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
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WINTER 2016 ISSUEGASTRO MAGAZINE
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.
GASTRO HEALTH Welcomes You
Happy New Year!
Kathy Ireland encourages colon cancer screening
6
What is the purpose of colon cancer screening?
8
This is a great time to reflect on what we’ve accomplished, the journey we’ve taken to get to where we are and the plans we have for an exciting, bright future. In this winter issue you’ll find informative and educational articles on various digestive health topics such as: colon cancer screening, hepatitis C update and Crohn’s and colitis among others. We are also delighted to feature Kathy Ireland who fights to promote the importance of colon cancer screening. Gastro Health’s mission is to provide outstanding medical care and an exceptional healthcare experience. The physicians, nurses, nutritionists and support staff of Gastro Health seek to exceed the expectations of the patient experience by treating everyone as a member of their immediate family. At Gastro Health, we measure patient satisfaction. We have engaged Press Ganey as a solution that captures the patient voice and identifies more targeted improvement opportunities through advanced analytics and strategic advisory services. We thank you for the confidence you have placed with us by giving us the opportunity to serve you and your primary care provider.
Healthy aging after 50
10
Food allergies in children
15
Heartburn in adults
Alejandro Fernandez MBA, CMPE Chief Executive Officer
9500 South Dadeland Boulevard Suite 802, Miami, FL 33156 T. 305.468.4180
www.gastrohealth.com
Copyright © 2015 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.
Designed and Published by: TM
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11900 Biscayne Boulevard Suite 100, Miami, FL 33181 T. 305.820.0690 info@creativemindworks.com
All rights reserved. Cover Photo Credit: Europa Press /Getty Images
We are pleased to announce that Gastro Health is back in the Aetna network!
BETTER TOGETHER
Aetna members once again have access to the unparalleled skills and experience that Gastro Health physicians provide in the tri-county area. Please call to make an appointment
1-855-427-8761
or visit us online at www.gastrohealth.com
GASTRO MAGAZINEWINTER 2016 ISSUE
3
Lawrence Rothman, MD Gastroenterologist
hepatitis
c
Hepatitis is a significant medical problem both in the United States as well as worldwide. 170 million people are thought to harbor the virus globally, and it is estimated that 1.8% of the US population (about 4 million Americans) are infected with the hepatitis C virus. It is the most common cause of chronic viral liver disease in United States and the most common indication for liver transplantation. Infection is most prevalent among those born between 1945 and 1965, the majority of who were likely infected during the 1970s and 80s when the rates were highest. In 2013, the CDC issued recommendations that all people born during that period be screened for hepatitis C. Hepatitis C is spread primarily by contact with infected blood and blood products. Risk factors include having received transfusion of blood before 1992 (the year routine screening for blood donors was initiated), the use of injected illicit drugs, patients with tattoos and body piercings, healthcare workers after exposures, long-term kidney dialysis patients and infants born to hepatitis C infected mothers. Although rare, it can be transmitted by sexual encounters but is not considered a sexually transmitted disease. Unlike most other forms of viral hepatitis, a person infected with acute hepatitis C has only a 20-25% chance of the body’s own defenses clearing the virus. If it is not cleared within six months, it is defined as being chronic. Patients with chronic hepatitis C are at risk for developing cirrhosis that is the significant scarring of the liver, that results in liver dysfunction and increased risk of developing primary liver cancer. The development of cirrhosis (a condition in which the liver does not function properly due to long-term damage) is usually a slow process that occurs over several years. Also, unlike viral hepatitis A and B, there is no vaccine currently available. Only about 20-30% of people acutely affected with hepatitis C will develop symptoms. The symptoms include fatigue, abdominal pain, itching, nausea, poor appetite and jaundice (yellowing of the skin and eyes). These usually occur anywhere from 4-12 weeks after exposure. Likewise, many people with chronic hepatitis C may have no symptoms at all. Signs and symptoms may be more prominent and may
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include jaundice, muscle weakness, nausea, weight loss, abdominal swelling, vomiting blood, blood in the stool and confusion. It is well established that successful leads to a halt in the progression of the liver disease and even improvement or reversal of this cirrhotic process. In some patients a biopsy of the liver might be recommended to assess the degree of scarring and activity. More recently however, less invasive techniques have been developed to asses the extent of liver damage. The standard treatment of chronic hepatitis C until 2011 had been Interferon and Ribavirin for up to a year in duration. Interferon, an injectable agent and Ribavirin, given orally, has been the established antiviral drugs for many years. Side effects of that therapy were common and often debilitating. A significant number of patients were unable to complete the therapy due to this. Cure rates for this therapy averaged at 45%. In 2013 a specific anti-hepatitis C drug was released, initially given along with Interferon and Ribavirin. However, just a few months after their release in early 2014, additional drugs were approved which can be given together without Interferon and in most cases, without Ribavirin as well. These medications have generally mild side effects and have increased the cure rates to over 90% in most patients with 12- 24 weeks of therapy. It is now being recommended that all patients with chronic hepatitis C receive this type of treatment. It’s truly an amazing advance for patients as well as practitioners. It is important that therapy be initiated and monitored by medical professionals who have experience in treating patients with hepatitis C.
ADDRESSING THE TOUGHEST CHALLENGES IN GASTROENTEROLOGY
TAKES ALL OF US For over a decade, we’ve worked closely with physicians, investigators, and patients to take on the toughest health challenges. We’re studying new indications to address significant unmet needs. Creating programs proven to improve patient outcomes. Investing in next-generation research to keep advancing the frontiers of patient care. We’re determined to keep making a difference in gastroenterology. That’s why you can count on our continuing commitment to you and your patients.
LEARN MORE AT ABBVIE.COM
PEOPLE. PASSION. POSSIBILITIES. ©2015 AbbVie Inc.
