Hampton Roads Physician Winter 2016

Winter 2016

www.hrphysician.com

SOHAM SHETH, MD ROBERT D. VORONA, MD

PATRICK HARDING, MD

Honoring Physicians Who Specialize in

SLEEP MEDICINE

Partnership and communication lead the way.

Improving patient-centered quality healthcare is our mission at EVMS Medical Group. We were one of the first multispecialty practices in the region to implement an Electronic Health Record (EHR) and achieve CMS PQRS certified registry status. We have developed disease-specific report cards, improved workflow processes, identified high-risk populations, and evaluated cost savings and population health measures.

Many of our physicians hold key local and national leadership roles that lead the charge in transforming healthcare delivery.

As early implementers of Meaningful Use, our clinicians are positioned to collaborate with our regional medical professional partners to improve the quality of healthcare in Hampton Roads. Our continued reporting of quality indicators, such as medication reconciliation and decreased inpatient and ER admissions, will pave the way for improved quality care and lower healthcare costs throughout Virginia.

For more information, contact Dr. Richard Bikowski, EVMS Medical Group Chief Quality Officer at 757-451-6200.

Learn more at EVMSMedicalGroup.com.

The knowledge to treat you better.

Winter 2016 VOLUME IV, ISSUE I

features

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CONTENTS

contents

8 Perchance to dream…Why it can be so hard to get a good night’s sleep…and why it matters 10 Patrick Harding, MD

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12 Soham Sheth, MD, MPH 14 Robert D. Vorona, MD

22 Sleep Apnea Might Not Just Take Our

Breath Away – It Can Also Take Our Sight

30 Creating an Effective Employee Handbook 31 You’ve been asked to serve as an expert

witness in a medical malpractice case 32 Treating Hip Fracture in the Older Patient

34 Chronic Pain and Sleep Disturbances:

The Chicken or the Egg?

28

36 Benign Prostatic Hyperplasia

43 The Benefits of Microprocessor

Knee Technology

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departments 4 Publisher’s letter

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6 Physician Advisory Board

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16 Medical Update: Unraveling the

Mysteries of the Thyroid 20 Good Deeds: Charles E. Horton, Jr., MD 26 Medical Professional:

Janine Brown MS, RN , CFNP 38 In the News 44 Welcome to the Community 46 Awards and Accolades

promotional features 24 The Group for Women: Introducing

the MonaLisa Touch® 28 Tidewater Physical Therapy:

Introducing Rebecca English, PT, DPT Winter 2016 Hampton Roads Physician | 3

ian.com

www.hrphysic

Physician H

Winter 2016

SOHAM SHETH,

MD

MD HARDING, PATRICK MD VORONA, ROBERT D.

EDICINE ialize in

Spec icians Who

Honoring Phys

SLEEP M

Celebrating Our ANNIVERSARY!

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ith this issue, Hampton Roads Physician begins its fourth year of publication. With twelve issues under our belt, we’ve had the privilege of spotlighting the work of 34 doctors practicing in a variety of specialties.

In addition, in our Good Deeds column, we’ve honored 12 physicians who routinely go above and beyond volunteering their time and talent to serve their patients, their communities and the world. We’ve also featured 12 medical professionals – Nurse Practitioners and Physician Assistants – whose exceptional performance complements the work of treating physicians.

And in the Medical Update, introduced just last year, we’ve covered infectious diseases, allergy and asthma, treating children with chronic conditions and the growing role of the hospitalist.

In this issue of our cover story Perchance to Dream, we look at sleep – why we need it, why it can be so hard to get and how our three cover doctors are helping those who experience the unwanted wakefulness of sleep disorders.

Our second article features a discussion about a very small gland and its very big job: the hardworking thyroid.

It’s our continuing hope that these articles prove useful Holly Barlow to our readers and honor those medical professionals in our Publisher community for their outstanding acheievements. And please know that we’re always available to discuss your ideas for future issues as well. You can call, email or fax us at any time.

It’s time to start thinking about nominations for the Spring/Summer issue of Hampton Roads Physician. We’ll be featuring physicians who practice in the fields of psychiatry and mental health; if you’d like to nominate a colleague or partner, please go to www.hrphysician.com and click the “Nominate” tab – or if you’d prefer, call our editor at 757.773.7550 to have one emailed directly to you.

