Florida md november 2016 by FloridaMD

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

Florida Center for Hormones and Wellness Offers Life-Changing Options for Patients Dr. Carrozzella Focused on Nontraditional Approach to Hormone Treatment

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NOVEMBER 2016 COVERING THE I-4 CORRIDOR

 COVER STORY

PHOTO: DONALD RAUHOFER / FLORIDA MD

At the Florida Center for Hormones and Wellness, the waiting room has a therapeutic calm about it. The soothing atmosphere is the first impression John Carrozzella, MD, MSMS a hormone and metabolic wellness specialist, wants his patients to experience when they walk in his doors of his clinic nestled in the heart of the Dr. Phillips community. The Center is not a typical doctor’s office, offering nontraditional approaches to treating patients with hormonal deficiencies, sexual dysfunction, metabolic imbalances, auto-immune disorder and cosmetic needs. Carrozzella is passionate about his work and meeting the needs of his patients, many of whom have exhausted all other options and come to him looking for a solution to their health problems which are wreaking havoc on their lives.

PHOTO: DONALD RAUHOFER / FLORIDA MD

ON THE COVER: JOHN CARROZZELLA, MD

DEPARTMENTS 2

FROM THE PUBLISHER

PULMONARY & SLEEP DISORDERS

HEALTHCARE BANKING, FINANCE AND WEALTH

ORTHOPAEDIC UPDATE

10 MARKETING YOUR PRACTICE 11 CANCER

14 CARDIOLOGY

FLORIDA MD - NOVEMBER 2016 1

FROM THE PUBLISHER

am pleased to bring you another issue of Florida MD. Of all my senses, I think I value sight the most. Unfortunately, vision loss due to accident, disease or aging has become quite common. Central Floridians who are experiencing loss of sight can now turn to Lighthouse Central Florida for help. Lighthouse Central Florida strives to provide individuals with vision loss or blindness the tools and education they need to continue leading productive and satisfying livelihoods through the many programs they offer. I have asked them to tell us a little about some of these programs so if you have a patient experiencing loss of sight you can refer them to Lighthouse Central Florida. Please join me in supporting this wonderful organization. Best regards, Donald B. Rauhofer Publisher

COMING NEXT MONTH: The cover story focuses on HealthSouth Rehabilitation Hospital . Editorial focuses Pain Management and Occupational Therapy.

Ophthalmologists and eye care specialists are on the frontline of blindness prevention and the first resource for those who face vision loss or blindness as part of their life. Specifically related to seniors, glaucoma, age-related macular degeneration (AMD) and diabetic retinopathy are among the most common risks faced by seniors toward loss of vision – and subsequently – their independence. But what happens when a person is faced with an event, or a condition, that does not allow them the comfort and mobility they’ve grown accustomed to all their life? Lighthouse Central Florida believes that loss of sight does not mean loss of vision or independence – actually, quite the contrary. Lighthouse Central Florida strives to provide individuals with vision loss or blindness the tools and education they need to continue leading productive and satisfying livelihoods. This can be seen in the many programs offered by Lighthouse Central Florida, but none more significant to seniors than its Independent Living Skills program. Independent Living Skills training provides individuals with improved ability to perform activities of daily living with adaptations for vision impairment. Tasks such as pouring liquids, labeling personal and household items, note taking, dialing a phone and cooking are able to be done with less frustration, and more confidence. During a six-week course, participants receive adjustment to blindness counseling and selfadvocacy skills that empower them to remain actively involved with family, friends, employers and the community. Independent Living Skills training prevents premature placement into assisted living and nursing homes. Workingage adults who complete Independent Living Skills training are often able to return to gainful employment. Lighthouse Central Florida strives to educate the community not only about the many risks, diseases and injuries that can result in blindness and other sight impairment, but options that enable people with vision loss to continue leading meaningful and productive lives. Please take a moment to learn more about Lighthouse Central Florida and other organizations whose sole purpose is to help those with vision loss or blindness – www.lighthousecentralflorida.org.

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Publisher: Donald Rauhofer Photographer: Donald Rauhofer / Florida MD Contributing Writers: Katie Dagenais, Daniel Layish, MD, Jeffrey K. Raines, MD, Zoraida Catherine Navarro, MD, Jennifer Tseng, MD, Jeff Holt, CMPE, VP, Jennifer Thompson, Corey Gehrold Art Director/Designer: Ana Espinosa Florida MD is published by Sea Notes Media,LLC, P.O. Box 621856, Oviedo, FL 32762. Call (407) 417-7400 for more information. Advertising rates upon request. Postmaster: Please send notices on Form 3579 to P.O. Box 621856, Oviedo, FL 32762. Although every precaution is taken to ensure accuracy of published materials, Florida MD cannot be held responsible for opinions expressed or facts expressed by its authors. Copyright 2012, Sea Notes Media. All rights reserved. Reproduction in whole or in part without written permission is prohibited. Annual subscription rate $45.

PULMONARY AND SLEEP DISORDERS

Blood Testing for Noninvasive Assessment of Pulmonary Nodules By Daniel T. Layish, MD, FACP, FCCP, FAASM With the frequent use of CT scans, incidental findings of lung nodules are a common problem. Clearly, some of these lung nod-

and nodule size or nodule location. It is also not affected by the presence or absence of COPD. Therefore, it provides additional risks stratification above and beyond these clinically evident parameters. When the Xpresys Lung test reveals a high probability of a benign nodule, this may allow the clinician to continue sequential CT monitoring and avoid the need for invasive procedures. There was a validation study of this technology published earlier this year in the Journal of Thoracic Oncology. This was a retrospective multicenter case control study. Nodules between 8 and 30 mm in size were studied. The researchers found 90% negative predictive value in the study. At this point, the strength of the test appears to be negative predictive value. However, it should be noted that the test has not been evaluated in a prospective study. In addition, it has not been evaluated in a large sample of patients.

ules are eventually found to represent early lung cancers. However, most will wind up being benign. PET scan can be helpful in the evaluation of lung nodules, but only when they are above 10 mm in size. In addition, PET scan is expensive. PET scan does have a false positive rate typically felt to be between 12 and 20%. Bronchoscopy is invasive and may not be helpful in the evaluation of very small lung nodules. In addition, bronchoscopy can result in complications such as bleeding, hypoxia and pneumothorax. CT guided fine-needle aspiration is helpful for peripheral lung nodules. However, this is also invasive and can be associated with complications such as pneumothorax and bleeding. Therefore, it would certainly be helpful to have a blood test that would serve as a tool in the assessment of a patient with a lung nodule found on an imaging study. There is now a commercially available blood test called XpresysÂŽ Lung. This test uses proteomic technology to measure multiple circulating proteins associated with lung cancer. The blood is analyzed using multiple reaction mass spectrometry. The Xpresys Lung blood test is not affected by age, smoking history, gender,

Therefore, although the test is commercially available, its role in the diagnostic evaluation of lung nodules remains to be completely defined. Nevertheless, it is an option worth being aware of and hopefully will signal the beginning of a new era in the diagnostic evaluations of lung nodules. 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. î Ž

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COVER STORY

Florida Center for Hormones and Wellness Offers Life-Changing Options for Patients Dr. Carrozzella Focused on Nontraditional Approach to Hormone Treatment By Katie Dagenais At the Florida Center for Hormones and Wellness, the waiting room has a therapeutic calm about it. The soothing atmosphere is the first impression John Carrozzella, MD, MSMS a hormone and metabolic wellness specialist, wants his patients to experience when they walk in his doors of his clinic nestled in the heart of the Dr. Phillips community. The Center is not a typical doctor’s office, offering nontraditional approaches to treating patients with hormonal deficiencies, sexual dysfunction, metabolic imbalances, auto-immune disorder and cosmetic needs. Carrozzella is passionate about his work and meeting the needs of his patients, many of whom have exhausted all other options and come to him looking for a solution to their health problems which are wreaking havoc on their lives. For Carrozzella, his medical career began in a completely different field over 25 years ago. After graduating from Yale University with honors in molecular biophysics and bio-chemistry he headed to the University of Cincinnati for medical school where he graduated in the top 5% of his class with a Junior Year award of Alpha-Omega-Alpha. From there he pursued a career in orthopedics and practiced as an orthopedic surgeon for decades. But over those years, as the world of medicine and healthcare began to

PHOTO: DONALD RAUHOFER / FLORIDA MD

Dr. Carrozzella reviews a treatment plan with a patient.

