Florida md october 2016 by FloridaMD

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

Florida Hospital Celebration Health Offers Cutting Edge Option for Breast Cancer Treatment Dr. Ivanov and Intraoperative Radiation Therapy Saving Lives and Changing Face of Cancer Care

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OCTOBER 2016 COVERING THE I-4 CORRIDOR

î&#x201A;&#x2020; COVER STORY

PHOTO: DONALD RAUHOFER / FLORIDA MD

The mood is bright in the office of Olga Ivanov, MD, FACS, Medical Director of the Comprehensive Breast Health Center. As a board certified and fellowship-trained breast surgeon, she is a highly respected, forward thinking leader in breast cancer treatment and has played an integral role in advancing breast cancer treatment nationwide. Specifically, she has played a critical role in bringing a breast cancer trial to Florida Hospital Celebration Health that over the years has not only improved the quality of life for many of her patients, but has helped them move on from their cancer diagnosis and get back to a normal life.

PHOTO: DONALD RAUHOFER / FLORIDA MD

ON THE COVER: OLGA IVANOV, MD, FACS

22 REGULAR PROSTATE CANCER CHECK-UPS INCREASE EARLY DETECTION

DEPARTMENTS 2

FROM THE PUBLISHER

PULMONARY & SLEEP DISORDERS

MARKETING YOUR PRACTICE

HEALTHCARE BANKING, FINANCE AND WEALTH

ORTHOPAEDIC UPDATE

1o CANCER 13 INPATIENT REHABILITATION

15 CARDIOLOGY 18 DIGESTIVE AND LIVER UPDATE

FLORIDA MD - OCTOBER 2016 1

FROM THE PUBLISHER

am pleased to bring you another issue of Florida MD. I can only imagine the emotional and physical trauma that a woman goes through when she has a mastectomy. The procedure affects not only her body, but her mind and her self-esteem. Now add in the inability to not be able to reconstruct her breasts and give that part of her life back, because she’s uninsured or under insured, and it becomes an unthinkable crushing blow. Fortunately there is My Hope Chest to help women who are unable to afford reconstructive surgery. I asked them to tell us about their organization and how you, as physicians, can help. Please join me in supporting this truly wonderful organization. Best regards,

COMING NEXT MONTH: The cover story focuses on John C. Carrozzella, MD, Physician / Founder – Florida Center for Hormones and Wellness. Editorial focus is on Urology, Geriatric Medicine and Glaucoma.

Donald B. Rauhofer Publisher

MY HOPE CHEST — Making Women Whole Again In 2010, more than 22,000 uninsured women lost their breasts to cancer and were left disfigured, deformed and feeling “less than whole.” How many years has this figure been growing? Many organizations raise funds for research, education and “awareness” of breast cancer. Most have no idea there lies a huge gap in assistance for delayed reconstruction and co-pays for survivors wanting this surgery. My Hope Chest is the ONLY national 501c3 non-profit organization focused on funding breast reconstruction for the uninsured and under insured survivors. Our services “pick up” where other breast cancer organizations leave off… providing the “final step in breast cancer treatment. ” My Hope Chest is about addressing the needs of survivors now. Through wonderful surgeon partnerships we are able to transform the lives of breast cancer survivors who otherwise have no hope of reconstruction. We hope to hear from you to learn how we can work together to eliminate our wait list and take action to help every woman who desires reconstruction after mastectomy and feel restored in body, mind and spirit. Wish List • Surgeons to create awareness for My Hope Chest and to identify new clients • Doctors of Distinction- Surgeon partners nationwide to join our program. • Corporate partners, interested in Win-Win, Commercial- coventure marketing campaigns promoting their product or service by sharing our vision to make sure there is always coverage for reconstruction surgery. For additional information on how you can help or refer a patient please go to www.MyHopeChest.org.

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Publisher: Donald Rauhofer Photographer: Donald Rauhofer / Florida MD Contributing Writers: Katie Dagenais, Daniel Layish, MD, Srinivas Seela, MD, Jeffrey K. Raines, MD, Zoraida Catherine Navarro, MD, Nikita Shah, MD, Richard C. Senelick, 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

Orexin Antagonist Therapy:

A New Option for the Pharmacologic Treatment of Insomnia By Daniel T. Layish, MD and Kathleen Summo RN, MSN Insomnia can be divided into two categories: difficulty initiating sleep and/or difficulty maintaining sleep. Approximately 30 percent of the adult population is affected by insomnia at some point, thus creating a major risk factor for anxiety, depression and/or substance abuse. Current pharmacologic therapy options for insomnia include benzodiazepines and non-benzodiazepine gamma-amino butyric acid (GABA) acting hypnotics such as zolpidem and eszopiclone. Other options include antihistamines, sedating antidepressants and melatonin agonists. Orexin, a neurotransmitter (also known as hypocretin) was discovered in 1998. There are approximately 15,000 orexin neurons in the brain, primarily located in the perifornical lateral hypothalamus. Hypocretin deficiency is associated with decreased levels of epinephrine and histamine, important chemicals in promoting arousal, alertness and wakefulness. Ninety percent of patients with narcolepsy have been found to have decreased levels of orexin in their cerebrospinal fluid. Cataplexy, (the most common form of narcolepsy) causes sudden, transient episodes of muscle weakness triggered by emotions (such as crying or laughing). Seventy percent of narcoleptics have cataplexy, which is caused by the autoimmune destruction of orexin. The FDA recently approved suvorexant, a duel orexin receptor antagonist, as the first in a new class of pharmacologic agents for the treatment of insomnia. This new medication blocks both 0X1R and OX2R, has been shown to improve both sleep onset as well as sleep maintenance. One major advantage of suvorexant is its low potential for addiction or rebound. In gaining FDA approval, three Phase III studies were conducted. Two of these studies lasted three months and the largest evaluated more than 1200 elderly and non-elderly subjects for safety and efficacy. Plasma concentrations were unchanged in patients with moderate hepatic or renal dysfunction. However, suvorexant should be avoided in individuals with severe hepatic impairment. At doses of 15-20 mg, Suvorexant reduced latency to persistent sleep by about 10 minutes as compared to placebo. By the third month of therapy this was down to 5 minutes. Wakefulness after sleep onset (WASO) was about 35 minutes less than placebo (verified by polysomnography) at the 15-20 mg dose. This effect also lessens over time to a 23 minute improvement in WASO (versus placebo) by month three. Suvorexant may cause daytime sleepiness as well as some daytime confusion. The daytime sleepiness is dose dependent. There is also a potential for next day driving impairment at the higher doses. Suvorexant should be used cautiously in the setting of other moderate CYP3A medications and is contraindicated with severe CYP3A inhibitors. It is recommended that this medication be taken within 30 minutes of going to bed and by those ready to stay in bed for at least seven hours. Many of the studies that led to the FDA approval of suvorex-

ant looked at higher doses than were eventually approved. This fact should be kept in mind when interpreting Daniel T. Layish, MD these clinical studies. Suvorexant is now available under the brand name BelsomraÂŽ in 5, 10, 15, and 20 mg tablets. Suvorexant is a controlled substance (Schedule lV) and is contraindicated in narcolepsy. In addition to pharmacologic therapy for insomnia, it is important to remind patients about cognitive behavioral therapy, sleep hygiene, and other non-pharmaceutical treatments of insomnia (such Kathleen Summo RN, as avoidance of caffeine, nicotine, MSN alcohol, etc.). Perhaps in the future, there will be an orexin agonist available to treat excessive daytime sleepiness, as this is currently an active area of clinical research.

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. Kathleen Summo RN, MSN, CCP is the Clinical Director of Research and Cystic Fibrosis at the Central Florida Pulmonary Group, PA. She has a Masters degree in Nursing with a minor in Clinical Research and fifteen years of experience conducting clinical trials. î Ž

FLORIDA MD - OCTOBER 2016 3

COVER STORY

Florida Hospital Celebration Health Offers Cutting Edge Option for Breast Cancer Treatment Dr. Ivanov and Intraoperative Radiation Therapy Saving Lives and Changing Face of Cancer Care By Katie Dagenais The mood is bright in the office of Olga Ivanov, MD, FACS, Medical Director of the Comprehensive Breast Health Center. As a board certified and fellowship-trained breast surgeon, she is a highly respected, forward thinking leader in breast cancer treatment and has played an integral role in advancing breast cancer treatment nationwide. Specifically, she has played a critical role in bringing a breast cancer trial to Florida Hospital Celebration Health that over the years has not only improved the quality of life for many of her patients, but has helped them move on from their cancer diagnosis and get back to a normal life.

