Florida MD NovemberDecember 2023 by FloridaMD

NOVEMBER/DECEMBER 2023 • COVERING THE I-4 CORRIDOR

Orlando Health Jewett Orthopedic Institute Downtown Complex

Orthopedic Leaders Open New Facility with Focus on Patient Care, Education and Research

Minutes From Home. A Lifetime of Healing.

You’re not just our patient. You’re our neighbor. For more than a century, Orlando Health Orlando Regional Medical Center has been honored to provide nationally recognized care for the Central Florida region we proudly call home. And because it’s your home, too, you deserve trusted healthcare within reach, so we can foster a partnership focused on health and wellness — together. Giving you more reasons to choose well. OrlandoHealth.com/ORMC

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contents PHOTO: PROVIDED BY ORLANDO HEALTH JEWETT ORTHOPEDIC INSTITUTE

NOVEMBER/ DECEMBER 2023 COVERING THE I-4 CORRIDOR

 COVER STORY

Orlando Health is proud to announce the grand opening of Florida’s first dedicated orthopedic hospital. With a longstanding track record in providing excellent patient care and a highly skilled team of physicians and other healthcare professionals, the Orlando Health Jewett Orthopedic Institute aims to raise the bar for orthopedic care throughout the region. As the region’s largest orthopedic and sports medicine practice, Orlando Health Jewett Orthopedic Institute provides advanced orthopedic care to more than 250,000 patients each year. Physicians specialize in every area of orthopedics, including joint replacement, hand and upper extremities, foot and ankle, orthopedic trauma, spine, sports medicine, concussions, musculoskeletal radiology, bone health and anesthesia.

PHOTO: PROVIDED BY ORLANDO HEALTH JEWETT ORTHOPEDIC INSTITUTE

ON THE COVER: Orlando Health Jewett Orthopedic Institute Downtown Complex

Located at the corner of Columbia St. and Lucerne Terrace in Orlando, the 375,000-square-foot, seven-story Orlando Health Jewett Orthopedic Institute Downtown Complex is the first of its kind in the southeastern U.S. While the specialty hospital opened in August, the first phase of the project, which was completed in March of 2023, included imaging services, an ambulatory surgery center, walk-in orthopedic clinic, and rehabilitation space.

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18` HEALING ECZEMA: BEYOND SKIN DEEP

DEPARTMENTS 2

FROM THE PUBLISHER

DERMATOLOGY

MARKETING YOUR PRACTICE

PULMONARY AND SLEEP DISORDERS

PEDIATRICS

ORTHOPEDICS

FLORIDA MD - NOVEMBER/DECEMBER 2023

FROM THE PUBLISHER

am pleased to bring you another issue of Florida MD. .This time of year is special to all of us regardless of religious persuasion. It is especially important to children. However, it can be a particularly distressing time for children that are neglected, abandoned or live in abusive homes. The Children’s Home Society of Florida tries to make a better life for these children by finding them a loving home either temporarily through foster care or permanently through adoption. But there are a lot of children – nearly 20,000 – in Florida who can’t live safely with their families right now. They need more than Children’s Home Society of Florida … they need all of us. I hope some of you can find the time to assist this very worthwhile organization in its efforts to help these special children. To find out more information please visit www.chsfl.org. Have a wonderful holiday season and a happy, healthy and prosperous New Year. Best regards,

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Publisher: Donald Rauhofer Photographer: Donald Rauhofer / Florida MD Contributing Writers: JJohn “Lucky” Meisenheimer, MD, Daniel T. Layish, MD, John Meisenheimer, VII, MD, Christine Jablonski, MD, Joseph Cannizzaro, MD, Luke Elms, MD, Adela Casas-Melley, MD. Omar Cruz-Diaz, MD, Abishek Seth, MD, Sonda Eunus, MHA, CMPE 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 2023 Sea Notes Media. All rights reserved. Reproduction in whole or in part without written permission is prohibited. Annual subscription rate $45.

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COVER STORY

Orlando Health Jewett Orthopedic Institute Downtown Complex – Orthopedic Leaders Open New Facility with Focus on Patient Care, Education and Research

By Staff Writer

OVERVIEW Orlando Health is proud to announce the grand opening of Florida’s first dedicated orthopedic hospital. With a longstanding track record in providing excellent patient care and a highly skilled team of physicians and other healthcare professionals, the Orlando Health Jewett Orthopedic Institute aims to raise the bar for orthopedic care throughout the region. As the region’s largest orthopedic and sports medicine practice, Orlando Health Jewett Orthopedic Institute provides advanced orthopedic care to more than 250,000 patients each year. Physicians specialize in every area of orthopedics, including joint replacement, hand and upper extremities, foot and ankle, orthopedic trauma, spine, sports medicine, concussions, musculoskeletal radiology, bone health and anesthesia.

PHOTO: PROVIDED BY ORLANDO HEALTH JEWETT ORTHOPEDIC INSTITUTE

Michael Jablonski. “Physicians and other team members helped create the design, which is a unique feature of this facility. That insight will lead to a safer, efficient environment that promotes wellness and healing for our patients.” “The Orlando Health Jewett Orthopedic Institute Downtown Complex provides an elevated level of orthopedic care for people in Central Florida and the surrounding region,” said Carlos Carrasco, president of the Orlando Health Jewett Orthopedic Institute. “This project combines world class physicians, state of the art technology and thoughtful dedication to safety and a patient’s experience.”

ORTHOPEDIC SPECIALTY HOSPITAL Patients are experiencing innovation in motion at the first and only orthopedic hospital of its kind in the Southeast. To prepare and alleviate any anxiety before surgery, the lobby of the hospital features a simulated operating room, so that patients can see the area, tools and technology that will be used during their operation.