North Chicago, IL 60064
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Printed in U.S.A.
GASTRO MAGAZINEWINTER 2016 ISSUE
5
athy Ireland
Encourages Colon Cancer Screening
Kathy Ireland, Chair, CEO and Chief Designer for Kathy Ireland Worldwide, as well as leading health advocate, has joined the efforts of the American Society for Gastrointestinal Endoscopy (ASGE) to promote colon cancer screening for men and women 50 years and older. Only one in three adults are currently getting tested, resulting in an approximate 137,000 diagnoses and more than 50,000 unfortunate deaths a year. The disease however is preventable and treatable with early detection. Coined the “silent killer” because there usually aren’t any symptoms until it’s too late, awareness is being spread and testing encouraged as the single largest risk factor is age, even for those who have led healthy lifestyles. 6
“Everyone wants to stay healthy for their family and part of a healthy lifestyle if you are 50 or over includes getting screened for colon cancer.” -Kathy Ireland “As a wife, mother of three and business owner, I know how hectic life can get, but I took time out of my busy schedule to get screened for colon cancer. I’m delighted to be partnering with ASGE to encourage colon cancer screening. If like me, you are 50 or over, or you have a family history of colon cancer, please talk with your doctor about
WINTER 2016 ISSUEGASTRO MAGAZINE
getting screened; it could save your life.” Kathleen Marle “Kathy” Ireland was born in Glendale, California on March 20, 1963. Celebrated for her philanthropic activism, the former supermodel of the 1980’s and 1990’s is best known for making the Sports Illustrated cover 13 consecutive issues, one of her most memorable covers being the highly celebrated 25th anniversary issue that remains one of the best-selling issues to date. The model-turned-entrepreneur has transformed her career and is now one of the wealthiest business owners in the world leading a two billion dollar design empire. Kathy Ireland
Worldwide is primarily a lifestyle brand and the 28th most powerful licensed brand on earth. Still, Kathy finds the time to deliver keynote speeches at corporate events, industry conventions, expos, entrepreneurial events, social media conferences and at life events. She has written six books, including three for children, has published several fitness videos that led to her design of fitness apparel and has appeared in a number of movies and television shows including the ninth season of Dancing with the Stars. Still, Kathy has remained involved and dedicated to causes that bring awareness to women’s rights and justice, education, emergency response and training for children, HIV/AIDS and diseases research and management. By Michelle MenÊndez GASTRO MAGAZINEWINTER 2016 ISSUE
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Edward J. Feller, MD Gastroenterologist
What is the Purpose of Colon Cancer Scre ening
Colon cancer is the third most common cancer in the United States. More than 136,000 new cases and 50,000 colon cancer deaths are expected this year. It is estimated that 5% of Americans will get colon cancer during their lifetime. Screening for colon cancer has been among the most successful programs in reducing both the occurrence and death rate of cancer. Although there are other methods to screen for colon cancer, none come close to approaching the success rate of a colonoscopy. A nationwide screening program began in the mid 1980s and was promoted by the U.S. Department of Health and Human Services along with multiple medical organizations. The incidence of colon cancer, which began declining with the commencement of the program, plunged an additional 30% in the last decade among Americans 50 years of age and older, as more people had colonoscopies. The drop in colon cancer related deaths fell about 3% a year between 2001 and 2010. 8
Unlike other cancers which develop anywhere in their tissue of origin, colon cancer, with very few uncommon exceptions, begins in colon polyps. Polyps are small growths on the inside wall of the colon which usually give no symptoms. They grow slowly and take several years to reach a size in which they statistically become at risk to turn into cancers. The purpose of colonoscopy is to find and remove these polyps before they have the chance to turn cancerous. The procedure is to prevent the patient from getting cancer, not just to find it at an early stage.
Who is more at risk and who should be screened for colon cancer? It is recommended that everyone have a screening for colon cancer at age 50 and again at regular intervals. African Americans have a higher risk of colon cancer and some doctors have recommended screening at age 45. For those with risk factors such as a strong family history
WINTER 2016 ISSUEGASTRO MAGAZINE
of colon polyps or colon cancer at an earlier age, screening may start in the 40s. There are some families in which colon cancers are quite frequent and in which a clear genetic source has been identified. These individuals should follow up more frequently. It should be remembered that we are talking only about screening for colon cancer in an asymptomatic individual. If a person has symptoms, such as rectal bleeding, change in bowel habits, unexplained abdominal pain, etc., then a colonoscopy should be done as a diagnostic procedure.
How often should an individual have a colonoscopy? National standards propose that for asymptomatic people with no additional risk factors, this should be done at 10 year intervals. If a patient had one or more benign polyp(s) removed, then depending on the size and pathology, it should generally be done again in 3-5 years. If a patient had a malignant polyp removed, it should be done sooner. Again, this might vary as per the physical condition and age of the patient. As so many things are in medicine, many variables exist. Every patient is unique. Speak to your primary physician or your gastroenterologist and ask them about whether a screening colonoscopy is indicated for you.