4 FLORIDA MD - NOVEMBER 2016

change he began looking for a change himself. However, he never expected how he would stumble across his new specialty. “About 10 years ago my wife Sheryl went through dramatic and sudden menopause after neck surgery. Her life was miserable,” describes Carrozzella. “Here I was a doctor and there was nothing I could do to help her. Other doctors told us there was nothing they could do. So, we did our research and that’s when we found a physician who was doing hormone pellet therapy, it was an option that changed her life and mine.” Burned out from a career in orthopedics and with his wife undergoing a therapy that improved her life dramatically, Carrozzella began looking down a new path of medicine and discovered the American Academy of Anti-Aging and Aesthetic Medicine. “I found they offered exactly what I wanted to learn more about, anti-aging and wellness. And the best part about it was that everything they teach is evidence based medicine,” said Carrozzella. “Sheryl’s life turnaround was so dramatic it prompted me to change my whole career.” And change it he did. Ever a scholar of medicine, Carrozzella began looking for options to become an expert in the fields of hormone therapy, wellness medicine and aesthetics. He became an Advanced Fellow of the American Academy of Anti-Aging and Aesthetic Medicine. From there, Dr. Carrozzella went on to earn a Master’s Degree in Metabolic and Nutritional Medicine from the University of South Florida School of Medicine. He earned a Certificate in Advanced Endocrinology, also from USF. In addition, he became a Diplomat of the American Board of Anti-Aging and Regenerative Medicine after passing both oral and written examinations. Dr. Carrozzella has always understood that the area of hormone therapy has been quite controversial in medicine, so to make sure that he was as familiar with the world’s literature on the subject as possible, he found a mentor in Dr. Neal Rouzier, an international lecturer

COVER STORY and an expert in the field, who serves as Medical Director of The Preventative Medicine Clinics in Palm Springs, California. “I believe in training and I set out to be as highly trained as anybody in this field and specialty,” said Carrozzella.

In August of 2015, Carrozzella opened his practice in the Dr. Phillips section of Orlando and dedicated his career full time to hormones, metabolic medicine and non-surgical aesthetics. He offers several literature-based yet nontraditional treatments, among them, bio-identical hormone replacement therapy (BHRT). According to Dr. Carrozzella, BHRT uses a safer and a more natural approach to hormone therapy when compared to the synthetic hormones Premarin® and Provera®. Even though they are manufactured in a lab, the bio-identical hormones estrogen, progesterone and testosterone have the exact same chemical structure as do the natural hormones. And, as he points out, when used propertly, these “near-natural” hormones are easily recognized by the body and they exert the same physiologic effects on the body as do the natural hormones. For Carrozzella, it is important for patients and other physicians alike to fully understand the difference between bio-identical and traditional hormone therapy as well as the history behind both. “Traditional hormone therapy, such as Premarin® (conjugated estrogens) and Provera® (medroxyprogesterone acetate, a synthetic progestin) was used for many years up until the early 2000s when a major landmark study, the Women’s Health Initiative, was published. That study pointed out that extra potent horse urine estrogens (Premarin®) tended to over stimulate breast tissue and when combined with the magnifying effects of Provera® breast cancer rates, in women taking these medications, increased. The resulting panic and fear about “hormones” overtook the country and the world. Unfortunately, all hormones were improperly judged by the results of this study and even ones with good literature behind them were shunned leaving millions of women to ‘suffer,’” explains Carrozzella. “When we look at bio-identical hormones there are no well-done studies that show that they cause any medical problem, disease or illness when used properly and in appropriate dosages. To the contrary, the medical literature is overwhelming supportive of the fact that when women and men use bio-identical hormones to restore their diminished endogenous hormones there are declines in many diseases of aging such as a reduction in the incidence of cardiovascular disease, colon cancer, diabetes, osteoporosis, Alzheimer’s disease and even some cancers. When men and women are hormonally balanced mortality rates decline and they live longer and healthier lives. I’ve witnessed it first hand in my own family with my wife Sheryl and I witness it every day in my clinic.”

PHOTO: DONALD RAUHOFER / FLORIDA MD

BIO-IDENTICAL HORMONE REPLACEMENT THERAPY (BHRT)

The pellet insertion procedure is very quick and virtually painless.

BHRT MODALITIES Carrozzella is trained in all modalities of BHRT, but is partial to pellet therapy. BHRT can be delivered via pellets, pills, creams, under the tongue sublingual pills and injection. “Pellets are an ideal option for many patients because the hormone can be delivered at a nice constant level,” explains Carrozzella. In pellet therapy, a pellet, the size of a grain of rice comprised of purified hormone, is implanted under the skin and slowly releases hormone therapy over four months. Determining the right modality is about assessing each individual patient’s situation. For Carrozzella it’s about meeting the patient’s needs and adopting a treatment plan that is right for that specific patient.

THE PATIENT EXPERIENCE At the Florida Center for Hormones and Wellness, women and men between 45 and 60 years old make up the core age group for bio-identical hormone therapy. And, while most hormone imbalances occur within this age range, there are many hormonal and metabolic conditions that exist both at younger and older age ranges, so there are many interventions that can be done for them as well. “We see more women than men because the hormonal changes that women go through are more dramatic and less addressed by traditional medicine,” says Carrozzella. Patients of the Center first undergo a detailed general medical history evaluation – a specific hormonal history and focused FLORIDA MD - NOVEMBER 2016

COVER STORY

PHOTO: DONALD RAUHOFER / FLORIDA MD

“There are so many things that affect the cell function and physiology that are often overlooked in traditional medicine,” he explains. “This not only holds for the thyroid but all hormones. The cell receptor is waiting for the hormone to come along and plug into it like a key. The hormone then ignites a reaction that leads to a physiologic action that then leads to symptomatic improvement. Those receptors are so often damaged by factors such as inflammation, external radiation, chronic infections and toxicity that sometimes it takes more of the hormone to get the receptor to do what it is supposed to.”