For our second feature, we’re taking a cue from the March 2015 issue of Forbes magazine, which reported that by the year 2025, the United States will likely face a potential MD shortage of as many as 52,000. We’ll look at how the advent of telemedicine, or telehealth, is already determining how people will be diagnosed, treated and followed in that new world.

Bobbie Fisher Editor

Deadline for all nominations – including cover doctors, medical professionals and good deeds is

March 1st

Please visit our website to view our 2016 editorial calendar. www.hrphysician.com Published four times a year, Hampton Roads Physician provides a wide variety of the most current, accurate and useful information busy doctors and health care providers want and need.

Cover stories concentrate on one branch of medicine, featuring profiles of practitioners in that specialty.

Featured physicians are chosen by the advisory board through a nomination process involving fellow physicians and public relations directors from local hospitals and practices.

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A publication for

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and about the local medical community

Winter 2016, Volume IV/Issue I

Recognizing the achievements of the local medical community Publisher Holly Barlow Editor Bobbie Fisher Contributing Writers Jenny L. F. Andrus, MD Jessica Flage Kapil G. Kapoor, MD Ali R. Jamali, MD John Robb, CPO Raj N. Sureja, MD Lawrence Volz, MD Physician Advisory Board Alfred Abuhamad, MD O.T. Adcock, Jr., RPh, MD John W. Aldridge, MD, FAAOS Brian L. Johnson, MD Mark W. McFarland, D.O. Jennifer Miles-Thomas, MD, FPM-RS Jennifer F. Pagador, MD Michael M. Romash, MD Lynne A. Skaryak, MD Jolson Tharakan, MD Emeritus and Voting Board Jon M. Adleberg, MD Anthony M. Bevilacqua, DO Silvina M. Bocca, MD, PhD, HCLD Mary A Burns, MD, FACOG, FPMRS Jeffrey R. Carlson, MD Kevaghn P. Fair, DO Bryan Fox, MD Margaret Gaglione, MD, FACP Emmeline C. Gasink MD, FAAFP, CMD Jerry L. Nadler, MD, FAHA, MACP, FACE Paa-Kofi Obeng, DO Michael J Petruschak MD Richard G. Rento II, MD Michael Schwartz MD JohnM. Shutack, MD I. Phillip Snider, DO Deepak Talreja, MD, FACC, FSCAI Jyoti Upadhyay, MD, FAAP, FACS Christopher J. Walshe, MD Elizabeth Yeu, MD Magazine Layout and Design Desert Moon Graphics Published by Publishing, LLC Contact Information 757-237-1106 holly@hrphysician.com Hampton Roads Physician is published by DocDirect Publishing, LLC, 7445 N. Shore Rd., Norfolk, VA 23505 Phone: 757-237-1106.

This publication may not be reproduced in part or in whole without the express written permission of DocDirect Publishing, LLC.

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Although every precaution is taken to ensure accuracy of published materials, DocDirect Publishing, LLC cannot be held responsible for opinions expressed or facts supplied by its authors.

B O A R D A D V I S O R Y P H Y S I C I A N

MEET THE 2016 ADVISORY BOARD

We are honored to introduce our 2016 Advisory Board. Their input will help guide the editorial content, format, and direction of the magazine. Along with our Emeritus Board, they will select our featured physicians.

Alfred Abuhamad, MD Obstetrics & Gynecology Dr. Abuhamad serves as the Vice Dean for Clinical Affairs and the Mason C. Andrews Professor and Chair, Department of Obstetrics and Gynecology at EVMS. He is Board Certified in Obstetrics & Gynecology and Maternal-Fetal Medicine. He is the current president of the Society of Ultrasound in Medical Education, and the National Council of Safety in Women’s Healthcare and past president of the American Institute of Ultrasound in Medicine.

O.T. Adcock, Jr., RPh, MD

Jennifer Miles-Thomas, MD, FPM-RS Urology Dr. Miles-Thomas is a Urologist with The DevineJordan Center for Reconstructive Surgery and Pelvic Health-a division of Urology of Virginia, an Assistant Professor in the Department of Urology at EVMS, and the Medical Director for the Pelvic Health Center at Chesapeake Regional Medical Center. Dr. Miles-Thomas is board certified and fellowship trained in urology. She is also board certified in female pelvic medicine and reconstructive surgery

Jennifer F. Pagador, MD

Registered Pharmacist and Physician, Board Certified in Family Medicine in practice in Hampton for 32 years. Currently serves as Associate Medical Director and Service Line Chief for Primary Care and Access for Riverside Medical Group.

