never discussed the problem with a professional.

Nursing home residence is by far the most common association with fecal incontinence, with an almost 50% prevalence. There are other contributing factors such as diabetes, multiple sclerosis, Parkinson’s disease, stroke, rectal dysfunction and/or damage, and childbirth, which increase the risk of fecal incontinence.

Treatment plans are usually overseen by a gastroenterologist or colorectal surgeon. Options may include diet modification, medications, bowel training, and pelvic floor physical therapy (Biofeedback). Most people have some improvement with these conservative treatment plans. There is a subset of patients who will require surgery.

nerves carry messages through our spinal cord to the brain and back to the pelvic area.The procedure involves the implantation of a small electrical device similar to a pacemaker in the buttocks.

This device sends electrical impulses to coordinate the reflexes and restore the right information among the brain, bowel, pelvic floor and anal sphincter. The procedure is a two step process. The first part of the procedure involves the implantation of the leads to stimulate the nerves. A test phase of 1-2 weeks is then recorded to determine if the device is improving continence. If there is marked improvement, we proceed with the second stage of the procedure which is to implant the battery.

Patients generally have better bowel control and significantly improved quality of life. Living and managing fecal or bowel incontinence can seem hopeless for a number of people of all ages, not just the elderly. It often results in isolation and depression.

The first step is to bring up these issues with your physician. There are very promising solutions and support for fecal incontinence which can give you your life back.

For more information about fecal incontinence treatment options and/or Interstim Therapy, call for an appointment at (407)846-3166 or schedule your appointment online at OsceolaSurgicalAssociates.com/appointments.

Sphincteroplasty has been the best option for many years. This procedure involves the repair of a torn anal sphincter muscle in Lucrecia Sta.Ana, MD is a Colorectal Surgeon practicing order to recreate normal anatomy and improve strength. Artifiat Osceola Surgical Associates, 320 West Bass Street, Kissimcial anal sphincters have also been successful in some patients, mee, FL 34741. Contact her by calling (407) 846-3166.  but only a few centers offer this technology. These procedures have helped the muscle damage component of fecal incontinence, but they do not improve the damaged nerves. Nerve damage is usually a large component in fecal incontinence. As a last resort, we can offer a colostomy. The end of the colon is brought out through the abdominal Tqfblfs;!Mjtb!Bsmfehf!Qpxfmm-!Qsftjefou-!NfejbTpvsdf ! wall and the stool is released into a bag attached Mjtb-b!gpsnfs!ufmfwjtjpo!ofxt!sfqpsufs-!tqfdjbmj{ft! to the skin. This allows for easier nursing care, jo!csboe!kpvsobmjtn!boe!xpslt!xjui!uif!obujpoÖt! more independence and less embarrassment for upq!iptqjubmt!boe!csboet!up!hfu!uifjs!nfttbhf!up! people with severe incontinence as they will be ubshfufe! bvejfodft/! Bt! bo! joevtusz! joopwbups! jo! able to empty the bag at their own will withcsboe! kpvsobmjtn-! Mjtb! jt! b! tpvhiu.bgufs! qvcmjd! out the concern of having to wear a diaper or sfmbujpot!uipvhiu!mfbefs/ ! worry about accidents. In the past few years, Lfz!Ublfbxbzt!Jodmvef; we have introduced a new treatment for fecal .!Vtf!csboe!kpvsobmjtn!up!buusbdu!obujpobm!nfejb!dpwfsbhf Lisa Arledge Powell ! incontinence. It is called Interstim Therapy, .!Tibsf!dpnqfmmjoh!dpoufou!po!dpnqboz.pxofe!nfejb! !!!!diboofmt also referred to as sacral nerve stimulation or ! ! .!Svo!zpvs!nbslfujoh!ufbn!mjlf!b!ofxtsppn sacral neuromodulation. Mild electrical pulses .!Hfu!fyfdvujwf!cvz.jo!gps!csboe!kpvsobmjtn are focused on the nerves that control the pelvic floor muscles, anal sphincters and colon. This Ebuf;!Gsjebz-!Nbsdi!38-!3126 in turn improves control of continence. Sacral Mpdbujpo;!Dibsu!Ipvtf-!Dpvsuofz!Dbnqcfmm!Usbjm-!Ubnqb Nerve Stimulation works by sending electri!

Mfbso!npsf!ps!sfhjtufs!bu!BNBUbnqbIfbmuidbsf/fwfoucsjuf/dpn/! cal impulses to the sacral nerves that control our muscles and sensation in the pelvis. These

BNB!UBNQB!CBZ!IFBMUIDBSF!TJH!QSFTFOUT UIF!OFYU!CSFBLGBTU!XJUI!DIBNQJPOT

28 FLORIDA MD - MARCH 2015

2015

EDITORIAL CALENDAR

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

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

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

JANUARY –

Digestive Disorders Diabetes

FEBRUARY –

Cardiology Heart Disease & Stroke

MARCH –

Orthopaedics Men’s Health

APRIL –

Surgery Scoliosis

MAY –

Women’s Health Advances in Cosmetic Surgery

JUNE –

Allergies Pulmonary & Sleep Disorders

JULY –

Imaging Technologies Interventional Radiology

AUGUST –

Sports Medicine Robotic Surgery

SEPTEMBER – Pediatrics & Advances in NICU’s Autism OCTOBER –

Cancer Dermatology

NOVEMBER – Urology Geriatric Medicine / Glaucoma DECEMBER – Pain Management Occupational Therapy

Please call 407.417.7400 for additional materials or information.

FLORIDA MD - MARCH 2015 25

Florida Hospital is ranked the #1 hospital in the state of Florida for the second year in a row.

And ranked nationally in ten specialties.

Cancer

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We thank you for trusting us with your care.

We thank our clinicians for their commitment to excellence.

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