CLINICAL TRIAL COMES TO FLORIDA HOSPITAL CELEBRATION HEALTH The cutting-edge treatment approach called Intraoperative Radiation Therapy (IORT) came to Florida Hospital Celebration Health as a clinical trial in 2012. At the time IORT was a relatively new cancer treatment technique in the United States; although European countries had been using it for the past decade. Dr. Ivanov was among the first breast surgeons in the country to explore clinical trials surrounding the usage and effectiveness of IORT in patients diagnosed with early stage breast cancer. It was while practicing at Little Company of Mary Hospital in Chicago that Dr. Ivanov and her former Radiation Oncologist colleague, Dr Ivanov explains breast IORT surgery to a patient.

Adam Dickler, MD, completed a clinical study with data gathered from 75 patients over a four-year period. The results of this clinical trial, under Dr. Ivanov’s direction, were published in Annals of Surgical Oncology. In 2012, the goal of the national trial was to enroll 1,000 eligible patients at sites nationwide and monitor them for 10 years post-surgery. Now, four years later Florida Hospital Celebration Health has treated more than 70 women with IORT as part of this trial and monitors them regularly. None of these 70 women, who have taken part in this trial at Florida Hospital, have experienced recurrence. Nationwide, 827 patients have been treated on this IORT trial, with only one experiencing recurrence. For Dr. Ivanov the results are encouraging “I am excited and optimistic. So far the study has probably exceeded what we would have expected, we would have expected a higher rate of recurrence.”

INTRAOPERATIVE RADIATION THERAPY (IORT) Dr. Ivanov has had thousands of women sit down in her office with her, fearful and uncertain as they embark on a journey no woman wants to take. “I have these women come in all set for a double mastectomy and they may not qualify. We are trying to provide the most effective way to treat patients without over-treatment,” says Dr. Ivanov.

PHOTO: DONALD RAUHOFER / FLORIDA MD

Intraoperative Radiation Therapy is an option for women over the age of 50, with early stage lymph node negative disease (stage 0, I and IIA) and no genetic predisposition. According to Dr. Ivanov, nearly seventy percent of patients diagnosed with early stage breast cancer select a lumpectomy, a breast conserving surgery, combined with up to six weeks of radiation therapy. The 30 treatments are stressful on the physical and emotional health of the patient and their loved ones, and nearly one-third of patients don’t fulfill their full radiation treatment plan. Dr. Ivanov offers them a possible alternative to six weeks of traditional radiation therapy - IORT, an innovative treatment plan that delivers optimum lifesaving results. 4 FLORIDA MD - OCTOBER 2016

COVER STORY

PHOTO: DONALD RAUHOFER / FLORIDA MD

Patients opting for IORT undergo a lumpectomy followed by radiation treatment while still in surgery. The surgeon removes the area around the lump followed by one dose of radiation directly into the remaining tissue. Based on clinical trial outcomes, this one dose controls tumor recurrence as effectively as the six weeks of radiation treatment. In addition, patients experience considerably less downtime and less severe side effects. Dr. Ivanov describes it like this, “Do you want six weeks in pain, with expanders and possibly follow up surgeries, or do you want an outpatient procedure, with general anesthesia and approximately an hour and a half in the operating room? With IORT you can be back to normal the next day.” Dr. Ivanov says that patients who come to see her often requesting bilateral mastectomies do so because of the fear of follow up radiation from lumpectomies. IORT provides them an option where they can avoid a mastectomy and the six weeks of radiation. “Their reaction goes from one extreme to the other. Once I educate them that a double mastectomy is not indicated for them and there is an alternative to six weeks of driving somewhere to radiation, they make the switch and ask to be signed up,” adds Dr. Ivanov. The IORT trial at Florida Hospital Celebration Health is using a type of device called Xoft® Axxent® Electronic Brachytherapy (eBx®) System®. A study recently released at the national American Society for Radiation Oncology (ASTRO) annual conference in Boston, Massachusetts found that IORT with the Xoft® System is safe, has low morbidity, good cosmetic results and a low rate of low-grade adverse events.

THE PATIENT EXPERIENCE WITH IORT Patients who are considered possible candidates for IORT will first learn about all care options. If eligible, the potential IORT Dr Ivanov performing breast ultrasound.

Dr Ivanov going over mammogram findings with a patient.

patient will then undergo genetic counseling, and if appropriate genetic testing, prior to surgery. Patients will also meet with a member of the radiation oncology team at Florida Hospital for consultation. According to Dr. Ivanov, ninety-nine percent of the time patients who meet the criteria for IORT are able to move forward. While in surgery, however, surgeons check for additional disease in the lymph nodes. Lymph nodes are biopsied immediately. If clear, IORT is administered instantly. In all cases patients are discharged the same day and, most of the time, will not require additional radiation. Approximately one percent of the time patients may need additional radiation and may need to be back in for additional surgery. “Ninety-nine percent of the time, once patients are wheeled out of the OR, they are done. Their margins are clean, their lymph nodes are clear and they are done with radiation. They may still need chemotherapy if they have a high risk cancer and they may need hormonal therapy, but they won’t have to undergo six weeks of radiation,” adds Dr. Ivanov. In addition to avoiding six weeks of treatment, Dr. Ivanov points out that the physical toll on patients after undergoing IORT is far less than traditional radiation.

PHOTO: DONALD RAUHOFER / FLORIDA MD

“The majority of my patients don’t have to use prescription pain medication, just extra strength acetaminophen. It truly is a cost effective treatment and just as effective in terms of outcomes. What can be more satisfying for a patient than taking over-thecounter medication and going on with their life the next day?” says Dr. Ivanov. To date, IORT is now covered by the vast majority of insurances, making it even more accessible for patients. The majority of patients undergoing IORT at Florida Hospital are from Florida, with patients traveling to Central Florida for IORT from as far away as California, Michigan and Illinois. For Dr. Ivanov the success that Florida Hospital Celebration Health has seen with IORT treatment is due to a unique group of dedicated radiation oncologists on board. FLORIDA MD - OCTOBER 2016

COVER STORY genomic testing if this simplified treatment is an option,” says Dr. Ivanov.

PHOTO: PROVIDED BY FLORIDAHOSPITAL

Whether it’s using cutting edge treatment such as IORT or other advanced cancer care options, Dr. Ivanov believes that the Comprehensive Breast Health Center is cutting-edge in its ability to refine breast cancer treatment and treat the whole patient. “Breast cancer is such an assortment of diseases, not every breast cancer is created equal. What we are getting good at is defining that category, we are getting better at defining that population. It’s about getting down to the biology of the cancer, drilling down to the cancer cell itself and determining whether to treat it as a systemic disease or a local disease.”

They are exceptional,” adds Dr. Ivanov. “They have embraced this vision. This group is very much on par with the new protocols, more localized, efficient, effective and shorter care. They are the main drivers and are passionate about that. They want to deliver effective treatment to control cancer and they won’t compromise. They are committed to this program and IORT and have contributed greatly to our overall success.” Presently Florida Hospital has three radiation oncologists specifically trained and dedicated to the IORT technique. In addition, each patient is paired with a nurse navigator who helps them with their logistics for treatment. Every patient undergoes a formal class that explains what to expect from their treatment plan and gets a tour of the hospital, which takes the fear and apprehension away. After performing IORT for the past four years at Florida Hospital Celebration Health, Dr. Ivanov uses a simple analogy to explain it to colleagues and patients. “Imagine you have a splinter in your right foot. Would you amputate both feet? Instead of amputation, we take out the splinter and provide one powerful dose of radiation.” Dr. Ivanov believes that educating patients and physicians about the proven benefits of cancer treatment is key. “Bilateral mastectomy is not going to prolong your survival. But, for sure it is going to be extensive and a longer recovery. Or, you can go to sleep, get a lumpectomy, receive IORT, wake up and you are likely done with treatment.” Dr. Ivanov reminds that the success of any kind of treatment, however, depends on early diagnosis and finding the cancer early. “If we find it early we can give these treatments in one day. Obviously though we are not naive, sometimes cancer is aggressive, even if found early. But, we are much better at figuring out though 6 FLORIDA MD - OCTOBER 2016

Moving forward, Dr. Ivanov hopes that primary care physicians and oncologists will move their conversations with their patients towards IORT. Currently, The National Institute for Health and Care Excellence (NICE) in the United Kingdom, the UK version of the Centers for Medicare and Medicaid Services (CMS), recommends that IORT is encouraged for women who meet the criteria. Dr. Ivanov would like the United States to adopt similar practices. She is hopeful that with the IORT trials at Florida Hospital and around the nation, and the overwhelming positive outcomes that it is showing, that the National Comprehensive Care Network (NCCN) guidelines will join the UK and other European countries in exploring IORT as a preferential treatment for breast cancer patients. During the month of October, all Florida Hospital locations will offer $35 screening mammograms for those women who do not receive full insurance coverage as a preventative service. The hope is that more women will get screened and breast cancer will be diagnosed early when it has a better chance for a cure.  Dr Ivanov performs lumpectomy on a breast cancer patient.

