Floridamd october 2013 by FloridaMD

OCTOBER 2013 â&#x20AC;˘ COVERING THE I-4 CORRIDOR

Integrated Mathematical Oncology at Moffitt Cancer Center: Pushing Boundaries, Inciting Innovation

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FLORIDA MD - OCTOBER 2013

FROM THE THE PUBLISHER PUBLISHER FROM

am pleased to bring you a new issue of Florida MD. Every year thousands of Americans Iam pleased to bring you another issue of Florida MD Magazine. It’s hard to imagwill be diagnosed some form of cancer. In particular, ovarian ine anyone who is notwith familiar with the March of Dimes and the work they cancer do to is expected to strike approximately 23,000 women in the United States this year, making it the

second-highest ranked gynecologic disease, according the American always reinventing themselves to create new programs andtoservices. Coming Cancer up next Society. The month is the annual March for Babies. It’s a wonderful team-building opportunity for throughout Ovarian Cancer Alliance of Florida (OCAF) works with doctors and nurses the state to make sure healthcare providers receive the latest information about -this deadly tions on how you and your family can join the march or how to form a team for your disease. I urge you to join me in supporting OCAF and their efforts to save women’s lives. whole practice. I hope to see some of you there. Best regards, Warm regards, Donald B. Rauhofer Publisher

Coming Next Month: The cover story focuses on the BayCare Hospitals Breast Care Centers. Editorial focus is on Urology and Geriatric Medicine.

Donald B. Rauhofer Nurses hold theCoordinator key to unlocking a door that could lead to early detection and treatment of ovarian cancer. The Ovarian Cancer AlPublisher/Seminar liance of Florida (OCAF) has been working hand-in-hand with nursing students to teach them to spot symptoms of the disease before it’s too late. When Join OCAF’s more than a million people walking in March of Dimes, March for Babies and Nurses Educational Initiative (NEI) is training nurses at Central Florida universities to fully understand ovarian cancer and Saturday, April 24th in many cases, can raising help givequestions every baby a healthy start! Invite your family friends to askmoney patientstothe right to make the necessary connections thatand could result in an early diagnosis which, 7am Registration 8am Walk life.in March for Babies, or even form a Family Team. You can also join with tosave joinayou not news anyonea that rely on nurses relaymore details aboutand a patient not find out otherwise. Sometimes your It’s practice and to become teamphysicians captain. Together you’lltoraise money share they might Where a patient thinks a symptom is insignificant and may not want to bother her busy doctor with what she believes is “probably nothing.” a meaningful experience. Lake Lily Park, Maitland To an untrained healthcare professional, ovarian cancer symptoms – bloating, back pain, constipation and abnormal bleeding – could mean many things or nothing at all. But to a nurse who has been through the NEI program, these symptoms could be the green light Some keys to success: Ask your friends, For more information on March Steps for New Users: to move toward the crucial early diagnosis of ovarian cancer. family and colleagues to support you by for Babies please call: 1. The Go to marchforbabies.org NEI curriculum, with trained facilitators who are also ovarian cancer survivors, is offeredPhone: to nursing students during a single class (407) 599-5077 2.period. ClickThe JOIN A TEAM students are given a pre-test to see what they already know about ovarian cancer. They are then given a Fax: (407) 599-5870 visual presentation the most recent statistics scientific facts. After hearing survivors recount their cancer stories, students are then provided time 3.with Search for your team nameand in the reason why people do not donate is that Central Florida Division forsearch a Q&Abox. session and a follow-up evaluationnotoone determine the program’s effectiveness. asked them to give (don’t be shy)! 341 N. Maitland Avenue, Suite 115 Emailing them is an easy way to ask. OCAF works with various physicians, healthcare agencies and others to take this effective course into the classroom. To learn more Maitland, FL 32751 4. Click on your team name about the NEI program and how you can partner with OCAF, call 407-339-0024 or visit them at www.ocaf.org. 5. You’re done! Your personal page has been created for you and you are ready to begin fundraising! password for future reference.

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Publisher: Donald Rauhofer Associate Publisher: Magley Photographer: DonaldJoanne Rauhofer / Florida MD; Photographer: Tim/ Kelly / Tim Kelly Portraits, Nicholas J. Gould Moffitt Cancer Center Donald Rauhofer / Florida MD Magazine Contributing Writers: Cherie Faircloth, Harinath Contributing Writers: Magley, Sheela, MD, James D. Joanne Huysman, Psy.D,Sam Jennifer Pratt RPh, Mitchell Levin, MD, Thompson, Corey Gehrold, SyedJennifer Mobin, MD, Tom Thompson, Vincenzo Giuliano, MD, DavidTrotti S. Murphy, Jimmy Caudell, MD, PhD, Andrea Klein, Stephen P. Toth, CLU,Reed, Jennifer III, MD,MD, T. Kevin Taylor, Katherine MD, RobertsKlein, MD Richard Designer: Ana Espinosa

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contents Photo: Nicholas J. Gould / MOFFITT CANCER CENTER

OCTOBER 2013 COVERING THE I-4 CORRIDOR

 COVER STORY

Imagine a floor plan for a scientific research building where you have the offices of a prolific grant funded Department Chair of Diagnostic Radiology and Chair of Cancer Imaging and Metabolism next to a team of creative mathematicians and graduate students. Envision a “collaboratorium” where couches, a blackboard, and an espresso machine invite ad hoc scientific discussion throughout the work day. Conjure up a lab where the way cancer cells grow and metastasize can be modeled on a computer. All this and you have just seen only the first ripple in the vast pond of Integrated Mathematical Oncology (IMO) at Moffitt Cancer Center.

Photo: Nicholas J. Gould / MOFFITT CANCER CENTER

ON THE COVER: Integrated Mathematical Oncology at Moffitt Cancer Center

24 BREAST TOMOSYNTHESIS 29 New Surgery Provides Option for those Afflicted with Lymphedema 31 CURRENT TOPICS

DEPARTMENTS 2

FROM THE PUBLISHER

MARKETING YOUR PRACTice

12 PULMONARY & SLEEP DISORDERS 14 Behavioral Health 16 Medical Malpractice Expert Advice 18 ORTHOPAEDIC UPDATE 20 CANCER 22 FINANCIAL UPDATE: Insurance•Benefits•Wealth MGMT. 26 DIGESTIVE AND LIVER UPDATE

FLORIDA MD - OCTOBER 2013

COVER STORY

Moffitt Cancer Center’s Integrated Mathematical Oncology Team:

Pushing Boundaries, Inciting Innovation By Sarah E. Hoffe, MD Imagine a floor plan for a scientific research building where you have the offices of a prolific grant funded Department Chair of Diagnostic Radiology and Chair of Cancer Imaging and Metabolism next to a team of creative mathematicians and graduate students. Envision a “collaboratorium” where couches, a blackboard, and an espresso machine invite ad hoc scientific discussion throughout the work day. Conjure up a lab where the way cancer cells grow and metastasize can be modeled on a computer. All this and you have just seen only the first ripple in the vast pond of Integrated Mathematical Oncology (IMO) at Moffitt Cancer Center.

ity” of cancer cells: what promotes the evolutionary mechanisms underlying these adaptations? What happens at the level of the tumor microenvironment surrounding the neoplastic cells? Can such growth patterns be modeled prospectively by incorporating data from “super” computers? And, perhaps most importantly, are these models true to life in vivo? Moreover, can they be prospectively predictive and potentially modified to maximize treatment effect? Yes, the “aha” moment now resonates. Moffitt Cancer Center

For an NCI-designated comprehensive cancer center whose mission is the prevention and cure of cancer, the strategic investment in the IMO may seem like an unusual choice. Dr. Gatenby agrees, noting that there are few programs of its kind in the world. Yet what may seem non-intuitive at first glance gains a payload of traction as you dig beneath the surface. Consider the “immortal-

Photo: Nicholas J. Gould / MOFFITT CANCER CENTER

The chief architect of the IMO has been Dr. Robert Gatenby. Dr. Gatenby left the University of Arizona and recruited many of his colleagues, such as Robert Gillies, PhD, to build a new scientific universe at Moffitt that brings these diverse specialists together under one roof. When “the Bobs” came to Tampa, the senior leadership at Moffitt quickly realized that “thinking outside the box” did not apply to a team that did not even see a box to transcend. Indeed, as the Chair of the IMO, Alexander R.A. “Sandy” Anderson, PhD, notes, “Cancer is a dynamic complex multi-scale system that can only truly be understood via the integration of theory and experiments. The goal of the IMO is to use such an integrated approach to better understand, predict, and treat cancer.”

Robert A. Gatenby, MD.

Photo: Nicholas J. Gould / MOFFITT CANCER CENTER

Dr. Gatenby (above photo) and Dr. Alexander “Sandy” Anderson (second from right) invite ad hoc scientific discussion with their IMO team.

4 FLORIDA MD - OCTOBER 2013

COVER STORY

Progress to date has been steady. Thanks to Dr. Anderson’s selective recruitment and the lure of the IMO’s unique environment of open collaboration, the IMO now houses a robust faculty as well as a large research lab where tumors can be modeled, imaged, and treated in animals. In addition, the IMO has a formal relationship with the Mathematical Biology Program at Oxford University dedicated to the training of PhD candidates in mathematical oncology, such as Dr. Jacob Scott. Those of you who watched the 2012 TedMed talks may recall his standing ovation lecture. You may have seen him come to the stage following prominent healthcare experts such as the national director of the Centers for Disease Control and the Director of the National Institute of Health. You may have wondered how a young astrophysicist and former nuclear sub engineer, now training in radiation oncology at the USF/Moffitt program, became so interested in mathematical oncology that he extended his residency to simultaneously obtain a PhD in the combined Tampa/ Oxford Mathematical Biology program and how his work earned him a TedMed invitation. To know Dr. Scott, however, is to see the immediate answer: his passion is to find ways to inject imagination into medicine to cure cancer. As Dr. Scott notes, “In medicine, we memorize, we recite…. that is not what we need. We need to collaborate, innovate, and develop new pipelines of thought that cross pollinate the best ideas from different disciplines. We have too many dots in biological science that don’t get connected. That is what the IMO is all about. That is what kind of physician I want to be….. A dot connector in the purest sense.” For example, Dr. Scott became interested in the lack of a coherent understanding of the mechanisms of cancer metastasis despite the detailed knowledge many biologists had of certain aspects of the metastatic process. Frustrated with the lack of overwhelming progress in changing the death sentence of metastasis, Scott joined forces with Alexander R.A. Anderson, PhD. Together with Peter

Photo: Nicholas J. Gould / MOFFITT CANCER CENTER

has long been a national leader in the concept of individualized cancer care as espoused for the last decade by former cancer center CEO and current M2Gen CEO William Dalton, MD, PhD. Dr. Dalton and his colleagues recruited “the Bobs”, in fact, to explore new scientific frontiers at Moffitt with bold pursuit of the personalized cancer care dream.