The orthopedic specialty hospital features 10 operating rooms and 75 inpatient smart rooms. The smart rooms offer an enhanced patient experience with customization options, interactive entertainment and seamless communication with the care “We’re really excited to see this project come to life,” said Orteam. Patients can use advanced remote technology to optimize lando Health Jewett Orthopedic Institute Physician President Dr. their comfort level by controlling environmental The 375,000-square-foot Orlando Health Jewett Orthopedic Institute Downtown Comfactors such as temperature and window shades. The plex is located at the corner of Columbia St. and Lucerne Terrace in Orlando. Phase rooms also have large screens so that patients can 1 of the building opened March 27. Phase 2, which includes an orthopedic specialty hospital, opened in August. view their medical information, recovery plan and watch their personal entertainment through their streaming service accounts like Netflix. “Sometimes, simply knowing when your next medication is coming or what type of physical therapy plan is in store can be a huge relief to patients,” said Orlando Health Jewett Orthopedic Institute Chief Operating Officer April Ernst. “We want to make sure our patients have easy access to that information with the touch of a button.” Providing a safe and clean environment has been a top priority throughout the project. The Orlando Health Jewett Orthopedic Institute’s Sterile Processing department is 12,000-sq.-feet. It has a best in class clean-to-dirty-to-clean flow. The process begins when the cart with dirty instruments leaves the OR using a dedicated contaminated elevator and arrives in the decontamination area. Once the items are de4 FLORIDA MD - NOVEMBER/DECEMBER 2023

COVER STORY

PHOTO: PROVIDED BY ORLANDO HEALTH JEWETT ORTHOPEDIC INSTITUTE

contaminated, they are loaded into one of six STERIS washer disinfectors, and the carts go through separate STERIS cart washers. These are extremely high temperature machines that render the items free of microbes. On the clean side of the department, the instruments are prepped, packed, and loaded into one of five pass through steam sterilizers or V-pro peroxide plasma sterilizers. Once the process is complete, the instruments are returned to the operating room using a dedicated clean elevator that arrives directly to the sterile core of the operating room. When patients visit or stay at the Orlando Health Jewett Orthopedic Institute, they can expect unique dining options. Many orthopedic patients are healthy and active, so the food will match that lifestyle. All food is made to order, with fresh meat and fish options.

BIOSKILLS LAB A research and innovation center on the seventh floor provides a hands-on learning environment for orthopedic surgery residents. It includes a 10-station cadaver lab, 3D printer and 116-seat auditorium. “We know we have physician shortages throughout the United States. If physicians could be educated at a facility of this caliber, that puts people out in the community that have access to the latest technology and the best training you can get in the Southeast,” said Dr. George Haidukewych, Orlando Health Jewett Orthopedic Institute Academic Chairman. An institute is defined by excellence in patient care, education, and research. The Orlando Health Jewett Orthopedic Institute’s world-renowned surgeons have published hundreds of research studies, book chapters and instructional videos. They are highly

Media event celebration marking grand opening of hospital in late August

sought after speakers at national and international orthopedic meetings, and many are involved in new implant development and design. This ensures that patients have unique access to cutting-edge technologies and techniques. Orlando Health offers a comprehensive, hands-on orthopedic surgery residency program that allows each resident to gain experience in the full range of orthopedic care, from hand and upper extremity, foot, ankle and hip subspecialties, to pediatric orthopedics, spine care and sports medicine. Orlando Health’s fellowship programs in trauma, pediatric orthopedics, surgical sports medicine and primary care sports medicine allow fellows to participate in diagnosis and treatment within their area of focus. Orlando Health also offers an orthopedic physician’s assistant and nurse practitioner fellowship.

PHOTO: PROVIDED BY ORLANDO HEALTH JEWETT ORTHOPEDIC INSTITUTE

Media event celebration photo featuring Orlando Mayor Buddy Dyer, Carlos Carrasco, Dr. George Haidukewych, David Strong and Dr. Michael Jablonski

IMAGING Phase I of the Orlando Health Jewett Orthopedic Institute Downtown Complex was completed in March of 2023. Every detail of the institute has been designed to ensure the best experience for patients. For many, this begins with imaging. Orlando Health is the first health system in Florida to receive MRI technology that significantly accelerates scans and provides new entertainment options. When patients arrive for the MRI exam, they will be able to set mood lights inside the room. The scan itself will be enhanced with augmented reality. Patients can immerse themselves in videos or music throughout the imaging experience, while a visible clock counts down their scan time. According to Siemens, some knee exams can be completed in less than two minutes. “Most orthopedic patients are used to spending 30 to 40 minutes inside an MRI machine,” said Orlando Health Jewett Orthopedic Institute musculoskeletal radiologist Dr. Jonathan Kazam. “By sigFLORIDA MD - NOVEMBER/DECEMBER 2023

COVER STORY nificantly reducing scan time, we expect that patient comfort inside the MRI machine will be greatly enhanced, which will result in less motion and higher quality images.”

ORTHOPEDIC CLINIC The orthopedic clinic includes 62 exam rooms, three procedure rooms, seven x-ray suites and two casting rooms. On average, 12 providers will staff the clinic daily, offering expertise in traumatology, spine, foot and ankle, hand, joint replacements, sports surgery, non-operative sports medicine, concussion management and pediatric sports medicine. The Orlando Health Jewett Orthopedic Institute employs highly-trained orthopedic and sports medicine physicians, many of whom completed sub-specialty fellowships in their areas of focus. They are trusted to care for Central Florida’s elite athletes, as the official medical provider for Orlando City and Orlando Pride soccer, University of Central Florida and Orlando Ballet. They will provide that same level of care to all of their patients. Same day appointments are available in the Orlando Health Jewett Orthopedic Institute’s newest walk-in center at the downtown complex. “We’re really excited to offer walk-in orthopedic care at the downtown complex,” said Orlando Health Jewett Orthopedic Institute assistant vice president Kelsey Kiser. “This is a convenient alternative to an emergency room visit and can save patients time and money.” Providers in the clinic are trained to assess and diagnose orthopedic injuries and concerns. Some patients may be able to leave the same day with a treatment plan and all follow-up appointments scheduled. In addition, Orlando Health Jewett Orthopedic Educational Showroom at Orlando Health Jewett Orthopedic Institute.