Family, Bariatric and Age Management Medicine Dr. Pagador is Medical Director of Seriously Weight Loss, LLC and Attending Physician at Revita Medical Wellness, specializing in medical weight loss and hormone optimization

John W. Aldridge, MD, FAAOS

Michael M. Romash, MD

Orthopaedic Surgeon Dr. John Aldridge is board certified orthopaedic surgeon with Hampton Roads Orthopaedics & Sports Medicine. He specializes in minimally invasive muscle sparing spinal surgery and total joint replacement surgery. Dr. Aldridge practices at both the Newport News and Williamsburg office locations of HROSM. In addition to his many interests in the field of orthopaedics, he also serves as a Lieutenant Colonel in the United States Army Reserves.

Board Certified Orthopaedic Surgeon A lower extremity specialist practicing for over 30 years, Dr. Michael Romash is a Fellow of the prestigious American Orthopaedic Association and known as a pioneer in his field. Author of numerous medical journal articles and chapters in text books about foot and ankle surgery, he has developed treatments commonly used for various heel fractures.

Brian L. Johnson, MD

Lynne A. Skaryak, MD

Dermatology Dr. Johnson is the founder of The Virginia Dermatology & Skin Cancer Center. He is a Fellow of the American Academy of Dermatology, American College of Mohs Surgery, and the American Society of Dermatologic Surgery.

His emphasis is on the treatment of skin cancer using the Mohs Micrographic surgical technique, an advanced surgical procedure for the treatment of skin cancers.

Thoracic Surgery Dr. Skaryak is Director of Thoracic Surgery and Co-Director of Thoracic and Lung Health at Chesapeake Regional Medical Center. She is board certified in Thoracic Surgery.

Mark W. McFarland, DO

Jolson Tharakan, MD

Orthopaedic Spine Surgery Dr. McFarland practices at the Orthopaedic & Spine Center in Newport News and is board certified In Orthopaedic Surgery and Fellowship trained in Spine Surgery

Family Medicine Dr. Tharakan is a board- certified physician with Bon Secours Grassfield Medical Associates. He is a diplomate of the American Board of Family Medicine and has a special interest in diabetes care.

Visit our website to see all members of the Emeritus Board 6 | www.hrphysician.com

Established in 2002 and dedicated to patient care, Dominion Pathology Laboratories, (DPL) is an independent laboratory that offers expert diagnosis on biopsies performed in healthcare facilities throughout Hampton Roads and greater Richmond.

Robert A. Frazier, Jr., M.D.

Kevaghn P. Fair, D.O.

Michael T. Ryan, D.O.

• 24 Hour Turn-Around On Routine Specimens • Board Certified Pathologists With Over 70 Years Of Combined Experience • Immediate Access To Our Physicians Whenever You Need Them • Continuous Internal Quality Control Where Second Opinions Are Routinely Provided In The Diagnosis Of Unusual, Suspicious, Or Malignant Cases.

733 Boush Street, Suite 200 • Norfolk,VA 23510 Phone 757-664-7901• Fax 757-664-9122 www.dominionpathology.com

Perchance to dream…

Why it can be so hard to get a good night’s sleep…and why it matters of physical renewal. It was nearly another 200 years before Galen established that consciousness resides in the brain, not the heart.

“I couldn’t sleep at all last night…”

- Bobby Lewis, “Tossin’ and Turnin’” What we know of early sleep medicine comes from the Edwin Smith, Ebers and Kahun papyri. These documents refer to Egyptian remedies for insomnia, which consisted of poppy seeds out of which the then current recipe for opium was prescribed.

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eople have been sleeping, not sleeping, and chronicling their sleep (or lack thereof ) throughout recorded history.

In 450 BC, the Greek physician Alcmaeon produced the earliest documented theory of sleep, which he described as a loss of consciousness as blood retreats from the surface of the body.

Fifty years later, Hippocrates theorized that sleep was due to blood retreating to the inner regions of the body. Still fifty years after Hippocrates, Aristotle saw sleep as caused by warm vapors rising from the heart during digestion, and concluded that sleep is a time

What these early healers didn’t know, however, was that many cases didn’t require medication at all. Instead, those early Egyptians were experiencing paradoxical insomnia, that is, complaining they weren’t sleeping when in fact, they were. In fact, the most common cause of most insomnia is psychological: it can be related to some underlying anxiety, a stressful life event like divorce, death or trauma – sufferers develop poor sleep hygiene and eventually become chronic insomniacs.