PHOTO: PROVIDED BY FLORIDAHOSPITAL

Thumbs up: proceeding with radiation portion of breast surgery.

MARKETING YOUR PRACTICE

How to Create Video Content Like a Pro By Jennifer Thompson We know the future of web content is all video. If you think about your viewing habits (or your child’s) then you probably know it is too - even if you don’t want to admit it. In fact, by 2017, video will account for 69 percent of all consumer Internet traffic, according to Cisco. So, how can you capitalize on this trend and put your medical practice ahead of the curve? The best way is to start creating engaging video content today. Not sure how? Don’t worry, we’ve got you covered.

TIPS FOR CREATING ENGAGING VIDEOS You know how they say a picture is worth a thousand words? Well, one minute of video is worth 1.8 million words, according to Forrester Research. Kind of a big difference. Oh, and seven in 10 people view brands in a more positive light after watching interesting video content from them, according to Axonn Research. The key phrase there is “interesting.” Marketing your practice in a video can be as simple as a patient testimonial or an ask the doctor series answering common health questions. Videos should be educational and/or emotional and contain a message that connects with the viewer quickly. Here are tips to help your practice create engaging videos: • Connect to patients’ emotions. One of the main drivers of video storytelling is human emotion. Healthcare practices are filled with compelling, human interest stories from patients and staff. Share them. Don’t focus on the procedure side of a testimonial, instead discuss the fact the patient is able to walk again and visit with their grandchildren. • Consider your patients and potential audience. Ensure the video is going to be relevant to them and that it’s not just something you or your doctors would be interested in. In other words, don’t get too technical and put yourself in the patient’s shoes when planning or asking questions. • Make professional quality videos. Advances in technology have driven the costs of video production down. A video will represent your brand and you will want viewers to know that your brand is professional. If you don’t have the means or knowledge to make a professional video, hire someone to do it for you. If your videos look amateurish, what does that say about your quality of care? • Get b-roll for your videos. Even if it’s only two minutes in length, make sure there is plenty of b-roll footage to keep the segment interesting. Staring at someone for two minutes straight is boring (and creepy).

clear beginning, middle and end. If necessary, create a storyboard ahead of time that describes exactly how your video should be filmed and edited together. Keep this structure on all relevant videos so your videos have a “brand” and “identity” that can be felt in each. • State your video’s purpose. Make sure your viewers know within the first 10 seconds why they should keep watching. Focus on the outcome. Most patients don’t care what it takes to get there, just how long it takes to recover and what they will experience when healed. • Choose one topic. Focus on one topic per video and delivering that idea well. • Consider the length. Most viewers will only watch a video for about two minutes. Try to keep videos less than 5 minutes no matter what. • Share your videos on social media. Promote your video on Facebook, Twitter, in email blasts and on other social media channels your practice engages in. When you promote your video, make it easy for patients to share it. • Put your video on your website. You worked long and hard to create your masterpiece, so make sure it lives on past your social post. Embed your video on your website so patients can view it indefinitely. There you have it. Follow these tips and you should be well on your way to creating quality video to attract and retain more patients for your medical practice. Jennifer Thompson is co-founder and chief strategist for DrMarketingTips.com, a website designed to help medical marketing professionals market their practice easier, faster and better.

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• Have a consistent video structure. Make sure your video has a FLORIDA MD - OCTOBER 2016

HEALTHCARE BANKING, FINANCE AND WEALTH

To Have a Partnership or Not... Some Key Points to Consider When Looking at Being a Partner By Jeff Holt, CMPE, VP, Senior Healthcare Business Banker with PNC Bank In today’s practice environment consolidations, expansions, and buy-ins are all some examples of when it is time to properly consider if a partnership is the right option. If the answer is “Yes”, then the next biggest consideration may be is who is the best fit. There are many good reasons to take on a partner or partners for your practice. You’ll have someone to share your vision, help grow your patient list, cover for you when you take time off (and vice versa), and share the risks and rewards of hard work and growth. At the same time, building a successful partnership takes dedication and long-term commitment. Up to 60% of strategic business partnerships fail[1], and untangling yourself from a broken partnership can be messy. While there are no guarantees a partnership will work, considering a few basic questions in advance may help you decide whether it makes sense to move ahead.

WHAT’S OUR VISION? As nice as it is to be in practice with someone you personally like, it’s perhaps even more crucial to find someone whose goals align with yours. Say, for example, that you dream of expanding your expertise and building one of the preeminent practices in your region, but your prospective partner, though unquestionably skilled, wants to work just hard enough to support a comfortable lifestyle. While neither choice is wrong, a partnership based on such divergent goals is unlikely to succeed.

HOW WILL WE MAKE DECISIONS? Just like a corporation, a healthcare partnership works best when guided by clear governance rules established up front. Over the years, you’ll face hundreds of major and minor decisions, from leasing office space to purchasing equipment to hiring or firing employees or taking on new partners. No matter how collegial or in synch you and your prospective partner(s) feel, set clear rules for who makes what decisions, and how you’ll break a tie.

WHAT ABOUT THE MONEY? As tempting as it is to assume a 50-50 split on income, you would be wise to spell out the details in advance. If one partner is clearly putting in more hours or bringing in more business, how will that be reflected in pay? By the same token, how will you divide costs?

WHAT’S YOUR EXIT STRATEGY? Lives and goals change. What if a decade passes and suddenly you’re eager to uproot and start anew on the opposite coast? Or a partner passes away and you’re unsure how to compensate the surviving family? Or the partnership just isn’t working out the way you intended? Setting clear guidelines for the end game at 8 FLORIDA MD - OCTOBER 2016

the very outset of a partnership can only make the alliance — and your comfort level — that much stronger going in. Your practice is one of your largest investments, so planning ahead regarding timing and details for a transition will be a vital key to success. Also, consider engaging true qualified healthcare business professionals who can properly support the entire process. References: 1. http://www.forbes.com/sites/kimberlywhitler/2014/10/24/why-strategicalliances-fail-new-cmo-council-report/#63a45ba66f8e503564346f8e The third-party trademarks referenced in these articles are owned by and are the registered trademarks of their respective third-party owners. There is no affiliation, sponsorship or endorsement relationship between PNC or its affiliates and any such third party. PNC is a registered mark of The PNC Financial Services Group, Inc. (‘‘PNC’’)

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

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ORTHOPAEDIC UPDATE

Bunionectomy Helps Patient Return to Shoes She Loves By Corey Gehrold

According to the Podiatry Institute, bunions are one of the most frequent structural deformities seen in podiatric medicine, with more than 150,000 bunion surgeries performed annually in the United States. When Athena Staton became unable to wear the shoes she loves (or any shoes for that matter), she turned to Joseph Funk, D.P.M., a board certified foot and ankle surgeon at Orlando Orthopaedic Center. Together, she and Dr. Funk determined bunion surgery was the best option to get her back on her feet and into her shoes. “Dr. Funk prepared me so well that I actually was able to recover from double bunionectomy virtually pain-free,” says Athena with a smile. “Last night my husband and I went to an impromptu dinner. I was walking around the house in flat sandals, and realized, oh my gosh, I can put on my high heels!”

WHAT IS A BUNION?