Moffitt/Oxford PhD Candidate Dr. Jacob Scott at work.

Kuhn, PhD of the Scripps Research Institute Physical SciencesOncology Center they developed a unifying theory on the causes of cancer metastasis that was published in a May 24, 2012 Nature Reviews Cancer article. Their article explores the role of the circulating tumor cells (CTCs) that are in the blood vessels of advanced cancer patients in the development of metastatic disease. They note that although both the site of a metastasis (the soil) and the metastatic cells (the seeds) are needed for cancer dissemination to occur, just how the seeds seek specific soil is not clear. Dr. Scott thinks that it is indeed just a dilemma like this that mathematical oncology can help clarify. As he noted in the Journal of the National Cancer Institute (JNCI), “we think this process is governed by solvable physical rules that relate to the dynamics of the circulatory flow between different organs and how these organs filter. Although these biological mechanisms are not yet known, we might be able to infer their existence by finding out which measurements do not fit a model that is defined only by physical flow and filtration.” The IMO has been very successful in grant funding for pioneering research such as this. In 2011, Dr. Anderson and colleagues were awarded a 5 year $3 million dollar grant to model the aggressiveness of prostate cancer. The problem of metastatic prostate cancer is ripe for mathematical modeling: who are those patients that respond to systemic therapy? Some respond transiently and some don’t respond at all. How can models be generated to predict such tumor behavior and guide the clinician to give therapy that FLORIDA MD - OCTOBER 2013

Photo: Nicholas J. Gould / MOFFITT CANCER CENTER

COVER STORY

Dr. Robert Gillies working on the imaging correlation of tumor heterogeneity.

maximizes the patient’s time to progression?

logical information can be generated before they go home.”

Work such as this is ongoing in the IMO and getting closer to clinical reality according to Dr. Gatenby.

Drs. Gatenby and Gillies have also infused cutting edge analysis of imaging for response identification. Many patients often find this aspect of care the most frustrating. They visit their physician, have a scan, and wait for the dreaded report. Often, disappointment ensues, with ample uncertainty of what these imaging findings “mean” with respect to their individual prognosis.

“We’re fairly close to developing computational models for every patient’s individual cancer that takes advantage of all their personal data at the genomic, cellular, clinical, demographic and imaging level. The conceptual model is then like a hurricane….. We need models to predict the path of a hurricane since any complicated system cannot be understood intuitively. So, if we view the cancer like a hurricane, we can then determine the various paths that are possible. What if we did not do anything, then based on where the cancer ‘has been’ and where it ‘is now’ scenario X is likely. Alternatively, if we perturb it with various therapies, then the model will predict scenario Y. And if we do perturb it with these therapies, the model would need to be continually updated as we give the therapy so we can get real time information to readjust it’s course.” Dr. Gatenby explains further, “we are making significant progress in multiple myeloma at Moffitt. In fact, for myeloma, we have developed computational models for individual tumors based on data from bone marrow biopsies, aspirated cells, clinical data, and previous therapies. The goal here is to help guide the clinician with reliable information for the individual patient about the specific drug and dose, as well the timing and duration of administration. The dream is for the patient to come in to Moffitt Cancer Center and a computer model integrating all of their clinical and patho6 FLORIDA MD - OCTOBER 2013

This could all change, according to “the Bobs.” Both have been exploring ways of extracting data from the patient’s imaging that can be further characterized and studied to go way beyond the traditional report. Some of this work has been done in collaboration with the MAASTRO center in Europe. The results are yielding new ways of interpreting patient data that can be incorporated into these predictive models to help the individual patient truly gain valuable insight into the course of their disease and prognosis. Dr. Gatenby reports some early progress in glioblastoma, the lethal brain tumor that Ted Kennedy succumbed to a few years ago. “We can view cancer not as a self-organized organ like system but as a coalition of habitats each with different blood flow and other adaptive characteristics. Each habitat has a unique pattern of responsiveness to different therapies. In glioblastoma, we can gain a lot of information from the patient’s magnetic resonance imaging (MRI) scan. We have found that there are typically five

COVER STORY

Given that imaging data is like the human brain, with vast areas housing untapped information, how might the radiology program of the future appear? If Dr. Gatenby could wave his magic wand, he would ensure that novel molecular agents exploiting different processes of the cancer cell and its microenvironment be developed so that we could maximize non-invasive prognostic information merely by imaging the patient. For example, there is the potential of nanoparticles to be incorporated as imaging contrast agents. Work has been reported from Moffitt Cancer Center and University of Florida collaborators on the promise of nanotechnology for solving clinical problems in breast cancer. Consider the current difficulty discriminating between benign and malignant lesions within the breast. The current standard of care after careful imaging is typically to proceed with a biopsy if there is radiographic concern for cancer. The future may include using these nanoparticles as part of breast imaging to non-invasively determine whether the lesion is malignant. If cancer is diagnosed, nanotechnology may play a role in sentinel node evaluation with possible elimination of the need for axillary surgery in many patients. Validation of innovative agents such as these would change patient care dramatically.

Photo: PROVIDED BY MOFFITT CANCER CENTER

habitats that we see consistently. We have analyzed this and found that the higher the number of low vascular habitats, the worse the prognosis can be. Thus, by integrating additional features from the patient’s MRI scan, we can gain individual prognostic information that may be helpful for stratifying patients so that we know which patient would benefit from which individual therapy.”

Computer model of a glioblastoma. Lab work with computer models holds promise.

Photo: Nicholas J. Gould / MOFFITT CANCER CENTER

Ultimately, the ideal radiology reading room would be then be transformed. Imagine that the patient’s scan is up on the viewing station. The radiologist clicks on the image, sends it to a partner vendor who analyzes the data to look at the habitat of the tumor, generate a relevant metric about the status of the disease, and send the information back in real time so that the doctor in the clinic can use the information to guide patient management. The clinician wants to know if the patient is responding, and if not, wants the FLORIDA MD - OCTOBER 2013

Photo: Nicholas J. Gould / MOFFITT CANCER CENTER

COVER STORY

Dr. Sandy Anderson, the IMO Chair, in the collaboratorium.

earliest possible data point to know a “non-responder” so that therapy can be modified immediately. Dr. Anderson agrees that “Imaging is certainly a crucial part of the toolset that the IMO needs in order to validate and parameterize its models but another important piece of this puzzle is basic science experiments, whether they are in the dish or in the mouse; they can provide critical insight as to the realism of the models and allow them to be tuned and/or modified if they don’t fit with the biological reality. Perhaps the ultimate contribution of the IMO will be to provide a new way to look at an old problem, to give our collaborators a set of mathematical glasses that allow them to see their own research in a completely new light. It’s common that experimentalists develop their own mental map of how different components of a system interact and drive specific outcomes (such as treatment failure), however, this systemic view was derived from many experiments that considered each interaction in isolation. Mathematical models allow us to place the complete system in an integrated framework where we can directly examine the impact that changing one component (or multiple) has on the whole system. This often drives new experiments that ultimately lead to a deeper understanding of the system. This iterative dialogue between theory and experiment is why the I in IMO stands for integration: over biological scales, across disciplines, within a cancer center. With the IMO, such goals appear within reach. After all, this diverse and interdisciplinary group is already breaching borders and unifying mathematics, computer science, imaging, clinical 8 FLORIDA MD - OCTOBER 2013

science, radiological physics and experimental biology. The scientific body of work that is emerging spans multiple specialty fields with a common goal that has been inspiring integration. Moffitt’s NCI designated comprehensive cancer center is modeling the cure to cancer…. Now, as Dr. Scott would say, we just have to connect the dots. 

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Marketing Your Practice

Google Encrypting All Keyword Searches: What That Means to You By Jennifer Thompson, President of Insight Marketing Group You may have heard of a little upstart search engine calling themselves Google. Averaging just over 5 billion searches per day throughout the world, Google has become the undisputed â&#x20AC;&#x153;go toâ&#x20AC;? answer engine. Recently, theyâ&#x20AC;&#x2122;ve started to encrypt all keyword searches, making it more difficult to drill deep into what people are looking for when searching and thus write your online content accordingly. But what does that mean for your Orlandobased medical office marketing? We explain below.

Background Keywords are the search terms a user enters to find content around the web. Successful inbound marketers have been using the data for years to help determine how to help clients display in search results with higher rankings throughout Google. Think about it: by knowing what people are looking for to find your site (or your competitors), it helps you know how you should word things in order to be found even more. You can watch trends for free â&#x20AC;&#x201C; or at least you used to be able to.

In 2011, Google started to add Secure Sockets Layer (SSL) encryption for users signed-in to Google and Google-related products (Chrome, G Mail, YouTube, etc.). Essentially, that meant anything you searched for was encrypted to keep it private as long as you were signed in to your Google account. But, the search giant is now working to bring this extra level of protection to everyone that uses the site â&#x20AC;&#x201C; but why? Sure, extra protection is great and all, but many inbound marketing minds think the switch is an attempt by Google to block NSA spying activity through their products. Since Google was recently accused of giving the NSA accesses to its search data (which they have repeatedly denied), this would be an extra step to protect users. Way back in 2011, Google said the encryption would impact less than 10 percent of searches conducted. In January of this

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FLORIDA MD - OCTOBER 2013

Marketing Your Practice year, however, about 55 percent of organic searches were encrypted says Hubspot. Today, according to the website Not Provided Count, nearly 74 percent of search terms are encrypted.