Dr. Carrozzella personalizing a treatment plan with one of his staff.

exam. Women are asked to describe their lifetime experiences with hormones from when they began their menstrual periods to present day. Then Carrozzella looks at the medicines they are on and does lab work. Specifically, he looks at a wide variety of hormone values including thyroid. “I don’t think it is correct to treat without measuring and monitoring, but I don’t treat just numbers, I treat symptoms and outcomes of my patients,” says Carrozzella. “I am looking for symptomatic improvement, functional improvement and improvement in associated physiological parameters (like glucose and cholesterol metabolism).” Carrozzella pays particular attention to the thyroid. “The thyroid is the master hormone. It’s probably the most widely known metabolic hormone that there is. It can cause such profound abnormalities in the body,” he explains. “I find it interesting that a woman can say she has dry skin and thinning hair and she describes other symptoms that suggest hypothyroid; yet she is told by other doctors that her thyroid is fine. I have had many patients whose labs were on the lower end of normal; if they are symptomatic, they are functionally hypothyroid. Now, if they are treated by elevating their free T3 level from the lower quintile to the upper quintile the improvement in their symptoms, metabolism and their overall sense of well-being is dramatic. In my experience, female patients in particular, report that they feel better when their thyroid levels are in the higher end of the normal range.”

BHRT AND NONTRADITIONAL TREATMENT MYTHS Carrozzella is very aware of the skeptics of bio-identical hormone replacement therapy. 6 FLORIDA MD - NOVEMBER 2016

He looks to his patient outcomes and research when defending his practice for hormone therapy replacement. He feels it is important to dispel many of the common myths associated with nontraditional hormone treatments and hormones in general.

DOES BHRT CAUSE CANCER OR BLOOD CLOTS? “Many studies show that testosterone is breast cancer protective and progesterone is as well. Overall women with balanced hormones have cancer at lower rates,” says Carrozzella. “As for blood clots, there has been no incidence of blood clots with bioidentical hormones, but there are increased incidences with synthetic hormones.”

DO WOMEN NEED TESTOSTERONE? “Yes,” says Carrozzella. “Women do need testosterone and it leads to a better quality of life. Women have less disease and their relationships are better when the hormones are balanced. And, this includes testosterone.” For men, a couple of prevalent myths out there are that testosterone can lead to higher risk of heart disease and that it also causes or worsens prostate cancer. To the contrary. “There is an overwhelming abundance of literature that has shown that men who have low levels of testosterone have higher rates of heart disease. When they are then supplemented to higher testosterone levels, their cholesterol profiles improve and they develop less heart disease,” says Carrozzella. “There are recent articles that suggest otherwise but they were poorly done studies with flawed analysis. There is lots of historical evidence to show that testosterone is very heart beneficial. As for prostate cancer, the old saw that using testosterone in men is like “throwing gasoline on a smoldering fire” came from a very old “study” of just one patient. More recent studies have shown that older men with low levels of testosterone get more aggressive prostate cancer than men with higher levels. In fact, new research going on at Harvard University right now is looking at actually

COVER STORY treating prostate cancer with testosterone. The research is in its early stages, but it is very promising.”

PATIENT OUTCOMES For Carrozzella, the passion for his career in hormones, wellness and metabolic medicine comes directly from his patients and from his wife who inspired him to pursue this path of medicine. “I see women in pain, who have been given no hope for their condition. And to turn that around and give them hope is unbelievable,” he describes. “My patients say they never thought they would feel normal again. Men thank me for giving them their wives back and vice versa.” Carrozzella knows that to get others in the medical community to understand the benefits of the therapy he offers is to help them see just how his treatments directly benefit a patient’s life and longevity. “A typical male patient who I see experiences mental cloudiness, feels like he can’t keep up with his peers, his enjoyment in life is declining, he can’t stay in shape, he can’t perform sexually as he once could,” explains Carrozzella. “He has been prescribed pills and perhaps testosterone cream, but no one is really looking at these patients and seeing what their concerns are.” Female patients experience some of the same symptoms, in addition to hot flashes, forgetfulness, irritability and depression. “In traditional medicine, these symptoms are treated with over the counter remedies and often anti-depressants,” says Carrozzella. “Sadly enough these options aren’t meeting these women’s needs. They are band-aids, not solutions to their problems.” Carrozzella encourages primary care physicians and gynecologists to consider BHRT, and the life changing effects it has on large numbers of patients. “I can’t tell you how many times women break down in tears with the dramatic changes they’ve experienced because of BHRT,” describes Carrozzella. “Many times I hear that hot flashes and night flashes are gone within 72 hours of receiving BHRT. Typically, energy levels pick up in seven to 10 days, sex drives improve in 10 days to two weeks, within a month they report that they are thinking and acting clearer. We check blood levels in six weeks and usually by six to 12 weeks post BHRT they are feeling more normal, they are alert, sharp and active. They are seeing results in the gym. Their hair is thicker. Their sexual pain is gone. Their lives are better.”

tion that his medical career has undergone. He considers his work as a hormone and metabolic wellness specialist a gift, one that makes a difference in his patients’ lives on a daily basis. “I help people in some of the most tumultuous years of their lives. With the use of BHRT, metabolic medicine and a variety of aesthetic medicine options I can give them back their normalcy so they can have physical intimacy and togetherness and focus on important things in their lives,” he recounts. “I have been given a tremendous gift that I can then turn around and give to people. It is a life changing gift.” 

SERVICES OFFERED AT FLORIDA CENTER FOR HORMONES AND WELLNESS • Women’s Hormone Replacement • Men’s Hormone Replacement • Menopause • Low Testosterone • Male and Female Sexual Dysfunction • Erectile Dysfunction • Incontinence • Advanced Endocrinology and Hormone Management • Platelet Rich Plasma (PRP) • O-Shot Procedure • Priapus Shot Procedure • Vampire Face Lift • Vampire Facial • Vampire Breast Lift • Botox • Juvederm • Voluma • Fillers • Liquid Facelift • Metabolic and Functional Medicine • Auto-immune disorders

But, Carrozzella points out that for this growing field the key is for referring physicians to find an appropriate and well trained specialist. “Hormone and metabolic wellness is now becoming mainstream and is being taught at major medical schools such as USF, George Washington University and the University of Arizona,” he explains. “This is a specialized field that requires detailed and intimate knowledge. The key is to refer patients to a trained professional in this specialty who will evaluate the patient carefully and set out a treatment plan and monitor that plan accordingly.” Once an orthopedic surgeon, Carrozzella is proud of the transi-

John Carrozzella, MD 7575 Dr. Phillips Blvd. Suite 370 Orlando, FL 32819 • Phone: 407-505-6456 www.hormonesandwellness.com FLORIDA MD - NOVEMBER 2016

HEALTHCARE BANKING, FINANCE AND WEALTH

When is a Good Time to Expand Your Practice? Points to Consider Prior to Deciding! By Jeff Holt, CMPE, VP, Senior Healthcare Business Banker with PNC Bank If you’re considering expanding your practice, it means you’re doing a lot of things right. Maybe you’d like to ramp up your revenue or become a larger player in your market. Perhaps patients have increased to the point that existing staff can’t serve them as effectively or your facilities feel ready to burst. These are great reasons to consider enlarging your current office or even launching a new branch. First, though, carefully consider these key factors.

POLL YOUR PARTNERS Growth, like any change, can be disruptive. It can mean vastly different things to different people. Have you spoken with your partners about what level of growth they aspire to? No matter how busy your practice is, build in time for big-picture discussions, including how (and how fast) you want your practice to grow. If your growth plans include taking on additional partners, be sure everyone agrees on the proper process for accepting or rejecting potential newcomers.

