WOMENS CORNER
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THE NEW FACE OF TRANSPLANTS
JESSICA ALBA The film and television star lives with allergies and sensitivities
RESEARCH Be Part of the Answer
GLUTEN Reality and Myths
SPRING 2014 ISSUE
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WHAT IS EOE
Care for the whole you. For a referral to a specialist, call Consult-A-NurseÂŽ at 305-480-6666.
HCA Hospitals of Miami-Dade County MiamiDadeHospitals.com Aventura Hospital and Medical Center + Kendall Regional Medical Center Mercy Hospital — A Campus of Plantation General Hospital
Colon cancer is the second-deadliest form of cancer in the U.S., yet it doesn’t have to be. Did you know that it’s 90 percent preventable? Screening is the key. Colon cancer stops with you This simple procedure – called a colonoscopy – can actively prevent colon cancer. Do it for you and your loved ones. If you are at-risk, get screened, and get on with your life! Who should get screened? Anyone 50 and older People who have a family history of polyps or colon or rectal cancer African-Americans who are 45 and older Other minority groups where the disease is more prevalent
Simon Behar, M.D. Jose P. Ferrer, Sr., M.D. Jose P. Ferrer, Jr., M.D. Nelson Garcia, Jr., M.D. Alfredo Hernandez, M.D. Eugenio J. Hernandez, M.D. Moises E. Hernandez, M.D. Jerry Martel, M.D. Seth D. Rosen, M.D. Andrew Sable, M.D. Galloway Surgery Center 7600 SW 87th Ave., Suite 100 Miami, FL 33173 Phone: 786-245-6100 www.gallowaysurgerycenter.com
To schedule your colon cancer screening, please call 786-245-6100
GASTRO HEALTH Welcomes You
6 GLUTEN Reality & Myths 7 Herbal and Dietary Supplements: A Cause of Liver Disease 8 Jessica Alba The film and television star lives with allergies and sensitivities
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10 What is Eosinophilic Esophagitis? We are pleased to present Gastro Health Magazine’s spring 2014 issue. Gastro Health, PL continues to be a leader in the field of digestive health, nutrition, liver disease and colorectal surgery. With over 20 locations and over 75 healthcare providers throughout South Florida, the Gastro Health team constantly seeks to educate, innovate, and collaborate with other experts in the industry that can provide our patients with outstanding medical care and an exceptional healthcare experience. Our latest addition to the team is a skilled surgeon, Dr. Rodolfo Pigalarga. Dr. Pigalarga is a board certified colorectal surgeon and an excellent person whose character and personality embodies our guiding principle of “treating each patient as a valued member of our immediate family.” In addition, during the month of November 2013, over 100 South Florida community physicians gathered at The Biltmore Hotel’s Conference Center of the Americas in Coral Gables to participate in a CME Event titled “2013 Annual Gasrto Health Clinical Update by the Gastro Health Foundation.” This event provided a venue for our physicians as leaders in the community to educate their peers on the latest treatments, techniques, and best practices in digestive health. During the month of March 2014, the Gastro Health Foundation, Gastro Health staff and physicians participated in the American Cancer Society “Relay for Life.” In May 2014, Gastro Health teams will participate in the Crohn’s and Colitis Foundation of America “Take Steps Walk” to raise funds for education and research.
12 Research Be a part of the Answer 13 Crohn’s & Colitis Foundation of America 19 Gastro Health Physician Directory
24 Quality Measures in Gastroenterology 26 Medidas de Calidad en Gastroenterología 28 The New Face of Intestinal and Multivisceral Transplantation 30 Advanced Endoscopic Techniques At Gastro Health 32 Sacral Nerve Stimulation: A New Effective Option for the Treatment of Fecal Incontinence
Alejandro Fernandez, MBA, CMPE Chief Executive Officer
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33 Join Gastro Health’s Crohn’s and Colitis Support Group 34 Women’s Corner More options than fiber and water
Inside this issue, you will find articles that cover informational and educational topics in all areas of digestive health. From Jessica Alba’s struggle with food allergies and sensitivities, to our Crohn’s and colitis support group and our clinical research opportunities. This issue strives to guide our readers through digestive troubles. We thank you for the confidence you have placed in us by giving us the opportunity to serve you and your primary care provider. Gastro Health will continue to care for you and the ones you love.
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23 Gastro Health Clinical Update
33 Cover Photo: © 2003-2013 Shutterstock, Inc.
Designed and Published by: 9500 South Dadeland Boulevard Suite 802, Miami, FL 33156 T. 305.468.4180
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Copyright © 2014 Gastro Health, P.L. All rights reserved. This publication is published by Gastro Health, P.L., which is solely responsible for its contents. This information presented is intended only for residents of the United States. The material presented is intended only as informational, or as an educational aid, and it is not intended to be taken as medical advice. The ultimate responsibility for patient care resides with a healthcare professional.
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Caring for you and those you love.
MISSION
To provide outstanding medical care and an exceptional healthcare experience.
GUIDING PRINCIPLE
We will treat each patient as a valued member of our immediate family.
CORE VALUES Care and Compassion Provide competent, individualized care in a professional, respectful and caring way. Teamwork Recognize each other as valuable members of our healthcare team by treating one another with loyalty, respect, and dignity. Responsibility Provide excellent and efficient administrative, accounting, personnel, and business management services. Value and Excellence Develop valuable ancillary services that improve our patients’ quality of care and customer experience.
Honesty and Integrity Communicate openly and honestly, build trust and conduct ourselves according to the highest ethical standards. Stewardship Attract and retain great talent and the finest gastroenterologists by actively promoting a professionally satisfying work environment. Accountability Maintain mutually beneficial relationships with top referring physicians, payers, employers, and health systems using performance, outcome, as well as satisfaction measurements to demonstrate accountability and improvement in our care delivery.