Jerry Martel, MD, MPH Gastroenterologist
L A IC T E N I CL DA UP Medicine is dedicated to helping people. While the initial intent is to fully heal patients, I find that many times we cannot completely do so with one diagnosis, and instead we offer to help them the best that we can. The knowledge of how to go about this does not happen from one day to the next. It involves the greater portion of a decade to acquire the necessary skills, if not longer, to effectively care for patients. In this ever-changing world there are always new studies, new medications, new techniques and new approaches to even the most basic of healthcare issues that can sometimes seem overwhelming. Because of this, physicians are constantly learning and adapting to the ever-changing field of medicine in order to bring their patients the most up-to-date healthcare to ensure a longer life. Thankfully, we now have an easy way to be able to do just that: the Gastro Health Clinical Update. This is the third time we have been able to provide this type of direct service for primary care physicians, as well as gastroenterologists, the opportunity to review current medical evidence for many of the typical issues our patients present. We have also been able to present to the participants cutting edge research in many new advancing fields. We have our local experts as well as nationally recognized speakers come and educate us on the most up-to-date information and techniques on the forefront of health care services. From thorough reviews on a number of common diseases like celiac disease, diverticular disease and H. pylori, to the latest information in the treatment of hepatitis C and inflammatory bowel disease to name a few. We have been able to bring our participants the information they need to treat their patients individually and effectively. Last year in particular we were able to present to physicians information showing how quality measures in colorectal cancer are saving lives while cutting healthcare costs. This year’s Update will continue the tradition of excellent presentations in a pleasant environment while providing participants with the continuing medical education credits needed for continued licensure. Be on the lookout for the mailers with the topics to be covered at this year’s Gastro Health Clinical Update and I hope to see as many colleagues as last year, if not more, at this coming event! GASTRO MAGAZINEWINTER 2016 ISSUE
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Eugenia Riccombeni, RD, LDN Registered Dietician
Grains
Carbohydrates are the main source of energy in our bodies. Creating the balance between consuming the right kinds and amounts of carbohydrates is key. Some examples are whole grains, fruits and vegetables that are high in fiber and can help maintain a healthy digestive tract, stabilize blood sugars and make you feel fuller longer. Maintaining these qualities can be tricky, but it is recommended that you eat at least three servings of grains per day.
healthyaging after50
Low Fat or Fat-Free Dairy
According to the Academy of Nutrition and Dietetics, 90% of older adults have hypertension, diabetes and/or high cholesterol. While many things can be related to having a chronic disease, nutrition is a vital component.
Fats
Eating healthy is important in all stages of life, but it is especially important in older adults to aid in slowing down the aging process. Consuming a diet with plenty of fruits and vegetables, high in fiber, low in salt and saturated fats is key in preventing chronic disease and avoids deficiencies that are common in older adults.
Fruits and vegetables Try consuming a wide variety of fruits and vegetables every day. Each produce contains a unique combination of nutrients that are essential to avoid nutritional deficiencies such as potassium, magnesium, vitamin A, vitamin C, vitamin K, antioxidants and phytochemicals.
Protein As we become older, it can get harder to digest some types of meats properly which can lead to discomfort after eating them. Focusing on plantbased proteins like nuts, soy, peas and beans can aid this common discomfort found in older adults. Fish can also be a great option in meeting protein needs and gaining some heart healthy fats as well. You want to make sure to vary your proteins throughout the week.
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Besides providing nutrients like protein and carbohydrates, dairy can also provide high source of vitamin D and calcium that are important for preventing diseases like osteoporosis. You can choose options like milk, yogurt, cheese or even non-dairy options like almond milk. If you are 50 years or older, you need 1,200 mg of calcium per day.
Foods that are low in saturated fats, trans fats and cholesterol help reduce your risk of heart disease. Choose polyunsaturated and monounsaturated fats which can be found in oils, avocados and nuts. Choose lean cuts of meats and poultry, remove all visible fat and skin before cooking and use cooking methods like broiling, boiling or grilling.
Fluids
Thirst sensation may decrease with age and can lead to dehydration. Consume fluids like water, tea and broth based soups to stay properly hydrated. Being hydrated also allows for consistent digestion and prevents weight gain.
Maintaining a healthy weight
As we get older, our metabolism slows down due to physical inactivity and the loss of lean muscle mass which results in a decrease of caloric needs necessary to maintain a healthy weight. Stay in shape by consuming low-calorie and nutrient-dense foods such as fruits and vegetables, include physical activity on a daily basis and cut back on foods with added sugars and high fat. Overweight adults are at a higher risk of developing heart disease, diabetes, joint problems and some cancers. These methods have proven to be vital components to leading a healthier lifestyle for people over 50. If you have any further questions please contact your physician or your dietician.
PHYSICIAN DIRECTORY
GASTRO MAGAZINEWINTER 2016 ISSUE 11
Francisco J. Baigorri, MD * Gastroenterologist
Simon Behar, MD * Gastroenterologist
Barry E. Brand, MD Gastroenterologist
Gustavo Calleja, MD * Gastroenterologist
Marc S. Carp, MD Gastroenterologist
CC1
CC3
CC2
CC1
CC6
Lewis R. Felder, MD Gastroenterologist
Edward Feller, MD Gastroenterologist