Institute clinic locations across Central Florida will remain open with 24/7 access to scheduling online or through a call center.

REHABILITATION Orlando Health’s rehabilitation team has extensive experience, numerous board certifications and top-quality scores in change in function and efficiency. These expert therapists will collaborate with physicians daily to optimize care plans for patients. The therapists use a variety of techniques. For example, many therapists are certified in dry needling, which is the specialized use of micro needles to release muscular trigger points. This can often relieve pain within a day. The rehabilitation space is filled with the latest technology. For injured athletes, a simulator for golf and soccer helps track progress and guide treatment. This is the same simulator that the pros use on the PGA tour. Another game changer is the AlterG anti-gravity treadmill. Only about 10 percent of clinics have this technology, which allows patients to walk and run much earlier in their recovery, with up to 80 percent of weight removed from their bodies. The expert therapists use motion analysis cameras and force plates, which helps provide data on movement and balance. To better assess when an athlete is ready to return to the field or court, Orlando Health has installed turf and hardwood surfaces in the physical therapy space, to match those surfaces used in sports. The entire clinic was designed around returning patients back to their functional levels, from office workers to professional athletes, and everyone in between.

EUGENE JEWETT, MD SURGERY CENTER

PHOTO: PROVIDED BY ORLANDO HEALTH JEWETT ORTHOPEDIC INSTITUTE

The Eugene Jewett, MD Surgery Center is one of the largest ambulatory surgery centers in Florida with 12 operating rooms and three minor procedure rooms. The ORs will only be used for orthopedic and spine surgeries. Due to the specialized use, the lay out is specifically designed to prevent infection. The surgery center is embedded within the medical pavilion, a unique feature that provides all types of orthopedic services in one location. Not only do patients have easy access to the ASC with a dedicated parking garage and valet, they may also receive pre-admission testing, imaging services, pharmacy services and outpatient rehabilitation at the Orlando Health Jewett Orthopedic Institute Downtown Complex. 6 FLORIDA MD - NOVEMBER/DECEMBER 2023

Physicians helped configure the operating rooms to create the safest space for patients. A clean suite operating room ceiling system uses high-performance diffuser grilles to turn turbulent air flow into laminar flow, directing airborne particles and contaminants away from the patient and OR staff while encompassing the room in HEPA-filtered air. The operating rooms are equipped to live stream surgeries so residents and fellows can further their learning opportunities at the Orlando Health Jewett Orthopedic Institute. Physicians worldwide can access the streams for additional learning and collaboration opportunities. The integration of video technology also provides a direct route for all intra-operative imaging to be uploaded into the patient’s electronic medical record. This allows the post-operative care team, such as physical and occupational therapists, the ability to review the anatomy and repair. That information helps customize post-operative therapy to achieve the most successful outcomes. In the Eugene Jewett, MD Surgery Center nano-suites, the state-of-the-art NanoScope operative arthroscopy system uses high definition, chip-on-tip image sensor technology to provide surgeons with a needle-sized, single-use camera system. The portability of the imaging system allows the surgeon to perform minimally invasive arthroscopy without the need for anesthesia. Pre-planning and post-operative care remain at the center of positive outcomes for all same-day surgeries. Patients can access total joint replacement education classes to prepare for their surgery and classes that focus on the recovery work needed after surgery.

OUR HISTORY Orlando Health acquired Jewett Orthopaedic Clinic in 2019 to begin work on the Orlando Health Jewett Orthopedic Institute – named to honor Dr. Eugene Jewett. Dr. Eugene Jewett was a Central Florida orthopedic surgeon, and founder of the Jewett Orthopaedic Clinic, whose dedication to the specialty saved hundreds of thousands of lives. When injured and bedridden patients couldn’t access orthopedic care in the 1930’s, he would bring the care to their homes. Known to drive around with an x-ray machine and a nurse, his reputation became well-known. Soon, hospitals were asking him to visit. They assembled rooms full of orthopedic patients for Dr. Jewett to examine and treat. His inventions include the Jewett Hip Nail and the Jewett Hyperextension Back Brace. Both devices significantly improved the outcome for orthopedic patients. The earnings he received from the pioneering devices were poured back into medicine and education for others. Orlando Health was founded in 1918 on the heels of World War I, in the midst of the Spanish Flu epidemic that raged across the world. Orange General Hospital, as it was known then, was supported financially by community members and a dedicated group of physicians. More than 100 years later, the healthcare system is recognized around the world for Central Florida’s only pediatric and adult Level I Trauma program as well as the only

state-accredited Level II Adult Trauma Center in Pinellas County. It is the home of the nation’s largest neonatal intensive care unit under one roof, the only system in the southeast to offer open fetal surgery to repair the most severe forms of spina bifida, the site of an Olympic athlete training facility and operator of one of the largest and highest performing clinically Captain Eugene Jewett in the Navy, 1944 integrated networks in the region. Orlando Health has pioneered life-changing medical research and its Graduate Medical Education program hosts more than 350 residents and fellows. Orlando Health is excited to build upon these two rich histories, to create a new legacy in orthopedics. 

OUR SPECIALTY ORTHOPEDIC CENTERS Our doctors specialize in the full range of orthopedic care, including: • Bone Health • Elbow • Hip • Hand and Wrist • Shoulder • Spine • Sports Medicine • EMG/NCV • Knee • Foot and Ankle • Head (Concussion) • Trauma • Upper Extremity Program

60 COLUMBIA ST., ORLANDO, FL 32806 321-843-5851 • ORLANDOHEALTH.COM FLORIDA MD - NOVEMBER/DECEMBER 2023

PHOTO: PROVIDED BY ORLANDO HEALTH JEWETT ORTHOPEDIC INSTITUTE

COVER STORY

DERMATOLOGY

The $8500 Tube of Cream

By John “Lucky” Meisenheimer, MD and John Meisenheimer, VII, MD Several years ago, a patient came back to my office for a return visit. She had been seen earlier that week for a small amount of intertrigo underneath her breasts. Intertrigo is a common inflammatory condition of the skin folds, and it is aggravated by heat, moisture, and friction. Occasionally a patient might get a minor secondary yeast infection in the area as well. The treatment is keeping the area dry and using a topical cream to clear the yeast and decrease the inflammation.