Seth D. Rosen, MD Gastroenterologist
Gluten – once a relatively obscure protein found in grain products and known only to gastroenterologists, dieticians, and a few patients diagnosed with Celiac disease – has become a hot topic during the last few years. It is now purported to be the cause of many health problems for some people, and its avoidance is touted as the secret to a long, healthy and happy life. Let’s try and separate the hard facts, possibilities and myths. Gluten is found in several types of grains – barley, rye, oats and wheat. Pure oats do not contain gluten, but those in commercially processed food often do. Gluten is what gives many of our favorite foods their body and texture, like in cookies, breads, pizza dough and pasta. It can also be found in beer. It is ubiquitous in most of our diets. When a person’s immune system reacts to the gluten protein, Celiac disease occurs. The normal lining of the small intestine has innumerable microscopic finger-like projections called villi; these projections increase the surface area of the intestines to maximize absorption of nutrients. When celiac disease occurs, the villi are attacked by antibodies and destroyed, flattening out the villi and resulting in decreasing the absorptive capacity of the intestines. Although there is not a strict family link to the condition, there is a genetic basis which, combined with as of yet undefined environmental factors, means that often more than one family member may be affected. There can be many consequences
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Reality & Myths of this condition, including chronic diarrhea, iron deficiency, various vitamin deficiencies and calcium malabsorption, to name a few. Symptoms may include gas and bloating, diarrhea, abdominal pain and weight loss. It can also cause a skin condition called dermatitis herpetiformis which appear as small clear pimples. Celiac disease can be found in adults as well as children. Some of the symptoms can mimic other conditions such as Irritable Bowel Syndrome (IBS), Crohn’s disease, Ulcerative colitis, and lactose or other food intolerances. The diagnosis is made by blood tests combined with a biopsy of the first part of the small intestine called the duodenum. This can be done during an upper endoscopy. If a patient with Celiac disease has been following a strict gluten-free diet for 6 or more months, both the blood tests as well as the biopsies may look normal. The treatment for Celiac disease is simple yet difficult – avoid foods that contain gluten. This is simple because there are no other restrictions or medications; it is hard because gluten is in many of the foods that make up our daily diets. It is hidden in sauces, drinks and even in some medications. People with Celiac disease become excellent label and menu readers. There are a host of gluten-free products available at the super markets and online – breads, cookies, pastas and yes, even beer. Many restaurants now also feature gluten-
GASTRO HEALTH MAGAZINE
free items. With the avoidance of gluten, the damage to the small intestines is repaired and the symptoms and nutritional issues resolve. Recently, there have been a number of conditions ascribed to gluten without having Celiac disease. “Non-celiac gluten sensitivity” has become a commonly described condition to explain a variety of symptoms such as chronic abdominal pain, fatigue, constipation or diarrhea, immune dysfunction, depression and a general lack of wellbeing. There are few scientific studies to support the connection between these non-specific symptoms with gluten, but many people swear they feel better after removing it from their diet. Other than the inconvenience of following the diet, there is no harm in removing gluten from one’s nourishment – so if it makes a patient feel better, it should not be discouraged. Because a strict gluten-free diet usually contains fewer calories, it often leads to weight loss. Losing weight is beneficial for many people and often weight loss alone will give people a sense of feeling healthier and having more energy. If you suspect you have Celiac disease or non-celiac gluten sensitivity – discuss it with your physician. Appropriate testing as well as proper nutritional counseling can then be arranged.
SPRING 2014
Herbal and Dietary Supplements: A Cause of Liver Disease The true incidence of drug-induced liver injury in the United States is difficult to discern. The most recent and well-executed population-based studies, however, have estimated an annual incidence of around 20 new cases per 100,000 persons; Herbal and dietary supplements (HDS) are implicated in approximately 16% of these cases. Herbal and dietary supplements are commonly used by many people, both healthy and with specific ailments, with the perception that HDS are safe and effective. It is estimated that over 40% of the U.S. population uses alternative therapies of some kind, most commonly HDS.
Jose P. Ferrer, Sr., MD Gastroenterologist
RECOMMENDATIONS Always inform your doctor about the herbal and dietary supplements that you may be taking. In the event of a possible liver injury or abnormal tests, you must cease all supplement use. ď Ž For more information, visit www.livertox.nih.gov
COMMON USERS Alarmingly, most patients who use HDS do not reveal this to their primary care provider. Users of HDS tend to be Asian, of young age, highly educated, and more health conscious than non-users. The most common reasons for their use include obesity/weight loss, body building, menopausal symptoms, gastrointestinal disorders such as indigestion or constipation, liver disease, and neurological complaints such as headache and migraines.
SIDE EFFECTS The hepatotoxic potential of HDS has been recognized for many years and appears to be increasing. As mentioned above, it also seems to be implicated in up to 16% of all cases of drug-induced liver injury. Many single herbs have been implicated in liver toxicity; however, most currently available HDS comprise a complex mixture of ingredients and although the FDA requires that a product label accurately reflect the contents, reports exist of product contamination and unlabeled ingredients. Most of the time, the liver injury has a very mild course and it will resolve by stopping the offending supplement. In rare cases, however, the disease will have a more severe course leading up to requiring liver transplantation or even causing death.
SPRING 2014
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The film and television star lives with allergies and sensitivities By Bonnie Siegler From Living Without Magazine
Multi-talented Jessica Alba plays many different roles. A wildly popular actor, the 31 year old has starred in Dark Angel, Fantastic Four, Sin City and Machete. A wife and parent, she is married to producer Cash Warren and is mother to two little girls, Honor and Haven. An activist, she has raised money for AIDS research and does charity work for groups like Habitat for Humanity and the National Center for Missing and Exploited Children. An environmentalist, Alba is passionate about green products, throwing her super powers behind the Safe Chemicals Act and testifying in front of the U.S. Congress. She’s the spokesperson for the Safer Chemicals, Healthy Families
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Coalition. Now Alba adds “entrepreneur” to her list of accomplishments. In January 2012, she launched The Honest Company, a company providing nontoxic products for the home, babies and children. Allergies and asthma have plagued Alba ever since she was a little girl. Before she was ten years old, she suffered from a long list of medical issues and was hospitalized with problems ranging from a collapsed lung to pneumonia. “I know my allergy triggers now,” she says. “I know what to eat and what not to eat.” Recently, Alba talked with Living Without about her special dietary needs and the inspiration behind her new company.
GASTRO HEALTH MAGAZINE
SPRING 2014
Living Without You’ve had asthma and severe allergies since early childhood. What triggered your attacks and do you keep those things away from you and your children now? Jessica Alba I was allergic to so many are sprayed on fruits and vegetables and that’s what I react to. When I eliminate all that from my diet and when I eat organic, I’m fine. I also have to read labels on products that I bring into our home.
How do you stock your kitchen? What foods would we always find there? We have a ve ry co mpre he nsi ve array of foods in o ur ki tche n—a l o t o f f re sh, o rgani c i t ems . I think mo st who l e f o o ds are ve ry nutri ti o us. We eat a lot o f who l e grai ns and l e gume s and al l of our drink s are o rgani c. Pre tty much e ve ry thi ng i n my k itchen i s o rgani c.
What happens if you ingest this stuff? If I eat conventionally grown produce from a regular grocery store, my throat swells and starts to close up.