Jose P. Ferrer Jr., MD * Gastroenterologist
Jose P. Ferrer Sr., MD * Gastroenterologist
Paul G. Fishbein, MD Gastroenterologist
CC7
C C15
CC3
CC3
C C18
Nelson Garcia Jr., MD * Gastroenterologist
Pamela L. Garjian, MD* Gastroenterologist
Daniel Gelrud, MD * Gastroenterologist
Carla Ginsberg, MD Gastroenterologist
Harris I. Goldberg, MD Gastroenterologist
CC8
C C16
CC1
CC1
CC1
Ruben Gonzalez-Vallina, MD * Pediatric Gastroenterologist
Pedro J. Greer Jr., MD * Gastroenterologist
Mitchell Gregg, MD Radiologist, Imaging Center
Guillermo Gubbins, MD * Gastroenterologist
CC1
C C13
C C11
IC
CC10
Alfredo J. Hernandez, MD * Gastroenterologist
Enrique Hernandez-Sanchez, MD*
Pediatric Gastroenterologist
Eugenio J. Hernandez, MD * Gastroenterologist
Moises E. Hernandez, MD * Gastroenterologist
Richard E. Hernandez, MD * Gastroenterologist
CC11
C C14
CC3
CC3
CC5
John Ibarra, MD* Radiologist, Imaging Center
Susan Kais, MD Gastroenterologist
Raghad Koutouby, MD Pediatric Gastroenterologist
Eduardo Krajewski, MD * Colorectal Surgeon
Vicente Lago, MD * Gastroenterologist
IC
CC1
C C12
CC9
C C19
Roberto Gonzalez, MD * Gastroenterologist
Robert C. Lanoff, MD * Gastroenterologist
Jose A. Lavergne, MD * Gastroenterologist
James S. Leavitt, MD Gastroenterologist
Marc Lederhandler, MD Gastroenterologist
Oscar Loret de Mola, MD* Pediatric Gastroenterologist
CC2
CC7
CC1
CC1
C C17
Jerry Martel, MD, MPH * Gastroenterologist
Curtis L. McCarty III, MD Pathology Medical Director Pathology Laboratory
Flavia Mendes, MD * Gastroenterologist
Pedro Morales, MD * Gastroenterologist
Brett R. Neustater, MD Gastroenterologist
CC1
CC8
CC7
Khristian Noto, MD * Colorectal Surgeon
Javier L. Parra, MD * Gastroenterologist
Rodolfo Pigalarga, MD* Colorectal Surgeon
Alfredo Rabassa, MD * Gastroenterologist
Andres I. Roig, MD * Gastroenterologist
CC9
CC1
CC9
CC1
CC3
Ricardo J. Roman, MD * Gastroenterologist
Seth D. Rosen, MD Gastroenterologist
Neil E. Rosenkranz, MD Gastroenterologist
S. Lawrence Rothman, MD Gastroenterologist
Eduardo Ruan, MD * Gastroenterologist
CC7
CC2
CC2
CC1
CC1
Andrew I. Sable, MD Gastroenterologist
George A. Sanchez, MD * Gastroenterologist
Howard I. Schwartz, MD Gastroenterologist
Somal S. Shah, MD * Gastroenterologist
Jason Slate, MD * Gastroenterologist
CC2
CC1
CC1
C C11
C C11
Arie Slomianski, MD * Gastroenterologist
Marcos Szomstein, MD * Colorectal Surgeon
Stefania L. Vernace, MD Gastroenterologist
CC1
CC9
CC1
CC8
* Habla Espa単ol GASTRO MAGAZINEWINTER 2016 ISSUE 13
Allied Healthcare Staff
Yamila Akmuradova PA-C * Care Center 11
Darlene Boytell-Perez, ARNP* Care Center 1
Carol Hernandez, PA-C Care Center 1
Jessica Jairala, PA-C * Care Center 1
Sabrina Kaplan, PA-C * Care Center 1
Rebecca Karousatos,MS,RD,LDN Care Center 1
Kathy Kim, Pharm D * Specialty Pharmacy
Ellen Matas-Sosa, PA-C Care Center 1
Jose A. Miguel, PA-C * Care Center 1
Ronal R. Ricano, PA-C * Care Center 11
Yetzabel Rizo, ARNP * Care Center 1
Eugenia Riccombeni, RD, LDN* Care Center 3
Noe Tacoronte, PA-C * Care Center 1
Kayce Tugg, MSN, RN Imaging Center
* Habla Espa単ol
Care Centers
Insurances
Care Center 1 Main Office 7500 SW 87 Avenue, Suite 200 Miami, FL 33173 305-913-0666
Care Center 7 Satellite Office #2 21110 Biscayne Blvd, Suite 206 Aventura, FL 33180 305-770-0062
Care Center 14 9980 Central Park Blvd N., Suite 316 Boca Raton, FL 33428 561-206-6064
Care Center 1 Satellite Office 6141 Sunset Drive, Suite 301 Miami, FL 33143 305-913-0666
Care Center 8 8200 SW 117 Avenue, Suite 110 Miami, FL 33183 305-274-5500
Care Center 15 8353 SW 124 Street, Suite 203 Miami, FL 33156 305-259-8720
Care Center 2 9555 N. Kendall Drive, Suite 100 Miami, FL 33176 305-273-7319
Care Center 9 7765 SW 87 Avenue, Suite 212 Miami, FL 33173 305-596-3080
Care Center 16 8353 SW 124 Street, Suite 108 Miami, FL 33156 305-669-1115
Care Center 3 8950 N. Kendall Drive, Suite 306-W Miami, FL 33176 305-596-9966
Care Center 10 475 Biltmore Way, Suite 207-A Coral Gables, FL 33134 305-662-6170
Care Center 17 7775 SW 87 Avenue, Suite 120 Miami, FL 33173 305-274-8243
Care Center 4 15955 SW 96 Street, Suite 307 Miami, FL 33196 305-468-4191
Care Center 11 3661 S. Miami Avenue, Suite 805 Miami, FL 33133 305-856-7333
Care Center 18 8950 N. Kendall Drive, Suite 506W Miami, FL 33176 P 305-595-2710
Care Center 5 7765 SW 87 Avenue, Suite 105 Miami, FL 33173 305-274-0808
Care Center 11 Satellite Office Florida International University 885 SW 109 Avenue, Suite 131 Miami, FL 33199 305-856-7333
Care Center 19 351 NW 42nd Avenue, Suite 305 Miami, FL 33126 (305) 541-1041
Care Center 6 1400 NE Miami Gardens Drive, Suite 221 Care Center 12 8525 SW 92nd Street, Suite C-11A North Miami Beach, FL 33179 Miami, FL 33156 305-949-2020 305-512-3345 Care Center 7 Main Office Care Center 13 16855 NE 2nd Avenue, Suite 202 9260 SW 72 Street, Suite 217 North Miami Beach, FL 33162 Miami, FL 33173 305-770-0062 305-271-7330 Care Center 7 Satellite Office #1 5803 NW 151 Street, Suite 105 Miami Lakes, FL 33014 305-770-0062
Imaging Center 7500 SW 87 Avenue, Suite 202 Miami, FL 33173 305-468-4190 Pathology Laboratory 12485 SW 137 Avenue, Suite 103 Miami, FL 33186 305-468-4194 Specialty Pharmacy 7500 SW 87 Avenue, Suite 202 Miami, FL 33173 305-468-4199
AARP Medicare Complete Aetna American Heritage Life Insurance American Medical Security AvMed Baptist Executive Health Beech street Blue Cross Blue Shield Cigna Coventry Health Care Dimensions Health First Health Network HealthSun Health Plans Humana Humana Champus Tricare Magellan Healthcare Mail Handlers Benefit Plans Medica Health Plan Medicare Part B Molina Healthcare MultiPlan Neighborhood Health Plan Preferred Care Partners Prestige Health Choice Simply Healthcare Sunshine Health United Healthcare Wellcare Only accepted at our Pediatric Care Centers
Ruben Gonzalez-Vallina, MD Pediatric Gastroenterologist
Food Allergies in Children What is a Food Allergy? A food allergy is an immunologically mediated adverse reaction to food or food ingredients. Infants and children are particularly prone to allergies. It occurs in 5.5%-6% of infants in the first three years of life. 90% of those allergies can be attributed to five or six foods: Cow’s milk protein Soy Eggs Peanuts Wheat Shellfish Young infants are more susceptible to developing food allergies due to the immaturity of the immune system.