Now, if they filled the prescription and didn’t use the medicine, I am flummoxed as I am not sure how to respond. So, I usually say “oh” and stop talking, leaving a long moment of uncomfortable silence that eventually forces the patient to speak. Then the response comes, “so you think I should use the medicine you prescribed?” I reply, “Well, yes, as we have tried not using the medicine, and that plan is not working so good.” Amazingly, the patient seems okay with this response and goes happily on his or her way. Yes, this very conversation has happened on more than one occasion. Now, in this case, since this patient had not filled her prescription, I wanted to know why. In the past, the cream I prescribed called Alcor: Intertrigo - Would you spend $8500.00 on a tube of cream to tin sold for about $35 a tube, so I didn’t think the cost was a concern. treat this eruption? She then told me that the pharmacist wanted to charge her $8500.00 for a tube of the cream. I laughed out loud because I knew there had been some gross misunderstanding regarding the cost, and I said there must have been a decimal put in the wrong place. I was confident she didn’t understand the pharmacist correctly. The patient was very adamant that she had spoken with the pharmacist in person, and there was no question that the price was $8500.00. I asked her for her pharmacy, and I contacted the pharmacist myself. I started by saying, “well, I am just clearing up a misunderstanding. There is a patient here that is trying to tell me that Alcortin is $8500.00 a tube. I am sure the decimal point has been put in the wrong place, or you mistakenly thought I ordered a tractor-trailer full of the cream. There was a long pause, and the pharmacist said, “no, $8500 is correct,” and it wasn’t for a flatbed truck loaded with cream; it was for one lousy 60-gram tube. At the time, that cream was selling for four times its weight in gold! The pharmacist had no explanation for why the medicine went up so much in price; all he knew was that was the price. Since that bit of medical-cultural shock, other medicine prices have skyrocketed as well as everyone reading this knows. Nobody seems to know why, but I suspect this is due to our government meddling with the free market system. When the last big round of Medicare laws changed the way Medicare buys drugs, and this had bipartisan support I might add, this is when the chaos started. Drug companies loved the clause that they could name their price without any negotiation on price, and we are all now living the outcome. Just recently, a study showed that worldwide, when several first world countries were compared for the average cost spent on nineteen different conventional medicines, the United States was paying 300% more than the average price paid by other countries. Iceland, for example, was paying approximately 50% the average cost, which means that we are spending six times as much as the Icelanders for the same medication. So why don’t we go to Iceland and buy all our medicines straight from Iceland? The answer is the drug companies have convinced the government that reimportation should be illegal. Therefore, it is unlawful to reimport medicines (a bill has been passed in Florida to allow reimportation, but it still faces an uphill battle for implementation). In other words, the United States is subsidizing the healthcare of the rest of the world by paying outrageous prices, allowing other countries to continue paying bargain-basement prices. Yet, we wonder why our healthcare costs so much here in America. So how did I resolve the problem of the $8500 cream? Well, we sent the prescription to the local compounding pharmacy and had virtually the same medicine compounded up for $75. The patient did well and saved $8425 along the way. And what happened to the company that made Alcortin and raised the price thousands of dollars? Well, they went bankrupt. What goes around comes around. Lucky Meisenheimer, M.D. is a board-certified dermatologist specializing in Mohs Surgery. He is the director of the Meisenheimer Clinic – Dermatology and Mohs Surgery. John Meisenheimer, VII is an MD practicing in Orlando.  8 FLORIDA MD - NOVEMBER/DECEMBER 2023

PHOTO: JOHN MEISENHEIMER, VII, MD

The patient said, “doctor, I am worse.” I asked how she was using the cream, and she responded that she had not filled her prescription. Now I have lived through this scenario before with other patients. I am always amazed when people seem surprised that their condition has not improved when they have either not filled their prescription or filled the prescription and never used the medicine.

MARKETING YOUR PRACTICE

Is Your Online Reputation Costing You Patients? By Sonda Eunus, MHA, CMPE What does your online reputation say about your practice? If you have a negative online reputation, you are missing out on new patients every day. Most medical practices now get the majority of their new patients through Google and other search engine queries, such as “Pediatrician in Orlando”. If your practice appears in these searches, the most common next step for a potential new patient would be to check out your reviews – what are other patients saying about your practice? It has been reported that 90% of consumers read online reviews before visiting a business and that online reviews influence 67% of purchasing decisions (Bright Local). For this reason, it is incredibly important to pay attention to the rating and reviews that your practice has on search engines, social media platforms, and local online business directories. However, despite the importance of cultivating a positive online reputation, only 33% of businesses report actively collecting and asking for reviews (1). One great process to set in place at your practice is asking for patient reviews after each patient visit. It can be as simple as training your front office staff to ask each patient how their visit went while checking them out, and if they receive favorable feedback then they can ask the patient to please leave a review on Google or Facebook about their experience. If they receive negative feedback, this feedback should be taken very seriously, and management should be notified as soon as possible so that the issue can be mitigated before the patient decides to post a