Those early healers had no way to diagnose narcolepsy until 1888, when it was identified by Gelineau. Similarly, they had no name for restless legs syndrome, which was described in 1945 by Ekborn.

“How blessed are some people … to whom sleep is a blessing that comes nightly.” - Bram Stoker, Dracula The modern approach to sleep disorders research began in 1913 with the publication of Le problem physiologique du sommeil, the first text to examine sleep from a physiological perspective. Dr. Nathaniel Kleitman, known as the Father of American sleep research, began questioning the regulation of sleep and wakefulness and of circadian rhythms in the 1920s. In 1953, he and Dr. Eugene Aserinsky made the landmark discovery of rapid eye movement (REM) during sleep.

Three years later, Aaron Lerner named the sleep disorder that is experienced by more than 18 million Americans today.

Obstructive sleep apnea can cause fragmented sleep and low blood oxygen levels.

One of the most common signs of obstructive sleep apnea is loud and chronic snoring, but snoring is the least of these poor sleepers’ problems. Obstructive sleep

2 8 |FullSpectrumAd.indd www.hrphysician.com

4/16/15 3:48:05 PM

apnea is linked to car crashes, high blood pressure, diabetes, stroke and heart disease. And there is increasing literature that demonstrates that treating sleep apnea accrues benefits in all sorts of different areas, whether lowering incidences of automobile crashes, lowering blood pressure, protecting the cardiovascular system.

In addition, according to the New York University Medical Center website, a 2015 study found “a troubling link between abnormal breathing patterns like snoring and brain function.” They studied the medical histories of more than twenty-four hundred people between the ages of 55 and 90. They found that those who snored or who had sleep apnea were diagnosed with mild cognitive impairment at an average age of 77. For those without sleep-related breathing problems, cognitive problems didn’t appear until an average age of 90.

And, the researchers found, those with breathing problems during sleep were also more likely to suffer from Alzheimer’s disease at an earlier age. For snorers, the Alzheimer’s diagnosis came at an average age of 83. For those without breathing problems, the average age for Alzheimer’s onset was 88.

“Leave me where I am; I’m only sleeping.”

- Lennon-McCartney, “I’m only sleeping.”

In dreaming sleep, with the exception of eye muscles and the diaphragm, the body is intended to be paralyzed. In REM sleep behavior disorder, an interesting condition predominantly seen in older men, sleepers will act out their dreams, often those with violent content. They lose the normal paralysis that is supposed to be present in dreaming sleep. A typical example: the patient dreams he is being chased by a bear, and he “reacts” by punching the bear in the snout. Unfortunately, it’s his wife who receives the blow. And while some defendants in criminal cases have used the “REM sleep behavior disorder defense,” few have done so successfully.

The body is far from inactive during sleep. In the deepest and most restorative stage of sleep, the blood pressure drops, breathing is slower, muscles are relaxed and blood supply to the muscles increases – and importantly, it’s when tissue growth and repair occurs. It’s vital for the restoration of brain function. It is, as one of our doctor honorees says, “when the trash is taken out, when the body has maximal benefit in terms of recovery.” 

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“I don’t sleep at night. The doctor can’t tell why. He’s a clever fellow, or I shouldn’t have him, but I get nothing out of him but bills.”

- John Galsworthy, The Forsyte Saga Fortunately, the science of sleep medicine has grown far beyond the understanding of Galsworthy’s luckless physician. With backgrounds in psychiatry, neurology, neurophysiology, and pulmonology, as well as Board certifications in sleep medicine, the three physicians featured on our cover – Dr. Soham Sheth, Dr. Patrick Harding, and Dr. Robert Vorona – have the most current and reliable knowledge of the mysteries of sleep and its disorders, and many more options to help their patients achieve what Shakespeare referred to as “Sleep that knits up the ravell’d sleave of care … chief nourisher in life’s feast.”

“Even a soul submerged in sleep is hard at work and helps make something of the world.”

