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FROM THE PUBLISHER
Iam 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,
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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: John “Lucky” Meisenheimer, MD, Daniel T. Layish, MD, Ramamoorthy Nagasubramanian, MD, Scott Bradfield, MD, MBA, Andy Kolb, MD, Naina Mehta, MD, Sonda Eunus, MHA, Michael Patterson NHA, OTR/L, CEAS, Juan Lopez, Pharm D, Pragati Gusmano, ND, John Meisenheimer, VII Art Director/Designer: Ana Espinosa Florida MD is published by Sea Notes Media,LLC, P.O. Box 621856, Oviedo, FL 32762. Call (407) 417-7400 for more information. Advertising rates upon request. Postmaster: Please send notices on Form 3579 to P.O. Box 621856, Oviedo, FL 32762. Although every precaution is taken to ensure accuracy of published materials, Florida MD cannot be held responsible for opinions expressed or facts expressed by its authors. Copyright 2021, Sea Notes Media. All rights reserved. Reproduction in whole or in part without written permission is prohibited. Annual subscription rate $45.
A recent study published in the JAMA NETWORK asked the age-old question; Is there an Association between Marijuana Exposure and Pulmonary Function over 20 years? The study can be found via the link below:
Association Between Marijuana Exposure and Pulmonary Function Over 20 Years | Adolescent Medicine | JAMA | JAMA Network
What they discovered was that “occasional and low cumulative marijuana use was NOT adverse effects on pulmonary function”. In other words, cannabis smoke – unlike tobacco smoke – doesn’t have such a drastic impact on lung function despite having some of the same chemical profile in smoke.
The study performed was called CARDIA, which is a longitudinal study designed to measure risk factors for coronary artery disease in a cohort of black and white women and men (n = 5115) aged 18 through 30 years and healthy at enrollment in 1985. Participants were sampled from 4 US communities without selection for smoking behaviors and comprise a broad crosssection of typical tobacco and marijuana use patterns.
Each study center (Oakland, Chicago, Minneapolis, and Birmingham), participants underwent a baseline examination and 6 follow-up examinations, with 69% retention at year 20. Pulmonary function testing was performed at years 0, 2, 5, 10, and 20. For this investigation, we included all visits for which pulmonary function, smoking behavior, secondhand smoke exposure, height, and waist circumference were available.
Current intensity of tobacco use (cigarettes smoked per day) was assessed at each examination. These data, along with baseline examination data on past years of smoking, were used to estimate cumulative lifetime exposure to cigarettes in terms of pack-years, with 1 pack-year of exposure equivalent to 7300 cigarettes (1 year × 365 days/y × 1 pack/d × 20 cigarettes/pack). Misclassification of smoking exposure by self-report, measured by comparisons with serum cotinine levels, is uncommon.
Current intensity of marijuana use (episodes in the last 30 days) was also assessed at each examination. Using baseline examination data on past lifetime exposure to marijuana, current intensity of marijuana use, and another question designed to assess number of joints or filled pipe bowls smoked per episode we calculated total lifetime exposure to marijuana joints in joint-years, with 1 joint-year of exposure equivalent to 365 joints or filled pipe bowls smoked (1 year × 365 days/y × 1 joint/d), as described previously.
The 5115 CARDIA participants recruited in 1985-1986 contributed 20 777 total visits that included pulmonary function testing. Of these, 959 visits were excluded for lack of complete information on smoking behavior, 114 for lack of height or waist measurements, and 1 for an unknown visit date, leaving 19 703 visits (95%) with complete data from 5016 participants (98%). Participants contributed 3.9 visits/participant on average; attrition was more common in tobacco smokers but not associated with marijuana use. FEV and FVC varied across participants, increased slightly with age through the late 20s, and declined slowly thereafter.
More than half of participants (54%; mean age at baseline, 25 years) reported current marijuana smoking, tobacco smoking, or both at 1 or more examinations. Smoking patterns differed by race and sex, with black women most likely to smoke tobacco only, white men most likely to smoke marijuana only, and black men most likely to smoke both. Tobacco smokers tended to have lower education and income and to be slightly shorter and less active, whereas marijuana smokers tended to be taller and more active. The median intensity of tobacco use in tobacco smokers was substantially higher (8-9 cigarettes/d) than the median intensity of marijuana use in marijuana smokers (2-3 episodes in the last 30 days). Although marijuana and tobacco exposures were strongly correlated, our sample included 91 participants with no tobacco exposure and more than 10 joint-years of marijuana exposure (contributing 153 observations of pulmonary function), 40 (56 observations) of whom had more than 20 joint-years of exposure.