negative review. Setting up an automated text or email campaign that asks each patient for their feedback after their appointment is also a great way to improve your online reputation as well as to correct any issues that may be occurring at your practice. When you receive feedback from patients, you are then able to prompt them to leave a public review on Facebook, Google, Yelp, Healthgrades, or other applicable review platforms. However, you must be aware that legally, you are not allowed to only direct people with favorable feedback to leave reviews, which is known as review-gating – so if you are implementing an automated system like this, just make sure that you are aware of this limitation. There are online reputation management platforms which allow you to customize the messages that people see when they leave negative feedback as opposed to positive feedback, but both of those messages must still offer the option to leave a public review. However, if you create your message in such a way as to communicate to the patient who may leave negative feedback that you are working hard on resolving the issue and that someone will be in touch shortly, that may prevent them from leaving a public negative review. When you receive a public review on Google, Facebook, or other review sites, make sure that you respond to it – either by thanking them for a good review or by asking them to contact you to discuss how you can improve their experience. Do not argue or try to defend yourself online – try to speak about it with them privately, fix the issue, and ask them to remove the review if possible. When you receive great reviews, make sure to cross-share them on your various social media platforms. You should also create a “Reviews” page on your website and add all great reviews to this page. This instantly adds credibility to your website. Finally, make sure that when you look over the feedback and reviews that you receive, you are paying attention to what the negative reviews are saying – this is a great opportunity to identify current process challenges and improve your patients’ experience at your practice. Need help managing your practice’s online reputation? Visit www.lms-plus.com to see how Leading Marketing Solutions can help. Sonda Eunus is the CEO of Leading Marketing Solutions, a Marketing Agency working with Medical Practices and other Businesses to help them identify the best marketing strategies for their business, create a strong online presence, and automate their marketing processes for a better return on their Marketing budget. Learn more about Leading Marketing Solutions at www.lms-plus.com.

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FLORIDA MD - NOVEMBER/DECEMBER 2023

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. The benefit from a pulmonary rehabilitation program may decline over time if the individual does not maintain their con10 FLORIDA MD - NOVEMBER/DECEMBER 2023

ditioning. 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. He may be contacted at 407841-1100 or by visiting www.cfpulmonary.com. 

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PEDIATRICS

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

Robotic assisted surgery is an advanced technology that allow surgeons to perform surgical procedures in hard-to-reach areas through small incisions. The specialized technology provides more dexterity and precise movements than the human hand and allows for enhanced magnification. Instead of working at the bedside, the surgeon sits at a console and controls every movement of the robotics arms and the camera. The camera allows for enhanced magnified 3-dimensional views of the surgical area. To perform robotic surgery, A surgical console provides surgeons complete specialprecise movements and enhanced magnification of the surgical area. ized training. WHAT MAKES ROBOTIC-ASSISTED SURGERY BETTER THAN TRADITIONAL SURGERY?

One of the major differences between robotic surgery and open surgery is the size of the incision. Many of the robotic-assisted surgical procedures have traditionally required larger, more uncomfortable incisions when performed via an open surgical approach. Also, the smaller instrumentation and mobility afforded by the robotic instrumentation allows for less pulling and tension on the tissues. These differences result in less postoperative pain and a lower risk of infection and bleeding. The improved pain control results in less use of opioids and allows children to return to school and activities sooner. The smaller incisions provide improved cosmesis, less pain and less risk of infection. Outcomes Comparison of robotic incisions with left with robotic surgery flank incision for pyeloplasty are comparable and often better than with open surgical procedures, related to greater precision and visualization when compared to open surgery and greater than open surgery with respect to parent satisfaction regarding cosmesis and recovery. The robotic arm’s movements have a greater range of motion and can rotate 370 degrees. The robotic camera provides for magnified, high-definition visualization of the surgical area and has three dimensional capabilities that are superior to the human eye. 12 FLORIDA MD - NOVEMBER/DECEMBER 2023

ARE THERE DISADVANTAGES OF ROBOTIC SURGERY IN PEDIATRICS?

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

Pamela I. Ellsworth, MD

WHY ROBOTIC SURGERY OVER LAPAROSCOPY?

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

Adela Casas-Melley, MD

Omar Cruz-Diaz, MD

Abishek Seth, MD

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

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

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

posterior mediastinal mass soon after her visit. The procedure went without difficulty. She spent 24 hours in the hospital and was discharged. She recovered quickly with minimal issues with pain or activity. She was able to proceed with her scoliosis surgery as preCase Study Image 2 viously scheduled 14 days after her robotic thoracoscopy and has already been seen in the office. She is doing well and recovering from her spinal fusion. Although her procedure could have been completed thorascopically, the use the robotic-assisted approach allowed for quicker and less painful recovery and allowed her to proceed with her previously scheduled spinal fusion. Dr. Ellsworth, who is a graduate of the UMass Medical School, completed a residency in urology at DartmouthHitchcock Medical Center in New Hampshire and then specialized in pediatric urology with a fellowship at the University of Florida. Dr. Ellsworth is certified in urology and pediatric urology by the American Board of Urology.

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

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

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

Dr. Adela Casas-Melley is the chair of the department of surgery at Nemours Children’s Hospital and professor of surgery at UCF College of Medicine. She is a skilled laparoscopic and robotic pediatric surgeon. Dr. CasasMelley has been responsible for the development of multiple multidisciplinary clinics and is the lead for the pediatric surgical robotic program. Dr. Omar Cruz-Diaz is the director of pediatric urology robotic surgery at Nemours Children’s Hospital. He completed his pediatric urology fellowship at the University of Miami and is an accomplished robotic surgeon. Dr. Abishek Seth is an associate professor of urology at UCF College of Medicine and the director of the Spina Bifida Clinic at Nemours Children’s Hospital. He completed his pediatric urology fellowship at Boston Children’s Hospital and is a skilled scientist-surgeon with an NIH funded grant. Dr. Seth is working alongside Dr. Cruz-Diaz to develop the urology robotic program at Nemours Children’s Hospital. Call 407.650.7715 or visit Nemours.org/robotics for more information about the pediatric robotic surgery program at Nemours or to refer a patient. 