What Does it Mean for You? The answer to that depends entirely on how much you used to use keyword data in your marketing efforts. If you have no idea what we’re talking about, it won’t change what you do at all. However, if you were using keywords to help you strategize your online marketing presence, it’s a bit of a blow (even if the intention is a worthy one). Although we don’t know exactly when the data will be made unavailable, it’s still something on the minds of many marketers throughout Central Florida and the U.S. We’ve always said that great content is worth far more than any keyword, and that still rings true. When you have quality content that’s shared and endorsed from authoritative websites, you will help your office and your website more than picking a few “hot” keywords any day of the week. Even without specific keyword information, you’ll still be able to track how much traffic comes to your website through organic searches via Google Analytics. This will allow you to correlate what you’re doing to help determine, at the very least, that your content creation efforts are paying off. Also, for the time being at least, you can still connect your Google AdWords account to Google Analytics and use that data for keyword research. Of course, this only works if you’re paying for pay-per-click advertising through AdWords. You will still be able to see clicks on your ads, so don’t worry there.

The Wrap Up Although this makes marketing a little bit more difficult, it’s not the end of the world. If you’ve ever done any of your own physician office marketing, you know that we are generally dealing with incomplete data no matter what project we’re working on. The trick is, and has always been, to interpret that data into meaningful ways that will fill up your appointment and/or surgery schedule. That remains unchanged. If you remember nothing else from this article, remember that even without keyword data, the best way to ensure a successful inbound marketing program for your medical practice is content. Then content again. Then content one more time.

Marketing Your Medical Practice: A Quick Reference Guide Are you ready to finally start marketing your practice? Visit www.InsightMG.com to get your copy of “Marketing Your Medical Practice: A Quick Reference Guide” by Jennifer Thompson and Corey Gehrold. Encapsulating their real world medical marketing knowledge and expertise, this easy-to-read eBook gives you all the tips and tricks you’ll need to start marketing your practice today in a fast, fun and friendly format – just like the articles in this series. To learn more, visit www.InsightMG.com.

Looking for more information? Contact Jennifer Thompson today for a free consultation and marketing overview at 321.228.9686 or e-mail her at Jennifer@InsightMG.com. Jennifer Thompson is president of Insight Marketing Group, a full-service healthcare marketing group focused on digital and social media administration, referral and partnership development, creative services and graphic design, online reputation management/development and promotional products. She is co-author of Marketing Your Medical Practice: A Quick Reference Guide and an avid Twitter user, regularly posting medical practice marketing tips, articles and more at www.Twitter.com/DrMarketingTips. You can learn more about her and her company at www.InsightMG.com. 

Coming UP Next Month: The cover story focuses on the BayCare Hospitals Breast Care Centers. Editorial focus is on Urology and Geriatric Medicine.

10 FLORIDA MD - OCTOBER 2013

“Patient emergencies don’t always

happen between

9 and 5.” - Magdy Nashed, MD Internal Medicine, Port Orange

Primary care physicians like Dr. Magdy Nashed, have the medical expertise to know where to send their patients for emergency care. “In an emergency, a hospital must have every kind of medical situation covered, and have every kind of specialist,” says Dr. Nashed. “I need to know patients will be treated right there, and that everything will be done the right way. So for hospital care, I only send patients where I have sent my own wife. I was very happy, and so was she.”

halifaxhealth.org FLORIDA MD - OCTOBER 2013 11

PULMONARY AND SLEEP DISORDERS

Pulmonary Hypertension and Scleroderma By Syed Mobin, MD Pulmonary Arterial hypertension PAH is a group of distinct disorders that includes idiopathic PAH (IPAH), familial PAH, PAH associated with other conditions (APAH) such as connective tissue disorder, HIV infection portal hypertension, or congenital heart disease. PAH is characterized by increased pulmonary artery pressure and pulmonary vascular resistance. If left untreated PAH can lead to right heart failure and premature death. CTDAPAH represents an important clinical subgroup of APAH that has a higher risk of death than IPAH. Approximately 0.5-15% of patients with CTD have PAH as a complication. The adult patient population with any PAH, up to 30%, has been estimated to have CTD-APAH. Most of these patient have PAH associated with systemic sclerosis SSc-APAH. The prevalence of PAH is 8-12% in patients with SSc. SLE compromise is the second largest group of patients of CTD-APAH. Risk of PAH in other connective tissue disorders like Mixed Connective Disorder MCTD, Rheumatoid Arthritis, Dermatomyositis is much less. It is recommended that every patient with SSc be screened for PAH due to high prevalence of PAH in SSc. In addition, MCTD or other CTD with prominent scleroderma features should also be screened for PAH. Screening for PAH in patients is very important for early detection. In a prospective study, SSc patients whose PAH was detected in an early detection program were compared with SSc patients whose PAH was diagnosed during routine clinical practice. At diagnosis 6 % of patients detected by screening were in the New York Heart Association Functional Class (NYHA FC) 1 and 44% were in functional class II. These results contrast sharply with those from patients diagnosed in routine practice, in which the majority were already in NYHA FC III or IV at the time of diagnosis, (69% and18.5%, respectively). Patients in the screening program had significant higher survival at 8 years than patients identified by routine daily practice (64% versus 17%). There are four approaches to screening for PAH in SSc . 1-RHC which is gold standard for diagnosing PAH. But is limited in use as is an invasive procedure. 2-Pulmonary function test with a discordant drop in diffusing capacity for carbon monoxide DLCO. 3-Transthoracic echocardiography with assessment of tricuspid regurgitation jet (TRJ). 4-Quantitation of serum N-terminal pro-brain natriuretic (NT-proBNP) level. Echocardiography is currently the most effective screening tool in patients with suspected PAH in SCc. In patients with SSc and Scleroderma spectrum of disorders 12 FLORIDA MD - OCTOBER 2013

and signs and symptoms of PH a TRJ 2.5-2.8 m/sec should be referred for a RHC. In addition, all patients with or without symptoms of PH with TRJ >2.8 m/sec should be referred for a RHC. Moreover all patients with right atrial and right ventricular enlargement (irrespective of TRJ) should be referred for RHC. A RHC is recommended for patients with signs and symptoms of PH and FVC% and DLCO ratio more than 1.6 and / or a DLCO < 60%. All subsets of SCc are at risk for development of PAH, however several risk factors increase the risk including: number of telangiectasias, reduced capillary nailfold density, anticentromere antibodies, antitopoisomerase antibodies, male sex, underlying pulmonary fibrosis, Raynaudâ&#x20AC;&#x2122;s phenomenon of greater than 3 years duration. Once PAH is recognized, the median survival (during the era before pulmonary vasodilator therapy was available) was 1-3 years. The eventual cause of death in SSc-PAH is usally the result of the right heart failure or refractory hypoxemia. The 1 year, 2 year and 3 year survival in recent studies with treatment were 86, 67, 65 % respectively. If a patient remains in functional class I/II during first 4 months of treatment, prognosis is relatively good, compared to patients who have deteriorated to functional class III/IV during this period. A cardiac index greater than 2.71 l/ min/m2 is associated with a better prognosis than a cardiac index less than 2.71 l/min/m2. Poor prognostic indicators are fast progression, syncope, stage IV functional class, less than 300 m walk in 6 minute, VO2 max less than 12 ml/min, BNP very high and increasing, PAD more than 15 mm of Hg . Although the manifestations of PAH in SSc are similar to those in patients with PAH due to other causes, several independent studies have demonstrated increased morbidity and mortality in patients with SSc-PAH compared to patients with IPAH. Data from REVEAL studies demonstrated that when compared to patients with IPAH and other forms of PAH, connective tissue disease â&#x20AC;&#x201C;PAH patients had more favorable hemodynamics at RHC, yet worse 6 minute walk distance, higher BNP level, increased likelihood of pericardial effusion and worse 1 year prognosis. Of the connective tissue associated PAH, SSc-PAH had the worst prognosis. Management of SSc-PAH is fundamentally the same as that for IPAH, although immunosuppressive agents may be useful in some patients with CTD-APAH. Oxygen supplementation, anticoagulation and diuretics may also be given where appropriate. In addition, the number of patients who show vasoreactivity to

PULMONARY AND SLEEP DISORDERS calcium channel antagonists is much lower in the CTD-APAH compared with IPAH. Generally, there are no effective primary therapies for SSc-PAH. As a result, advanced therapy is needed. Advanced therapy is directed at PH itself rather than the cause of the PH. Advanced therapy is considered for patients who have evidence of persistent PH and a WHO functional class II, III,IV. Advanced treatment of PAH includes: 1. Prostanoids (intravenous Epoprostenol, intravenous Treprostinil, subcutaneous Treprostinil, subcutaneous Treprostinil, Inhaled Treprostinil, Inhaled Iloprost) 2. Endothelin Receptor Antagonist ERA ( Ambrisentan, Bosentan) 3. Phosphodiestrase PDE5 Inhibitor ( Sildenafil, Tadalafil) Clinical studies have begun to evaluate combination therapy. It has been proposed that combination pharmacologic agents (with different mechanism of actions) may produce additional effect. Treatment of WHO functional class II preferred agents include Ambrisentan, Bosentan, Sildenafil, Tadalafil. WHO functional class III preferred agents are Ambrisentan, Bosentan, Intravenous Epoprostenol, Intravenous or subcutaneous Treprostinil, Inhaled Iloprost, Sildanefil, Tidalafil. WHO functional class IV should be treated with an intravenous Prostenoid. Atrial septostomy and lung transplantation may be considered in patients with refractory and severe PAH and right heart failure despite aggressive treatment. In those who need lung transplantation, bilateral lung (or heart and lung transplant) is the preferred choice. Syed L. Mobin, MD, completed his Fellowship at Mayo Clinic Rochester, MN and Mayo Clinic Jacksonville, FL and is board certified in Pulmonary Medicine, Critical Care Medicine and Sleep Medicine. He is Chairman of Division of Pulmonary Medicine at Florida Hospital and is Director of CFPG Institute of Sleep Medicine. Dr. Mobin is also a clinical assistant professor at University of Central Florida School of Medicine, a member of the American Academy of Sleep Medicine, the American College of Chest Physicians, the Society of Critical Care Medicine and a Mayo alumnus. Dr. Mobin is practicing with the Central Florida Pulmonary Group and can be contacted at (407) 841-1100 or by visiting cfpulmonary.com. 

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FLORIDA MD - OCTOBER 2013 13

Behavioral Health

Breaking Behavioral Health News for COVER STORY Serving Boomers and Seniors: Providers

A New Paradigm for “Quality of Life Indicators” Has Emerged By James D. Huysman, PsyD, LCSW In the past, our quality of life was determined by the various aches, pains and stress factors that invariably occur as we age. These physical changes coupled with our mental state of mind, at the moment, drove our concept of quality of life and what we, be default, valued. We saw life as a sum of the medical challenges and the overall changes that occurred in our lives after the age of 40.

summed up as the Three B’s of Aging.