Patients wearing narrow, tight shoes over long periods of time often develop inflammation affecting the base of the big toe. Gradually, a bony protrusion, called a bunion, may form in the foot, causing the big toe to curve outward and the big toe joint to become enlarged. In Athena’s case, she chose to have a bunionectomy, or a surgical procedure to remove the bunion. “A bunion changes the bone framework in the front portion of the foot, and as it gets worse, it can fill up with additional bone and fluid, sometimes causing the big toe to angle toward the second toe or to shift underneath it,” says Dr. Funk. “Bursitis or arthritis can also result from the damage if left untreated.” People with bunions generally experience great discomfort when walking or bearing weight on the foot, especially in constricting shoes. Often, a bunion can seriously impede proper functioning of the foot, and can lead to damage to the other toes as well, in the form of corns, hammertoes, ingrown nails, and calluses. Bunions can be hereditary, but individuals with lower arches, flat feet and slacker joints are more at risk. Habitually use of high heeled shoes can aggravate the situation, by cramming the toes into a small pointed space. This may well tell us why bunions affect significantly more women than men, by a ratio of ten to one. BUNION TREATMENTS

Patients with early-stage bunions can pursue a number of nonsurgical treatment avenues including: • Wearing shoes with wide toe boxes, having minimal arch support and minimally or no elevated heels, allowing the feet to spread • Regular massage and/or range of motion exercises • Orthotic shoe inserts to recover good balance in the feet • Wearing a splint while sleeping, to assist in straightening out the toe joint • Soaking the foot in warm water or placing an ice pack over the bunion However, individuals suffering from bunions whose unrelenting pain from their inflamed big toe joint becomes too much to bear, like Athena, may need surgical intervention to remove the bunion (a bunionectomy). In fact, Athena had a double bunionectomy performed - meaning bunions on both feet were removed at the same time.

“I couldn’t wear shoes anymore and searched out three different doctors. I found Dr. Funk, realized he was passionate about orthopaedics, and I knew right away that he was the doctor for me,” says Athena.

HOW IS A BUNIONECTOMY PERFORMED?

Joseph D. Funk, DPM

As with any type of surgery, it’s important to choose an experienced surgeon with whom one has a good rapport and feels comfortable. Athena was impressed with Dr. Funk’s professionalism and attitude from the moment they met. “Dr. Funk walked into the exam room and the energy in the room immediately changed,” she says. “(He was) very upbeat, very professional. He pulled out my X-rays, and put me immediately at ease. He knew exactly what he was talking about.” A bunionectomy is an outpatient procedure, meaning patients go home the same day as the surgery. To begin the minimally invasive procedure, Dr. Funk will make an incision at the top of foot in order to remove or shave off, the bony bunion lump. If necessary, the big toe bone may be shortened and the tendons, ligaments and nerves of the joint realigned. The incision will then be closed and the patient will be moved to the recovery area. Typically, patients return home within a few hours of their surgery. After the success of her surgery, Athena was ecstatic. “Finally, I’m able to wear the shoes that are in my closet,” she says. “I would buy shoes, put them on in the store, they fit great, they felt great. I’d get home and within twenty minutes, I could no longer wear them. I now can go out with just the shoes on my feet, and not ballet slippers in my bag.” RECOVERY FOLLOWING BUNION SURGERY

As with most surgeries, each individual’s recovery time will depend on a number of factors including: • The severity of the bunion deformity; • The patient’s current health and medical history; • Age; • Lifestyle. “The recovery process was long, as expected,” says Athena. “But Dr. Funk prepared me very well for that.” As a general rule, most patients will need to use a fracture shoe for four to six weeks after surgery. Some inflammation of the foot can be experienced for up to a few months after the procedure. After the incision has healed, one’s surgeon may suggest range of motion exercises to improve the foot’s endurance and flexibility. In general, patients are able to resume their daily activities within six to eight weeks after surgery. The American Orthopaedic Foot and Ankle Society has reported that complications were experienced in under ten percent of bunionectomy patients, and that patient responses indicated a 85–90% success rating for the procedure. After a successful bunionectomy surgery, Athena is eternally grateful to Dr. Funk.“If you’re like me, and you’re unable to wear shoes and live the lifestyle you like,” says Athena. “If you want to get your life back and get your personality back, then I say call Dr. Funk.”  FLORIDA MD - OCTOBER 2016

CANCER

Controversy Around Breast Cancer Screening By Nikita Shah, MD The American Cancer Society (ACS) says women with an average risk of breast cancer should get an annual mammogram beginning at age 45. By age 55, the frequency should decrease to every other year. The U.S. Preventative Services Task Force, an independent panel of health experts, issued recommendations in January that called for women between the ages of 55 and 74 to get a mammogram every two years. And in August, research underwritten by the National Cancer Institute indicated that breast cancer screening recommendations be tailored to patients based on their breast density. Under these recommendations, women 50 and older who are high risk likely would get an annual mammogram. Confused yet? If so, you aren’t the only one. This year, doctors will diagnose more than 246,000 new cases of invasive breast cancer, and for many of these women early detection could save their lives. Mammograms have been a powerful tool in our arsenal, helping us detect cancer early before it metastasizes or before more invasive and intensive treatment options become our only recourse. But in recent years, controversy around who should get a mammogram and when has created a lot of confusion for patients. Depending on where a patient gets her information, she may decide to wait two years before she gets a mammogram, but this decision can have a huge impact on certain patient’s long-term prognosis if they are ultimately diagnosed with breast cancer. Though there are conflicting schools of thought around breast cancer screening, my general philosophy is why wait and take that risk?

What is covered and what isn’t in regards to breast cancer screening is usually based on the U.S. Preventative Services Task Force recommendations, which today say there’s inadequate evidence of the benefits of MRIs and that regular screening in women under age 50 leads to more harm than good: “In addition to false-positive results and unnecessary biopsies, all women undergoing regular screening mammography are at risk for the diagnosis and treatment of noninvasive and invasive breast cancer that would otherwise not have become a threat to their health, or even apparent, during their lifetime (known as “overdiagnosis”),” the task force says. But most of us in the oncology world really question these recommendations. As a general rule, we continue to recommend annual mammograms starting at age 40 for women of average risk. We see women in the 40-45 age group with breast cancer every day in our clinic, and just as many women over age 55 whom we know that if they wait two years to do another mammogram, they likely could have more advanced stage disease.

WHAT WOMEN CAN DO Mammograms tend to pick up between 80-85 percent of breast cancer, but it’s still important for women to have a good understanding of what their breasts feel like. Though some organizations discourage breast self-exams as an early detection tool, my view is that patients have nothing to lose from doing them. If they don’t, they’ll never know what their normal or abnormal is. continued on page 12

THE CHALLENGES OF BREAST CANCER SCREENING RECOMMENDATIONS My concern with many of the current breast cancer screening recommendations is that not only do they conflict, but in many cases they aren’t personalized to a patient’s specific risk factors. The ACS recommendations, for example, are very broad, are not specific-based on breast density and don’t recommend an MRI for women with dense breast tissue. Early detection is more challenging for women with dense breast tissue, but they tend to benefit from MRIs used in conjunction with mammograms and breast ultrasound, an approach that sometimes can spot lesions a mammogram may miss. There are currently about 30 states in the country that have MRI screening guidelines for women with high-dense breast tissue (Florida is not one of them). Screening recommendations based on breast density vary from state-to-state because of local legislation, so the guidelines tend to be inconsistent, creating even more confusion. In general, the guidelines we follow for breast density is screening via an MRI, but the problem we run into often is that because MRIs are not part of the standard guidelines many insurance companies won’t cover it. 10 FLORIDA MD - OCTOBER 2016

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FLORIDA MD - OCTOBER 2016 11

CANCER Women in high-risk groups, including those with a family history, dense breast tissue or previous abnormal breast findings, should be even more proactive. These women need to be diligent about doing breast self-exams and annual mammograms. For some high-risk groups, preventative endocrine therapy or chemoprevention drugs like Tamoxifen also may be effective ways to lower their breast cancer risk. Previous history of ovarian, triple negative or bilateral breast cancer may be indications for genetic testing, as well. For patients in this category, I’d urge their primary care providers and gynecologists to get as full and as thorough a family history as possible before ordering testing. In many cases, it’s best to refer these patients to a genetic counselor who can do a risk assessment

that will empower these patients to be more proactive about their future care. In spite of conflicting screening recommendations, each woman will have to make the best decision in consultation with her health care provider. Screening recommendations seem to keep changing every year, but a good rule of thumb for patients is to talk to their primary care physician or gynecologist for direction about how often to get a mammogram. Review the recommendations with your health care provider, but also understand that not every patient will fall neatly into the categories outlined by these organizations and that there may be cases where a patient needs a different type of screening or additional screening.