- Heraclitus, “Fragments”

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Winter 2016 Hampton Roads Physician | 9

PATRICK HARDING, MD Medical Director, Riverside/Williamsburg Neurology and Sleep Disorders Center Medical Director, Riverside/Gloucester Neurology and Sleep Disorders Center

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rowing up in Italy, a self-styled “military brat,” Patrick Harding saw the practice of medicine up close – but not in a hospital or doctor’s office. Rather, every year during the period of Ferragosto, the annual Italian August holiday, his entire family would visit his grandmother’s ancestral home, where his aunt would hold clinic every morning. “She was a pediatrician,” Dr. Harding remembers, “and everyone in the region knew she would be there. So they’d show up every morning with their children, and with their own ailments as well.”

They often had no money, so his aunt would accept bread or eggs – even once a bleating goat – as payment for her services. “She couldn’t turn anyone away,” Dr. Harding says. “I saw the effect she had on people, how she helped them, and that’s when I knew I wanted to become a doctor.”

By the time he was ready for medical school, his family had returned to Virginia, so he earned his undergraduate degree in biology from the College of William and Mary, and enrolled in EVMS. He graduated in 1993, and remained to complete his internship in internal medicine in 1994, followed by a residency in neurology (as Chief Resident in 1997.)

He had initially planned to become a cardiologist, but found neurology more compelling. During his residency, he was fortunate to be mentored by the late, much respected Dr. Tom Pellegrino, who suggested he consider changing his focus. “He said he thought I’d be a good fit in neurology,” Dr. Harding says. “It was definitely the right decision.”

While he was doing rotations in neurology, he took a sleep medicine elective, and found it fascinating – so much that he did six months of rotations, and needed just six more to sit for the Board exam. “At that time, you could be Board certified if you did the equivalency of one year’s worth of fellowship training,” he explains. He was again fortunate to have a supportive mentor, Dr. Tom Bond, who was then working with EVMS Medical Group. “Dr. Bond had been assigned to the Williamsburg area,” Dr. Harding recalls, “so when I moved to Williamsburg in 1997, I asked if he’d be my sponsor, and help me get the extra six months I needed.” Dr. Bond agreed, and a few years later, Dr. Harding sat for the Board – passing on his first attempt. Today, he is the Medical Director of the Riverside Neurology and Sleep Disorders Center sleep lab, practicing with three other physicians and a PA. Sleep medicine is particularly gratifying to Dr. Harding, he says, because neurologists see many patients with neurological problems that can be managed, but not cured. “We can help them live better lives, but we can’t totally eliminate their

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disease. That can be frustrating,” he says, “but in sleep medicine, there are treatments we can offer that can actually reduce or even eliminate the problem, by educating patients and helping them improve their sleep habits.”

Some patients don’t – or can’t – believe they have a problem, he says. “I don’t know how many times I’ve heard patients say they don’t snore, or they don’t have apnea, or they don’t fall asleep at odd times.” One such patient was his father. “We were watching the Super Bowl together,” he says, “and my dad just fell right asleep during the game. I nudged him awake and asked him if it happened often and he denied it, just as so many other patients do when they don’t realize it.” He got his father into the sleep lab, discovered very significant apnea, and was able to cure it almost immediately. It’s a scenario that’s played out hundreds of times during his practice.

Dr. Harding also treats patients with more serious problems, like nocturnal seizures, a rare condition that patients are often unaware of until they wake up having bitten their tongue, lost bladder control, or even shrieking violently. “I probably see that more because I’m a neurologist,” he says, “as well as the narcolepsies, insomnias and leg movement disorders. Most sleep disorders have a neurological basis.”

In addition to caring for patients, Dr. Harding has been active in expanding the availability of sleep medicine to the residents of the Virginia Peninsula. From 1997 to 1999, he assisted in the creation and development of the Williamsburg Sleep Disorders Center at Williamsburg Community Hospital, in the City of Williamsburg, and served as its Medical Director for several years thereafter.

From 1999 to 2006, he assisted in the creation and development of the Williamsburg Neurology and Sleep Disorders Center, again acting as its Medical Director. He also assisted in the creation and development of the Williamsburg Neurology Infusion Center from 2004-2006; and since 2006, he has assisted in the creation and development of the Riverside Gloucester Neurology and Sleep Disorders Center, and has served as its Medical Director.