You ’v e s a id y ou don’ t l i ke to ex ercis e a nd tha t you have no s p ecia l work ou t r outi ne. Y et y ou r fig ure is outstandi ng. H ow d o y ou d o it? I don’t have any tricks. I do drink a lot of water—plain water. Our bodies are made of 70 percent water and there are so many bad health ramifications to be i ng de hy drate d. I believ e the mo re hy drate d we are, the be tte r. I’ ve al way s had a lot of wate r aro und.
Does anyone in your immediate family have allergies or sensitivities? My mom has bad allergies. She’s even allergic to the preservatives in certain epinephrine products and she can go into anaphylactic shock from that. Have you ever had such a severe reaction? Only once recently. I was very tired after filming for 22 hours. We got on an airplane and I accidentally ate some Brazil nuts and I’m allergic to them. I didn’t notice they were in there because I was so tired. They also weren’t organic and were covered in some kind of preservative. I had a bad attack.
Motherhood can change your life. How have your children inspired you? Ever since I was really young, I’ve always been interested in being socially aware and active. My main focus has always been making the world a better, safer place, especially for women and children. Having children is an intense responsibility that inspires all that even more and makes it that much more important. Having kids inspired me to start this new company. It is a direct response to some of the serious health concerns—rising rates of allergies, asthma, autism— affecting modern parents.
How was it treated? Thank God, my security guy had an inhaler with him. I ended up receiving some oxygen, too. Do you carry an EpiPen? I don’t—but I should! My mom does. I haven’t had that bad of a reaction since that one on the plane but it happens often with my mom. What foods have you completely omitted from your diet due to allergies or any other health concerns? Basically, I don’t eat anything that isn’t organic. I’ve stopped eating highly processed foods due to the preservatives and chemicals on them. I don’t eat from salad bars because of the potential for nitrates and sulfates. And I no longer eat anything that contains high fructose corn syrup or white flour because I believe they’re just not good for my overall health.
SPRING 2014
I was shopping for eco-friendly baby products for Honor and I realized I was spending all this money on something that didn’t work. While washing diapers in supposedly babysafe detergent, I had an allergic reaction and broke out in hives and started sneezing. I thought—No way am I putting this on my newborn. I want the world to be a safer place. Being a mom inspires that.
GASTRO HEALTH MAGAZINE
Reproduced with permission from Living Without Magazine. For subscription information please call (800)474-8614, or go to www.livingwithout.com.
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E osin O philic E sophagitis? George A. Sanchez, MD Gastroenterologist
Eosinophilic Esophagitis (EoE) is a chronic condition in which the immune system causes inflammation to the esophagus – the tube which carries food from the mouth to the stomach. In EoE, the lining of the esophagus has certain cells called “eosinophils” which cause inflammation and do not let the esophagus function properly. Eosinophils are allergy cells that normally are not seen in the esophagus. The exact cause of EoE is unknown, but it is thought to be related to allergies, in particular food allergies. What are the common symptoms? The symptoms of Eosinophilic Esophagitis can vary with age. Adults and teenagers usually develop symptoms of trouble swallowing as the most common symptom. It can begin with difficulty swallowing solid food or even the feeling as if food is getting stuck in the throat or chest. Other people can experience chest or upper abdominal pain, and possibly chest burning known as heartburn.
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In children, it usually presents with different symptoms such as refusing to eat solid foods, nausea or vomiting, and also abdominal pain. Patients with Eosinophilic Esophagitis can have other allergic disorders such as asthma, hay fever, or eczema. How is Eosinophilic Esophagitis diagnosed? Eosinophilic Esophagitis can be challenging to diagnose at first because it can resemble other conditions. However, the best available test to check for this condition is an upper endoscopy with biopsy. An upper endoscopy is a procedure performed by a gastroenterologist during which a small flexible tube with a camera is introduced through the mouth and passed into the esophagus. The lining of the esophagus can be looked at and a small piece of tissue from the esophagus is removed (biopsy). The sample of the tissue obtained is then sent to a pathologist to view under a microscope and determine if you
GASTRO HEALTH MAGAZINE
have Eosinophilic Esophagitis. At times, blood tests can show elevated levels of eosinophils, but this alone does not make the diagnosis. How is Eosinophilic Esophagitis treated? The treatment of Eosinophilic Esophagitis involves diet changes and medications which help control symptoms. As an initial approach, certain foods that commonly cause allergy are avoided in order to improve symptoms. These may include milk, egg, soy, peanuts, shellfish, and wheat. Patients can be sent to an experienced dietician to help with learning how to shop and substitute foods. Otherwise, patients can be referred to an allergist for further testing to determine food allergies. There are also different medications used to treat Eosinophilic Esophagitis. One common medication is called “Proton Pump Inhibitor” (PPI), which is commonly used to treat acid reflux. This medication blocks acid, which can trigger symptoms or contribute to the inflammation. Other medicines used include steroids, which help reduce inflammation and therefore improve symptoms. In some patients with EoE, inflammation may progress and cause narrowing of the esophagus which is known as an esophageal stricture. This is treated by performing an upper endoscopy and widening the esophagus, called dilation. Eosinophilic Esophagitis has become more commonly recognized and visiting your doctor can lead to its discovery.
SPRING 2014
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Be Part of the Answer Ivette de Pool, BA Clinical Research Manager
The National Institute of Health defines clinical trials as research studies that test how well new medical approaches work in people. Each study answers scientific questions and tries to find better ways to prevent, screen for, diagnose, or treat a disease. Clinical trials may also compare a new treatment to a treatment that is already available. So why should you participate in research? Have you ever considered it? Being a part of research is necessary to bring about advancements in the medical field. Without studies and potential volunteers, scientists will never really know how the body fully functions. Advancements in medicine have all come about because someone just like you decided to make a difference. Participating in a clinical trial is a major decision and should be considered with plenty of time. When an individual agrees to participate in a research trial, this process is called “Informed Consent.” By signing the Informed Consent, the participant is agreeing to all the terms and conditions set forth in the protocol.
is it possible to find newer, more innovative therapies. Focusing on education about clinical trials allows for the advancement of new discoveries that will aid in the treatment of diseases for generations to come. If you haven’t already done so, now is the time to consider being a part of medical research. Currently, Gastro Health Research offers several study opportunities in the following treatment areas:
Eligible participants may even receive compensation for their time and travel. To learn more about Gastro Health’s research studies, please contact: (786)456-8676 or visit our website at www.gastrohealth.com/ research. Clinical research trials can potentially aid in the saving of lives and improve overall health. Be part of the answer; be part of the change.