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The guidelines keep changing, but patients and their doctors have to weigh their individual risks and the potential risk and benefit of each test. That is why it’s so important screening be tailored to each individual. Doing so likely will lead to more clarity for women with a low-to-average breast cancer risk and earlier detection for patients with the highest risk. Nikita Shah, MD, serves as the medical oncology team leader for the Breast Cancer Specialty Section and medical director of the Cancer Risk Evaluation Program at UF Health Cancer Center — Orlando Health, where she has been a member of the medical team since 1999. Dr. Shah earned her medical degree from Baroda Medical College in India and completed an externship in the emergency department at Methodist Hospital in Indiana. As a medical student, Dr. Shah had the highest annual score in forensic medicine and received an award as an outstanding medical student. She completed a residency in internal medicine at St. Francis Hospital in Evanston, IL, and a fellowship in hematology/ oncology at Northwestern Memorial Hospital in Chicago. Dr. Shah is a member of numerous societies, including the Florida Medical Association, American Society of Clinical Oncologists, American Medical Association and American College of Physicians. 

INPATIENT REHABILITATION

Your First 3 Strategies to Prevent Another Stroke By Richard C. Senelick MD James has been your patient for 20 years and his stroke came as a total surprise to everyone, including you. He is only 52 years old and he is currently in a state of disbelief. “How could this happen to me?” He knew that older people had strokes, but it was never anything he thought could happen to him, especially before the age of 60. One thing is certain: he wants to do everything he can to make sure it doesn’t happen again and he’s looking at you for a lot of help. An article in the New England Journal of Medicine on “Secondary Prevention after Ischemic Stroke or Transient Ischemic Attack” provides an excellent review of what you need to do.(1)

WHAT ARE THE ODDS? It is important that you and your patient start working on secondary prevention as soon as possible. Most people and even many doctors don’t realize that the risk of a recurrent stroke is as high as 12.8% in the first week after a TIA (transient ischemic attack) (2). If you do not change certain lifestyle factors, the risk of a second stroke within the next 5 years can be as high as 30%. Waiting is not an option. A large study carried out in 22 countries identified 10 risk factors that account for 90% of all strokes (in no particular order). (3) • High blood pressure • Smoking • Waist size-obesity • Poor diet • Lack of physical activity • Diabetes Mellitus • Excessive alcohol consumption • Psychosocial stress/depression • Atrial fibrillation or previous heart attack • High cholesterol Fortunately, additional studies estimate that 80% of recurrent strokes can be prevented with diet modification, exercise, blood pressure control, cholesterol reduction with the help of statins and treatment with anti-platelet medications.(4) Ideally, you would focus on every possible risk factor. However, at first that can be overwhelming. Start with the big three.

THE BIG THREE BLOOD PRESSURE CONTROL Hypertension is the single most common cause of stroke and it is estimated that 75 million people—that’s one-fourth of the United States population—have high blood pressure. When you control blood pressure through the use of antihypertensive medica-

tion you reduce the risk of a first stroke by 32%. In patients who have had a TIA or a stroke, treatment of high blood pressure reduces the risk of a recurrent stroke by 28%. (5) The exact blood pressure number you need to shoot for is a decision unique to each person and should be made taking into account their age and the unique circumstances of your patient. .

STATINS TO LOWER CHOLESTEROL Statins have revolutionized the treatment of high cholesterol. They have also been touted for the treatment of many other disorders, but the facts are clear: statins reduce the risk of a recurrent stroke by 25%. (6). Statins work by • Lowering the overall risk of stroke • Slowing the progression of atherosclerosis • Decreasing the “stickiness” of platelets in the blood • Decreasing heart disease and myocardial infarction and therefore reducing the risk of blood clots traveling from the heart to the brain Statins lower LDL— our “bad cholesterol.” Over the last few years doctors have steadily lowered the ideal level for LDL in peo-

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INPATIENT REHABILITATION ple who are at risk for stroke or have an elevated LDL. The latest goal is less than 70mg/dl. The lower we drive the LDL level, the greater we can reduce the risk of a stroke or myocardial infarction. Most physicians now add statin therapy to their discharge instructions for stroke survivors. An exception may be hemorrhagic strokes.

ANTI-PLATELET AGENTS Commonly referred to by patients as “blood thinners,” antiplatelet agents attack the tiny platelets and make the blood less sticky and less likely to form blood clots. They prevent the formation of clots in arteries in the brain or heart. More good news—

anti-platelet agents reduce the risk of a recurrent stroke by 25%. The most commonly used medication is low-dose aspirin (25mg to 325mg), which is just as effective as higher doses and has fewer side effects. Clopidogrel (Plavix®) and aspirin plus dipyridamole (Aggrenox®) both decrease the risk of recurrent stroke to the same degree as aspirin. All three are acceptable forms of treatment, but low dose aspirin is much less expensive. A study looked at whether the combination of aspirin and clopidogrel might be more effective, but the study was discontinued because of excessive episodes of bleeding in the brain and death. As a result, combination therapy is recommended for only 21 days after mild stroke or TIA, but may be continued for 90 days in patients with intracranial stenosis. After that time the patient should be switched to aspirin alone. (7-8) Many patients ask the obvious question, “Should I take a daily low dose aspirin even I have not had a stroke or heart attack?” The less than satisfying answer is, “It depends.” As a rule the answer is “no,” unless you have multiple risk factors that put you at high risk for stroke or heart disease.

BREAK THE OLD HABITS For James, there is lots of good news. 25% seems to be the magic number. If he controls his blood pressure, takes statins and anti-platelet agents, he can decrease his risk of another stroke by at least 25%. If you both start working on the longer list of 10 risk factors you can drive that number much lower. It is easy for patients to revert back to old habits and continue to put themselves at a high risk for another stroke or heart attack. Take a few moments, meet with them and their families to start changing the way they live—it just may save their life. Bibliography available upon request or go to floridamd.com. Dr. Senelick is a neurologist who specializes in neurorehabilitation. For 30 years he was the medical director of HealthSouth Rehabilitation Institute of San Antonio (RIOSA) and is currently the editor- in- chief of HealthSouth Press. 

Check out our website – www.floridamd.com! 14 FLORIDA MD - OCTOBER 2016

CARDIOLOGY

Soteria Cardiac Platform: New Technology for the Identification of Patients with Atherosclerosis and Guideline Management of Associated Risk Factors – Part 1 By Jeffrey K. Raines and Zoraida Catherine Navarro 1. FOREWORD / INTRODUCTION This is the first installment of a four-part series covering this important topic. We know, in the developed world, at least 20% of individuals with NO symptoms of cardiovascular disease and NO identified cariovascular risk will be found by the newly developed Soterogram to be at increased risk for atherosclerosis, which is the disease responsible for heart attack, stroke, and peripheral vascular disease. This single disease is the cause of over 50% of ALL deaths in the United States and the Western World. The developers of this new technology fully realize that to identify individuals with increased cardiovascular risk will NOT reduce cardiovascular morbidity and mortality, unless, armed with the Platform information/results, methods to reduce risk factors for atherosclerosis, are aggressively institued. At this point, two facts need to be mentioned. First, atherosclerosis is generally a slow process; for reasons which are not science-based, this produces a sense on non-urgency, which does not work to the benefit of patients. Second, current medical science does not have a single cure for atherosclerosis, as was the case with Polio, which was eliminated with a single-dose of medication. The good news is that current medical science is aware of the most important cardiovascular risk factors and have proven ways to reduce current and future cardiovascular risk. The bad news is that, the patient and the patient’s family, play a major role in reducing this risk. We like to say – “the patient is on the wrong cardiovascular trajectory and changes are needed”. The central missions of this Series are to describe new noninvasive methods of assessing current cardiovascular status, describe the operational cardiovascular risk factors, and illustrate guidelines and treatment protocols, both aggressive and non-aggressive, that CAN reduce risk of future heart attack, stroke, and peripheral vascular disease. This sounds like a tallorder for a short four-part Series, but cardiovascular risk reduction with reduced morbidity and mortality are within our grasp!

2. WHAT IS ATHEROSCLEROSIS AND HOW CAN IT BE MEASURED?

the arterial wall to the intima. In the early stages of this process, the changes can be subtle. In addition to thickening of the intima, disease in the arterial wall develops involving lipid pools, thrombus, necrosis, fibrous caps, calcification, plaque rupture, and disruption of the endothelial surface (interface between the wall and flowing blood). The following plates (Fig. 1) show a normal arterial cross-section on the right with a thin wall and thin intima and smooth endothelial surface. The diseased artery on the left shows a thickened wall, thickened intima, and irregular endothelial surface. This is a clear picture of early atherosclerosis.