MIND YOUR INFRASTRUCTURE First thoughts center on adding new physicians, but don’t overlook the crucial support (both human and otherwise) that an expanded operation will require. Manufacturers refer to this phase of expansion as “scaling up”— making sure they have the necessary equipment, transportation and tech support to accommodate an influx of new orders. Your practice faces similar challenges. Will your digital records system work across several branches? How many support staff will you have to hire? Are waiting areas roomy enough for new patients?[1]

THINK LIKE A BUSINESS Though your primary purpose is treating patients, growth plans should be based on a clear review of your financials: your revenue, costs, profits and cash flow, and how each of these is likely to be affected by your expansion. As you think of growing, now may be the time to assess which parts of your practice are most and least successful, and to focus your attention on areas driving the greatest return.[2]

ASSESS THE MARKET A busy waiting room or the desire to earn more isn’t by itself justification to expand. Any growth plan should include a detailed assessment of the market. How much of the local market do you currently control? What segment or segments will you go after? Is the local population shrinking or growing? Who is your competition? How will your expansion complement what you’re currently doing, rather than creating redundancies?[3] A project like this can be a great undertaking, so having the right healthcare business professionals supporting the success of 8 FLORIDA MD - NOVEMBER 2016

your expansion is vital for achieving your goals. If you need help…. just ask me for assistance! References: 1. http://www.amednews.com/article/20130128/business/130129959/7/ 2. https://www.americanexpress.com/us/small-business/openforum/articles/the-next-levelunderstanding-the-costs-of-business-growth-mtmc/ 3. ibid. The third-party trademarks referenced in these articles are owned by and are the registered trademarks of their respective third-party owners. There is no affiliation, sponsorship or endorsement relationship between PNC or its affiliates and any such third party. PNC is a registered mark of The PNC Financial Services Group, Inc. (‘‘PNC’’) Business Insights for Dental Professionals/Business Insights for Healthcare Professionals is prepared for general information purposes by Manifest, LLC and is not intended as legal, tax or accounting advice or as recommendations to engage in any specific transaction, including with respect to any securities of PNC, and do not purport to be comprehensive. Under no circumstances should any information contained in the presentation, the webinar or the materials presented be used or considered as an offer or a commitment, or a solicitation of an offer or a commitment, to participate in any particular transaction or strategy, nor should it be considered legal advice. Any reliance upon any such information is solely and exclusively at your own risk. Please consult your own counsel, accountant or other advisor regarding your specific situation. Neither PNC Bank nor any other subsidiary of The PNC Financial Services Group, Inc. will be responsible for any consequences of reliance upon any opinion or statement contained here, or any omission. The opinions expressed in these materials or videos are not necessarily the opinions of PNC Bank or any of its affiliates, directors, officers or employees. Banking and lending products and services, bank deposit products, and Treasury Management products and services for healthcare providers and payers are provided by PNC Bank, National Association, a wholly owned subsidiary of PNC and Member FDIC. Lending and leasing products and services, including card services and merchant services, as well as certain other banking products and services, may require credit approval.

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

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

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ORTHOPAEDIC UPDATE

MAKOplasty Knee Replacement– Precisely What the Doctor Ordered By Corey Gehrold MAKOplasty technology allows a robotic arm to help specially trained orthopaedic surgeons perform minimally invasive partial knee replacements in one or two compartments of the knee. For patients, that means a surgeon can virtually eliminate knee pain by selectively targeting a diseased part of the knee, removing it and replacing it while sparing healthy bones and ligaments to speed recovery time. Patients go home the same day of surgery following this outpatient procedure. When Gary Stevens was told about the technology by Eric G. Bonenberger, M.D., a board certified orthopaedic surgeon specializing in partial and total knee replacements at Orlando Orthopaedic Center, he was thrilled at the thought of alleviating his pain and being what he called a “bionic man” thanks, in part, to the new technology. “The biggest benefit (from the surgery) is not having the pain all the time, constant,” says Gary. “I don’t have to move in different sitting positions; I don’t have to stop walking, because of the pain in the knee.”

WHAT IS MAKOPLASTY? MAKOplasty is an innovative partial knee replacement procedure that uses a robotic arm along with a state of the art computer navigation system, to help pinpoint implant placement and enhance surgical accuracy. The technology provides the surgeon with a patient-specific 3D model to pre-plan the partial knee replacement. Then, during surgery, the surgeon uses the MAKOplasty robotic-arm to replace the specific area of the knee causing pain due to osteoarthritis. The surgeon is also able to visualize and fine tune the procedure prior to surgery by moving the patient’s knee through various range of motion exercises. The final plan is then programmed into the robot’s computer navigation system in preparation for surgery. Throughout the procedure, the doctor is in complete control of the robotic arm. The arm’s navigation system will provide realtime sensory feedback, to ensure proper preparation of the bone,

and correct, pinpoint placement of the implants. The implants are fixed to the surface of the bone once a few millimeters of bone have been smoothly resurfaced.

Eric G. Bonenberger, MD

“I was excited about doing the robotic surgery,” says Gary. “I’m all about technology. I like the idea of being a bionic man and I think the procedure is fantastic.” Gary was also appreciative of the care he received from his entire patient team at Orlando Orthopaedic. “They did a fantastic job of answering all our questions and making sure everything was in place,” Gary says. “Because of some existing medical conditions, I had to go through a lot of extra procedures, and they helped us get through all that.”

BENEFITS OF MAKOPLASTY PARTIAL KNEE REPLACEMENT Perhaps the greatest benefit of MAKOplasty surgery is that it repairs only the deteriorated portion of the knee, and leaves the healthy parts of it intact. Other benefits of MAKOplasty include: • A quicker recovery compared to traditional knee replacement surgery • Patients are discharged and go home the same day as the surgery • The exceptional accuracy of component placement and alignment provides a smoother and more natural knee motion following surgery in many cases • No muscles are cut during the procedure and the incisions made are relatively small, helping qualify the procedure as minimally invasive • Minimal blood loss In general, patients are able to walk out of the clinic, and between three to five weeks after the procedure, most report feeling better than they did prior to surgery. Gary’s successful surgery is a testament to MAKOplasty’s effectiveness. “Dr. Bonenberger got me up and walking the next day at the hospital after the surgery,” Gary says. “Five weeks out, the strength is coming back, it’s a lot better than it was. I can go downstairs a little easier, and the pain’s not there.”

I’m all about technology. I like the idea of being a bionic man and I think the procedure is fantastic.” - Gary, Patient of Dr. Bonenberger

Gary is also relieved that he didn’t wait to have the surgery done. “The reason I wanted to get it done now is so that I could have the mobility for the rest of my life,” says Gary. “They told me that the knee would last at least 25 years before it would have to be replaced, but I think it’ll last a lot longer than that.”  FLORIDA MD - NOVEMBER 2016

MARKETING YOUR PRACTICE

5 Simple Ways to Go the Extra Mile for Patients By Jennifer Thompson Everyone is guilty of getting caught up in the day-to-day grind, right? We have so much to do and so little time to do it. Sometimes, successful marketing is just about going above and beyond and delivering a great customer service experience (especially in today’s age of online reviews that can make or break your practice). Sure, part of marketing is getting the patients in the door, but the other part is converting them into lifelong lovers of your practice. With that said, we wanted to share 5 simple ways to go the extra mile for patients without creating a ton of work for you. They’ll love the office for it and you’ll look all the better to the guys in white coats that sign your checks.

1. ANSWER THE CALL ON SOCIAL MEDIA Someone actively manages your social media accounts, right? When someone checks in on Facebook, respond to them immediately and say you’re glad to see them, and ask if there’s anything they need. An overwhelming amount of time they won’t need anything, but they’ll be extremely glad you responded and engaged with them. That’s a story they’ll tell their friends, as silly as it may sound. If they do need something? Do what you can to get it, or find someone who can help. They’ll be forever grateful and, odds are, their request is small and reasonable.