We have been taught that the quality of our lives could perchance be improved by simply addressing these growing medical changes. Could it be that this way of viewing the quality of our lives was a perception of a narrow and unyielding focus? I am in definitely in that camp of opinions.

• Physical being includes the aforementioned medical points, our goals of the past, nutrition, exercise and general physical appearance.

For years, our quality of our lives as boomers or seniors was based solely on our blood pressure, cholesterol, insulin numbers, the amount of sleep we attained and of course how marginalized, detached and isolated we felt. Maybe it was my training as a Jungian therapist who believed that aging was a wonderful process. I always believed there was so much more!

• Spiritual being is our personal values, as well as standards of conduct and core beliefs.

Thankfully, pretty stunning research out of the University of Toronto now tells us that boomers and seniors today are looking at quality of life factors in a new, different and innovative way. In this new world of healthcare reform, we seem to be transforming the old perception of what the true quality of life indicators are as we age. The current transformation is welcomed and could not come at a better time as we shift our country’s psyche from a disease model to one of wellness and prevention. First, it is important for us to address the definition of “quality of life.” What does that mean exactly? For most, it refers to our ability to enjoy all that life has to offer; to create and live a life full of meaning and purpose. Having the ability to make choices about what you want to do with your time, your beliefs and what you buy shape your quality of life. In plain talk, the medical, psychological and social successes we experience may now be seen as the foundation of new values and boomers and seniors’ quality of life indicators. Why is this change in the way we perceive our quality of life important? Let’s get right to the findings. The University of Toronto found through its research, focus groups and overall observable data collection that new values and quality of life indicators could be 14 FLORIDA MD - OCTOBER 2013

At the core of this new paradigm shift is this question: How do we see ourselves in three categories with their own subsets masterfully entitled Being, Belonging and Becoming? Let’s examine each category separately. Being has three important subsets:

• Psychological being consists of our mental health, coping skills, feelings, general balance, and our state of mind.

Belonging is the second “B”. It addresses how we connect with our environment. There are three parts to this quality of life indicator as well: • Physical belonging includes our home, work, neighborhood and community. • The social belonging component revolves around our connection with others, family, friends, co- workers, etc. • Community belonging reflects our income, social and health services such as doctor, dentist and wellness workers. And yes I would include “support groups” in this category. How we approach community events and activities is also an important part of this “B”. What may be the most important change in the way we see aging is the third “B” of Becoming. It reflects the possibility that there is more powerful living in front of us throughout our “Golden Years”. • Practical becoming reflects our domestic activities, paid work, school and social volunteering. Seeing to our own health and social needs is also a strong component of practical becoming. • Leisure becoming includes any and all activities that promote relationships and stress reduction. • Growth becoming is perhaps the most aspirational part of the becoming process. It reflects the need for activities that promote or improve our knowledge base, practice skills and adaptation to change. This is a very powerful way of making life meaningful and vital as we age.

Behavioral Health While the younger generation is just “Waiting on the World to Change”, we know that we are the change! Bob Dylan pointed out to us, over 40 years ago that The Times They Are A-Changin’. As healthcare and our attitudes toward ageing shift, the times continue to change. As we embrace how we look at our values and quality of life indicators, striving to adopt the Three “B’s” in our lives will surely inspire us to live long and prosper. Dr. James Huysman, PsyD, LCSW aka Dr. Jamie is a fierce advocate of patient-centered healthcare and a work force in touch with its own wellness. He is a popular conference speaker and media guest on the topics of caregiver burnout, compassion fatigue and addictions and healthcare reform. Dr. Jamie blogs for Psychology Today and sat on the NASW committee to establish national protocols for certification and standardization of caregiving practices. He writes for Florida MD and Today’s Caregiver magazines. He co-founded the Leeza Gibbons Memory Foundation and created the signature programming for its psychosocial drop-in model, Leeza’s Place, opening 8 national locations, each with a different funding partner, in a four year period. He co-wrote the acclaimed caregiving book, Take Your Oxygen First: Protecting Your Health and Happiness While Caring for a Loved One with Memory Loss, with Gibbons and Dr. Rosemary Laird. He also contributed to the Healing Project’s offerings, Voices of Caregiving and Voices of Alcoholism. He currently works as Vice President of Provider Relations and Government Affairs for WellMed Medical Management in Florida, a UnitedHealthcare company.

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Medical Malpractice Expert Advice

Medical Practice Consolidation and its Effect on Workers’ Comp By Tom Murphy Now that the Patient Protection & Affordable Care Act has become a reality, Florida is starting to see greater activity in physician and medical-practice consolidation. This consolidation is creating a whole new set of risks and exposures for hospitals, large groups, and ACOs (Accountable Care Organizations), as well as for the physicians who are joining them. Many of the individuals involved in this process are so consumed with making the transition that they have not taken the time to realize and understand the new risks associated with this transition. Workers’ compensation coverage is one of these issues that needs to be discussed prior to completing the transition from small practice to hospital or large-group employment. When contemplating the move to a hospital or large-group setting, physicians and administrators need to be aware of who is responsible for the employees. Some physicians and groups maintain an LLC or other corporation even after joining a hospital or larger group. You need to be clear on who is required to provide the workers’ comp coverage. Typically, the hospital is self-insured or has coverage in place for this transition. The larger groups and ACOs may not have established the coverage due to their recent formation and overwhelming workload trying to secure the necessary contracts and comply with new government regulations. Regardless of the type of transition, it would be wise to discuss the responsibility for the workers’ compensation coverage and request the proof of coverage when applicable. The Florida Division of Workers’ Compensation has increased their investigations into fraud and compliance and the fines can be hefty. If you have additional questions or would like more information about this issue, please contact your agent or feel free to call Tom Murphy at 800-966-2120. Tom Murphy is a workers’ compensation and medical malpractice insurance specialist agent with Danna-Gracey, an independent insurance agency based in downtown Delray Beach with a statewide team of specialists dedicated solely to insurance coverage placement for Florida’s doctors. He can be reached at (800) 966-2120 or Murphy@dannagracey.com. 

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ORTHOPAEDIC UPDATE

Treating Degenerative Disc Disease with Pain Management Techniques By Corey Gehrold Did you know the term “degenerative disc disease” is actually a misnomer? What was once believed to be a disease by physicians has been revealed to be a natural, and sometimes painful, part of aging. Fortunately, the majority of individuals with degenerative disc disease are treated with pain management techniques without undergoing traditional surgery.

What is Degenerative Disc Disease? “Bones in the spine – called vertebral bodies – stack on top of each to form the spinal column. Between these bones sit “discs” which act as cushions or shock absorbing pads as you move,” says Matthew R. Willey, M.D., the newest pain management specialist to join the Orlando Orthopaedic Center team. “As one ages, these discs sustain wear-and-tear injuries and may start to breakdown, become compressed or even bulge out to one side of the spinal column. This is what is often referred to as degenerative disc disease.”

Dr. Matthew R. Willey, left, explains nonsurgical treatment options available to a patient experiencing spinal problems.

As the cushions become less capable of performing their daily duties, the vertebral bodies in the spine may impact each other when walking, running or performing various other activities. This results in intense, sometimes prolonged, pain for sufferers.

“Although it can occur in any region of the spine, it most often appears in the lumbar spine,” Dr. Willey assures. “Aging, arthritis and trauma all play a contributing role in the onset of degenerative disc disease.” He says the only real symptom a sufferer will feel is pain; and the discomfort can be felt either suddenly after an injury or gradually increase over time. According to Dr. Willey, pain associated with degenerative disc disease for most individuals may include weakness, tingling, burning, numbness and pressure in the spinal region. Typically, degenerative disc disease is seen in middle-aged, active lifestyle individuals.

Treating Degenerative Disc Disease Once the appropriate testing has been done and a patient has been diagnosed with degenerative disc disease, it’s time to discuss non-surgical treatment methods. Oftentimes, a pain management specialist, like Dr. Willey, is brought in to create a treatment plan for the patient. Medication. Over-the-counter and/or prescription medication 18 FLORIDA MD - OCTOBER 2013

may be used to treat a patient’s pain as an initial step by the pain management doctor. These medications may include acetaminophen (Tylenol) to control pain or NSAIDs (ibuprofen or naproxen) to reduce inflammation. “Typically, once we’re brought in to treat a patient, they’re willing to try anything short of surgery to help decrease or eliminate the pain. Medication is a good starting point in many cases,” says Dr. Willey. “If symptoms continue to present themselves, or we can’t find the level of relief we’re looking for, we will continue working with the patient to find other treatment options that might work better.” Activity Modification/Bracing. Many times, a certain motion or activity may cause the pain to present itself or increase to substantially. If that’s the case, a plan to modify said activity through behavioral changes is created with the help of a physical therapist. In addition, doctors may also recommend that the patient wear a back or neck brace to help provide pain relief. Again, an occupational or physical therapist may be brought in to help teach exercises to strengthen the back and/or neck muscles. “Helping a patient find a pattern that can help them get through the day and get a helpful night’s sleep can really do wonders for pain relief,” says Dr. Willey. “It’s a team effort between myself, the

ORTHOPAEDIC UPDATE therapist and the patient. We all have to be on the same page for this treatment method to be successful.â&#x20AC;? Epidural Steroid Injections. If pain has not improved significantly with medication and activity modification/bracing, a pain management specialist may choose to inject a patientâ&#x20AC;&#x2122;s spine with corticosteroid medication to relieve pain. â&#x20AC;&#x153;Patients often report pain relief when using this method to deliver steroids directly into the epidural space in the spine,â&#x20AC;? says Dr. Willey. â&#x20AC;&#x153;Typically, epidural steroid injections are considered safe and very effective in providing significant pain relief; but we must try to limit patients to no more than three or four injections per year.â&#x20AC;?

The Purpose of Pain Management Itâ&#x20AC;&#x2122;s important to note that the purpose of non-surgical pain management treatment for degenerative disc disease is meant to relieve pain and restore daily function to patients. The methods listed will not correct structural issues in a disc or vertebral body. â&#x20AC;&#x153;It is important to remember that degenerative disc disease and the resulting pain is just as much a part of life as gray hair. If you put enough miles on your car, eventually your tires are going to wear out. While you can replace your tires, medicine has not yet developed the back replacement,â&#x20AC;? explains Dr. Willey. â&#x20AC;&#x153;We are working on ways to help regenerate the shock absorbers, or discs, but we are not quite there yet. Fortunately, we do have a lot of other methods that can dramatically improve pain and function.â&#x20AC;?