“Sleep is a reflection of your day, and ultimately reflects on your life,” Dr. Harding emphasizes to his patients. “People need to respect their sleep cycles. We’re living in a fast paced everchanging world where everyone’s “plugged in;” we’re living on less and less sleep, and it’s affecting our wellbeing and longevity. I’m asked frequently why do we need sleep, and I explain that sleep is vital to the restoration and maintenance of normal brain function. Ultimately, sleep is when we take out the trash in order to get a fresh start to each day.”

Winter 2016 Hampton Roads Physician | 11

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SOHAM SHETH, MD, MPH The Sleep Center at Chesapeake Regional Healthcare

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y the time Soham Sheth was a high school student in Ahmedabad, India, he already knew he wanted to become a physician. He had relatives who were doctors, and he had gone with them to volunteer at the Bhansali Trust in Radhanpur, one of the peripheral areas of the Gujarat state of India. He worked with the Trust in some of India’s remote villages, participating in diagnostic camps, health exhibitions and educating health workers. Those early experiences confirmed that he wanted a career in medicine.

By 1999, he had graduated from Smt. NHL Municipal Medical College in Ahmedabad, and was beginning a rotating internship at VS General Hospital. His initial medical focus was ophthalmology, but after five or six months, he started to realize that was likely not going to hold his interest.

About the same time, he had the opportunity to come to the United States to complete a Masters in Public Health at Johns Hopkins School of Public Health. “I wasn’t about to pass up that chance,” Dr. Sheth remembers. It was a wise decision that led to other opportunities: first, a post-doctoral research fellowship at Johns Hopkins School of Medicine. His initial project was in neuro ophthalmology, which fit perfectly with his growing interest in neurology. “My main love was neuro muscular medicine and peripheral neuropathy,” he says, “and almost all of my research was in that area.”

He completed an observership at Hopkins under attending physician Michael Polydefkis, MD, Director of the Cutaneous Nerve Lab and Director of Neurology at Johns Hopkins Bayview Medical Center. He later left Maryland for Detroit, where he completed a residency in neurology and was chief resident in the neurology department at Detroit Medical Center, Wayne State University. He also completed a fellowship in neuromuscular/ clinical neurophysiology at Detroit Medical Center, Wayne State University.

He came to Virginia to join Chesapeake Regional Medical Center as its Stroke Director in 2008.

Dr. Sheth still considers neuromuscular neuropathy one of his main specialties and admits that his career focus on sleep medicine was born of a personal experience. “When I moved to America, I began gaining weight, quite a bit, actually,” he says. “I was young, 21 years old, and I didn’t know how to cook. I had little money and little spare time, so I stayed on a fast (junk) food diet.”

He began to notice that he was having trouble concentrating, even to the point of having difficulty getting through one of his rigorous exams. “I had never had any trouble with exams,” Dr. Sheth remembers. “I tried to figure out what was going on, and realized that I was snoring.” He had studied sleep medicine during his residency and fellowship, and recognized

that he had developed obstructive sleep apnea secondary to his weight gain and got treatment. He also went into action: eating more healthfully, losing weight, exercising, and paying better attention to his sleep habits. When he lost the weight, his symptoms improved.

“I realized how important sleep is,” Dr. Sheth says, “and I felt the need to help patients with sleep difficulties as well.” There are many such people, many of whom go undiagnosed for some time.

For example, in his capacity as Stroke Director for Chesapeake Regional Medical Center, he sees many patients who have sleep apnea that had never been explored. “We know that sleep disorders are an independent risk factor for strokes,” he explains, “but they also adversely affect other conditions as well.” In fact, he says, he often finds sleep problems in patients who were not referred for sleep issues: “We have patients referred for headaches, or for fatigue and other presentations, and we find they have primarily a sleep problem.” Board certified in neurology, neuromuscular medicine, electrodiagnostic medicine and sleep medicine, Dr. Sheth frequently sees patients who describe chronic ‘sinus headaches.’ However, he notes, “Most patients who wake up every day with headache are probably suffering from sleep apnea.”

He routinely sees patients who have high blood pressure, diabetes out of control, small vessel damage in the brain, and even irregular heartbeat – all related to sleep disorders.

It can be especially concerning for young patients. Too often, these adolescents are being put on a variety of different headache medicines, when in fact, a thoughtful exam or sleep study would reveal an underlying sleep problem, and avoid giving medicines that can potentially cause damage.

Of course, in younger patients with headache and/or insomnia, Dr. Sheth says, the culprit is often found at the end of a USB port.