PARTICIPATE NOW!
CROHN’S DISEASE ULCERATIVE COLITIS CAPSULE ENDOSCOPY ANEMIA COLORECTAL CANCER SCREENING CLOSTRIDIUM DIFFICILE ASSOCIATED WITH DIARRHEA (CDAD)
At Gastro Health, our mission is “to provide outstanding medical care and an exceptional healthcare experience.” We believe that clinical research is vital in order to fulfill our mission. For over two decades, the physicians at Gastro Health have been involved in clinical research studies, aiming to restore the way we think about research in general. Only by clinical trials and research
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GASTRO HEALTH MAGAZINE
SPRING 2014
Alina Suarez was a lovely and bright 11 year-old, “having a blast” at her sleep-away camp in the summer of 2012 when the stomach pains hit her. She found herself having to stop what she was doing to rush to the bathroom throughout the day, and even spent an entire night in the camp infirmary. The on-duty nurse sent her to see a doctor who prescribed some pills and suggested a restricted diet. She did her best to follow the instructions, but the pains and bathroom breaks continued. The events put a damper on her camp experience, and things were about to become worse.
Now at age 12, Alina sees her experience in a positive light. “In my opinion, I think God blessed me with Ulcerative Colitis, because I now see the world very differently,” explains the brave young lady. “I am more thankful for the wonderful blessings I have, including my family, friends, and my life on Earth. I am more sensitive about others and their problems. I know how to enjoy life and take care of the body that God has given me. Thanks to my diet, my entire family is healthier and we all have a better lifestyle.” Part of Alina’s help with others has included raising awareness of her disease, and the raising of funds through participation in the Crohn’s & Colitis Foundation of America (CCFA)’s annual Miami Take Steps Walk. Her family raised more than $10,000 in last year’s walk, and plans to raise even more funds this year.
After camp, Alina began seeing mucus and blood in her stool, and her bathroom breaks were now occurring up to ten times a day. After trying an unsuccessful treatment plan, the Suarez family was referred to a gastroenterologist. Dr. Raghad Koutouby, a gastroenterologist at Gastro Health, examined Alina and had a strong inclination of what the problem was. The colonoscopy she performed confirmed Alina had Ulcerative Colitis (UC). Dr. Koutouby prescribed different medications, but Alina continued to have flare-ups through 2012. Alina’s mother, Margie Suarez, put her on the restrictive Specific Carbohydrate Diet. Alina found the severely limited diet a challenge – but she restrained herself and followed the diet’s strict guidelines. However, the flare-ups continued to occur. It was worrisome as Alina’s growth rate was already being affected.
SPRING 2014
“I cannot express how much the CCFA has meant to us,” says Margie. “As soon as the diagnosis came, Dr. Koutouby introduced us to CCFA, where I’ve been able to attend seminars. It was also through CCFA that Alina attended a week-long camp where, for the first time, she was able to be with other young people who are living with her disease. “The Take Steps Miami Walk gave her the forum to be able to openly talk about her disease with her friends and peers.” If you are interested in learning more about the Crohn’s & Colitis Foundation of America and the yearly Take Steps Walk, please visit / Miami or call (561) 218-2929.
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PHYSICIAN DIRECTORY
PHYSICIAN DIRECTORY
Francisco J. Baigorri, MD * Gastroenterologist Care Center 1
Simon Behar, MD * Gastroenterologist Care Center 3
Barry E. Brand, MD Gastroenterologist Care Center 2
Gustavo Calleja, MD * Gastroenterologist Care Center 1
Marc S. Carp, MD Gastroenterologist Care Center 6
Lewis R. Felder, MD Gastroenterologist Care Center 7
Edward Feller, MD Gastroenterologist Care Center 15
Jose P. Ferrer, Jr., MD * Gastroenterologist Care Center 3
Jose P. Ferrer, Sr., MD * Gastroenterologist Care Center 3
Nelson Garcia Jr. MD * Gastroenterologist Care Center 8
Pamela L. Garjian, MD* Gastroenterologist Care Center 16
Daniel Gelrud, MD * Gastroenterologist Care Center 1
Harris I. Goldberg, MD Gastroenterologist Care Center 1
Ruben Gonzalez-Vallina, MD * Pediatric Gastroenterologist Care Center 13
Pedro J. Greer Jr., MD * Gastroenterologist Care Center 11
Mitchell Gregg, MD Radiologist
Guillermo Gubbins, MD * Gastroenterologist Care Center 10
Alfredo J. Hernandez, MD * Gastroenterologist Care Center 11
Enrique Hernandez-Sanchez, MD* Pediatric Gastroenterologist Care Center 14
Eugenio J. Hernandez, MD * Gastroenterologist Care Center 3
Moises E. Hernandez, MD * Gastroenterologist Care Center 3
Richard E. Hernandez, MD * Gastroenterologist Care Center 5
Raghad Koutouby, MD Pediatric Gastroenterologist Care Center 12
Eduardo Krajewski, MD * Colorectal Surgeon Care Center 9
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Jose A. Lavergne, MD * Gastroenterologist Care Center 7
James S. Leavitt, MD Gastroenterologist Care Center 1
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Oscar Loret de Mola, MD* Pediatric Gastroenterologist Care Center 17
Jerry Martel, MD, MPH * Gastroenterologist Care Center 8
Antonio Martinez, MD Pathologist Pathology Medical Director
Flavia Mendes, MD * Gastroenterologist Care Center 1
Pedro Morales, MD * Gastroenterologist Care Center 8
Brett R. Neustater, MD Gastroenterologist Care Center 7
Javier L. Parra, MD * Gastroenterologist Care Center 1
Rodolfo Pigalarga, MD* Colorectal Surgeon Care Center 9
Alfredo Rabassa, MD * Gastroenterologist Care Center 1
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George A. Sanchez, MD * Gastroenterologist Care Center 1
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Somal S. Shah, MD * Gastroenterologist Care Center 11
Arie Slomianski, MD * Gastroenterologist Care Center 1
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2013 ANNUAL
GASTRO HEALTH CLINICAL UPDATE at the Biltmore Hotel, Coral Gables On Saturday, Nov. 2, over 100 South Florida community physicians gathered at The Biltmore Hotel’s Conference Center of the Americas in Coral Gables to participate in a CME Event titled “2013 Annual Gastro Health Clinical Update, presented by the Gastro Health Foundation.” Dr. Nelson Garcia and Dr. Javier Parra served as course directors and several other Gastro Health’s physicians made informative presentations on new techniques, medications, and treatments for digestive and colorectal disease and the prevention of colon cancer. The presentations included lively discussions on nutrition, surgical approaches, and updates on chronic disease management. We would like to thank all in attendance including our panel of speakers and the contributions made by corporate sponsors for without which their participation the event would not have been possible.