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CANCER

Advanced Technologies Drive Better Outcomes in Head and Neck Cancers By Jimmy Caudell, MD, PhD, and Andy Trotti, MD Locally advanced squamous cell carcinomas of the head and neck region pose difficult management issues. First, there is the problem of location. With tumors of the throat, tongue, and larynx, organ preservation is of the highest concern. Second, there is the potential of long term morbidity since cure in these sites has been associated with chronic xerostomia and swallowing issues. Modern radiation techniques, however, have significantly improved outcomes. At present, the standard of care for the treatment of most head and neck cancers includes intensity modulated radiation therapy (IMRT). This technique has the ability to divide the radiation beam into individual beamlets so that the physician can maximize the delivery of dose to the tumor target and minimize the dose to the healthy tissue. This technique takes advantage of the ability to shape the beams three dimensionally to conform the dose to the precise anatomic location of the tumor. Moreover, with the ability of metabolic imaging with a Positron Emission Tomogram (PET) combined with a Computed Axial Tomogram (CT) or PET/CT, target volume delineation has significantly improved. In practice, the patient will undergo a treatment planning CT in a special immobilization device. Quite often, this involves the custom fitting of an aquaplast mask that fixes the head and shoulders in a position that reproduces daily. The patient can then undergo a PET/CT in the exact same position so that when the physician contours the tumor, they are incorporating the biologic extent of disease. In the event that the PET/CT scan was performed prior to the treatment planning scan, modern radiation oncologists also have the ability to use a soft tissue deformation program that “matches” the tissue and allows a reasonable approximation to the patient’s actual treatment position. Better definition of the tumor itself and better precision with the radiation beams, however, increases the complexity for the treating physician. Studies have shown that in the IMRT era there can be a higher rate of what is termed a “marginal miss”; in essence, if the tumor and extent of subclinical disease is not precisely specified as target, it will not be included in the treatment volume and will likely be underdosed or missed entirely. Thus, never has the skill of the treating physician been more important to identify those tumor related structures as well as those normal tissues. In the head and neck area, it is essential that the clinician have a solid understanding of the complex normal anatomy that can be in the radiation field. Identifying these normal structures and then working with the dosimetry team to maximally avoid these tissues is of the utmost importance to prevent long term sequelae. Radiation of head and neck cancers is thus highly challenging; we both specialize in this area and restrict our practice to only treating cancers of this site due to its complexity. We work with a dosimetry team that specializes in head and neck cancer as well. 20 FLORIDA MD - OCTOBER 2013

Prior to the IMRT era, one of the worst quality of life issues for patients who were cured of their head and neck cancers was xerostomia. In this two dimensional radiation era, the bilateral parotid glands were routinely Jimmy Caudell, MD, PhD irradiated for most cancers with large fields. These techniques resulted in high rates of cure but correspondingly high rates of late effects. At present, the standard of care is to carefully contour not only the parotid glands, but the submandibular glands, and minor salivary glands that are located in the oral cavity on the patient’s individual treatment planning CT. The physician can then tell the planning team to ensure the dose to these salivary glands Andrea “Andy” Trotti, III, MD are below the threshold for producing late xerostomia. Moreover, the physician also must carefully specify the doses to be received to the larynx and swallowing muscles to avoid long term swallowing problems. In this manner the modern radiation oncologist essentially “sculpts” the high dose to the exact region of interest. Now that technology has improved, the next question for investigators is whether we can individualize the dose for each patient. Radiobiology has established that each tumor histology has an intrinsic radiosensitivity. For example, melanomas tend to be radioresistant while lymphomas tend to be radiosensitive. Moreover, within a histologic type, there can be significant variations in effective dose. Since the potential of normal tissue toxicity can increase with higher dose, clinicians are motivated to determine the lowest effective dose for each patient. In the last decade there has been an increasing incidence of oropharyngeal cancer. Specifically, these oropharyngeal cancers are related to infection with the Human Papilloma Virus (HPV), which is associated with sexual transmission. Investigators observed anecdotally that those HPV related tumors seemed more radiosensitive than their non-HPV related counterparts. To further evaluate this association, our group is studying in a prospective clinical trial whether HPV related cancers can be effectively treated with a less toxic chemotherapy and radiation regimen. The results of this trial will be helpful to lead the future of personalized delivery of radiation oncology care. Finally, at Moffitt Cancer Center, our colleagues have developed an assay that is designed to test an individual tumor’s radiosensitivity. Dr. Javier Torres-Roca and Dr. Stephen Estrich have collaborated on this test which is now undergoing clinical valida-

CANCER tion studies. Data so far indicates that this test will be able to tell clinicians about the individual radiation sensitivity of the tumor prior to treatment. This has profound treatment implications so that we can potentially deliver lower doses to sensitive tumors and higher doses to resistant tumors. Tremendous progress has thus been achieved on both the physical as well as biological front in the last decade. Patients with head and neck cancer who are treated by specialist radiation oncology teams can benefit from the optimization of these advanced radiation technologies and look forward to more opportunities for organ preservation with enhanced quality of life. Dr. Jimmy Caudell, M.D., Ph.D, Assistant Member, Department of Radiation Oncology, Moffitt Cancer Center also serves as Assistant Professor in the Department of Oncologic Sciences at the University of South Florida College of Medicine. Clinical interests include treatment of head and neck cancer and cutaneous malignancies with radiotherapy. Research interests include prediction of radiation sensitivity, evaluation of novel radiosensitizers and radioprotectants, as well as the use of technology to improve radiation delivery for head and neck cancer. Dr. Andrea “Andy” Trotti, III, MD is a Senior Member of Radiation Oncology at the Moffitt Cancer Center and Senior Professor in the Department of Oncologic Sciences at the University of South Florida College of Medicine. He is the Principal Investigator for the Radiation Therapy Oncology Group (RTOG) at USF and serves the RTOG as Co-Chair of the Head and Neck Committee. He has led numerous NCI or industry sponsored clinical trials, including recently serving as PI for the largest reported randomized international trial for the prevention of mucositis. Dr. Trotti has been a principal investigator for 9 clinical trials and has participated in an additional 40 clinical trials. He is currently the Principle Investigator and national leader of an RTOG 700 patient multicenter trial investigating treatment intensity reduction in HPV related caner of the oropharynx, comparing cisplatin to cetuximab. He serves as a reviewer and consultant to the NCI, NIH and the Medical Research Council in the UK. His research interests include improving the efficacy of radiotherapy in head and neck cancer, reducing toxicity by use of chemotherapy alternatives, as well as studies of reporting systems and interventions of the adverse effects of cancer treatment. Both physicians are accepting new patients at Moffitt Cancer Center. Appointments can be scheduled by contacting the New Patient Appointment Center at 813-745-3980. 

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FLORIDA MD - OCTOBER 2013 21

Financial Update: Insurance • Benefits • Wealth Management

2012 Taxpayer “Relief” Act …Really?? By T. Kevin Taylor, JD, LLM

As you may recall, to avoid the “fiscal cliff” at the 13th hour Congress passed the 2012 TAXPAYER RELIEF ACT which the President signed on January 2nd. Upon review, you may prefer to forget this law because you will actually find very little “RELIEF.” With the exception of those who pay little or no income tax to begin with, at almost every turn, individuals will pay higher rates and have fewer deductions in 2013. In addition to the socalled “RELIEF” in the 2012 act, there are several NEW TAXES imposed this year by the extremely ballyhooed and cumbersome Patient Protection Affordable Care Act of 2010 (PPACA). So, if you paid taxes in 2012, you need to prepare early to avoid a higher tax bill in 2013.

Highlights of the “RELIEF” found in the 2012 Act: 1. Ordinary Income Rates: Although all the existing brackets were retained (10%, 15%, 25%, 28%, 33%, and 35%), a new top rate of 39.6% has been added. It applies to taxable income over $400,000 for singles, and $450,000 for married couples.

Beginning in 2013, an additional 3.8% Net Investment Income Tax (NIIT) will be assessed on taxpayers with a modified adjusted gross income (MAGI) exceeding $250,000 for those filing jointly and $200,000 for singles. The tax is 3.8% of the lesser of net investment income or the excess of MAGI over the threshold amount. This new surtax potentially pushes the top marginal rate on ordinary income to 43.4% and the top capital gains/dividend rate to 23.8%. 2. Hospital Insurance Tax: On wages above $250,000 for joint filers and $200,000 for singles, the employee portion of the hospital insurance tax part of FICA, is increased by 0.9% to 2.44%. 3. Medical Care Itemized Deduction Threshold: The 7.5% threshold for the deduction for unreimbursed medical expenses has increased to 10% of AGI. However, if either the taxpayer or spouse turns 65 before 12/31/2016, the increase does not apply.

2. Capital Gains and Dividend Rates: In 2012, the rates were 0% or 15%. In 2013, if your Ordinary Income bracket is 10 or 15% you’ll pay 0%; those in the 25%-35% brackets will pay 15%; and those in the 39.6% bracket will pay 20%. 3. AMT Exemption Phase-out The exemption from AMT is phased out for taxpayers with income above certain thresholds ($115,400 for singles and $153,900 for joint filers) 4. Estate and Gift Tax Rates: The estate and gift tax exclusion remains at $5 million (indexed for inflation), but the top tax rate increases from 35 to 40%. 5. Phase-out of Personal Exemptions: The personal exemption is phased out at $250,000 for single taxpayers and $300,000 for married taxpayers. 6. 3% - 80% Limit on Standard Deduction: Reinstatement of the Pease limitation will reduce the amount of itemized deductions taxpayers can utilize. The deductions are phased-out by 3% of the amount adjusted gross income exceeds a specific threshold ($300,000 for joint filers, and $250,000 for individuals). Deductions cannot be reduced by more than 80%.