The patient had a robotic thoracoscopy with resection of the FLORIDA MD - NOVEMBER/DECEMBER 2023 13

Multimodal Pain Management with Opioid Minimization By Luke Elms, MD In 2016, overdoses accounted for more than 42,000 deaths in the United States according to data from Health and Human Services (HHS). While many of these deaths are multifactorial, a majority reportedly involved opioids. Despite HHS declaring a nationwide public health emergency regarding the opioid crisis in October 2017, the numbers have continued to rise, which many experts believe is being driven by counterfeit pills containing illicit fentalogues. Recently, the government released provisional numbers reporting more than 100,000 overdose deaths for the 12-month period ending April 2021. Although there is debate whether the number of overdose deaths attributable to legal prescription opioids is being overestimated, opioids and the overdose crisis has become a frequent topic of public discourse and raised concerns regarding opioid exposure in some patients. As the opioid crisis was gaining national attention, I was involved in Orlando Health’s Right Care Initiative for the ERAS (Enhanced Recovery After Surgery) protocol. The ERAS protocol has multiple tenants, and one of the main tenants was the utilization of multimodal pain management. This area really sparked my interest, as alleviating the suffering of postoperative pain is always a battle I’m willing to fight. So, along with my colleague Dr. Bobby Gibbons, we began implementing the protocol in our practice. Through a gradual process over the next few years, we made modifications to the ERAS protocol’s multimodal pain regimen and settled on our own multimodal pain control protocol. We now utilize this protocol in all our surgical patients without a contraindication, most of who undergo minimally invasive or robotic procedures. When we implemented the multimodal pain control, our patients started reporting much less use of the opioids we were prescribing and some even reported eliminating their use altogether. In response, we were able to transition from oxycodone to tramadol, which is a less powerful schedule IV drug compared to the schedule II status of oxycodone. After finding success with this change, we started decreasing the quantity of opioid pills we were prescribing. Now, with some smaller procedures we can achieve good pain control with no opioids, but most patients still get a one-day supply of 50 mg tramadol to ensure they have a rescue medication to add if non-opioid medications alone are not sufficient. Many patients do not fill the tramadol prescription or only take 1-2 pills and still report great pain control at their follow-up. With better pain control and reduction of the uncomfortable side effects of the opioids like nausea and constipation, our patient satisfaction increased. In 2018, I realized that most patients who had poor pain control while using the protocol were unintentionally noncompliant with the instructions. This was addressed with more purposeful 14 FLORIDA MD - NOVEMBER/DECEMBER 2023

patient education prior to surgery and the creation of patient education handouts that were created and modified in response to patient feedback. Proper patient education includes explaining the benefits of opioid minimizing multimodal pain control, setting proper expectations so patients understand that surgery does cause pain, and that while they can expect to experience pain, it will be managed with the addition of an opioid is necessary. It is vitally important to have these conversations up front, because when patients are properly prepared and understand the reasoning, they are much more comfortable and willing to attempt opioid-minimizing analgesia. Now, with our updated education, we have found the need to prescribe oxycodone or refill their tramadol prescriptions to be less than 5 percent for most of our operations. One underestimated opportunity is the use of multimodal pain control in the nonsurgical realm. There are people all over the country who had their first exposure to an opiate from accessing routine medical care. These people were in pain and needed intervention, but were opioids always necessary to provide adequate pain control? We have an opportunity for a paradigm shift in the way we think about postoperative pain management in the United States. Historically, in the United States, 90 percent of major or minor medical procedures were prescribed an opiate. After using opioids post-surgery to maintain adequate pain control during recovery, there are 3.3 billion opioid pills left over every year in the United States. With all this considered, there is an opportunity to shift our prescribing practices to opioids not as first-line treatment for acute pain, but as an adjunct when non-opioid alternatives are not sufficient to provide adequate pain relief. It is possible to drastically reduce that number while still providing compassionate pain control with opioids to those who need it. The vitally important point is that medically indicated prescription opioid pain medications are not the enemy, and neither are the patients who rely on them. Prescription opioids are a vital tool in our battle to alleviate the suffering of pain. Opioids responsibly prescribed and utilized are both safe and necessary for many of our fellow Americans who suffer from chronic pain, palliative conditions and other causes of uncontrolled pain. The opportunity for discussion and change lies in the portion of our patients we have historically treated with an opioid as a first-line pain control method when non-opioids could provide high quality, compassionate pain control. Eliminating the use of opioids while leaving our patients in uncontrolled pain is not a compassionate, or ethical, solution. That practice runs afoul of many of the tenants that

we are called to uphold as medical providers. It should not be considered a victory if going “opioid-free” means leaving people in uncontrolled pain. Instead, when possible, we must replace the prescription opioids with a viable, effective alternative, and non-opioid multimodal pain control can fill that role. What multimodal pain control protocols have demonstrated is that significant opioid minimization while maintaining adequate pain control is possible in many cases. The broader application of opioid-minimizing multimodal pain control presents the opportunity for a muchneeded discussion regarding how we approach acute pain control in a compassionate, safe manner, not just within our own practice, but throughout the entire healthcare system. Luke Elms, MD, is a board-certified general surgeon with Orlando Health Medical Group at Orlando Health Dr. P. Phillips Hospital. He also has certification in robotic surgery and serves as teaching faculty for the general surgery residency program at Orlando Health. After earning his medical degree from the University of Oklahoma College of Medicine, Dr. Elms completed his general surgery residency at Orlando Health. Over his years in practice, Dr. Elms has developed both a professional and personal passion in the opioid epidemic. This passion has led to a focus on minimally invasive and robotic surgery techniques with postoperative opioid-minimizing multimodal pain control.

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ORTHOPEDICS

Healthy Bones — A Foundation for a Stronger Body By Christine Jablonski, MD Bones may be one of the strongest components in our body, but as we age, they often become weak, brittle, and prone to fractures. Osteoporosis, the most common bone disease, severely affects bone health. It impairs our body’s ability to make new bone cells and replace worn and old ones. As a result, bones become thinner and more fragile over time, and tend to break even with minor injury. Osteoporosis affects nearly 12 million Americans, and over 50 million have low bone mass, the stage before osteoporosis. One in two women and one in four men in the United States break a bone due to osteoporosis. About 1.5 million osteoporosis-related fractures occur each year in the country—mostly in the forearms, shoulder, hip and spine—costing patients a whopping $10 billion in healthcare expenses. Diagnosing the condition is tricky as patients often don’t notice any changes in their body and hence don’t bring it to the attention of their doctors. Most people find out they have osteoporosis after they break a bone. But recognizing risk factors can help catch the “silent disease” early and prevent its progression and the resulting fractures.