The findings suggest that occasional use of marijuana for these or other purposes may not be associated with adverse consequences on pulmonary function. It is more difficult to estimate the potential effects of regular heavy use, because this pattern of use is relatively rare in our study sample; however, our findings do suggest an accelerated decline in pulmonary function with heavy use and a resulting need for caution and moderation when marijuana use is considered. ANALYSIS
While this study is good news, smoking cannabis for medical purposes is not the most efficient way to consume medicine. A lot of cannabinoid effects are lost when cannabis is burned to be smoked. A similar, but better way to consume cannabis is via vaporizer or vape pen. The cannabis not being burned but heated into a vapor, which maintains all of the cannabinoids in order to be available for absorption into the body. Furthermore, more accurate dosing of cannabis can be found via edibles or tinctures, which allow a patient to have a measured amount of cannabinoids (THC, CBD, THCA, CBG, CBN, etc.) to build confidence and certainty in the reaction of cannabis medicine on the body.
Michael Patterson NHA, OTR/L, CEAS is CEO of US Cannabis Pharmaceutical Research and Development LLC. (uscprd.com). He is a healthcare executive with 25+ years experience in: Cannabis-Hemp investment, Law, Regulation, Compliance, Operations, & Management, Skilled Nursing, Pharmacy, Laboratory, Assisted Living, Home Healthcare, & Healthcare Analytics. He is a subject matter expert in the Global Cannabis and Hemp Industry with Gerson Lehrman Group (glg.it) & Guidepoint. He is an editorial board member of the American Journal of Medical Cannabis, licensed Nursing Home Administrator, & li-
censed Occupational Therapist in 4 states.
Nemours Children’s Health –
Building Central Florida’s Premier Pediatric Orthopedic Program
By: John Lovejoy, III, MD, Chair of Orthopedics, Nemours Children’s Health
Nemours Children’s Health has been caring for children and adolescents for more than 80 years. But in Central Florida, our footprint and services have grown exponentially during the past decade.
There’s been a tremendous amount of change over the years since we first started seeing patients in Central Florida in 1997. Not only did we open Nemours Children’s Hospital in 2012, but we made a conscientious effort to extend our services out into local communities throughout Central Florida.
HOSPITAL IMPACT
Previously, we were in agreements with other children’s hospitals to provide our surgical and inpatient care but having our hospital in Lake Nona has really changed the dynamics of our department and the care we can provide.
We have outstanding access to operating rooms and leadingedge technology. The hospital also supports us as a department with clinic space and inpatient services, which makes for a more seamless process. And when it comes to our offsite outpatient clinics, it’s easy to get patients back to the hospital, when necessary, for emergent or nonemergent treatment. Combine all of that with the support of our foundation, and it gives us the flexibility and some opportunities that might be more challenging in a different situation.
CARE CLOSER TO HOME
It became more apparent as our organization grew its reputation and awareness that we were drawing patients from all across Florida. But we knew that families in Central Florida really wanted more expert care closer to home whenever possible.
As an orthopedics department, we developed a thoughtful plan to see how we could grow and expand our presence in the region. This resulted in a combination of projects with some of our internal Nemours Children’s programs like other surgical specialties and our primary care offices. Our organization as a whole looked at opportunities to partner with other organizations in the communities we serve as well. Through that approach we ended up with seven locations for orthopedics in Central Florida, with our services really anchored at Nemours Children’s Hospital in Lake Nona.
We believe it’s really important to get into the neighborhoods where our patients live. As an organization, we want to be a part of the communities around Central Florida. When you’re there in person, it’s easier to truly become part of the community. For the day-to-day visits or follow up visits, people prefer to have those appointments closer to home. Without these services located in neighborhoods, it leaves communities vulnerable. In some cases, we need to bring families to our hospital in order to provide them with the highest level of care and ensure the best outcomes. Then we can give them the opportunity to have follow up visits at a clinic near where they live. I think that’s really beneficial for the families we serve.
In several of the areas that we provide care, we continue to grow our services. We might start out
Nemours Children’s has grown its orthopedics and sports medicine program to now include a comprehensive team of pediatric orthopedic surgeons, sports medicine physicians and physician assistants along with additional support staff to offer a full range of expert care throughout Central Florida.
seeing patients one or two days a week at a location, but then we can expand as the demand increases.
For these outpatient clinics, we are in locations that can provide the most impact. We started caring for patients in Central Florida at our clinic in downtown Orlando, but then added services in Lake Mary, Melbourne and Winter Garden. Then our Lake Nona outpatient clinic on Narcoossee Boulevard was our first really specialized clinic offering dedicated fracture and sports medicine services five days a week to help fill those specific care needs. We also have a partnership with Lakeland Regional Health to provide pediatric orthopedic care for kids, along with other pediatric services, at their facility.
This growth has truly helped increase our overall presence throughout Central Florida as well as our dramatically increasing our patient access.
We had around 10,500 patient visits in 2014 and we’re now projected to conduct around 35,000 patient visits in 2021.