Family History of Allergy If there is no family history: 20%- 30% chance of developing allergies If one parent or sibling has allergies: 40-50% chance of developing allergies If both parents have allergies: 60-70% chance of developing allergies
Kinds of Food Allergies Food allergy presents with immediate or delayed reactions. In immediate reactions, occurring within minutes to hours, the child may develop hives, wheezing, or swelling of the face as well as tightening of the chest. The reaction can be so severe that the child cannot breathe (anaphylaxis). In these cases, emergency treatment
is needed. Luckily, these dangerous reactions are relatively uncommon. Delayed reactions occur from hours to days after eating the offending food.
that this food might be involved, but it does not mean that the child will have an allergic response to the food. The allergy is dependent on the allergen.
Most Common Clinical Manifestation
Your doctor may do an endoscopy to take samples of the lining of the intestine to rule out any major inflammation caused by allergies or an immune system reaction.
Atopic dermatitis: skin rash, eczema, hives Gastrointestinal: poor feeding, irritability, vomiting, diarrhea, bloody stools, poor growth Respiratory: bronchitis, asthma Delayed reactions are the most common form of food allergies. If a careful history of your child’s symptoms and the physical examination suggest food allergy, tests may be performed to have a better handle on situation and regulate the flare-ups.
How Food Allergies are Diagnosed and Treated
A limited elimination (or hypoallergenic) diet may be recommended to indicate if symptoms go away when common allergy-causing foods are not eaten. If the child is better on the elimination diet, foods are gradually added back to see if the symptoms return. Trial and error methods are often the answer.
If Mothers are Breastfeeding Maternal avoidance of potential allergens: Cow’s milk Soy Eggs Patients improve most of the time with these measures.
Skin prick tests and RAST (blood) tests are used to test foods that might cause immediate reactions. A negative test for a food tends to rule it out. A positive test means GASTRO MAGAZINEWINTER 2016 ISSUE 15
For moderate to severe ulcerative colitis or Crohn’s disease when certain other medications have not worked well enough or cannot be tolerated
RELIEF AND REMISSION WITHIN REACH Individual results may vary.
Ask your doctor if Entyvio may be right for you. Uses of ENTYVIO® (vedolizumab): ENTYVIO is a prescription medicine used in adults: • with moderate to severe ulcerative colitis (UC) when certain other UC medicines have not worked well enough or cannot be tolerated. ENTYVIO may help to: begin reducing some symptoms, induce and maintain remission, reduce or stop the use of corticosteroids, and improve the way the lining of your large intestine looks to your healthcare provider. • with moderate to severe Crohn’s disease (CD) when certain other CD medicines have not worked well enough or cannot be tolerated. ENTYVIO may help to: begin reducing some symptoms, achieve remission, and reduce or stop the use of corticosteroids.
Important Safety Information about ENTYVIO® • Do not receive ENTYVIO if you have had an allergic reaction to ENTYVIO or any of its ingredients. • ENTYVIO may cause serious side effects, including: 16 WINTER 2016 ISSUEGASTRO MAGAZINE
• Infusion and serious allergic reactions can happen while you are receiving ENTYVIO or several hours after treatment. You may need treatment if you have an allergic reaction. Tell your healthcare provider or get immediate medical help if you get any of these symptoms during or after an infusion of ENTYVIO: rash, itching, swelling of your lips, tongue, throat or face, shortness of breath or trouble breathing, wheezing, dizziness, feeling hot, or palpitations (feel like your heart is racing). • ENTYVIO may increase your risk of getting a serious infection. Before receiving and during treatment with ENTYVIO, tell your healthcare provider if you think you have an infection or symptoms of an infection, such as fever, chills, muscle aches, cough, shortness of breath, runny nose, sore throat, red or painful skin or sores on your body, tiredness, or pain during urination. • Although it has not been reported with ENTYVIO, it may be possible for a person to get progressive multifocal leukoencephalopathy (PML) (a rare, serious brain infection caused by a virus). People with weakened immune systems can get PML, which can result in
Visit Entyvio.com for more information. death or severe disability. There is no known treatment, prevention, or cure for PML. Tell your healthcare provider right away if you have any of the following symptoms: confusion or problems thinking, loss of balance, change in the way you walk or talk, decreased strength or weakness on one side of the body, blurred vision, or loss of vision. • Liver problems can happen in people who receive ENTYVIO. Tell your healthcare provider right away if you have any of the following symptoms: tiredness, loss of appetite, pain on the right side of your abdomen, dark urine, or yellowing of the skin and eyes (jaundice). • The most common side effects of ENTYVIO include common cold, headache, joint pain, nausea, fever, infections of the nose and throat, tiredness, cough, bronchitis, flu, back pain, rash, itching, sinus infection, throat pain, and pain
in extremities. These are not all the possible side effects of ENTYVIO. Call your healthcare provider for medical advice about side effects. • Before receiving ENTYVIO, tell your healthcare provider about all of your medical conditions, including if you: have or think you may have an infection or have infections that keep coming back; have liver problems; have tuberculosis (TB) or have been in close contact with someone with TB; have recently received or are scheduled to receive a vaccine; or if you are pregnant, breastfeeding, plan to become pregnant, or plan to breastfeed. Please see the Medication Guide for ENTYVIO on the adjacent page and talk with your healthcare provider. You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.