NEW TAXES IMPOSED BY PPACA: 1. 3.8% Net Investment Income Tax: 22 FLORIDA MD - OCTOBER 2013

ENDO-SURGICAL CENTER OF FLORIDA Recognized by American Society for Gastrointestinal Endoscopy (ASGE) One of 450 endoscopy units to be granted this recognition since 2009 To be recognized by ASGE, a peer-reviewed application process must prove: t DPOUJOVFE DPNQFUFODF PG BMM TUBČ SFMBUJWF UP their roles t EFNPOTUSBUF UIF BEPQUJPO PG VOJU policies specific to ongoing assessment of performance relative to key quality indicators t BUUFTU UIBU UIF VOJU IBT BO FTUBCMJTIFE infrastructure and personnel dedicated to infection control and prevention The Place Doctors Choose for Themselves. 100 N. Dean Rd., Suite 102, Orlando, FL 32825 Call 407-384-7388 for more information or to schedule a colonoscopy or endoscopy.

Financial Update: Insurance • Benefits • Wealth Management 4. Flexible Spending Arrangements:

4. Re-Balance Your Portfolio by Tax Type

The maximum amount of tax free salary reduction contributions that an employee may make to a flexible spending arrangement is $2,500 for medical only expenses and $5,000 for dependent care expenses.

Investments that produce ordinary income are good candidates for placing into an IRA, 401(k), 529 plan or other tax-deferred savings plan. Placing income-producing investments into tax-deferred accounts defers income, and may avoid the impact of higher rates and the Medicare surtax. Also, so far income from IRA distributions and other pension plans are not subject to the Medicare surtax. So if you’re re-balancing your investment portfolio, investments that produce ordinary income may fare better inside tax-deferred plans, and investments that produce long-term gains may produce more optimal results in taxable accounts.

These are only some of the changes that will impact your tax liability this year. So, as you can see, in spite of all of the supposed relief, there is a high likelihood your taxes could be significantly higher in 2013.

WHAT CAN YOU DO TO GET RELIEF FROM THE “RELIEF”? There are many year-end techniques high income households can utilize to manage or reduce taxes. Some of the most common include: 1. Income Deferral or Acceleration Strategies These strategies shift income between tax years if your taxes will be lower overall as a result. Common strategies include: • Asking employers to pay bonuses in the most advantageous year. • Holding off on selling investments with taxable gains until next year. • Holding off on distributions from an IRA or other retirement account until 2014. • Converting pre-tax retirement savings to ROTH to lock-in a known tax liability or utilize a known deduction. 2. Deduction Acceleration or Deferral Strategies Accelerating deductions functions like deferring income and vice versa. The tactic is to deduct the expense in the tax year that yields the most benefit. Some examples are: • Paying tax deductible expenses, such as medical bills, charitable donations and property tax in the year with the largest impact. • Selling investments that have lost value in the appropriate year. • Increasing 401(k) or IRA contributions. • Funding a Roth IRA instead of a tax-deductible traditional IRA. 3. Alternative Minimum Tax (AMT) Planning People who are or might be impacted by AMT have additional considerations. The AMT reduces the federal tax savings for medical expenses, state and local taxes, property taxes, and miscellaneous itemized deductions. The suggestion here is to pay those expenses when they are due instead of trying to accelerate or defer them. For example, instead of prepaying the next installment of your property tax, wait until the actual due date to pay that since property tax is an adjustment for the AMT calculations. Similarly, anyone impacted by the AMT may sell incentive stock options they exercised during 2013 since the value of an exercised but unsold ISO is added to your income for AMT.

5. Pair Losses with Gains This minimizes the impact of selling investments at a profit by selling off investments with losses. This is a hybrid tactic that accelerates income and losses to create the smallest possible tax impact. 6. IRA Distributions to Charity: For 2013 only, taxpayers over age 70.5 may deduct up to $100,000 of distributions from IRAs to qualified charities. Every year we recommend our clients begin year-end tax planning by late 3rd/early 4thquarter at the latest. It never pays to wait until January to consider the impacts and it is extremely important to start early this year. So contact your tax advisor or give us a call to see if there could be any relief from the “RELIEF.” Securities and Investment Advisory Services offered through NFP Securities, Inc., Member FINRA/SIPC. NFP Securities Inc. is not affiliated with the Vaughn Group, Inc. NFP Securities, Inc. does not provide tax or legal advice.

Kevin is a principal at The Vaughn Group, Inc. and manages the wealth management department. Before becoming a financial advisor, Kevin practiced law in Orlando, focusing on tax, estate, and asset protection planning for ultrahigh-net-worth families. As a financial advisor, he has presented educational seminars and made presentations to the Florida Bar Association, regional Estate Planning Councils, the National Association of Retired Employees, the Arthritis Foundation, and the National Business Institute. Kevin graduated from the University of Florida with a B.A. in Economics, a J.D. with Honors, and a Masters of Laws in Taxation. He can be reached via email at kevin@ vaughngroup.com or by phone at (407) 872-3888. The Vaughn Group, Inc.’s offices are located at 1407 E. Robinson St., Orlando, FL 32801. 

Be sure and check out our NEW and IMPROVED website at www.floridamd.com! FLORIDA MD - OCTOBER 2013 23

Breast Tomosynthesis By Katherine Reed, MD

Introduction: Breast tomosynthesis, also referred to as 3-dimensional (3D) mammography, is a recently developed technology which marks the first fundamental change in mammography in decades. All previous mammographic techniques, from xeromammography to film mammography to conventional digital (2D) mammography, compress the three-dimensional breast tissue into a single two-dimensional image. This superimposes multiple layers of tissue which can both obscure a breast cancer and simulate the appearance of a cancer, decreasing sensitivity and specificity. In breast tomosynthesis, multiple images are generated which allow the breast tissue to be viewed as individual layers, significantly reducing the problems associated with tissue superimposition and improving the detection of cancers.

Technique: In breast tomosynthesis, the x-ray tube head moves in a 15 degree arc over the breast and acquires 15 low-dose images which produce a dataset that is reconstructed into multiple 1mm thick slices covering the entire compressed breast. These reconstructed images can be analyzed on a diagnostic workstation individually or in cine format. The physical appearance of a 3D unit is nearly identical to conventional digital mammography equipment. There is no noticeable difference to the patient other than a several second longer exposure time. As currently required by the FDA, a screening 3D mammogram must also include 2D images. Both the 3D dataset and 2D image can be acquired during a single compression. There is also FDA approved technology which allows 2D images to be generated from the 3D dataset. This eliminates the radiation exposure of a separate 2D image. Even when the 3D and 2D images are individually acquired the combined dose is below FDA/MQSA allowable limits and typically less than average annual background radiation. Doses at current levels are low and risks of low level radiation are hypothetical.

Clinical results: There are 2 basic problems encountered in the interpretation of traditional 2D mammograms. One is that superimposition of normal tissues can create the appearance of a mass. This leads to women being called 24 FLORIDA MD - OCTOBER 2013

back for additional imaging of normal overlapping tissue. Clinical studies consistently show significant reduction in recall rates when 3D mammography is added to a 2D screening mammogram. In a recent study published in the June 2013 issue of the American Journal of Roentgenology, recall rates were reduced by 37 percent. The second limitation of the traditional mammogram is that a cancer may be obscured by superimposed normal tissue. This is a particular problem in women with dense or heterogeneously dense breast tissue. It is much easier to detect a mass when the overlapping normal breast tissue is eliminated. Clinical studies consistently show an improved cancer detection rate with tomosynthesis. In the Oslo Tomosynthesis Screening trial of over 12,600 patients, cancer detection rates were 40% higher for invasive cancers and 27% higher for all cancers. Similarly, in a recent U.S. study of over13,800 women, cancer detection rates were 50 percent higher for invasive cancers and 30 percent for all cancers. These results are much better than results achieved by the transition from film to digital mammography. 3D mammography improves breast cancer detection in all types of breast tissue, from fatty to dense, with the greatest benefit in dense and heterogeneously dense tissue. Breast cancer detection rate is reported to be 2 to 3 times higher in dense breast tissue. However, even with 3D mammography, cancer detection may be significantly limited if the breast tissue is extremely dense. Example 1.

Clinical Applications: Tomosynthesis has demonstrated utility in both screening and diagnostic or problem solving mammograms. When used for screening, a standard 2D mammogram and tomosynthesis images are obtained. Calcification detection is better with conventional 2D images, and mass detection is better with 3D images. The 2D images are also useful for comparison with prior 2D studies. When used in diagnostic mammography 3D imaging not only improves cancer detection but can also reduce the total number of exposures and more precisely define tumor size, extent, and location.

Future: Clinical results justify the use of tomosynthesis in breast cancer screening but the cost of the technology will likely slow widespread use and/or concentrate screening in a smaller number of facilities.

Example 2.

Computer-aided detection (CAD) is not currently available for 3D mammography but, just as in conventional 2D digital mammography, may help detect suspicious findings in a tomosynthesis dataset. Tomosynthesis, used with a radiographic contrast agent, is in the early stages of evaluation. Contrast-enhanced breast imaging has the potential to combine the functional information from the distribution of contrast with the morphological information of the 3D images.

Conclusion: Breast tomosynthesis is a new and innovative technique which allows the radiologist to view breast tissue layer by layer. Clinical trials consistently demonstrate significantly improved cancer detection, particularly invasive cancers and decreased recall rates, avoiding unnecessary workup of women without disease. Useful in both screening and diagnostic mammography, 3D mammography is quickly gaining clinical acceptance and is on the path to fundamentally change the way mammography is practiced.

Tomo System.

Katherine Reed, MD, is Medical Director of the Breast Care Center at Florida Hospital Tampa. Dr. Reed earned her medical degree at the University of Florida College Of Medicine. She completed her residency and fellowship at Mallinckrodt Institute of Radiology at Washington University School of Medicine in St. Louis, Missouri. Dr. Reed is board certified by the American Board of Radiology and the American Board of Nuclear Medicine. And she is a member of the Radiological Society of North America, the American College of Radiology and the Society of Breast Imaging.

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FLORIDA MD - OCTOBER 2013 25

Digestive and Liver Update

Abdominal Pain: Gastroparesis By Harinath Sheela, MD

Gastroparesis (delayed gastric emptying) is a common cause of nausea, vomiting, and other upper gut symptoms in patients referred to gastroenterologists. The true prevalence of gastroparesis is unknown. It is estimated to occur in 20â&#x20AC;&#x201C;40% of patients with diabetes mellitus, primarily those with long duration of type 1 diabetes mellitus with other complications. Delayed gastric emptying may also be present in 25%â&#x20AC;&#x201C;40% of patients with functional dyspepsia, a condition affecting approximately 20% of the US general population. The etiology of gastroparesis is multifactorial; the main categories are diabetic, idiopathic, and postsurgical. Diabetic gastroparesis is believed to represent a form of neuropathy involving the vagus nerve. Hyperglycemia itself can also cause antral hypomotility, gastric dysrhythmias, and delayed gastric emptying in some patients. Idiopathic gastroparesis is present in many patients with functional dyspepsia and may in some cases occur after a viral infection.