Jeffrey K. Raines

It has become clear to cardiovasZoraida Catherine cular specialists and other physicians Navarro that the focus of attention in preventing and treating cardiovascular disease must shift toward the arterial wall. The key to reducing cardiovascular risk is understanding endothelial dysfunction and reduced compliance (i.e. reduced elasticity). For illustration purposes, a balloon has a HIGH compliance, where a steel pipe has a LOW compliance.

Fig. 1 – Development of Early Atherosclerosis (Note the thickened Intima (I) on the left)

Atherosclerosis simply means destruction (sclerosis) of the arterial wall (athero). The Arterial Wall, in addition to the one-cell thick lining (endothelium) between the flowing blood and the wall, is composed of three circular layers: intima (I), media (M), and adventitia (A) [Fig. 1]. The Lumen (L) is the open center portion of the artery in which oxygen-rich blood flows. Smooth Muscle, which is a protein, is primarily located in the media of the arterial wall and provides strength. Atherosclerosis importantly involves the movement of smooth muscle cells from the media of

Soteria Medical, LLC has been working from the tenant that early atherosclerosis increases the thickness of the arterial wall (occurring well in advance of blood flow alterations detected by other diagnostic measures). The major technical challenge was to devise an accurate method to measure local arterial volume change. This was accomplished in 2014 with FDA clearance of the Soteria Cardiac Platform which accurately and noninvasively measures arterial compliance in the lower extremity and closely correlates with coronary and cerebrovascular disease. FLORIDA MD - OCTOBER 2016 15

CARDIOLOGY 3. WHAT ARE THE RISK FACTORS FOR ATHEROSCLEROSIS AND HOW CAN THEY BE REDUCED? The lead author of this Series (jr) was involved in vascular surgery for 40 years and kept careful records as to the presenting cardiovascular risk factors in patients requiring vascular surgery. Other investigators, who have practiced cardiology and other cardiovascular-related specialities, over the same period, believe this presented material regarding risk factors, is similar to their experience. Table 1 illustrates in 600 consecutive patients undergoing vascular surgery, the percentage of those patients presenting with the six major cardiovascular risk factors. Each Risk Factor is discussed separately in subsequent sections. The Second Installment will cover Tobacco Use, Hypertension, and Diabetes. The Third Installment will discuss Elevated Blood Lipids, Obesity, and Lack of Exercise. TABLE 1 – CARDIOVASCULAR RISK FACTOR PREVALENCE

Cardiovascular Risk Factor

Prevalence in Vascular Surgical Patients (%)

Tobacco Use (Current and Prior)

Hypertension (Per Current AHA Guidelines)

Diabetes (Fasting Glucose >126 mg/dl x 2 Samples

Elevated Blood Lipids (Per Current AHA Guidelines) 22 Obesity (Body Mass Index > 25)

Lack of Exercise (< 20 minutes per week)

4. SOTEROGRAM RESULTS The Soterogram is the flagship module of the Soteria Cardiac Platform (includes 5 Modules). The other Platform modules are: (i) Registration, (ii) Framingham Risk Profiling and Body Mass Index, (iii) Ankle / Brachial Index (ABIgram), and (iv) Multilevel Lower Extremity Pressure Measurements for evaluation of lower extremity peripheral arterial disease (PADogram). These modules will be briefly discussed in other Sections of this series. The Soterogram has been developed to provide physicians with information that will be helpful with both Primary and Secondary Prevention of Cardiovascular Disease. Early-onset atherosclerosis is known to cause the arterial wall to thicken and become stiffer. This increased stiffness has been referred to as loss of elasticity and/ or loss of viscoelastic properties. Actually, in pathophysiology, this is also referred to as Loss of Compliance, where Compliance is technically defined as (Δ volume / Δ pressure). The Soterogram is the first medical device cleared by the FDA to accurately and noninvasively measure local Arterial Compliance. Due to the prominance of Smooth Muscle Cells in the coronary arteries, the coronary arteries, more than other arterial bed, develop early atherosclerosis. The arterial wall distribution of Smooth Muscle Cells, in addition to Elastin and Collagen, associated with the distal abdominal aorta, femoral arteries (common and superficial), and popliteal artery, mirror the protein distribution in the coronary arteries. The Soterogram measures Arterial Compliance in the Femoral and Popliteal Arteries and uses this data to predict 16 FLORIDA MD - OCTOBER 2016

the status of the Coronary Arteries, as regards atherosclerosis. A. Blood Pressure: The measurement of Brachial Blood Pressure is taken by the Platform using the FDA cleared SP-10 Oscillographic Method of determining Systolic Pressure, Diastolic Pressure, Pulse Pressure, Mean Pressure and Heart Rate. The SP10 technology has been shown to exceed the accuracy of Korotkoff Sounds and Continuous–Wave Doppler Ultrasound. The Soterogram takes at least three separate complete measurements of Blood Pressure over a period of 12 to 15 minutes. One measurement is taken at Registration; the other two measurements are taken at the beginning (1st BP) and end of Soterogram testing (2nd BP). These measurements are averaged to set Pulse Pressure (Mean PP).

The physician interpretating this report should note the absolute level of blood pressure and heart rate, as well as, the variation of these parameters in the three measurements. Since these are repeated-measures, the combined accuracy is high. It is assumed each physician has personal Criteria for Normal and Abnormal Blood Pressure and Heart Rate. The American Heart Association (AHA), in general terms, believes that a Systolic Pressure > 140 mmHg is abnormal. The abnormal level for Diastolic Pressure is > 90 mmHg. The AHA and many physicians believe tachycardia is present when Heart Rate is > 90 bpm and that bradycardia is present when Heart Rate is < 60 bpm. Clearly, normotension is better than hypertension; further, hypertension is a sensitive parameter when dealing with atherosclerosis. It has been shown that hypertension is present in 42% of individuals with significant atherosclerosis. This frequency is only exceeded by past and current cigarette smoking. Further, reduced Heart Rate is often associated with satisfactory cardiovascular tone. B. Cuff Pressures [Pcuff (1-5)]: The first measurement of Blood Pressure (1st BP), sets the pressures to be used in the lower extremity cuffs during the Arterial Volume measurements. Essentially, the patient’s Mean Pressure (1st Pmean) is determined. The five cuff pressures are: (i) 10 mmHg below Pmean, (ii) 5 mmHg below Pmean, (iii) Pmean, (iv) 5 mmHg above Pmean, and (v) 10 mmHg above Pmean. This mosaic of pressures is needed for accuracy (repeated-measures) and to account for arterial wall mechanics (i.e. expansion and collapse). C. Calf and Thigh Segmental Volume Measurements (Vm):

Five meassurements of Total Arterial Volume Change (Vm) under the respective cuffs (Calf and Thigh) are measured and displayed in milliliters (ml) separately for each Cuff Pressure (Pcuff). These are intermediate measurements and are not used directly by the Interpreting Physician. The Vm versus Pressures Chart is helpful in graphically affirming the expected study results and therefore study integrity. D. Calf Max Vm50 and Thigh Max Vm50: These parameters are calculated by the Platform and refer to the Maximum Volume Change under the Calf Cuff and Thigh Cuff during the patient’s Cardiac Cycle. The value is in ml and is normalized to a Pulse Pressure of 50 mmHg. This normalization is performed to expedite the direct comparison of these parameters between patients.

CARDIOLOGY Since, Arterial Compliance is defined as Δ volume / Δ pressure, the larger the Max Vm50, the greater the Arterial Compliance. Reduced Arterial Compliance is a hallmark of atherosclerosis. Please consider the following cardiovascular physiology. For a standard Cardiac Output of 5 liters/min (5000 ml/min) with a Heart Rate of 70 bpm, the Stroke Volume will be 71 ml (5000 ml / 70 bpm). Blood is essentially an incompressible fluid. This means the Systemic Arterial System must in-total over a Cardiac Cycle accommodate this infused volume (i.e. 71 ml). Soteria FDA / NIH Alpha, Beta, and Clinical Studies have demonstrated in normal subjects that Calf Max Vm50 averaged 2.0 ml and Thigh Max Vm50 averaged 3.5 ml (Total: 5.5 ml per Combined Calf and Thigh Segments – Two Limbs, therefore would total 11 ml). It is physiologically consistent that 11 ml or approximately 15% of the Stroke Volume would be absorbed by the combined expansion of the Calf and Thigh Arterial Beds. As will be described, the Calf Max Vm50 and Thigh Max Vm50 will be combined to form a single Soterogram Score. This ends the first installment of a four-part series. The second installment, scheduled for next month, will begin by illustrating how the above described measurements are used to establish the level of atherosclerosis and continue the discussion in the arena of risk factor reduction.