5. HOLIDAY FOOD DRIVES There’s that “F” word again. A lot of people host food drives and support causes around holiday time, so why don’t you? Contact a local organization and put up a display so patients can donate as they walk in. At the end of the month, mention how much you raised and share the word on social media and in newsletters. If you really want to get crazy, host a different drive each month and at the end of the year you can recap how much you raised and the impact it had in the community. Being more active in your community never hurts, and patients will love your office even more for the amount you give back. Who doesn’t love a free donut every now and then? Silly? Maybe, but it will help build loyalty without breaking the bank.

2. PROVIDE A SNACK OR TWO A little TLC goes a long way. We suggest randomly having coffee, donuts or other snacks in the waiting area. Nothing gets people excited like free food. It’s a great way to show your patients you care by giving them a little something extra. Often, it will change someone’s day (and have them raving about your office). If you really want to impress them, hand out the food personally and take a moment to make them smile. Crazy, right?

3. THANK YOU CARDS FOR THE WIN A great way to make patients feel special is to send them a thank you card after a big surgery, and also a greeting card around the holidays (or, more realistically, have a giant pile of thank you cards and get the doctor to sign them). Then, just drop them in the mail as needed. Your patients spend thousands of dollars with you; so, spending fifty cents and a few seconds to mail them a card is the least you can do...and they’ll love you and the doctor for sending out a personalized card just for them.

4. CREATE AN EVENT WHEN THERE AREN’T ANY Host events that allow patients to talk to doctors. There’s a doctor based in California that does a “Walk with a Doc” event every month. He and a few staff members meet up at a park to take a walk. Patients are welcome to join them, just to mingle and chat. Think about how many doctors do that in your area? Go ahead and name one. The dividends thinking outside the box like this can pay with both existing and prospective patients and their families is astounding. 10 FLORIDA MD - NOVEMBER 2016

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. 

CANCER

Advances in Lung Cancer Treatment By Jennifer Tseng, MD Lung cancer is the leading cause of cancer death in the country, according to the American Cancer Society. The cancer movement in the U.S. has grown in recent years. Each October, people, businesses and even sports teams are awash in pink for Breast Cancer Awareness month, but not as many people may be aware that the following month is devoted to lung cancer awareness. November is Lung Cancer Awareness Month. We have a long way to go, but we’ve made significant strides in treatment and research that should be celebrated, while also maintaining a focus on how to save more lives.

EVOLUTION IN LUNG CANCER TREATMENT We’ve made two large gains with lung cancer: first in understanding the biology of lung cancer and finding targeted therapies that address genetic mutations, and secondly in the field of immuno-oncology. Twelve years ago, we didn’t have a means to molecularly characterize lung cancer. Now we know of dozens of driver mutations. Though most of these mutations still lack a targeted therapy, the ability to refine therapy and personalize therapy to the molecular signature of lung cancer has been a huge game-changer. We have targeted therapies now for epidermal growth factor receptor(EGFR) driven tumors, with at least four therapies currently approved. For a subset of patients who have EGFR mutations, these drugs are potentially life-changing. Still, we’re trying to catch up. We now know of more than 200 different genetic mutations, but we still have a lot of work to do to find targeted drugs for these mutations.

disease. For patients with late-stage disease, we must rely on systemic treatment such as chemotherapy, immunotherapy or targeted agents. What we’re fighting for is to help our patients live longer and preserve their quality of life. The survival gains are changing each year, and a lot of this has to do with advances in our molecular understanding of the disease. All tumor cells have a complex makeup of different genes, with their own fingerprint. Some tumors will have a dominant gene, or what we call a driver mutation, such as EGFR, which is present in about 10-15 percent of patients, particularly in the non-squamous type of non-small cell lung cancer. This represents a very important type of non-small cell lung cancer tumor for which we have multiple targeted agents. Another example is the ALK gene. We now have three FDA-approved targeted treatments for this specific gene as well. We’re still pinpointing what leads to these genetic mutations, but very often these driver mutations occur in patients that don’t have a smoking history — about 15 percent of patients with nonsmall lung cancers aren’t smokers. In certain areas of the world, about 30-50 percent of patients with lung cancer are EGFR-driv-

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Immunotherapy drugs also have transformed lung cancer treatment. Nivolumab is the first immunotherapy drug to be approved for non-small cell lung cancer. The approved indication is for patients who have had traditional chemotherapy that didn’t work. There are also two other immunotherapy drugs approved: pembrolizumab, which was just approved for first line treatment along with second line treatment, and atezolizumab, approved for second line treatment.

MOLECULAR DRIVERS OF LUNG CANCER The majority of lung cancer patients we treat at Orlando Health have late-stage

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CANCER en, so it’s a very different epidemiology today than what we saw 25 years ago.

MAKING STRIDES IN LUNG CANCER RESEARCH There are still certain areas of research that need improvement, including lowering recurrence rates for early stage patients. In patients who have had surgery, the recurrence rate is significant and we don’t have as many adjuvant treatment options. We’ve reached a therapeutic plateau with chemotherapy where the gains are about a 20-percent decrease in relapse. Obviously,

there’s room for greater gains in this area, and it’s part of the reason researchers are examining whether immunotherapy drugs can lower the recurrence rate. Orlando Health’s partner institution, Shands Hospital in Gainesville, currently has an open immunotherapy study to assess whether this treatment will improve outcomes for patients who have had surgery. However, we still can make more gains for patients with locally advanced lung cancer. One of the areas where we hope to see improvement is radiation therapy. The Proton Therapy Center at UF Health Cancer Center — Orlando Health recently opened, which will give some patients the option for targeted proton radiation treatment which may improve tolerability. We also need to emphasize early detection. For patients with stage IV disease, the average survival is about 15-18 months. For some stage IV patients with EGFR or ALK mutations, survival may be up to five years or longer, depending on the tumor’s molecular profile. Furthermore, we can increase survivorship if we focus on early detection and work with our partners in the primary care and pulmonary communities to promote screening, especially now that the Centers for Medicare and Medicaid Services has approved low-dose screening CT. With these changes, we hope to diagnose more patients at an earlier stage, thereby improving their long-term prognosis. I’d also encourage patients to be their own advocates. If you’ve smoked for decades, ask your primary care doctor for a screening CT. Primary care physicians also should be aware that if their patient has a 30-year smoking history, these patients may be candidates for a screening CT. Many lung cancer patients are referred to us because their primary care doctor did exactly that. For years, there’s been a stigma around lung cancer, which has slowed some of the strides we could have made with awareness, treatment and research. But every day we make progress. From clinical trials to combination therapies and early detection, we can save more lives if the international community comes together and focuses on research and funding. We need the same level of public outcry for this disease as we have for other forms of cancer. This November, during Lung Cancer Awareness Month, is the perfect time to reinvigorate this effort.