“There are many things that contribute to poor sleep,” he says, “including stress, trauma, anxiety. But to me, the gadgets are the main problem today.” He explains: when it gets dark, the brain secretes melatonin, the chemical hormone that indicates it’s time to sleep. But watching television, or playing with iPads or other devices that give off artificial light trains the brain that in fact, it’s not time to sleep.

“So the brain doesn’t secrete melatonin,” Dr. Sheth tells his patients, and cautions, “it doesn’t have any appreciable effect for a few days or even a few weeks, but over the years, it becomes a very big problem.”

So important is sleep and the role it plays in maintaining good health, that Dr. Sheth believes a sleep component should be part of every patient’s history and physical examination: “Good, restful sleep is vital to a healthy lifestyle. It benefits the organs, the weight, the skin, the mood – and so much more.”

Winter 2016 Hampton Roads Physician | 13

ROBERT D. VORONA, MD

Medical Director, EVMS/SNGH Sleep Disorders Center

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r. Robert Vorona likes to say he approached his career in sleep medicine backwards. After graduating with a degree in psychology at Duke in 1977, he earned his medical degree from the University of Virginia in 1981. He completed a residency in internal medicine at the University of Michigan at Ann Arbor, and a pulmonary fellowship at University of North Carolina at Chapel Hill.

Following his fellowship, he joined Pulmonary Medicine of Virginia Beach in 1986, practicing with Drs. Bruce Johnson and Bill Cooper. Dr. Johnson had become Board certified in sleep medicine, and suggested that Dr. Vorona do likewise. “I had been introduced to sleep medicine at Carolina and became interested in it while doing a small research project,” he says. Practicing pulmonary, critical care and sleep medicine, he stayed with the Virginia Beach practice for 10 years before relocating to Winston-Salem in 1996 to join Winston-Salem Health Care, where he practiced internal medicine, pulmonology, and sleep medicine.

He might have stayed in North Carolina, but for an invitation from Dr. J. Catesby Ware (Division Chief ) and Dr. Leon Georges, then Chairman of Internal Medicine at EVMS. Recognizing Dr. Vorona’s clinical skills and academic potential, Dr. Georges recruited him to become the Medical Director of EVMS Sleep Medicine. He accepted, with the proviso that he would spend a percentage of his time working with Drs. Cooper and Johnson. “Initially I was at EVMS about 80 percent of the time, and with my old partners about 20 percent,” he recalls. “But eventually, the opportunities at EVMS became my entire focus.”

Those opportunities include patient care – he sees patients four days out of five – and still finds it interesting that some in Hampton Roads do not know that the medical school cares for patients. His responsibilities also involve rewarding educational interactions with medical students, medical and ENT residents, practicing physicians from a variety of specialties, dentists, oral surgeons and sleep technologists. The medical school environment allows more opportunities for sharing current knowledge; for example, he says, “We meet every Tuesday morning in a multidisciplinary fashion to review a recent article in the sleep medicine literature, and to discuss challenging cases.”

Dr. Vorona devotes 10 percent of his time to performing research with his fellow specialists, students and mentees. There is plenty to research, as sleep medicine is still a relatively new field. “It’s been interesting to see the field grow from the standpoint of the number of sleep medicine specialists who come from different disciplines,” he says, “and the increase in knowledge.” An example of the maturation of sleep medicine is the development of sleep fellowships. In 2011, Dr. Vorona and EVMS colleague Ms. Etta Vinik, MA, medical educator at the Strelitz Diabetes Center, developed the Commonwealth’s first 14 | www.hrphysician.com

Accreditation Council for Graduate Medical Education (ACGME) accredited sleep medicine fellowship.

The first fellow, Dr. Steven Kanarek, a neurologist, completed his fellowship in 2014. The second, Dr. Ubha Rayamahji, a psychiatry resident, finished in 2015. The third, a pediatrician, will begin in July 2016. Because sleep disorders can have many different etiologies, Dr. Vorona appreciates working with fellows with different backgrounds than his. “I have found it personally interesting, because while I’m teaching them, I’m also learning from them.”

In 2008, Dr. Vorona and Dr. Richard Parisi of Richmond spearheaded the development of the Virginia Academy of Sleep Medicine, an education/advocacy organization that serves as the voice of sleep medicine professionals in Virginia. VASM’s first educational conference was in 2009, an annual event that today attracts attendees from across Virginia and beyond. VASM successfully lobbied for the licensing of polysomnographic technologists, a key step in the development and maintenance of standards for the field of sleep medicine. Dr. Vorona now serves a second term on the Governor’s Board of Polysomnographic Technology.