Diagnosis of gastroparesis The diagnosis of gastroparesis is based on the presence of appropriate symptoms/signs, delayed gastric emptying, and the absence of an obstructing structural lesion in the stomach or small intestine.

Symptoms of gastric dysmotility Clinical symptoms that suggest gastroparesis include nausea, vomiting, and postprandial abdominal fullness. In contrast, dyspepsia refers to a symptom complex of chronic or recurrent upper abdominal pain or discomfort that may have associated symptoms of early satiety, nausea, and postprandial fullness/bloating. There is overlap of the symptoms of gastroparesis and functional dyspepsia. Idiopathic gastroparesis may be one of the causes of functional dyspepsia. The differential diagnosis of nausea and vomiting is extensive and includes a broad range of pathologic and physiologic conditions affecting the gastrointestinal tract, the central nervous system, and endocrine/metabolic functions. Assessment of the patient begins with a careful history aimed at understanding the patientâ&#x20AC;&#x2122;s symptoms. Vomiting needs to be differentiated from regurgitation, rumination, and even bulimia; the duration, frequency, and severity of symptoms together with a description of their characteristics and the nature of any associated symptoms should be delineated. The physical examination should be directed toward any consequences or complications of vomiting and identification of any signs that may point to the cause of the symptoms. 26 FLORIDA MD - OCTOBER 2013

Evaluation for gastroparesis Gastric emptying scintigraphy of a radiolabeled solid meal is the best accepted method to test for delayed gastric emptying. Conventionally, the test is performed for 2 hours after ingestion of a radiolabeled meal. Shorter test durations are inaccurate for determining gastroparesis. For the test meal preparation, the radioisotope needs to be cooked into the solid portion of the meal. Performing the test for a longer duration, up to 4 hours, has been proposed to increase the yield in detecting delayed gastric emptying in symptomatic patients. Breath testing can be used to measure gastric emptying using the nonradioactive isotope 13C to label octanoate, a mediumchain triglyceride, which can be bound into a solid meal. Studies have also reported labeling the proteinaceous algae (Spirulina) with 13C. By measuring 13C in breath samples, gastric emptying can be indirectly determined. The octanoate breath test has been used primarily for clinical research and pharmaceutical studies. Antroduodenal manometry provides information about coordination of gastric and duodenal motor function in fasting and postprandial periods. Decreased antral contractility and origination of organized fasting migrating motor complexes in the small intestine rather than in the stomach are observed in gastroparesis. With accurate stationary recording, a reduced postprandial distal antral motility index is correlated with impaired gastric emptying of solids. A normal study with a normal transit test result strongly suggests that antral motor dysfunction is not the cause of symptoms. Antroduodenal manometry may differentiate between neuropathic or myopathic motility disorders and may help to diagnose unexpected small bowel obstruction or rumination syndrome.

Treatment of gastroparesis Primary treatment of gastroparesis includes dietary manipulation and administration of antiemetic and prokinetic agents. Dietary recommendations include eating frequent smaller-size meals and replacing solid food with liquids, such as soups. Foods should be low in fat and fiber content. Antiemetic agents are administered for nausea and vomiting. The principal classes of antiemetic drugs are antidopaminergics, antihistamines, anticholinergics, and more recently serotonin receptor antagonists. The antiemetic action of phenothiazine compounds is primarily due to a central antidopaminergic mechanism Continued on page 28

3D Mammography is here.

The Florida Hospital Tampa Breast Care Center is excited to announce that we now offer 3D mammography â&#x20AC;&#x201C; an extraordinary technology that lets radiologists see breast tissue in a way never before possible. With 3D mammography doctors can review the breast in sections, almost likes turning pages in a book, allowing them to find cancer earlier and reduce false positives.

Dedicated to Comprehensive Breast Care The Florida Hospital Tampa Breast Care Center is dedicated exclusively to breast care because itâ&#x20AC;&#x2122;s the only thing we do. Our Breast Care Center offers a comprehensive program focusing on breast cancer prevention, detection, treatment and recovery with our board certified female radiologists and all female staff. Our comprehensive center offers: A Spa-like Environment Breast Ultrasound, Breast MRI Stereotactic, Ultrasound-guided and MRI-guided Biopsy

Genetic Testing including BRCA Analysis Bone Densitometry (DEXA) Center of Excellence Accreditation

To refer your patients for a 3D Mammogram, please call (813) 615-7120.

FHTampa.org | FHT-10615 FLORIDA MD - OCTOBER 2013 27

Digestive and Liver Update in the area postrema of the brain. Commonly used agents include prochlorperazine, trimethobenzamide, and promethazine. Serotonin (5-HT3) receptor antagonists are helpful in treating or preventing chemotherapy-induced nausea and vomiting. The sites of action of these compounds include the area postrema as well as peripheral afferent nerves. These agents are frequently used for nausea and vomiting due to other etiologies with little published evidence demonstrating their efficacy. These agents are best used on an as-needed basis. Current prokinetic agents include metoclopramide and erythromycin, which can be administered orally or intravenously. Domperidone, a dopamine (D2) receptor antagonist, is not approved in the United States but is available in Canada, Mexico, and Europe. Tegaserod, a partial 5-HT4 receptor agonist, enhances gastric emptying; however, no clinical trials have confirmed its efficacy in reducing symptoms in patients with gastroparesis.

Harinath Sheela, 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 significant amount of time in basic and clinical research and has published articles in gastroenterology literature. His interests include Inflammatory Bowel Diseases (IBD), Irritable Bowel Syndrome (IBS), Hepatitis B, Hepatitis C, Metabolic and other liver disorders. He is a member of the American Gastroenterological Association (AGA), the

Patients refractory to the initial treatment of gastroparesis can be difficult to manage. Treatment may involve switching prokinetic and antiemetic agents, combining prokinetic agents, injecting botulinum toxin into the pylorus, using gastrostomy/jejunostomy tubes, and implanting a gastric electric stimulator.

American Society for Gastrointestinal Endoscopy (ASGE)

A treatment recently reported to be helpful for refractory gastroparesis is endoscopic injection of botulinum toxin into the pyloric sphincter. Botulinum toxin, which reduces the release of acetylcholine from cholinergic nerves, may relax pyloric sphincter resistance, allowing more food to empty from the stomach. In open-label trials, pyloric botulinum toxin has been reported to produce modest temporary symptom improvements in selected patients. To date, no placebo-controlled trials have been reported for this therapy of gastroparesis. Long-term control is not to be expected from this treatment.

Dr. Sheela is a Clinical Assistant Professor at the University

and the American Association for the Study of Liver Diseases (AASLD) and Crohnâ&#x20AC;&#x2122;s Colitis foundation (CCF).

of Central Florida School of Medicine. He is also a teaching attending physician at Florida Hospital Internal Medcine Residency and Family Practice Residence (MD and DO) programs.

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Decompressing gastrostomy and feeding jejunostomy tubes are occasionally used when necessary. A jejunostomy tube may provide a route for administering enteral nutrition, hydration, and medications. Gastric electric stimulation is an emerging therapy for refractory gastroparesis. There are several ways to stimulate the stomach by varying the electrical parameters. With gastric electrical pacing, the goal is to entrain and pace the gastric slow waves at a higher rate than the patientâ&#x20AC;&#x2122;s normal 3-cpm myoelectric frequency. One unblinded study in a small number of subjects has shown this to accelerate gastric emptying and improve dyspeptic symptoms. The second method is to use high-frequency stimulation at 4 times the basal rate (12 cpm). High-frequency gastric electric stimulation has been evaluated in several studies, showing an improvement in symptoms with only a modest change in gastric emptying. Studies to better evaluate the efficacy of gastric electric stimulation are ongoing. As this type of treatment evolves, further delineation of the overall effectiveness, the type of patient who will likely respond, optimal electrode placement, and stimulus parameters should be explored. 28 FLORIDA MD - OCTOBER 2013

NOVEMBER 2013 ISSUE

Coming UP Next Month: The cover story focuses on the BayCare Hospitals Breast Care Centers. Editorial focus is on Urology and Geriatric Medicine.

New Surgery Provides Option for Those Afflicted with Lymphedema Vascularized Lymph Node Transfer is “Life Changing” By Richard Klein, MD Lymphedema is a chronic condition that leads to swelling of the arms and legs. Those plagued with this condition have had very limited treatment options other than therapy and massage. Now a new surgical option has emerged - called a Vascularized Lymph Node Transfer (VLNT), bringing relief and life changing results. This microsurgical procedure transfers lymph nodes from one area of the body to another that is affected by lymphedema - a blockage in the lymphatic vessels. In early 2013, the Plastics and Reconstructive Surgical Team at Orlando Health – including myself, Drs. Kenneth Lee and Jeffrey Feiner – performed the first ever Vascularized Lymph Node Transfer (VLNT) in the state of Florida. Our hope was that this surgery would be effective at reducing a patient’s symptoms, reduce swelling and heaviness of the limb, as well as relieve pain and discomfort, allowing patients to restore normal function to arms and legs and resume their daily activities. The first patient to undergo the VLNT procedure in Florida was a breast cancer survivor who developed lymphedema in her right arm following breast surgery and radiation. She had been living with lymphedema for 18 months before undergoing the surgery. The lymphedema severely limited her day-to-day activities, despite attempts to manage her symptoms with therapy and message. Our team transferred lymph nodes from her abdomen to her arm pit and reconnected arteries and veins to provide the transferred lymph nodes oxygen and nutrients to survive, thrive and develop new lymphatic channels. The patient’s response to the surgery was remarkable. Within a matter of weeks, she began seeing a steady decrease in the symptoms of her lymphedema and an improvement in the mobility of her arm. Six months following surgery she has had a 60% reduction in the size of her extremity without the use of compression garments or sequential pumps. She continues working with our lymphedema therapist and we expect she will see additional improvements in the coming months. So who could benefit from a vascularized lymph node transfer? Lymphedema affects 3-4 million adults and children in America and is, unfortunately, not an uncommon side effect of breast cancer treatment. It occurs in about 15-20 percent of breast cancer patients, where lymph nodes have been damaged or removed along with breast tissue (mastectomy) in combination with radiation. What should patients expect? It’s important to keep in mind that the success of the VLNT procedure is dependent on the patient’s commitment to lymphatic therapy both pre and postsurgery. Pre-surgical lymphatic therapy prepares the body for surgery by decongesting the affected area. The VLNT procedure takes approximately 3 to 4 hours and patients can usually go home the following day. Following the surgery, patients may begin to see improvement within 1 to 2 months; however, the majority of