12 FLORIDA MD - NOVEMBER 2016

CANCER Jennifer Tseng, MD, hematologist/medical oncologist, is the Thoracic/Head and Neck Specialty Section leader for Medical Oncology and the associate director of Clinical Research for Medical Oncology at UF Health Cancer Center — Orlando Health. Dr. Tseng received her medical degree from Duke University School of Medicine. She completed her residency and served as assistant chief resident in internal medicine at Duke University Medical Center. She completed a fellowship in medical oncology and hematology at The University of Texas MD Anderson Cancer Center in Houston. She is board-certified in internal medicine and medical oncology and board-eligible in hematology. Dr. Tseng has received several honors and awards, including the C.D. Howe Award for clinical excellence in medical oncology and a Clinical Research Award from MD Anderson, the American Medical Women’s Award, Hewlett Packard Award, the Alpha Omega Alpha Research Symposium Award from Duke University and a Beneficial-Hodgson scholarship from The Johns Hopkins University. She was also awarded Attending of the Year from the Internal Medicine Residency Program from Orlando Regional Medical Center and received the Exemplary Physician Colleague Award from Orlando Health in 2009. In addition to her clinical studies, Dr. Tseng has published research on various topics including molecular alterations in lung cancer and novel agents in the treatment of head and neck cancer. She has recently presented at the Annual Thoracic Oncology Symposium of the Puerto Rican Society of Hematology Oncology and spoke on neoadjuvant and adjuvant treatment strategies in lung cancer.. 

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CARDIOLOGY

Soteria Cardiac Platform: New Technology for the Identification of Patients with Atherosclerosis and Guideline Management of Associated Risk Factors – Part 2 By Jeffrey K. Raines and Zoraida Catherine Navarro Part 1 of this 4 part series appeared in FloridaMD October 2016 issue

F. Soterogram Score… The designer of the Soterogram

realized that providing two diagnostic parameters would be complicated for physicians performing interpretation. For that reason, the Calf and Thigh Max Vm50 values were combined into a single score, referred to as the Soterogram Score. From extensive clinical studies with the Soterogram, weighting of the parameters was established which allowed combining. The Soterogram Score is given in ml. Soterogram Score is directly correlated with Local Systemic Arterial Compliance and within the theory of the Soterogram, correlates with generalized atherosclerosis. As will be described, the Soterogram Score is compared to a Predicted Soterogram Score. Interpretation will be further discussed below.

G. Predicted Soterogram Score: In order to have a “standard” to compare the Soterogram Score taken in specific patients at specific points in time, a Predicted Soterogram Score was established. This was accomplished secondary to requirements of the FDA to obtain clearance for this technology. Over an extensive period of time and in four major United States Clinical Centers (Columbia University, Bowman Gray School of Medicine – Wake Forest University, Emory Medical School, and the University of Miami) and two European Clinical Centers (University of Leiden and University of Groningen), thousands of normal subjects were evaluated between the ages of 20 and 80 years of age. These subjects, to the degree possible, were free of cardiovascular risk factors, symptomatology, and pharmacy. This means that Soteria Medical, LLC was able to create a Predicted (i.e. Normal or Standard) Soterogram Score which is simply Gender and Age based. This non-diseased group may be compared to the target patient’s Soterogram Score. The DEGREE to which the patient’s Soterogram Score differs from the Predicted Soterogram Score determines the patient’s level of arterial elasticity, physiologic atherosclerotic burden, and cardiovascular risk. The developer of the Soterogram believes the Predicted Soterogram Score is a rigorous standard. However, if the patient’s Soterogram Score is reduced by more than -35% of the Predicted Soterogram Score, moderate (not mild) generalized atherosclerosis is clearly suggested. If the patient’s Soterogram Score is reduced by more and -49% of the Predicted Soterogram Score, advanced or severe arterial atherosclerotic disease is suggested.

H. Actual Age: Actual Age is given as the age of the patient at his or her last birthday.

I. Arterial Age: Arterial Age is based on the patient’s demographics, risk factor profile, and Soterogram Score. If a patient

14 FLORIDA MD - NOVEMBER 2016

is 35 years of age temporally and has an Arterial Age based on Soteria Data that suggests his or her arteries are 42 years old, this is a negative finding for the patient. In contrast, if a patient is 35 years of age temporally and his or her calculated Arterial Age is 30 years old, this is a positive finding for the patient.

Jeffrey K. Raines

J. Elasticity: Elasticity is reported as a Percentage (%). The Percentage is based entirely on the Soterogram Score and compared to normal subjects (i.e. without evidence of atherosclerosis), gender and aged matched. If the Elasticity is NEGATIVE, the Patient’s Arterial Wall Elasticity is locally and systemically (assumed) reduced Zoraida Catherine secondary to atherosclerosis when Navarro compared to absolutely normal controls. An Elasticity of -35% is consistent with significant atherosclerosis. An Elasticity greater than -49% is consistent with advanced atherosclerosis and associated cardiovasular risk. A positive Elasticity means that the subject’s Elasticity has exceeded the predicted levels in absolutely normal controls. Elasticity and Atherosclerotic Burden have proven to be the most important diagnostic criteria derived from the Soteria Cardiac Platform. Our data clearly suggests the following important point – reduced Elasticity and associated Atherosclerotic Burden clearly are consisitent with atherosclerotic disease and the patient should be treated accordingly unless other credible data is found to the contrary. Table 9 provides the suggested the cutpoints for Elasticity and Degree of Generalized Atherosclerosis. TABLE 9: ELASTICITY VERSUS DEGREE OF GENERALIZED ATHEROSCLEROSIS

Elasticity +% to -15% -16% to -34%

-35% to -49% >-49%

Generalized Atherosclerosis No Evidence of Significant Generalized Atherosclerosis Evidence of Mild Generalized Atherosclerosis Evidence of Moderate Generalized Atherosclerosis Evidence of Severe Generalized Atherosclerosis

CARDIOLOGY K. Atherosclerotic Burden: The FDA and the NIH

required, to obtain clearance for routine use of this technology, Soteria Medical, LLC obtain data that correlated Atherosclerotic Burden with Soterogram Score. This data was obtained at the four United States Clinical Centers mentioned above. The Control Measure was Degree of Atherosclerotic Wall Disease of the Abdominal Aorta as determined by Research-Level MRI ($4.5 million magnet). This data was published in many journals, including the AHA’s Circulation. This article and others are available in PFD format from Soteria Medical, LLC, on request. Our studies found that Atherosclerotic Burden was a direct function of arterial Elasticity. In order to link the Elasticity measurement and level of Generalized Atherosclerosis (Table 9) to arterial obstructive anatomy, commonly used clinically, the picture given in Fig. 8 is displayed in Soterogram reporting.

Fig. 8 – Anatomic Descriptor for Atherosclerotic Burden Based on Elasticity

From a practical standpoint, as confirmed by independent studies, many adult subjects present with Mild Atherosclerotic Burden. The P-Day Study found that 40% of individuals in the age group of 30-34 years (Male and Female) had evidence of Type-4 Atherosclerotic Lesions in the arterial beds from the Distal Abdominal Aorta through the Femoropopliteal Arteries. This number was limited to 20% in the Male Left Anterior Descending Coronary Artery (LAD). Significant generalized disease should be expected if Atherosclerotic Burden is > 40% and advanced disease is suggested if the Atherosclerotic Burden is > 50%. Extensive P-Day Results are available from Soteria Medical, LLC in Booklet and PDF formats on request.

L. Closing: In closing this section, we will stress the following tenets:

(i) Early identification of atherosclerotic burden is essential in changing the trajectory of cardiovascular disease, including events. (ii) If the Cardiovascular Trajectory mentioned above is to be changed, physicians must be very aggressive with individuals identified as having early and established atherosclerotic disease. (iii) Currently, aggressive therapy is limited to precise examination and control of traditional cardiovascular risk factors. On balance, patients are often not well controlled and many patients require considerable effort to obtain adequate control of

atherosclerotic risk factors.