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. 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. 

FLORIDA MD - OCTOBER 2016 17

DIGESTIVE AND LIVER UPDATE

Gastric Cancer Diagnosis, Management and Treatment By Srinivas Seela, MD Gastric cancer is the third most common cause of cancer-related death in the world, and it remains difficult to cure in Western countries, primarily because most patients present with advanced disease. In the United States, stomach malignancy is currently the 15th most common cancer. The stomach begins at the gastroesophageal junction and ends at the duodenum. Almost all gastric cancers are adenocarcinomas (cancers that begin in cells that make and release mucus and other fluids). Other types of gastric cancer are gastrointestinal carcinoid tumors, gastrointestinal stro-

mal tumors, and lymphomas. Stomach cancer is uncommon in the United States, and the number of people diagnosed with the disease each year is declining. Stomach cancer is much more common in other areas of the world Infection with bacteria called H. pylori is a common cause of gastric cancer.

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Gastric cancer is often diagnosed at an advanced stage because there are no early signs or symptoms.

SIGNS AND SYMPTOMS Early gastric cancer has no associated symptoms; however, some patients with incidental complaints are diagnosed with early gastric cancer. Most symptoms of gastric cancer reflect advanced disease. All physical signs in gastric cancer are late events. By the time they develop, the disease is almost invariably too far advanced for curative procedures. Signs and symptoms of gastric cancer include the following: • Fatigue • Feeling bloated after eating • Feeling full after eating small amounts of food • Heartburn that is severe and persistent • Indigestion that is severe and unrelenting • Nausea that is persistent and unexplained • Stomach pain • Vomiting that is persistent • Weight loss that is unintentional • Dysphagia • Loss of appetite • Melena or pallor from anemia • Hematemesis • Palpable enlarged stomach with succussion splash • Enlarged lymph nodes such as Virchow nodes (i.e., left supraclavicular) and Irish node (anterior axillary) • Late complications of gastric cancer may include the following features: • Pathologic peritoneal and pleural effusions • Obstruction of the gastric outlet, gastroesophageal junction, or small bowel • Bleeding in the stomach from esophageal varices or at the anastomosis after surgery

DIGESTIVE AND LIVER UPDATE • Intrahepatic jaundice caused by hepatomegaly • Extrahepatic jaundice • Inanition from starvation or cachexia of tumor origin

CAUSES: It is not clear what causes stomach cancer. There is a strong correlation between a diet high in smoked and salted foods and stomach cancer. As the use of refrigeration for preserving foods has increased around the world, the rates of stomach cancer have declined. H. Pylori is a WHO listed carcinogen and implicated in the development of stomach cancer and MALT (Mucosal Associated Lymphoid Tumor) In general, cancer begins when an error (mutation) occurs in a cell’s DNA. The mutation causes the cell to grow and divide at a rapid rate and to continue living when a normal cell would die. The accumulating cancerous cells form a tumor that can invade nearby structures. And cancer cells can break off from the tumor to spread throughout the body.

RISK FACTORS Factors that increase your risk of stomach cancer include: • A diet high in salty and smoked foods • A diet low in fruits and vegetables • Eating foods contaminated with aflatoxin fungus • Family history of stomach cancer • Infection with Helicobacter pylori • Long-term stomach inflammation • Pernicious anemia • Smoking • Stomach polyps

is rare. • Cancer that begins in hormone-producing cells (carcinoid cancer). Hormone-producing cells can develop carcinoid cancer. Carcinoid cancer in the stomach is rare. • Cancer that begins in nervous system tissues. A gastrointestinal stromal tumor (GIST) begins in specific nervous system cells found in your stomach. GIST is a rare form of stomach cancer.

IMAGING STUDIES Imaging studies that aid in the diagnosis of gastric cancer in patients in whom the disease is suggested clinically include the following: • Esophagogastroduodenoscopy (EGD): To evaluate gastric wall and lymph node involvement • Double-contrast upper GI series and barium swallows: May be helpful in delineating the extent of disease when obstructive symptoms are present or when bulky proximal tumors prevent passage of the endoscope to examine the stomach distal to an obstruction • Chest radiography: To evaluate for metastatic lesions • CT scanning or MRI of the chest, abdomen, and pelvis: To assess the local disease process and evaluate potential areas of spread • Endoscopic ultrasonography (EUS): Staging tool for more precise preoperative assessment of the tumor stage

BIOPSY

DIAGNOSIS TESTING The goal of obtaining laboratory studies is to assist in determining optimal therapy. Potentially useful tests in patients with suspected gastric cancer include the following: • CBC: May be helpful to identify anemia, which may be caused by bleeding, liver dysfunction, or poor nutrition; approximately 30% of patients have anemia • Electrolyte panels • Liver function tests • Tumor markers such as CEA and CA 19-9: Elevated CEA in 45-50% of cases; elevated CA 19-9 in about 20% of cases

TYPES OF STOMACH CANCER The cells that form the tumor determine the type of stomach cancer. The type of cells in your stomach cancer helps determine your treatment options. Types of stomach cancer include: • Cancer that begins in the glandular cells (adenocarcinoma). The glandular cells that line the inside of the stomach secrete a protective layer of mucus to shield the lining of the stomach from the acidic digestive juices. Adenocarcinoma accounts for the great majority of all stomach cancers. • Cancer that begins in immune system cells (lymphoma). The walls of the stomach contain a small number of immune system cells that can develop cancer. Lymphoma in the stomach

Biopsy of any ulcerated lesion should include at least six specimens taken from around the lesion because of variable malignant transformation. In selected cases, endoscopic ultrasonography may be helpful in assessing depth of penetration of the tumor or involvement of adjacent structures. Histologically, the frequency of different gastric malignancies is as follows [3] : • Adenocarcinoma - 90-95% • Lymphomas - 1-5% • Gastrointestinal stromal tumors (formerly classified as either FLORIDA MD - OCTOBER 2016 19

DIGESTIVE AND LIVER UPDATE leiomyomas or leiomyosarcomas) - 2% • Carcinoids - 1% • Adenoacanthomas - 1% • Squamous cell carcinomas - 1% See Workup for more detail.

TREATMENT AND MANAGEMENT SURGERY The surgical approach in gastric cancer depends on the location, size, and locally invasive characteristics of the tumor. Types of surgical intervention in gastric cancer include the following:

• Subtotal gastrectomy for tumors of the distal stomach • Lymph node dissection: Controversy exists regarding extent of dissection; the National Comprehensive Cancer Network (NCCN) recommends D2 dissections over D1 dissections; a pancreas- and spleen-preserving D2 lymphadenectomy provides greater staging information and may provide a survival benefit while avoiding its excess morbidity when possible [4]

CHEMOTHERAPY Antineoplastic agents and combinations of agents used in managing gastric cancer include the following:

• Platinum-based combination chemotherapy: First-line regimens include epirubicin/ cisplatin/5-FU or docetaxel/cisplatin/5FU; other regimens include irinotecan and cisplatin; other combinations include oxaliplatin and irinotecan • Trastuzumab in combination with cisplatin and capecitabine or 5-FU: For patients who have not received previous treatment for metastatic disease

CM RE E CEI CR VE ED IT S

• Total gastrectomy, if required for negative margins

• Esophagogastrectomy for tumors of the cardia and gastroesophageal junction

• Ramucirumab for the treatment of advanced stomach cancer or gastroesophageal (GE) junction adenocarcinoma in patients with unresectable or metastatic disease following therapy with a fluoropyrimidine- or platinum-containing regimen

NEOADJUVANT, ADJUVANT, AND PALLIATIVE THERAPIES Potentially useful therapies in gastric cancer include the following: • Neoadjuvant chemotherapy • Intraoperative radiotherapy (IORT) • Adjuvant chemotherapy (eg, 5-FU) • Adjuvant radiotherapy

Walt Disney World Swan & Dolphin Resort, Orlando, FL Saturday, Nov. 5, 2016

*This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical education through the joint providership of the American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) and the Association of Independent Doctors (AID). ABQAURP is accredited by the ACCME to provide continuing medical education for physicians. The American Board of Quality Assurance and Utilization Review Physicians, Inc. designates this live activity for a maximum of 6 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

20 FLORIDA MD - OCTOBER 2016

• Adjuvant chemoradiotherapy • Palliative radiotherapy • Palliative-intent procedures (e.g., wide local excision, partial gastrectomy, total gastrectomy, simple laparotomy, gastrointestinal anastomosis, bypass)