ENTYVIO is a trademark of Millennium Pharmaceuticals, Inc., registered with the U.S. Patent and Trademark Office, and is used under license by Takeda Pharmaceuticals America, Inc. © 2015 Takeda Pharmaceuticals U.S.A., Inc. 17 SUMMER 2015 ISSUEGASTRO MAGAZINE
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GASTRO MAGAZINEWINTER 2016 ISSUE 17
Medication Guide ENTYVIO (en ti' vee oh) (vedolizumab) What is the most important information I should know about ENTYVIO? ENTYVIO may cause serious side effects, including: • Infusion and serious allergic reactions. These reactions can happen while you are receiving ENTYVIO or several hours after treatment. You may need treatment if you have an allergic reaction. Tell your healthcare provider or get medical help right away if you get any of these symptoms during or after an infusion of ENTYVIO: rash, itching, swelling of your lips, tongue throat or face, shortness of breath or trouble breathing, wheezing, dizziness, feeling hot, or palpitations (feel like your heart is racing). • Infections. ENTYVIO may increase your risk of getting a serious infection. Before receiving ENTYVIO and during treatment with ENTYVIO, tell your healthcare provider if you think you have an infection or have symptoms of an infection such as fever, chills, muscle aches, cough, shortness of breath, runny nose, sore throat, red or painful skin or sores on your body, tiredness, or pain during urination. • Progressive Multifocal Leukoencephalopathy (PML). Although it has not been reported with ENTYVIO, it may be possible for a person to get progressive multifocal leukoencephalopathy (PML) (a rare, serious brain infection caused by a virus). People with weakened immune systems can get PML. PML can result in death or severe disability. There is no known treatment, prevention, or cure for PML. Tell your healthcare provider right away if you have any of the following symptoms: confusion or problems thinking, loss of balance, change in the way you walk or talk, decreased strength or weakness on one side of the body, blurred vision, or loss of vision. • Liver Problems. Liver problems can happen in people who receive ENTYVIO. Tell your healthcare provider right away if you have any of the following symptoms: tiredness, loss of appetite, pain on the right side of your stomach (abdomen), dark urine, or yellowing of the skin and eyes (jaundice). See “What are the possible side effects of ENTYVIO?” for more information about side effects. What is ENTYVIO? ENTYVIO is a prescription medicine used in adults: • with moderate to severe active ulcerative colitis (UC) when certain other UC medicines have not worked well enough or cannot be tolerated: ° to begin helping some of your symptoms ° in people who respond to ENTYVIO, to help get UC under control (induce remission) and keep UC under control (maintain remission) ° for people who respond to ENTYVIO, you may be able to reduce or stop the use of corticosteroid medicines ° to improve the way the lining of your large intestine looks to your healthcare provider during colonoscopy • with moderate to severe active Crohn’s disease when certain other Crohn’s disease medicines have not worked well enough or cannot be tolerated: ° to begin helping some of your symptoms ° in people who respond to ENTYVIO, to help get Crohn’s disease under control (achieve remission) ° for people who respond to ENTYVIO, you may be able to reduce or stop the use of corticosteroid medicines It is not known if ENTYVIO is safe and effective in children under 18 years of age. Who should not receive ENTYVIO? Do not receive ENTYVIO if you have had an allergic reaction to ENTYVIO or any of the ingredients in ENTYVIO. See the end of this Medication Guide for a complete list of ingredients in ENTYVIO. 18 WINTER 2016 ISSUEGASTRO MAGAZINE
Before receiving ENTYVIO, tell your healthcare provider about all of your medical conditions, including if you: • have an infection, think you may have an infection or have infections that keep coming back (see “What is the most important information I should know about ENTYVIO?”). • have liver problems • have tuberculosis (TB) or have been in close contact with someone with TB. • have recently received or are scheduled to receive a vaccine. Talk to your healthcare provider about bringing your vaccines up-to-date before starting treatment with ENTYVIO. • are pregnant or plan to become pregnant. It is not known if ENTYVIO will harm your unborn baby. Tell your healthcare provider right away if you become pregnant while receiving ENTYVIO. • are breastfeeding or plan to breastfeed. It is not known if ENTYVIO passes into your breast milk. Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins and herbal supplements. Especially tell your healthcare provider if you take or have recently taken Tysabri (natalizumab), a Tumor Necrosis Factor (TNF) blocker medicine, a medicine that weakens your immune system (immunosuppressant), or corticosteroid medicine. How will I receive ENTYVIO? • ENTYVIO is given through a needle placed in a vein (intravenous infusion) in your arm. • ENTYVIO is given to you over a period of about 30 minutes. • Your healthcare provider will monitor you during and after the ENTYVIO infusion for side effects to see if you have a reaction to the treatment. What are the possible side effects of ENTYVIO? ENTYVIO may cause serious side effects, See “What is the most important information I should know about ENTYVIO?” The most common side effects of ENTYVIO include: common cold, headache, joint pain, nausea, fever, infections of the nose and throat, tiredness, cough, bronchitis, flu, back pain, rash, itching, sinus infection, throat pain, and pain in extremities. These are not all of the possible side effects of ENTYVIO. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. General information about ENTYVIO Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. You can ask your pharmacist or healthcare provider for information about ENTYVIO that is written for health professionals. Do not use ENTYVIO for a condition for which it was not prescribed. What are the ingredients in ENTYVIO? Active ingredient: vedolizumab Inactive ingredients: L-histidine, L-histidine monohydrochloride, L-arginine hydrochloride, sucrose and polysorbate 80 Distributed by: Takeda Pharmaceuticals America, Inc. Deerfield, IL 60015 U.S. License No. 1898 For more information, go to www.ENTYVIO.com or call 1-877-825-3327 This Medication Guide has been approved by the U.S. Food and Drug Administration. Issued: May 2014 ENTYVIO is a trademark of Millennium Pharmaceuticals Inc. and is used under license by Takeda Pharmaceuticals America, Inc. All other trademark names are the property of their respective owners. ©2014 Takeda Pharmaceuticals America, Inc. VMB245 R1_CFBS L-BZV-0514-4