1. TOBACCO USE Burning or chewing tobacco results in the production of various chemicals which are ingested directly into the oral compartments and pulmonary system of the individual performing the burning or chewing. From the pulmonary system, these chemicals via blood absorption Fig. 2 – Pack of Cigarettes (20 are placed in contact with the cigarettes per pack) arterial wall. The one cell thick lining, known as the endothelium, separating the flowing blood from the other components of the arterial wall is a complex structure with many important functions. The endothelium responds to the presence of chemicals. Some chemicals cause the endothelium to change the arterial diameter of the flow surface (i.e. lumen). Other chemicals cause the endothelium to release chemicals into the blood stream to stabilize physiologic parameters such as: flowrate, velocity, and pressure. It has been clearly demonstrated, well beyond scientific contradiction, that the chemicals released by tobacco-use produce immensely negative affects in the endothelium and the arterial wall in general, and therefore, clearly promote atherosclerosis. Finally, while negatively affecting the arterial wall, these chemicals are also among the most carcenogenic and addictive known to science. Your attention should be drawn immediately to three tenets: First, there is absolutely NO doubt that ALL forms of tobacco use (Cigarettes, Cigars, Pipes, and Chewing) are EXTREMELY detrimental to the health of EVERYONE that uses tobacco. For decades, it has been proven to the satisfaction of all reasonable minds (i.e. those not addicted to tobacco and its subproducts) that tobacco use is the single most destructive force in the development of atherosclerosis and most malignant disease (i.e. Cancer). Consider Table 1. In individuals requiring surgery for peripheral vascular disease, 75% were either previous or current tobacco users. The next highest cardiovascular risk factor was hypertension, with a frequency of 42%. This means that hypertension has a frequency which is a clearly 33% less than tobacco use. The very common cardiovascular risk factors like diabetes, elevated blood lipids, and obesity are 50% less frequent in atherosclerosis than tobacco use. Please also consider the following fact. Tobacco use in the form of cigarette smoking was introduced to the United States via Europe after our soldiers fought in the World War I. Prior to World War I, Lung Cancer was a medical curiosity. In the early 1920’s, medical students would be summoned to autopsies that demonstrated lung cancer, and told, they may never see another case of this disease. Unfortunately, with tobacco use in the United States, lung cancer is now responsible for 60% of ALL cancer deaths. The concept that individuals continue to use tobacco in any form is a testimony to the addictive nature of tobacco and the general lack of understanding and self-responsibility taken by individuals for their FLORIDA MD - NOVEMBER 2016 15

CARDIOLOGY health and the health of their family members. Second, tobacco use is extremely addictive! Studies have repeatedly shown that tobacco-use can be MORE addictive than alcohol, prescription drug abuse, and even hard drug addiction. In many United States Veterans Hospital studies, it has been shown that individuals, despite being told of their atherosclerotic disease, which required lower extremity amputation, did not cease tobacco use, on average, until they had experienced a major lower extremity amputation (above-knee or below-knee) and a minor amputation (digits or transmetatarsal). Third, individuals addicted to tobacco constantly employ psychological deflection. This means, when told to stop smoking or chewing tobacco because it is extremely bad for their health, the individual deflects the suggestions and adopts the following positions: (i) the source of the recommendation is not credible or is overreacting to the situation, (ii) if the individual accepts some of the described facts, they are deflected by the belief that said results “do not apply to me”, and (iii) despite my addiction, I am really doing just fine. This is extremely dangerous because it places the addicted individual in a position where he or she is relying and therefore living on the short-end of a bell-shaped statistical curve where the odds of being right are less than 20%. If deflection does not carry the day, and the individual at risk begins to think rationally, the individual must construct an Individual Plan to Terminate Tobacco Addition. No doubt, these plans may include various features, however, in the experience of the author, said Plan must have several characteristics to be successful: A. Whereas the individual’s physician, spouse, children, friends, and co-workers may make a strong case for the individual to cease tobacco-use, in reality, the ONLY person that can complete the termination plan, is the individual. In other words, others can be supportive, but the individual at risk must be 100% committed to making the plan work. B. It has been shown time-and-time-again that plans that are associated with gradual reduction in tobacco use simple do not work and should be avoided. They are generally costly and produce desparation for the individual when they fail. In other words, the cessation must be both immediate and complete. C. Support by family and friends are needed. The individual must sit down and make a list of the “triggers” that promote tobacco use. They can be numerous. These triggers must be avoided at all cost. This section is closed by stating that Tobacco Users decrease their life expectancy, 16 FLORIDA MD - NOVEMBER 2016

on average, by 12 years. This means that for an average Cigarette Smoker, every time the individual finishes a pack of cigarettes, the User’s Life Expectancy is reduced by 6 hours. This is the reason, when applying for life insurance, Actuary Analysis generally requires only three questions be asked to estimate risk and life expectancy: (i) Gender, (ii) Age, and (iii) Tobacco Use Status.

2. HYPERTENSION The relational strength between Hypertension and Atherosclerosis, is only exceeded by the relational strength between Tobacco Use and Atherosclerosis. Hypertension is referred to by the American Heart Association as the “silent killer”, because Hypertension often is very often not accompanied by telltale symptoms. Despite the fact that many effective antihypertensive medications are available by prescription, study after study, continue to find that Hypertension is often not properly identified, and Fig. 3 – Diagram of Arterial Wall when identified is poorly con- Structure and Wall Perfusion

CARDIOLOGY trolled. Most investigators believe these findings are caused by two factors: (i) physicians do not prescribe the correct combination of medications and rely on poor confirmation that the prescribed regiment is working and (ii) lack of responsibility and action on the part of the hypertensive patient. Hypertension is directly linked to not only Atherosclerosis, but also aneurysmal arterial disease (i.e. arterial dilatation and rupture), cerebral hemorrhage, and kidney disease. For the record, there are individuals that are: (i) never hypertensive, (ii) hypertensive in response to specific stimuli, and (iii) hypertensive all the time. This is a simplistic Booklet and therefore, by definition will not present complex ideas. Blood pressure is classically defined by two Pressure Levels in the body. These Pressure Levels are Systolic Pressure and Diastolic Pressure. Due to the fact that the Heart functions as a pulsatile pump, the blood pressure is constantly changing with time and related to pumping status. Systolic Pressure is defined as the highest pressure in the body (i.e. systemic circulation) for a specific cardiac cycle. Diastolic Pressure is defined as the lowest pressure in the body for a specific cardiac cycle. The unit for Blood Pressure is mmHg (i.e. millimeters of mercury). The unit mmHg is a pressure measurement, exactly like the familiar PSI (pounds per square inch). In fact, One (1) PSI is equal to approximately 50 mmHg. An individual might have a Blood Pressure of 120 / 80. This means the Systolic Pressure is 120 mmHg and the Diastolic Pressure is 80 mmHg. Various medical organizations, including the American Heart Association, publish from time to time, “guidelines for blood pressure”. In December 2013, the 2014 Evidenced-Based Guidelines for the Management of High Blood Pressure in Adults was released by “the Panel Members Appointed to the Eighth Joint National Committee (JNC 8)”. This group had initially been sponsored by the National Heart, Lung, and Blood Institute (NHLBI) to write the guidelines based on an evidence-review sponsored by the NHLBI. Included in the Appendix of this document (Section 15) is the entire Hypertension Guideline File (Appendix 1), in Electronic Format. The following information in this section is taken/didacted from the referenced Guideline. Currently, the consensus is that if individuals consistently have Blood Pressure (taken at the Brachial Artery Level – upper arm) at or below 140 / 90, significant elevation in Blood Pressure is not present. The Blood Pressure measurement of 120 / 80 is considered the “classical norm”. Table 2 is important and provides suggested BP Goals and suggested Drug Treatment / Monitoring. continued on page18