WHO IS AT RISK? Anyone can develop osteoporosis. But some individuals are at a higher risk than others due to various factors, including genetics, nutrition, other medical conditions and medications. People with a family history of fractures, especially hip or spine fractures, are at higher risk of developing osteoporosis over time. Individuals with chronic conditions, such as diabetes, celiac disease, or rheumatoid arthritis, and those who take bone-harming medications, such as corticosteroids, proton pump inhibitors, or anti-epileptic drugs are also at an increased risk of osteoporosis. Compared to men, women are more likely to have the condition as their bones are smaller and thinner — especially those from Caucasian and Asian ethnicities. Post-menopausal women, or those who experience early menopause, are more likely to develop osteoporosis because the levels of bone-protecting estrogen hormones dip, leading to bone loss. The risk of osteoporosis in women is higher than that of heart attack, stroke and breast cancer combined. If their patients have risk factors associated with osteoporosis, I suggest general physicians (GPs) recommend a screening DEXA scan for them, typically once every two years. Dual-energy x-ray absorptiometry (DEXA) uses low-energy x-rays to measure the mineral content of bones in certain areas of the skeleton—mostly the wrists, hip and spine. The scan is quick and painless and is the most useful test to diagnose osteoporosis. While the thought of living with fragile bones and life-altering fractures can be scary for patients, GPs can recommend the B.O.N.E.S approach to anyone—with or without osteoporosis— 16 FLORIDA MD - NOVEMBER/DECEMBER 2023

to build stronger, healthier bones at any age.

BODY WEIGHT Osteoporosis is known to be common in underweight individuals, whose body mass index (BMI) less than 18.5, because they tend to have thinner, less dense bones. Obesity was perceived as a protective factor. However, recent studies have shown that having a BMI over 30 may contribute to poor bone quality and increased fracture risk, especially in the shoulders, upper legs and ankles. Advocating your patients to maintain a healthy body weight is the first step toward better overall health, including stronger bones. It also reduces the risk of developing other chronic conditions, such as diabetes, that may make osteoporosis more likely.

ONE DRINK A DAY Increased alcohol intake is associated with poor bone health and is a main reason men develop osteoporosis. Alcohol interferes with calcium and vitamin D — both nutrients required for healthy bones — and hampers how the body replaces old bone cells with new ones. It also reduces the levels of estrogen in women and testosterone in men, which protect your bones, thus increasing the risk of bone loss. Excess alcohol can also increase the risk of falling. While there is no “safe level” of drinking alcohol, studies show that anything beyond one to two standard drinks per day is inadvisable to maintain good health, including bones.

NO SMOKING Like alcohol, tobacco also wreaks havoc on bone health. Nicotine, the addictive chemical in tobacco, slows the production of bone-forming cells in the body, decreasing bone density. Smoking also reduces blood supply to bones, decreases the absorption of the necessary calcium and vitamin D, and rapidly breaks down estrogen. Studies show that elderly smokers are at a 30 - 40% higher risk of breaking their hip bones than non-smokers. Passive smoking also increases the risk of having brittle bones and developing osteoporosis.

EXERCISE Best exercises to promote bone health include weight bearing and resistance exercises, which force the body to work against gravity. Walking, aerobics, lifting weights, climbing stairs, playing tennis or dancing—all of these strengthen bones and muscles, reducing the risk of developing low bone density and osteoporosis. Practicing tai chi, yoga or simple stretches improves balance and reduces the risk of falls and fractures.

ORTHOPEDICS Exercising regularly, for at least 30 minutes a day, is recommended as it builds healthier muscles, boosts balance, improves our posture and reduces inflammation and pain. But those with osteoporosis should pay special attention to the environment in which they are exercising. They should avoid activities that make them susceptible to falls and injuries, such as walking on an icy pavement or jerky movements like jumping, bending and twisting the waist and spine. Instead of providing benefits, these movements may increase the risks of fractures.

SUPPLEMENTS Bones are a storehouse of calcium and phosphorus, and healthy bones need vitamin D, as it helps our body absorb calcium. A balanced diet with calcium-rich foods such as milk, yogurt and cheese, can supplement our body with necessary calcium. The skin has the remarkable prowess to make its own vitamin D when exposed to sunlight—so exposing the skin for about 15 minutes to sunlight every day, with no sunscreen, is hugely beneficial.

by an informed medical professional can mean healthy bones and a hearty life. Christine E. Jablonski, MD is a board-certified internist with the Orlando Health Bone Health and Osteoporosis Care program where she cares for patients who have osteoporosis or an increased risk of developing osteoporosis. After earning a bachelor’s degree in biology and graduating magna cum laude from Amherst College in Massachusetts, Dr. Jablonski earned her medical degree and completed a residency in internal medicine at the University of Florida College of Medicine in Gainesville. She is board certified by the American Board of Internal Medicine. She is a member of and holds certifications with the National

If getting the recommended levels of calcium (1000 mg for men and 1200 mg for women over 50) and vitamin D (600 IU for both) is not possible, taking supplements can help. But the recommended dosage for supplements should consider the patient’s age, diet and the body’s requirements. Sometimes, as in the case of vitamin D, a surplus can be harmful.

Osteoporosis Foundation, the International Symposium

Finally, for people at higher risk or who have been diagnosed with osteoporosis, FDA approved prescription medications and therapeutics treat and prevent osteoporosis and decrease the risk of broken bones. A consultation with an osteoporosis specialist can benefit these patients to determine the best treatment plan and optimally manage the condition long term.