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Quality Measures in
Gastroenterology Jose A. Lavergne, MD Gastroenterologist
Quality measures are tools used to evaluate how well healthcare services are being delivered. The quality measures adopted are those endorsed by the National Quality Forum, a nonprofit, nonpartisan public service organization formed by all those interested in healthcare (consumers and providers of health care). Among the goals of creating these measures are to generate data that will help consumers make informed choices about their healthcare. In addition, these measures are expected to enhance transparency and accountability.
In 2011, the NQF and the U.S. Department of Health and Human Services created the National Quality Strategy, which resulted in the National Performance Measure Set (NPMS), a group of quality measures to assess health outcomes, patient experience, and resources used. Most of the Quality Measures used by the Center for Medicare & Medicaid Services (CMS) and commercial insurances are contained in the NPMS. CMS was required by the Patient Protection and Affordable Care Act (ACA) of 2010 to establish the Physician Compare website, which was launched on December 30, 2010. CMS plans to add quality data, and will post the first set of measured data in 2014 from data collected not sooner than 2012. The Gastroenterology (GI) part of the National Performance Measures Set (GI-NPMS) was developed by the cooperation among the different gastroenterology societies (AGA, ASGE, ACG, AASLD), and the Crohn’s and Colitis foundation of America (CCFA) for the measures related to Inflammatory Bowel Disease. Currently the quality measures which are specific to gastroenterology have to do with Colorectal Cancer (CRC), Hepatitis C infection (HCV), Inflammatory Bowel Disease (IBD), and Gastroesophageal Reflux Disease (GERD). They are not the only care a patient with these conditions should receive, but they are indicators of the quality of care being given.
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COLORECTAL CANCER SCREENING
ADENOMA DETECTION RATE
Colorectal cancer (CRC) is the third most common cancer diagnosed among men and women, and the second leading cause of death from cancer in the United States. CRC may be prevented by early detection and removal of adenomatous polyps. Screening colonoscopy refers to the endoscopic exam of the colon in people without symptoms or history of CRC or polyps, while surveillance colonoscopy refers to the same type of exam but to people with history of colon polyps or CRC. Colonoscopy has been shown to reduce the mortality associated to CRC by detecting and removing significant colon polyps, and diagnosing early lesions when they are more amenable to a curative approach. The current CRC screening recommendations are based on the following: 1) Adenomatous polyps are common in adults over age 50, but the majority of polyps will not develop into colorectal cancer; tissue type (histology) and size determine their risk of evolving to CRC. 2) Adenomatous polyps, or “adenomas”, represent approximately one half to two thirds of all colorectal polyps, and are associated with a higher risk of CRC. 3) Advanced adenomas (higher risk of malignant transformation) are those polyps larger than 10mm, histologically (tissue) having high-grade dysplasia, or showing a significant villous components (villous adenoma, or tubulovillous adenoma).
COLONOSCOPY Currently, colonoscopy is the best screening option for early detection of CRC and adenomatous polyps for asymptomatic adults age 50 or older. The CRC quality measures (see table) try to assess that a screening colonoscopy starts at the appropriate age. The age of 50 years or older is used for average risk patients, defined as lack of a personal or family history of CRC or colon adenomas. The age of 40 years, or 10 years before the youngest case in the immediate family, is used for patients with either CRC or adenomatous polyps in a first-degree relative before age 60 or in 2 or more first-degree relatives at any age. The time interval to repeat a colonoscopy will depend on the findings, with 10 years for a negative colonoscopy, and usually between 3-5 years for those with polyps removed, depending on number of polyps and whether they were considered advanced.
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The detection of adenomatous polyps depends on the quality of the colonoscopy. The quality measure called the Adenoma Detection Rate (ADR) is the proportion of individuals undergoing a complete screening colonoscopy who have one or more adenomas detected. The recommended benchmarks for a quality colonoscopy have been an ADR on screening colonoscopies of at least 15% in women and at least 25% in men. There is an increased risk of a CRC lesion appearing before the next screening colonoscopy is indicated when the procedure is performed by an endoscopist with a lower than 20% ADR. Lastly, an adequate bowel preparation (cleansing) is a critical element in the accuracy and cost-effectiveness of CRC screening. Either splitting the preparation in 2 equal parts with the second part taken four hours before the colonoscopy, or taking the entire preparation the same day of the procedure, have been shown to improve the quality of the preparation and increase the detection of significant polyps.
COLORECTAL CANCER (CRC) MEASURES · Colorectal cancer screening rate of the appropriate population that is screened for CRC/polyps · Colonoscopy interval for patients with a history of adenomatous polyps (avoid of inappropriate use) · Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients · Screening colonoscopy adenoma detection rate
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Medidas de Calidad en
Gastroenterología Jose A. Lavergne, MD Gastroenterólogo
Las “Medidas de Calidad de Servicio” son usadas para evaluar la eficiencia de los servicios de salud. Las medidas utilizadas son las aprobadas por el “National Quality Forum” (NQF), una organización de servicio público sin fines de lucro o afiliación política, formada por todos los interesados en salud (consumidores y proveedores de cuidados de salud). Estas medidas han sido creadas con el fin de generar información que ayude al consumidor a tomar decisiones basadas en información pertinente. Además, se espera que favorezcan la transparencia y responsabilidad de los proveedores de salud. En el 2011, el NQF y el Departamento de Salud y Servicios Humanos de los Estados Unidos crearon la “Estrategia de Calidad Nacional”, la cual produjo el Grupo de Medidas de Rendimiento Nacional (NPMS), un grupo de medidas de calidad que miden los resultados de salud, experiencia del servicio recibido, y recursos utilizados. La mayoría de las Medidas de Calidad usadas por el Centro para Servicios de Medicare and Medicaid (CMS) y los seguros de salud comerciales están contenidos en el NPMS. A petición de la ley llamada Acto de Protección al Paciente y Cuidado Asequible (Affordable Care Act) del 2010, CMS (Medicare&Medicaid) creo el sitio de internet llamado “Physcian Compare”, el cual reporta la calidad de los servicios médicos. Este sitio de internet fue lanzado en diciembre 30 del 2010, y CMS planea agregar información sobre calidad en el 2014. La medidas de Gastroenterología del NPMS fueron desarrolladas con la cooperación de las diferentes sociedades de gastroenterología en los Estados Unidos (AGA, ASGE, ACG, AASLD), y la Fundación Americana de Crohn’s y Colitis a las medidas relacionadas a enfermedad inflamatoria intestinal (Enfermedad de Crohn y Colitis Ulcerativa). En la actualidad, las medidas de calidad específicas a Gastroenterología tienen que ver con Cáncer Colorectal (CCR), Hepatitis C (HCV),
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enfermedad inflamatoria intestinal (EII), y Reflujo Gastroesophagico (RGE). Estas medidas no son el único cuidado que los pacientes con estas condiciones deben recibir, pero si son indicadores de la calidad del servicio recibido en el tratamiento de ellas.