PARTNERING WITH THE COMMUNITY
As we build upon our services within our walls, our team continues to look for ways to partner with other types of organizations to help strengthen our presence in local communities. That often means providing our expertise to groups that share our same goals in improving the lives of children and adolescents. We are thrilled to serve as an official Medical Services Provider of the USTA National Campus which is located just down the road from our hospital in Lake Nona. Our sports medicine physicians are able to provide on-site care along with preventive and educational support for their athletes. We also work with Nona Soccer Academy as their medical partner and provide health care support to some of our local schools.
BUILDING SUCCESS WITH STAFFING
As part of our continued growth, we’ve enjoyed the ability to recruit an outstanding team. Our staff of providers was comprised of only three physicians and three physician assistants early on. Over the years, we’ve been able to grow that to seven surgeons, three non-operative sports medicine physicians, and nine PAs, including a PA who is dedicated to providing a reduction clinic in our hospital’s emergency department Monday through Friday. This is combined with a full complement of support staff to allow us to better serve the needs of our patients and their families across Central Florida.
IMPROVING ACCESS AND SERVICE OPTIONS FOR FAMILIES
All of this growth and expansion has allowed us to not only increase our access, but it has also allowed us to expand the subspecialties in pediatric orthopedics that we are now able to offer. We have specifically recruited specially trained physicians that give us the opportunity to improve our offerings in areas like sports medicine, spine, complex hip, limb reconstruction, tumor, foot and ankle, and a variety of other areas that were underrepresented.
We also looked for some opportunities outside of our organization, so we developed a partnership with a private practice that specializes in hand and now we’re able to have their surgeons come to our facility on a monthly basis and perform complex hand procedures. This gives us the ability to serve yet another segment of the pediatric orthopedic patient population in the Central Florida.
EDUCATION AND RESEARCH
Other areas that have dramatically changed over the years for us is our involvement in academics and research. In 2018, we were able to create the opportunity to have HCA residents complete rotations at Nemours Children’s Hospital. We also started a Fellowship program at our hospital. We were able to graduate our first orthopedic Fellow in June and have others lined up for next two years and continue to match for following years.
We have significantly expanded our involvement in research. Six of our faculty members are very actively involved in research and we have two grants in the department now. We have also grown the research infrastructure that supports our work, including the recruitment of a new research director. WORKING WITH REFERRING OFFICES
For our referral base, we want them to know we’re here in their communities as a resource. We’re here to listen to their concerns and problems and we’re accessible to them. They can also get to know our local doctors that service their area, so they’ll have a
Nemours Children’s has focused on enhancing its subspecialty care offerings throughout the years, including program areas like its spine center, to better serve families throughout Central Florida.
point person to go to when they need them. Our goal is to work with primary care providers – or other referring physicians – as partners in caring for their patients to ensure they receive the best care available to them.
DIRECTION OF THE DEPARTMENT
Overall, we’ve seen a dramatic change over the last decade. We’ve gone from being a small number of individuals providing a very select service at a single outpatient location to a full-blown department able to provide service to a catchment area of over 2.2 million. We’ve seen our volumes triple in that time and really generated some financial and operational success for our department.
Throughout this process, the priority for our orthopedics department has always remained the same: to build a true center of excellence. Our goal is to ‘provide an elite level of care and customer service to patients in need of pediatric orthopedic services in and around Central Florida,’ so the focus is centered around patients and their families.
For us, that focus breaks down into three categories:
Associates – having the right team in place and being dedicated to recruitment and retention
Quality – having superior outcomes that are the highest quality not only in the region but in the country
Customer Service – providing care in a way that is appealing to families and meets their needs while being as convenient as possible for them
We always strive to provide the highest level of care with the best customer service and some of the best outcomes with the lowest complications based on national metrics. We have been on a mission to really redefine how pediatric orthopedic care is provided in Central Florida. It hasn’t been perfect, and we’ve had to learn along the way, but we have not deviated from that underlying goal of building a true center of excellence for pediatric orthopedic care.
Every day our team comes into work wanting to be the best they can be. As families experience that, they realize what that care should look like now. It’s a dynamic process and we are constantly looking for ways to do it better. We are constantly trying to understand what needs we aren’t meeting well enough so we can redirect our efforts and resources to help meet those needs.
Our mission is to take care of all of the kids in Florida who seek out our help – even the ones who never step inside one of our buildings.
Nemours Children’s continues to grow its presence within the communities it serves by partnering with local organizations including the USTA National Campus and Nona Soccer Academy, among others. 2020 NEMOURS BY THE NUMBERS
Call (407) 650-7715 or visit Nemours.org to find out
more or schedule an appointment. 28,694 Total outpatient visits 1,282 Total surgical cases 193 Spinal procedures 1.1% Infection rate for all orthopedic procedures 14 Peer reviewed articles 14 Book chapters 14 National presentations