SUPPORTIVE (PALLIATIVE) CARE Palliative care is specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness. Palliative care specialists work with you, your family and your other doctors to provide an extra

DIGESTIVE AND LIVER UPDATE layer of support that complements your ongoing care. Palliative care can be used while undergoing other aggressive treatments, such as surgery, chemotherapy or radiation therapy. When palliative care is used along with all of the other appropriate treatments, people with cancer may feel better and live longer. Palliative care is provided by a team of doctors, nurses and other specially trained professionals. Palliative care teams aim to improve the quality of life for people with cancer and their families. This form of care is offered alongside curative or other treatments you may be receiving. Srinivas Seela, MD moved to Orlando, Florida after finishing his fellowship in Gastroenterology at Yale University School of Medicine, one of the finest programs in the country. During his training he spent a significant amount of time in basic and clinical research, and has published articles in Gastroenterology literature. His interests include advanced and therapeutic endoscopic procedures, colorectal cancer screening, Gastro Esophageal Reflux Disease (GERD), metabolic and other liver disorders. Dr. Seela is board certified in both Internal Medicine and Gastroenterology. He is a member of the American Gastroenterological Association (AGA), the American Society for Gastrointestinal Endoscopy (ASGE), the American Association for the Study of Liver Diseases (AASLD), and Crohn’s Colitis Foundation (CCF). In addition to being an Assistant Professor at the University of Central Florida School of Medicine, he is also a teaching attending physician at both the Florida Hospital Internal Medicine Residency and Family Practice Residence (MD and DO) programs. He is a regular contributing writer for Florida Md magazine. For an appointment with Dr. Seela, please call 407-384-7388. 

OUR FOUNDATION OF CARE

JUST GOT STRONGER Premier Hematology & Oncology Welcomes Dr. Asim Aijaz Asim Aijaz, MD joins the comprehensive cancer care team at Premier Hematology & Oncology. Dr. Aijaz is a highly experienced board-certified medical oncologist with special interest in gastrointestinal, gynecological, mediastinal and urologic tumors, and hematologic and myeloproliferative disorders.

Specialties Diagnosis and Treatment of All Cancers and Blood Diseases | Bone Marrow Failure State Hematologic Disorders | Leukemia and Lymphoma | Skin Cancers | Solid Tumors

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FLORIDA MD - OCTOBER 2016 21

Regular Prostate Cancer Check-Ups Increase Early Detection By Axel Anderson IV, MD Every three minutes a man in the United States is diagnosed with prostate cancer. Although the cause of prostate cancer is still unclear, regular testing can detect the disease, making it easier to treat. The prostate gland creates a fluid that is part of the formation of semen. About the size of a walnut, the prostate gland is located in front of the rectum, and physicians are able to feel it during a rectal examination. Prostate cancer has no symptoms in the early stages. When symptoms arise they can include: •

Dull pain in the lower pelvic area;

•

Problems with urination, weakened urine flow, blood in the urine or semen;

•

Painful ejaculation;

•

Pain in the bones, lower torso and upper thighs; and

•

Loss of appetite and weight.

After age 50, the likelihood of a man being diagnosed with prostate cancer greatly increases. In fact, more than 70 percent of the prostate cancer cases are diagnosed in men over age 65. Family history may also play a role in the risk of prostate cancer. A man’s chance of being diagnosed doubles if his father or brother had the disease. If several family members have been diagnosed, the risk is even greater. Race is another factor linked to prostate cancer diagnoses. Though it is not known why, African Americans are diagnosed 70 percent more often than white Americans, and diagnosis of African Americans usually occurs when the cancer is in a more advanced stage. Typically, men should begin testing for prostate cancer at age 50. However, those who are at a higher risk should begin being tested as early as ages 40 to 45. Two tests are performed to check for prostate cancer, and men should have these tests done yearly. A prostate-

Compassionate, Caring & Sophisticated Medical Care

Yale-Trained Gastroenterologists Harinath Sheela, MD, Seela Ramesh, MD, Srinivas Seela, MD, Sergio Larach, MD, and Megan Delimata, MD (not shown on picture above)

Our Expertise Includes:

• Bravo Placement • Bowel Control/Fecal Incontinence • Colonoscopy • Endoscopic Ultrasound • Esophageal Motility Disorders • Manometric and pH Studies • Non-surgical Hemorrhoid Treatment • Radiofrequency Ablation (for Patients with Barrett’s Esophagus)

407.384.7388 | www.dlcfl.com 22 FLORIDA MD - OCTOBER 2016

specific antigen (PSA) blood test will show the levels of PSA in a man’s blood. PSA is made by the prostate gland. High PSA levels suggest that prostate cancer may be present. Sometimes though, men with normal PSA levels are diagnosed with the disease. During the second test, a digital rectal examination (DRE), physicians are able to feel if the prostate is abnormal in some way, such as size or hardness. Abnormalities in these tests do not automatically point to cancer. Often other benign conditions may be diagnosed, such as benign prostatic hyperplasia (BPH). BPH is a disease that causes the urethra to narrow and the prostate to enlarge, resulting in difficulty urinating. If a slow-growing tumor is found, sometimes a patient will have the option to forego surgery. However, a recent study found that when prostate cancer tumors are left untreated, they become deadlier after 15 years. In addition to screening, men can take precautions to prevent prostate cancer. One potential risk that can be controlled is diet. It is recommended that men eat at least five servings daily of healthy foods, such as fruits and vegetables. Tomatoes of any kind (fresh, sauces, ketchup, etc.), pink grapefruit and watermelon are especially beneficial because they contain lycopenes, which are antioxidants, and have been linked to prostate cancer prevention. Prostate cancer affects more than 230,000 men each year, but regular testing and healthy eating habits are important tools to fight the disease. If you have questions or concerns about prostate cancer, contact your physician. For patients undergoing cataract surgery, the Tecnis® Symfony offers those whose conditions qualify for the new lens the chance to enjoy exceptionally crisp, clear vision, some for the first time in their lives. Says Dr. Wehrly, “This is an exciting development in IOLs and Lake Eye is proud to be the premier provider of this amazing technology.”

Dr. Axel Anderson graduated from Vanderbilt University in 1978 with a Bachelor of Arts Degree in Psychology/Zoology. After earning his Medical Degree at Ross University, he undertook his residency in General Surgery at University Hospital in Jacksonville. He then completed his Urology residency at the University of Connecticut Health Center, where he was named chief resident. Dr. Anderson earned his board certification in Urology in 1992. His practice, Urology Associates of St. Cloud, opened in 2010 at 2900 17th Street, Suite 2 St. Cloud, Fl 34769. To schedule an appointment call 407-891-2951 or for more information visit StCloudPhysicans.com. 

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• Newsletter • Responsive Web Design • SEO • Social Media • Traditional Advertising • Video

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Visit Our Website at

FloridaMD.com Your Medical Business Resource

• Practice Management Advice • Financial Information • Pod Cast Interviews with Specialists and Professionals • Medical Classifieds • Back Issues with Informative and Interesting Stories

For Information Please

Email: info@floridamd.com or call 407.417.7400

COMMUNITY HEALTH FAIR Saturday, November 12th, 2016 10:00 a.m. - 2:00 p.m. 100 N. Dean Rd. • Orlando FL 32825

For Directions and more information please call 407-384-7388 ext.722 • FLU SHOTS (FREE IF NO INSURANCE) RAFFLE OF MAMMOGRAM CERTIFICATES • FREE BLOOD SUGAR TEST RAFFLE PRIZES • FREE HEALTH SCREENINGS • FREE CHOLESTEROL CHECKS FREE 4 RIVERS BBQ • FREE HOT DOGS • POPCORN • FREE OCCULT BLOOD KIT • FREE BLOOD PRESSURE CHECK • FREE HEPATITIS C TEST

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24 FLORIDA MD - OCTOBER 2016

2016

EDITORIAL CALENDAR

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

JANUARY –

Digestive Disorders Diabetes

FEBRUARY –

Cardiology Heart Disease & Stroke

MARCH –

Orthopaedics Men’s Health

APRIL –

Surgery Scoliosis

MAY –

Women’s Health Advances in Cosmetic Surgery

JUNE –

Allergies Pulmonary & Sleep Disorders

JULY –

Imaging Technologies Interventional Radiology

AUGUST –

Sports Medicine Robotic Surgery

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

Cancer Dermatology

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

Please call 407.417.7400 for additional materials or information. FLORIDA MD - OCTOBER 2016 25

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