depende de los hallazgos en la colonoscopia previa, 10 años después de una primera colonoscopia negativa, y usualmente entre 3-5 años para aquellos pacientes con pólipos dependiendo de cuantos pólipos fueron sacados y si fueron considerados como adenomas avanzados.
DETECCIÓN DE CÁNCER COLORECTAL
TASA DE DETECCIÓN DE ADENOMAS
El Cáncer Colorectal (CCR) es el tercer cáncer más común en hombres y mujeres, y la segunda causa de muerte por cáncer en los Estados Unidos. El CCR se puede prevenir con la detección temprana y eliminación de pólipos adenomatosos. La colonoscopia de detección precoz de CCR/pólipos (examen con una cámara endoscópica del colon para detección de pólipos en personas sin síntomas o historia de pólipos o cáncer) y/o vigilancia (personas con historia personal o familiar de CCR o pólipos) han mostrado que reducen el número de muertes causadas por CCR al detectar y eliminar pólipos importantes, y por diagnosticar tumores tempranos cuando aún pueden ser curados.
La detección de adenomas del colon depende de la calidad de la colonoscopia. La medida de calidad llamada “tasa de detección de adenomas” (TDA) es la proporción de individuos a los que se le hacen una colonoscopia de detección temprana a quienes se les encuentra uno o más adenomas. El valor de referencia recomendado para una colonoscopia de detección temprana es una TDA de al menos 15% en mujeres y al menos 25% en hombres. Existe un aumento del riesgo de que un CCR aparezca antes de la siguiente colonoscopia cuando esta es realizada por un endoscopista con un TDA de menos de 20%.
Es importante que pacientes conozcan lo siguiente: A) Los pólipos adenomatosos son comunes en adultos después de la edad de 50, pero la mayoría de ellos no se transformaran en cáncer colorectal; el tipo de tejido (histología) y el tamaño determinan el riesgo de malignizarse.
Por último, la limpieza adecuada del colon antes de la colonoscopia es un elemento crítico para que el examen sea exacto y costo-efectivo. El dividir el total de la preparación en dos partes iguales con la segunda parte tomada 4 horas antes de la colonoscopía, o tomar toda la preparación el mismo día del examen, ha mostrado que mejora la calidad de la preparación y aumenta la detección de pólipos importantes.
B) Pólipos adenomatosos, o adenomas, representan de la mitad a dos tercios de todos los pólipos del colon, y tienen riesgo de progresar a un CCR. C) Adenomas “avanzados” (con el más alto riesgo de cáncer) son aquellos pólipos más grandes de 10 milímetros, con tejido mostrando “displasia de alto grado”, o con un componente “velloso” (adenoma velloso, o adenoma tubulovelloso).
· Prueba de detección temprana de CCR % de población adecuada que es examinada por CCR/pólipos
LA COLONOSCOPIA En la actualidad, la colonoscopia es el mejor que se puede usar para la detección temprana de CCR y adenomas del colon en pacientes sin síntomas de 50 o más años de edad. Las medidas de calidad (ver la tabla) tratan de evaluar que la colonoscopia de detección temprana empiecen a la edad correcta. La edad de 50 años o mas es usada para pacientes sin historia personal o familiar de cáncer de colon o adenomas de colon. La edad de 40 años, o 10 años antes de la edad del caso mas joven en la familia inmediata, es usada para pacientes con CRC o adenoma de colon en un familiar de primer grado antes de los 60 años, o en dos familiares de segundo grado de cualquier edad. La recomendación de cuando repetir una colonoscopia
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MEDIDAS DE CANCER COLORECTAL
· Tiempo entre colonoscopías en pacientes con historia de pólipos adenomatosos (evitar uso inadecuado del examen) · Endoscopia/vigilancia por pólipos: tiempo adecuado de seguimiento después de una colonoscopia normal en un paciente de riesgo normal
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THE NEW FACE Rodrigo Vianna, MD
of Intestinal and Multivisceral Transplantation
Thiago Beduschi, MD
The first isolated intestinal transplant was described Intestinal transplantation has proved to be cost almost 50 years ago and it has been 30 years since effective when compared to TPN. After two and half the first multivisceral transplant was performed. Even years, transplant becomes cheaper than all the costs though there has been remarkable progress after four related to parenteral nutrition. Quality of life is another decades, intestinal transplantation remains a rare point in favor of transplant. Patients report going back event and is only performed by a handful of centers to their regular activities. Freedom from lines and their throughout the world. Improvements in surgical complications is one of the highlights for patients. techniques, critical care, immunosuppressive drugs, and Intestinal and multivisceral immune-monitoring combined transplantation is not free • COMPLEX PORTO-MESENTERIC with a better understanding of complications. One of the THROMBOSIS (WHERE and management of the main factors affecting the LIVER TRANSPLANT IS NOT complications have resulted final outcome is the patient TECHNICALLY POSSIBLE) in excellent outcomes in the condition at the time of the modern era, even comparable surgery. Patients coming from • SLOW GROWING AND to other solid organ transplants. home perform much better NON-RESECTABLE INTRAthan patients coming from ABDOMINAL TUMORS In the last decade, new the hospital at the time of (NEUROENDOCRINE/ indications have come along transplant. with improvements in outcomes. DESMOID TUMORS) Other than the traditional patient For this reason, early referral to a • GASTROINTESTINAL PSEUDOwith short-gut syndrome and specialized intestinal transplant OBSTRUCTION (AND OTHER life-threatening complications center is fundamental for better from the total parenteral outcomes. It is common to be SEVERE DYSMOTILITY nutrition (TPN), indications now referred patients who already DISORDERS) include: have limited vascular access, • ABDOMINAL CATASTROPHES TPN induced liver disease and Peri-operatory mortality is rare in multiple infections. In some (TRAUMA, OPEN ABDOMINAL experienced hands and hospital cases, complete lack of central CAVITY, MULTIPLE ENTERIC stays have been decreasing venous access can preclude FISTULAS) drastically, with several patients the transplant. leaving the hospital in less than • QUALITY OF LIFE three weeks with no central lines Intestinal and multivisceral and complete enteral autonomy. transplantation has now evolved to be a valid therapy Most of the patients achieve enteral autonomy in two for complex patients, restoring the physiology of the to three weeks after the transplant and do not require abdominal cavity, the ability to eat and at the same any additional nutrition or hydration other than by time eradicating the baseline disease. mouth.