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CARDIOLOGY TABLE 2 – BP GOALS, DRUG TREATMENT, AND MONITORING Blood Pressure Goals The blood pressure (BP) goal for the general population aged 80 or older has been raised to < 150/90 mm Hg. The BP goal for the general population up to age 80 remains at < 140/90 mm Hg. The BP goal for the general population was 140/90 for patients of all ages. Diabetes and atherosclerotic cardiovascular disease (ASCVD) patients no longer have a lower BP goal than the general population. The BP goal for these populations has been raised to < 140/90 mm Hg. Diabetes and atherosclerotic cardiovascular disease (ASCVD) patients no longer have a lower BP goal than the general population. The BP goal for these populations has been raised to < 140/90 mm Hg. The BP goal for patients with diabetes or ASCVD was < 140/80 mm Hg. There are now two separate BP goals for patients with chronic kidney disease (CKD): < 140/90 mm Hg for those without albuminuria, and < 130/80 mm Hg for those with albuminuria. Drug Treatment and Monitoring Diuretics, ACE inhibitors/angiotensin receptor blockers (ARBs), and calcium channel blockers are now listed as equivalent first-line choices for the general population. Beta-blockers are no longer a first-line recommendation for hypertension for the general population. Beta-blockers were listed as first-line for patients with history of ASCVD, second-line for patients with heart failure, and fourth-line for patients with no history of ASCVD. Lisinopril/ hydrochlorothiazide (HCTZ) is now recommended as the starting medication in most clinical cases, with amlodipine as the next medication. A default, incremental medication pathway is recommended for most cases: • Lisinopril/HCTZ 20/12.5 mg x ½ tab daily • Lisinopril/HCTZ 20/12.5 mg x 1 tab daily • Lisinopril/HCTZ 20/12.5 mg x 2 tabs daily • Amlodipine 5 mg x ½ tab daily • Amlodipine 5 mg x 1 tab daily • Amlodipine 5 mg x 2 tabs daily For frail patients or those aged 60 years or older, there is now a recommendation to consider checking sodium level in addition to potassium and creatinine. Monitoring sodium levels was recommended optionally as well, but not as prominently.

Diabetes is another disease that has reached what is described as epidemic proportions in the United States and many locations in the developed world. It is estimated that in the United States, in only a few years, approximately 10% of the adult population will be Type 2 Diabetics. Further, the Ameri0% Markup can Heart AssociaPayment Processing tion (AHA) and the National Institutes of Fig. 4 – Bilaterial Lower Extremity Angiogram in a Diabetic Patient. Note the diffuse For Doctors Health (NIH) via re- arterial occlusion in the right lower extremcent study panels and ity, typical of findings in diabetics. On the Save Thousands Instantly On published guidelines left there is a patent/open graft in the meCredit Card Processing have equated for car- dial position. diovascular risk, the presence of Type 2 Diabetes with Documented Coronary Artery Disease. These positions clarify the importance Secure Supporrt of Diabetes which includes: (i) understanding, (ii) diagnosis, (iii) prediabetes, (iv) glycemic targets, (v) prevention, and (vi) diabetic management. The American Diabetes Association (ADA), this year Free Savings Analysis At Fattmerchant.com/Florida-MD (2016) published a comprehensive Diabetes Guideline. This entire Or Call 407-204-9657 file is found as Appendix 2 and 2A (Electronic Format). Table 3 given below is a summary of these guidelines and should be helpful in understanding and treating diabetes. 18 FLORIDA MD - NOVEMBER 2016

CARDIOLOGY TABLE 3 – UNDERSTANDING AND TREATING DIABETES Diagnosis Fasting Blood Glucose (Fasting is defined as no caloric intake for > 8 hours)

≥ 126 mg/dL

2-hr Blood Glucose (Glucose Load of 75g) A1C (DCCT Assay)

≥ 200 mg/dL ≥ 6.5%

Random Blood Glucose

≥ 200 mg/dL

Risk Factors (1) Physical inactivity, (2) First-degree relative with diabetes, (3) High-risk race/ethnicity, (4) Women who delivered a baby > 9 lbs or were diagnosed with GDM, (5) HDL < 35 mg/dL, (6) TG > 250 mg/dL, (7) A1C > 5.7%, (8) Insulin resistance, (9) History of CVD Prediabetes Fasting Blood Gucose

100 – 125 mg/dL

2-hr Blood Glucose

140 – 199 mg.dL

A1C

5.7 – 6.4%

A1C

< 7.0%

Preprandial Capillary Blood Glucose

80 – 130 mg/dL

Peak Postprandial Capillary Blood Glucose

< 80 mg/dL

Glycemic Targets (Adults with Diabetes)

Prevention A1C between 5.7% and 6.4% 7% Body Weight Loss and 150 minutes per week of Moderate Activity BMI > 35 and Age < 60 years Screen for Cardiovascular Risk Factors

Consider Medformin

Hypertension, Elevated Blood Lipids, Obesity

Management 1. Life Style Changes (see Sections 8, 9, and 10 of this Booklet) 2. If goals not reached add Metformin 3. If after 3 months goals are not reached add second Oral Agent, or GLP-1 Receptor Agonist, or Basal Insulin 4. If goal not reached add Insulin

Professor Jeffrey K. Raines was responsible for the Soteria Cardiac Platform including its design and module development. After attending Harvard Medical School and training in the Surgery Department of Massachusetts General Hospital, Dr. Raines received a PhD in Engineering from MIT. His thesis title was Diagnosis and Analysis of Arteriosclerosis in the Lower Limbs from the Arterial Pressure Pulse; this work outlined the construction and testing of a new medical device called the Pulse Volume Recorder (“PVR”). This device was built and distributed by Life Sciences, Inc. and became a central device in the diagnosis of peripheral vascular disease and in the development of vascular diagnostic laboratories around the world. Dr. Raines was Chief of Research at the University of Miami Department of Surgery until his retirement in 2004 and Director of the Miami Vein Center from 2004 to 2010. Dr. Raines has developed Soteria’s technology over a period of 43 years and now that it has FDA clearance, he looks forward to expanding the use of the Platform worldwide. Dr. Raines is Emeritus Professor of Surgery at Harvard Medical School and the University of Miami. Dr. Raines is a Senior Member of the Society of Vascular Surgery, was elected to American College of Cardiology in 1975 and the Harvard Surgical Society in 2006. Dr. Raines lives in Homestead, Florida with Glo, his wife of many years; they have four children and five grandchildren. continued on page 20 FLORIDA MD - NOVEMBER 2016 19

CARDIOLOGY Zoraida Catherine Navarro, MD practices at the Vein Center of the Palm Beaches and Navarro Dermatology Skin & Vein Care. Dr. Navarro earned a B.S. from MIT and medical degrees from Boston University School of Medicine and later, the University of Miami School of Medicine. As a member of the Palm Beach County Medical Society, she helped establish the Women Physicians Medical Society. In 1986, after a year as Director of Medicine for the Wellington Regional Medical Center, Dr. Navarro established the Vein Center of the Palm Beaches in West Palm Beach, an internal medicine solo practice with specialties in varicose vein sclerotherapy, skin care, and holistic approaches.

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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.

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