CONTACT:

Modern medicine has blessed this generation with life spans longer than previous generations. But for some, osteoporosis in later life can stand in the way of a healthy, independent life. Screening for and properly evaluating and treating osteoporosis

on Osteoporosis, and the International Society for Clinical Densitometry. 

Orlando Health Bone Health & Osteoporosis Care Program Women’s Pavilion - Winter Park Address: 1111 W. Fairbanks Ave. Ste. 110 Winter Park, FL 32789 Call: (321) 843-5851

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FLORIDA MD - NOVEMBER/DECEMBER 2023 17

Healing Eczema: Beyond Skin Deep By Joseph Cannizzaro, MD Oftentimes the children we treat in our practice suffer from asthma, allergies, eczema and other comorbid conditions, which create a persistent inflammatory state in the body. In these cases, we apply a synergistic mix of healing factors: nutrition with dietary modifications, supplements, enhanced detoxification, and medications when necessary. We determine food intolerances, look for nutritional deficiencies, and analyze chemical exposures. Additionally, salt therapy has proven to be a safe and effective healing modality that helps clear eczema completely.

HOW DOES SALT THERAPY HELP HEAL ECZEMA? In January 2018, our pediatric center became the newest location for The Salt Room® in Central Florida. Salt therapy is performed in this special spa-like room with salt-coated walls and floor, called a halochamber. Pharmaceutical-grade salt is pulverized into microscopic particles and pushed into the room by a halogenerator. Salt therapy involves lounging in this cozy room and passively breathing in the particles while listening to soothing music, reading, or just relaxing in a zero-gravity chair. Toys are provided so children can play with the salt in the room, much like sand at the beach. The salt particles enter the lungs and nasal passages, accelerating mucus clearance and improving lung function while killing harmful bacteria and soothing the respiratory system. The antibacterial, anti-fungal, and anti-inflammatory properties of salt have been documented to help with symptoms of both respiratory and skin conditions.

HOW SALT THERAPY PROVIDES RELIEF FOR ECZEMA: • Fortifies the skin’s protective barrier • Stimulates microcirculation • Reduces inflammation, redness and irritation • Has anti-bacterial and anti-fungal effects • Reduces IgE levels • Helps normalize the skin’s pH balance • Promotes healthy tissue regeneration • Facilitates deeper penetration of skin care products • Increases skin elasticity • Cleans impacted follicles • Promotes gentle exfoliation (cell turnover) For those suffering from eczema, salt therapy works by activating multiple physiological processes in the body. On the outside of the body, the salt particles kill bacteria and fungi, reduce inflammation on the skin, and improve circulation on the skin surface. Salt calms the itchy rash and heals cracks, which restores 18 FLORIDA MD - NOVEMBER/DECEMBER 2023

the skin’s barrier against infections and allergens. The skin and respiratory tract are cleansed of allergens like pollen, dust, or smoke. Salt therapy also reduces stress and strengthens the body’s defense system. Salt therapy is a clinically-proven, natural, safe, and beneficial method of treatment for every age group. Taking a holistic approach to eczema—identifying the underlying cause(s), applying the appropriate integrative protocol, and incorporating salt therapy—has yielded successful outcomes for our patients. This “beyond the surface” approach to a skin condition has proven to shorten the journey to lasting relief—with a side effect of smiles. Joseph Cannizzaro, MD has been practicing pediatrics in Central Florida for over 40 years and is the author of “Answers for the 4-A Epidemic: Healing for Kids with Autism, ADHD, Asthma and Allergies.” As a classicallytrained primary care physician who practices functional integrative medicine, Dr. Cannizzaro believes that integrative medicine can bring conventional and complementary healing modalities together, creating a highly personalized and high-touch healing environment. Call the Cannizzaro Integrative Pediatric Center at 321-2805867 for a meet and greet or to book a session at The Salt Room® Longwood. www.MyCIPC.com. 

2024

EDITORIAL CALENDAR

Florida MD is a monthly medical/business digital magazine for physicians.. Florida MD is emailed directly to healthcare providers in Orange, Seminole, Flagler, Volusia, Osceola, Polk, Brevard, Lake and Indian River counties. Cover stories spotlight extraordinary physicians affiliated with local clinics and hospitals. Special feature stories focus on new hospital programs or facilities, and other professional and healthcare related business topics. Local physician specialists and other professionals, affiliated with local businesses and organizations, write all other columns or articles about their respective specialty or profession. This local informative and interesting format is the main reason physicians take the time to read Florida MD. It is hard to be aware of everything happening in the rapidly changing medical profession and doctors want to know more about new medical developments and technology, procedures, techniques, case studies, research, etc. in the different specialties. Especially when the information comes from a local physician specialist who they can call and discuss the column with or refer a patient. They also want to read about wealth management, financial issues, healthcare law, insurance issues and real estate opportunities. Again, they prefer it when that information comes from a local professional they can call and do business with. All advertisers have the opportunity to have a column or article related to their specialty or profession.

JANUARY –

Digestive Disorders Diabetes

FEBRUARY –

Cardiology Heart Disease & Stroke

MARCH –

Orthopaedics Men’s Health

APRIL –

Surgery Scoliosis

MAY –

Women’s Health Advances in Cosmetic Surgery

JUNE –

Allergies Pulmonary & Sleep Disorders

JULY –

Neurology / Neuroscience Advances in Rehabilitation

AUGUST –

Sports Medicine Robotic Surgery

SEPTEMBER – Pediatrics & Advances in NICUs Autism OCTOBER –

Cancer Dermatology

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

Please call 407.417.7400 for additional materials or information. FLORIDA MD - NOVEMBER/DECEMBER 2023 19

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Kerri and Clay: “My son’s allergy medicines were causing terrible side effects. Now that we have been coming to The Salt Room we have been able to control his symptoms with salt therapy.” Jessica L.: “My son looked and felt better after just one session. His cough wasn’t as bad. I felt he could breathe so much better.”

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