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Does A Liver Or Intestinal Transplant Make Sense? For families facing serious liver and gastrointestinal diseases, including Crohn’s, hepatitis, liver cancer, intestinal failure and certain tumors of the abdominal cavity, a single organ or multi-organ transplant may be the best or only option for a renewed life. Led by Dr. Rodrigo Vianna, who has more experience performing intestinal/multivisceral transplants than any other surgeon in Florida, the Miami Transplant Institute at Jackson Memorial Hospital is the only program in the state that performs liver, intestinal and multivisceral transplants for both adults and children, and has a proven track record of success in each. Find out if transplant makes sense for you. Visit
MiamiTransplant.org, or call 305-355-5000.
U t
Advanced Endoscopic Techniques At
Gastro Health
Javier L. Parra, MD Gastroenterologist
As gastroenterologists, there are times when the tools available can’t give us enough information, or reach deep enough to treat the problems that our patients suffer from. Therefore, over the past few decades, a field of advanced endoscopy has developed to help gastroenterologists reach deeper and obtain better information, as well as treat difficult conditions through natural orifices, while avoiding surgery. In this article, I will elaborate on two of these techniques, although all advanced endoscopic procedures are available at Gastro Health.
DEVICE ASSISTED ENTEROSCOPY “Entero” is derived from the Greek word “enteron” for intestine, “-oscopy” is derived from the Greek word “skopos” for looking/observing. Hence, enteroscopy is a procedure performed to visualize the intestine. Particularly, the small intestine. On average, an adult human has about 15 feet of small intestine, where most of the digestion and absorption of nutrients takes place. The small intestine used to be considered a black box, in the sense that because it was difficult to visualize and obtain tissue from. In the past, ropes with weights were given to the patient in order to have them defecate them after a few days, then endoscopes were attached to them as they were pulled out of the patient’s mouth. This was called rope-way enteroscopy. Fortunately, these techniques have significantly evolved, and we can now use a longer, flexible, high definition camera that is inserted under sedation and has the ability to obtain biopsies, open narrowing’s and take out large polyps. These devices are used in association with a sleeve, or overtube that has a balloon, or a spiral. The balloon can be inflated, or deflated; the spiral can be rotated and the sleeve can be moved back and forth on the scope, in order to help advance the scope through the intestine. To try to visualize this, imagine you are pleating the small bowel onto itself, much like an accordion. The majority of patients undergoing this type of procedure are those with obscure gastrointestinal bleeding. Those that have had anemia of unknown origin with some
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evidence of blood loss through the gastrointestinal tract can have small blood vessels that are very superficial and delicate and will bleed slowly, causing the patient to have anemia. Cauterization of these vessels can be performed. Others have had abnormal imaging studies, such as CAT scans, MRIs, or even capsule endoscopies, which have to be confirmed with direct visualization. Lymphomas, muscular tumors, cancers and inflammatory bowel diseases, such as Crohn’s disease can be diagnosed with device assisted enteroscopy.
CHOLANGIOSCOPY This technique is used to access the bile duct with a small scope that goes through the working channel of another scope. This is called a mother-daughter system, where the mother scope is used to access the bile duct with wires, while the physician performing the procedure interprets x-ray images. Once the daughter scope is advanced, direct visualization of the bile duct and its lining, as well as its contents is possible. This technique is useful in diagnosing biliary tract cancers, as it allows the gastroenterologist to direct their forceps to obtain samples from the abnormal areas, as opposed to directing a brush to the abnormal appearing area on an x-ray. Also, it allows us to treat difficult to withdraw bile duct stones with a technique called lithotripsy. Thin and long catheters are advanced through the daughter scope and into the bile duct, where they apply shock wave, or laser energy in order to destroy these stones. Foreign bodies can be removed, and suspicious areas examined with this technique as well. Once again, this advanced endoscopic technique can avoid the patient a delay in diagnosis and also can treat difficult biliary diseases that were previously considered to need surgery. In conclusion, gastroenterologists have seen the evolution of endoscopy to be able to help patients obtain an accurate, prompt diagnosis and to avoid more invasive procedures, such as surgery. These procedures used to only be available at university-based institutions, however, at Gastro Health, fellowship trained physicians have made these widely available to our community.
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meichberg@ingham.com
Sacral Nerve Stimulation: A New Effective Option for the Treatment of Fecal Incontinence Rodolfo Pigalarga, MD Colorectal Surgeon
Fecal incontinence is the involuntary loss of fecal material through the anus. Both continence and defecation are very complex functions, involving multiple muscles and nerves to work together in a very sophisticated way. It is estimated that at least 18 million Americans suffer from this problem and it is not surprising that they do not want to talk about it with anybody, not even with their physicians which they might see often and regularly for other health problems. On the other hand, physicians don’t usually ask about this issue either, unless they are specialists. That is why it is thought that the real magnitude of this condition is largely under-estimated. Fecal incontinence weighs down heavily on these patients’ lives; they feel alone, anxious and humiliated. Many prefer to remain confined in their houses and adjust their social and professional lives to avoid embarrassment. In other words, the disease wins.
COMMON CAUSES The most common causes of fecal incontinence are anal sphincter damage due to trauma, previous rectal surgery or vaginal delivery; or damage to the pudendal nerves (the nerve that controls the pelvic floor muscles and transmit the sensation from the rectal area to the brain) either from trauma, pregnancy or diabetes. Female patients are especially vulnerable because of the stress and possible injuries that pelvic muscles and nerves withstand during pregnancy.
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TREATMENT Because of its complexity, it is extremely difficult to manage fecal incontinence. Even though we have the capability to comprehensively study the physiology and anatomy of the anorectal sphincter and pelvic floor muscles, treatment very often consists of simple diet modification (fiber supplements and anti-diarrhea medications), pelvic floor physical therapy (Biofeedback), or complex surgical procedures when there is obvious and severe muscle damage. The Sacral Nerve Stimulator, or InterStim Therapy, represents a real breakthrough in our ability to treat fecal incontinence. In the appropriate patient, chronic stimulation of the sacral nerve has been proven to decrease at least half the number of weekly episodes of fecal incontinence in 70-90% of patients, and has also proven to completely cure it in about 30-50% of them.