the observed improvement will gradually occur over the following 10 to 16 months. Most importantly, patients need to undergo decongestion therapy post-surgery to obtain maximal symptomatic relief and regain mobility in their arms or legs. The VLNT procedure is covered by most health insurance companies. We have already witnessed how this procedure has changed lives and has the potential to change many more. Until now, those affected by lymphedema had very few options for surgical treatment. Today, a novel surgical treatment option is available, offering great potential for restoring a patient’s quality of life. We are very excited to bring the VLNT procedure to Florida, and finally offer long term relief to those who have been suffering with lymphedema. To find out more about VLNT call our Orlando Health Plastic & Reconstructive Surgery office at 321-841-7090. Richard Klein, MD, MPH, oversees MD Anderson Cancer Center Orlando’s Plastic & Reconstructive Surgery Specialty Section and is a member of the Breast Care Center at Orlando Regional Medical Center (ORMC). Board certified by the American Board of Plastic and Reconstructive Surgery, Dr. Klein specializes in advanced cosmetic and reconstructive surgery procedures of the face and body. His area of expertise is in microvascular perforator flap reconstruction of the breast, head/neck and extremities after cancer resection and trauma wounds. Dr. Klein joins the center from H. Lee Moffitt Cancer Center & Research Institute and the University of South Florida, where he served as an assistant professor of plastic and reconstructive surgery. Dr. Klein received his medical and public health degrees from Tufts University School of Medicine. He trained in general surgery at the University of Pittsburgh Medical Center and completed a four-year research fellowship in trauma and burn surgery before finishing his residency in plastic and reconstructive surgery at the University of Michigan (UM) School of Medicine. His research culminated in being awarded a prestigious five-year research grant from the National Heart, Lung and Blood Institute at the National Institutes of Health as a research fellow at UM. Following his research, he completed a plastic and reconstructive surgery residency at UM and was named chief administrative resident. After his training at UM, Dr. Klein worked at the National Cancer Institute at the National Institutes of Health as a plastic surgeon consultant. He is the author of numerous peer-reviewed articles and has contributed to several medical textbooks. Dr. Klein is fluent in French and Spanish.  FLORIDA MD - OCTOBER 2013 29

2013

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. 30 FLORIDA MD - OCTOBER 2013

CURRENT TOPICS

Florida Hospital Hyperbaric Medicine Center Earns Accreditation Undersea and Hyperbaric Medical Society awards first accreditation in Central Florida Florida Hospital’s Hyperbaric Medicine and Wound Management Center received full accreditation from internationally recognized Undersea and Hyperbaric Medical Society (UHMS) for its hyperbaric oxygen services. This accreditation recognizes clinical hyperbaric facilities that demonstrate a commitment to providing exemplary patient care and facility safety. Hyperbaric chambers are sealed chambers designed to create a high-pressure environment, oxygen is then pumped into the chamber increasing the availability of oxygen to the body. It’s used to treat decompression sickness, carbon monoxide poisoning, tissue injury arising from radiation therapy for cancer and wounds that are difficult to heal. There are only 10 accredited hyperbaric chamber facilities in Florida and Florida Hospital is the only Level One hyperbaric chamber in Central Florida. UHMS, a non-profit organization comprised largely of scientist and medical professionals, conducts research and sets standards for the field. Their mission is to provide the highest standards in education, communication, cooperation and promote quality care for patients.

“On behalf of the hyperbaric leadership, I would like to congratulate the skillful staff and team at the Hyperbaric Medicine Center for their commitment to excellence, which is reaffirmed with this accreditation,” said Dr. Jason Sniffen, medical director of the Hyperbaric Medicine and Wound Management Center at Florida Hospital. Established in 1986, the Florida Hospital Hyperbaric Medicine and Wound Management Center is a regional referral center for wound care and hyperbaric oxygen therapy for the treatment of acute, chronic and non-healing wounds. The unit gained international recognition during the 2005 hurricane season when treatment for generator related carbon monoxide poisoning was necessary. Their experiences were published in Morbidity and Mortality Weekly Report and the Journal of the American Medical Association. Florida Hospital’s Hyperbaric Medicine and Wound Center can be reached at 407-3031549. 

Heart of Florida-Nemours Partnership Brings New Opportunities for Quality Care for Children in Central Florida Central Florida families have a new, local option for high-quality pediatric hospital care. Under a partnership that began October 1st, Nemours Children’s Hospital of Orlando will provide hospital-based Pediatricians to provide care to newborns and children at Heart of Florida Regional Medical Center in Haines City. This partnership will also allow doctors from Nemours to provide care to the communitybased Pediatrician’s patients during their hospitalization. “When a child needs to be hospitalized, it is best for the patient and family if the hospital is close to home,” said Ann Barnhart, CEO of Heart of Florida Regional Medical Center. “This partnership between Heart of Florida Regional Medical Center and Nemours Children’s Hospital makes it easier for families in and around Polk County to spend time with their hospitalized child while being cared for by the physicians employed by Nemours, an organization that solely focuses on the care of children.” Dr. Carolina Echeverri-Arranz will serve as the Medical Director for the Nemours - Heart of Florida Pediatrics Program. She trained at the University of Puerto Rico School of Medicine. She is board certified in pediatrics. Nemours Children’s Hospital (NCH) opened in October 2012 in Orlando’s Lake Nona Medical City close to the Orlando International Airport. NCH offers advanced pediatric specialty care never before offered in Central Florida including two pediatric interventional radiologists, a neurologist who specializes in the treatment of neuromuscular disorders and the only surgeon in the southeast who treats children living with intestinal failure. “Everything we do at Nemours Children’s Hospital is focused on providing the very best care for children,” said Roger Oxendale, CEO of Nemours Children’s Hospital. “We are proud to extend our expertise in caring for kids to work alongside the excellent team of physicians at Heart of Florida.” 

FLORIDA MD - OCTOBER 2013 31

CURRENT TOPICS

Florida Hospital Urologic Surgeon Launches Prostate Cancer Survivorship Program Dr. Vipul Patel kicks off Blueprint for Men’s Health: A GRI Survivorship Program The American Cancer Society estimates 238,590 men will be diagnosed with prostate cancer in 2013. While surgical treatment for prostate cancer can be extremely effective, there can be some post surgical side effects after the prostate is removed that can impact men and their partners. Dr. Vipul Patel, director of the Global Robotics Institute (GRI) and director of urologic oncology at Florida Hospital Cancer Institute, has created a Prostate Cancer Survivorship Program called Blueprint for Men’s Health: A GRI Survivorship Program for patients addressing after effects of prostate cancer. Dr. Patel specializes in robotic prostatectomy (removal of the prostate) with superior outcomes that remove the cancer and preserve urinary continence and sexual function. But over time patients often have concerns after surgery including questions about diet and exercise to physiological issues with their partner or fears of cancer re-occurrence or passing cancer genetically to their children. The program is a

blueprint for patients to achieve a healthy lifestyle and an enhanced quality of life. “We have developed a dynamic personalized healthcare plan that starts with the patient,” said Rebecca McLamara, RN, survivorship & genetics coordinator at the Global Robotics Institute. “We develop a multidisciplinary assessment of the patient’s disease, the surgical treatment provided and then follow up with their individualized needs holistically as they evolve over time.” The Global Robotic Institute launched the program in September as part of prostate cancer awareness month with 85 of Dr. Patel’s patients at the Florida Hospital Nicholson Center. “At the Global Robotics Institute our priority is getting patients cancer free, but also treat their emotional needs as they go through this process as well,” said Dr. Patel. “That is what the Prostate Cancer Survivorship Program is all about.” 

Florida Hospital Home Care Services Receives Reaccreditation from CHAP Community Health Accreditation Program, Inc., (CHAP) announced recently that Florida Hospital Home Care Services, (FHHCS) has been awarded CHAP reaccreditation with deemed status for the next three years, under the CHAP Standards of Excellence. This is the third consecutive accreditation that CHAP awarded to FHHCS. CHAP accreditation demonstrates that FHHCS meets the industry’s highest nationally recognized standards. Rigorous evaluation by CHAP focuses on structure and function, quality of services and products, human and financial resources, and long term viability. “Achieving CHAP accreditation and meeting their high standards of excellence demonstrates FHHCS’s commitment to quality of service, patient safety and exceptional patient care,” said Craig Moore, executive director for Florida Hospital Home Care Services. Florida Hospital Home Care Services is a state licensed, not-for-profit hospital affiliated home health agency established in 1985. It provides a variety of quality home care services to patients and their families in Orange, Seminole and Osceola County. The Florida Hospital Home Care’s team of 200 includes: Skilled Nurses • Physical Therapists, Occupational Therapists and Speech Pathologists • Home Health Aides and Certified Nursing Assistants • Clinical Support Staff Florida Hospital Home Care Services provides the following clinical specialities: Patient and Caregiver Education • Medical and Surgical follow up • Wound Ostomy Continence Management • Pain Management • Chronic Disease Management • Orthopedic, Neurologic and Musculoskeletal Rehabilitation • Lymphedema Therapy • Diabetes management • Alzheimer and Dementia Management CHAP is an independent, not-for-profit, accrediting body for community-based health care organizations. Created in 1965, CHAP was the first to recognize the need and value for accreditation in community-based care. CHAP is the oldest national, community-based accrediting body with more than 5,000 agencies currently accredited nationwide. Through “deeming authority” granted by the Centers for Medicare and Medicaid Services (CMS), CHAP has the regulatory authority to survey agencies providing home health, hospice, and home medical equipment services, to determine if they meet the Medicare Conditions of Participation and CMS Quality Standards. CHAP’s purpose is to define and advance the highest standards of community-based care. For additional information, call 407-691-8202 or visit the web site at www.FloridaHospitalHomeCare.com <http://www.FloridaHospitalHomeCare.com  32 FLORIDA MD - OCTOBER 2013

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