Melissa Jimenez Practice Manager
What to Expect at Gastro Health’s Infusion Center
Gastro Health offers a familiar and supportive in-house infusion center for our patients’ convenience; administering treatments for Crohn’s and colitis, rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, plaque psoriasis and iron deficiency anemia. Our infusion center promotes patient adherence as well as one-on-one therapy sessions and our dedicaed staff of skilled nurses and technicians carry you through every step of the way. We create an environment where patients can share information, discuss challenges and offer support to one another; hence strengthening the doctor-patient rapport. Our physicians closely monitor treatment, avoiding the need for referrals to hospitals or off-site facilities. We conveniently offer appointment times throughout the day to facilitate individual schedules and students also may benefit from our afternoon appointments, by not having their infusion interfere with their education. So what should you expect when you come in? Depending on the therapy, the infusion may take 30 minutes to three hours and we often recommend that patients come dressed comfortably. We provide blankets and pillows to ensure comfort and some patients even take the opportunity to get some “shut-eye” during their infusions. No time to eat breakfast or lunch? Not a problem. Patients are more
than welcome to bring in food and we even offer snacks. You can take advantage of the time and watch a movie on your MP3 or DVD player, work on your laptop via our Wi-Fi, read a book, or just simply relax and lay back on a reclining chair. Want to share some of the concerns you may be having due to your condition? Not a problem. We actually encourage patient interaction to discuss their matters and gain a sense of empowerment and control. A healthcare professional will be monitoring your infusion and for a period of time afterwards to ensure your well-being. Our registered nurses are available to answer any questions and/or concerns you may have, as well as offer patient education on your condition and treatment plan. They also make
sure that you are seeing your gastroenterologist on a regular basis or at least every six months. So you’re done with your infusion, what happens next? You will be able to drive yourself and continue on with your normal schedule. You can go back to work and continue with your day as usual. At Gastro Health, our mission is to provide outstanding medical care and an exceptional healthcare experience. We make sure that our staff and nurses’ follow our guiding principle of treating every patient like a valued member of their immediate family. Our patients look forward to their experience with us and know they can rely on our impeccable customer service.
19 SUMMER 2015 ISSUEGASTRO MAGAZINE
Jason Slate, MD Gastroenterologist
HEARTBURN IN ADULTS Heartburn is a very common symptom experienced by adults. It is the sensation one gets when acid from the stomach refluxes and comes in contact with the esophagus. Often mistaken as chest pain or abdominal pain but mainly described as a burning sensation in the chest. It is so common that the majority of American adults have taken medication at least once in their lifetime. Heartburn may be a symptom of gastro esophageal reflux disease, commonly referred to as GERD, which is the result of ongoing reflux of acid from the stomach. If left untreated, it can lead to complications over time. It is estimated that heartburn/reflux, and its complications, at one time or another will affect approximately 33% of American adults. If you have heartburn, it is important to prevent its progression to GERD. The earlier it is identified, the easier it is to treat and therefore prevent more severe complications. These complications include: severe inflammation and
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ulceration of the esophagus, esophageal rings or strictures (which are essentially scarring resulting from chronic reflux) and Barrett’s esophagus (which is when the cells in the bottom part of the esophagus start to change after years of reflux). If cells continue to become damaged, they can eventually turn into cancer. These symptoms can and should be treated in a timely manner before they get worse. Some people with mild heartburn actually have severe findings discovered on an endoscopic evaluation, or an EGD, which is the procedure where a thin tube with a camera on the end of it is passed, under gentle sedation, through the esophagus (swallowing tube), stomach and into a small part of the small intestine called the duodenum. Patients are asleep during the procedure and don’t experience any discomfort. Conversely, some patients have severe heartburn and have a completely normal endoscopy. Because of this uncertainty and inability to predict damage related to acid reflux, anybody having two to three heartburn related episodes a week should seek a medical consultation with a gastroenterologist. Those with warning signs are encouraged to undergo an endoscopy. Some warning signs that your heartburn/reflux may have
progressed and become complicated are difficulty or painful swallowing, chest pain, weight loss, anemia and black stools. Less common and sometimes more subtle signs to be aware of are hoarseness, globus (a ball like sensation in throat), nighttime cough, sour taste, whitish coating on tongue and chronic or recurrent sinusitis. An endoscopy may identify and even treat complications of GERD. A stricture, which is usually a narrowing at the bottom of the esophagus near the connection with the stomach, can be dilated at the time of endoscopy. Routine biopsies are taken to check for a bacteria called H. pylori, which is a common bacteria and treatable with a course of antibiotics. Ulcers can be biopsied and polyps are sometimes removed. The patient will not feel this during the procedure, as there are no sensory nerves affected by the biopsies. Additionally, other conditions associated with similar warning signs as with GERD may be identified during the study, such as gastric ulcers and gastric cancer. Partially digested food may also be seen during endoscopy, which may be related to gastro paresis, which is a condition where the stomach does not move properly. This may occur without any reason or may be related to diabetes. This condition may contribute to the symptoms of GERD by increasing the contact time of acid from the stomach with the esophagus. In addition, a frequently talked about “condition” called a hiatal hernia is also commonly identified during endoscopy. Normally the esophagus is protected from the refluxing acid by an intimate connection between a circular muscle called the lower esophageal sphincter (LES) and diaphragm (muscle instrumental in breathing). They both usually act together to squeeze the bottom of the esophagus closed. When the esophagus sphincter muscle separates and slides into the chest along with the upper part of the stomach, the protective pressure barrier