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InterStim Therapy is a two-stage, minimally invasive procedure performed in same-day surgery under local anesthesia and sedation. The first step consists of the implantation of a small wire in one of the openings of the sacral bone, which is then connected to a temporary portable stimulator. The patient goes home and records the number of episodes of incontinence for about two weeks. If the stimulation is effective, a second procedure is performed to implant the permanent stimulator. In my experience, this procedure has given amazing results. It has been a privilege to see patients that were uncomfortable and self-conscious from just going out for dinner become confident again, taking back their lives and living them to the fullest. Everything starts with the little step of realizing that you do not have to suffer in silence and that there is a lot we can do. Let’s talk about it.
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Join Gastro Health’s
Crohn’s and Colitis Support Group Hengi Shahidpoor, MSN, ARNP-C Nurse Practitioner
Inflammatory bowel diseases (IBD) are considered autoimmune diseases, in which our own immune system attacks elements of the digestive system. The main forms of IBD are Crohn’s disease and ulcerative colitis. The difference between Crohn’s disease and ulcerative colitis is its location and nature of the inflammatory changes. Crohn’s can affect any part of the gastrointestinal tract, from mouth to anus, although a majority of cases start in the terminal ileum. Ulcerative colitis, in contrast, is restricted to the colon and the rectum. Finally, Crohn’s disease and ulcerative colitis present with extra intestinal manifestations (such as liver problems, arthritis, skin manifestation and eye problems) in different systems. Although Crohn’s and ulcerative colitis are very different diseases, both present with many of the following symptoms: abdominal pain, vomiting, diarrhea, rectal bleeding, severe internal cramps/muscle spasms in the region of pelvis, and weight loss. Living with chronic diseases such as IBD can sometimes be discouraging, and patients can feel overwhelmed and have many questions regarding their disease. During the past 5 years, Gastro Health has been providing educational support group meetings for IBD patients. These meetings take place quarterly. Through our educational meetings, we have been offering patients with a variety of information on how to take care of themselves while living with this chronic illness. Our speakers have included physicians, dietitians, nurse practitioners, physician assistants and clinical nurse specialists. We have taught our IBD patients about diets and treatments, and we have also discussed the latest research studies regarding future treatments. Our meetings also serve as a support group for IBD patients. Support groups are an integral part of many health care organizations and a crucial foundation for those coping with chronic illnesses. Support groups bring together those who share a common diagnosis. This gives patients a venue to exchange ideas, ways of coping, share personal experiences and most importantly, to provide emotional support. These groups are more than just a safety net for patients; they can also improve physical health and wellness of participants. Just as in all support groups, our support group is completely confidential
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and allows the patient to feel safe and comfortable to voice their questions and feelings. We also encourage our patients to bring any member of their family, if desired. Studies show that people with chronic illnesses who attend support groups feel “less anxious, depressed and alone.” Probably the greatest advantage of support group therapy is to help the patient realize that he or she is not alone, and that there are other people who have the same problems. This is often a revelation, and a huge relief to the person.
While not everyone wants or needs support beyond that offered by family and friends, patients may find it helpful to turn to others outside of their immediate circle. As support group participants make connections with others facing similar challenges, they can cope better and will feel less isolated. A support group shouldn’t replace patient’s standard medical care, but it can be a valuable resource to help them cope.
AS AN OVERVIEW THE BENEFITS OF SUPPORT GROUPS ARE: • • • • • •
Feeling less lonely, isolated or judged Gaining a sense of empowerment and control Improving coping skills and sense of adjustment Talking openly and honestly about feelings Reducing stress, depression or anxiety Developing a clear understanding of what to expect while living with a chronic disease • Getting practical advice and information about treatment options • Comparing notes about coping skills, experiences and exchanging emotional support
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Women’s Corner More options than fiber and water. Stefania L. Vernace, MD Gastroenterologist
Many women suffer from constipation and hemorrhoids. We now have several new medications for constipation. They are Linzess and Amitiza. As women get older, constipation becomes more common. Most women try to increase water intake and fiber however, in certain individuals, this is not enough. With these new treatments which come in pill form, constipation can be treated easily. In addition, after childbirth or when suffering with constipation, women typically develop hemorrhoids. We have several medications to treat hemorrhoids. We also have a new method of performing an old procedure. Hemorrhoid ligation can now be performed in the office. The new method is quick and painless. Please call with any questions or to make an appointment to discuss these new medications or hemorrhoid ligation.
INTRODUCING OUR NEW PATIENT PORTAL ON GASTROHEALTH.COM
WITH OUR PATIENT PORTAL YOU CAN: Request appointments Fill out patient forms before your visit Update your personal and medical records Log in 24/7 with access anywhere Send a message to your physician Check your test results
C R E AT E YO U R U S E R I D A N D PA S S W O R D TO D AY A N D S TA R T TA K I N G A N AC T I V E R O L E I N YO U R H E A LT H C A R E !
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Introducing the
IBD Resource Center
from
A comprehensive news, resource, and counseling tool for GI professionals Now available for free in the iTunes Store for iPad The IBD Resource Center app features: IBD news and gastroenterologist video feeds Educational module with interactive anatomical models for use during patient consultations Treatment checklists and more! The app, brought to you by Janssen, includes features for both healthcare professionals and their patients, and is available as a free download from the iTunes Store.
VISIT
appstore.com/ibdResourceCenter to download the free app today!
iTunes, iTunes Store, and iPad are registered trademarks of Apple Inc. Š Janssen Biotech, Inc. 2014 03/14 009668-140203
C onvenient &C ompassionate Galloway Endoscopy Center is an accredited surgical facility offering diagnostic and therapeutic gastrointestinal procedures in a comfortable and convenient outpatient setting. Our compassionate, bilingual staff provides top-quality care while assisting our experienced and highly skilled doctors. Best of all, because of advances in medical technology, endoscopic procedures can be safely performed outside the hospital, so you can return to the comfort of your home the same day as your procedure. You have a choice in healthcare. Isn’t it time you got treated better?
A division of Baptist Surgery and Endoscopy Centers
7500 SW 87 Avenue, Suite 101 • Miami • GallowayEndoscopy.com • 305-595-9511 A not-for-profit organization committed to our faith-based charitable mission of medical excellence