weakens and acid is more likely to enter the esophagus. One may also experience chest pressure. Initially, treatment is focused on symptoms. With mild heartburn, prevention with diet and lifestyle modifications is effective. One should avoid tight fitting clothes, quit smoking, cut down or eliminate alcohol intake. Avoid foods that may relax the LES such as tomatoes, chocolate, peppermints/gum, onions and spicy foods. Eating your last meal no sooner then three hours before bed is helpful and dinner should be a smaller meal compared to lunch. Certain medications such as asthma inhalers and heart/blood pressure medications may worsen symptoms by relaxing the LES muscle as well. If possible, place bricks or cinder blocks under the legs at the head of the bed, which creates a decline to help acid drain out of the stomach. A large foam wedge is also available to achieve that same goal and saves your bed partner from experiencing this angulation of the bed. Avoid elevating yourself with pillows, as this worsens heartburn and reflux by bending you and increasing pressure at your stomach. At your first office visit, a histamine or H2 blocker may be prescribed such as Zantac or Pepcid. By the time you come to the office, you have most likely take many over-the-counter (OTC) antacids such as Gaviscon, Tums, Maalox, etc. All the above medications can be taken in situations where heartburn is mild and infrequent (< 1-2 times a week) and when experienced with certain foods. When heartburn occurs unprovoked >2-3 times a week, and when the warning signs are present, it is time for an endoscopic evaluation especially if you are older than 50 years. Personally, I don’t make any medication changes prior to the endoscopy as this helps to identify whether the medications you are taking prior to the study are working, or if you need to change or add another medication based on the endoscopic findings. Frequently, a stronger medication called a Proton Pump Inhibitor (PPI) is prescribed after the procedure due to the findings of inflammation, strictures, or ulcers. This medication will inactivate the pumps that produce acid. It is paramount that PPIs be taken 30 minutes before a meal, usually at breakfast because otherwise they are not effective. So take care of yourself, eat well, exercise and listen to your body. Heartburn is very manageable and by seeking an evaluation, you can prevent its avoidable complications. You will be glad you did! GASTRO MAGAZINEWINTER 2016 ISSUE 21
Marcos Szomstein, MD Colorectal Surgeon
Surgery
in Inflammatory Bowel Disease Inflammatory bowel diseases are generally either ulcerative colitis or Crohn’s disease. Crohn’s disease is an inflammatory bowel disease where the body’s own immune system creates an attack against the GI tract anywhere from the mouth, small intestine, the large intestine, the rectum or the anus. Ulcerative colitis only affects the rectum and the colon. Crohn’s disease generally starts to affect adults when they are between the ages of 16 and 40. Men and women are equally affected. Crohn’s disease can result in patients feeling pain, diarrhea and bloating. Ultimately with longstanding Crohn’s disease of many years, patients may even develop a stricture that needs surgery. Unfortunately Crohn’s disease can’t be cured, but the symptoms can be managed. Generally the symptoms of Crohn’s disease can be managed with medicines. The medicines all aim in turning off different parts of the immune system. Medical therapy is the most important aspect of the treatment of Crohn’s disease. At times, surgery is required. You may develop an infection and an abscess (which is a collection of pus around the intestine) where the intestinal fluid or food can’t pass readily. You may have bloating and distention of your abdomen because of this and surgery is required to address these issues. Surgery is usually the last recourse for these patients and timing is critical. Colorectal surgeons work closely with gastroenterologists and medical teams to help you feel better. When surgery is required, it brings tremendous benefits and improvements in your quality-of-life. 22 WINTER 2016 ISSUEGASTRO MAGAZINE
The symptoms of ulcerative colitis are bloody diarrhea and abdominal pain. The treatment of ulcerative colitis initially begins with medical therapy. The medications used to treat ulcerative colitis are those which turn off portions of the immune system. Treating the immune system reduces the inflammation of your intestinal track and may make you feel a lot better. Ulcerative colitis differs from Crohn’s disease in that it can be cured with surgery. Occasionally ulcerative colitis causes problems which required the need to remove your colon and rectum. These can include cancer, but most commonly involved the failure of medicines to work to continue to relieve your symptoms. Operations for ulcerative colitis always involve the removal of the rectum and the colon. There are options with how we want to restore the flow of food through your body. Sometimes a permanent Ileostomy is chosen. Other times an ileoanal J pouch is created. The decision to have either a permanent Ileostomy or an ileoanal J pouch is personal and individual. The quality of life however is excellent with either option. Surgery, when is required for ulcerative colitis or Crohn’s disease can make you feel better and improve your quality of life. Colon and rectal surgeons are experts in the surgical and nonsurgical treatment of diseases of the colon rectum and anus. We have completed advanced surgical training in the treatment of these diseases as well as full general surgical training and certification.
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