One research interest for Dr. Vorona is the role of obesity in sleep disorders. A 2005 study of approximately 1,000 patients demonstrated a strong relationship between obesity and sleep duration; in a follow-up study, he is collaborating with Dr. Ware on the relationship between objectively measured sleep and body mass index.

A main area of recent focus is the potential negative consequences of early high school start times. Dr. Vorona, Dr. Ware and Dr. Mariana Szklo-Coxe of ODU first compared two similar Tidewater communities with starkly different high school morning bells, and found that students who started school earlier were involved in more automobile crashes than the students who began later. Dr. Vorona and colleagues recently replicated these findings with two matched Central Virginia school districts, and they continue to explore this area. These studies are rewarding to him, as they may have public policy ramifications for the Tidewater region and beyond.

Over the course of his practice, Dr. Vorona has given presentations at international, national and local conferences on sleep disorders, their relationship to other medical conditions, and the growing field of knowledge today’s practitioners can bring to bear to help patients.

It’s a far cry from when he began. For example, he says, “When I first joined Pulmonary Medicine of Virginia Beach, Bruce Johnson and I would try to convince our colleagues and patients that sleep apnea was important, but there was skepticism, perhaps rightly, as sleep medicine was still in its relative infancy. Today we know that treating apnea and other sleep disorders improves sleep and quality of life, lowers the frequency of car crashes, lowers blood pressure, and probably protects the cardiovascular system as well.” 

Winter 2016 Hampton Roads Physician | 15

Unraveling the Mysteries of the

Thyroid

By Bobbie Fisher

T

he thyroid gland is often described as butterfly shaped, but the comparison doesn’t stop there. Although relatively small (.03-.04 grams), the average butterfly provides a wide range of environmental benefits, including pollination and natural pest control (in addition to being a food source itself ), making it one of nature’s workhorses. Similarly, despite its own relative small size (20-60 grams), the human thyroid produces and stores the hormones that regulate metabolism and influence the function of every cell, tissue and organ in the body, including the heart, the brain, the liver, kidneys, intestines and skin.

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For all its importance, the butterfly is a fragile and delicate creature, susceptible to many natural predators and having a very short lifespan. The thyroid, while not as fragile, is likewise subject to a variety of conditions, many of which are complex, and can be challenging to understand.

“Thyroid disease is very common,” says David C. Lieb, MD, an associate professor of internal medicine and program director of the Endocrinology Fellowship Program at Eastern Virginia Medical School.

More than 12 percent of the US population will develop a thyroid condition at some point during their lives. That is, an estimated 20 million Americans have some form of thyroid disease. “As many as 60 David C. Lieb, MD percent of them are unaware of their condition,” Dr. Lieb says, “which could be too much or too little thyroid hormone, a thyroid nodule or thyroid cancer. And untreated thyroid disease can put patients at risk for serious conditions, such as cardiovascular disease, osteoporosis, infertility, depression, mental slowing and others.”

Women are five to eight times more likely to have hypothyroidism.

“Despite the research, we still haven’t figured that out,” says Jennifer Wheaton, DO, an endocrinologist with Bayview Physicians Group.

However, hypothyroidism is often caused by an autoimmune process (termed ‘Hashimoto’s thyroiditis’). For unclear reasons, women are often more likely to develop autoimmune disease compared with men. “It’s also worth noting that the symptoms of menopause are almost identical to the symptoms of hypothyroidism: fatigue, weight changes, mood swings, difficulty sleeping. I’ve seen women who experienced these symptoms and assumed they were caused by menopause, and thus their diagnosis was delayed.” That happens less these days, she adds, as physicians and patients are more aware of hypothyroidism and its symptoms.

TSH Screening.

The routine test is the thyroid stimulating hormone, or TSH, taken from a blood sample. It’s considered the gold standard. From the American Thyroid Association: A high TSH level indicates that the thyroid gland is failing because of a problem that is directly affecting the thyroid (primary hypothyroidism). The opposite situation, in which the TSH level is low, usually indicates that the person has an overactive thyroid that is producing too much thyroid hormone (hyperthyroidism).

Occasionally, a low TSH may result from an abnormality in the pituitary gland, which prevents it from making enough TSH to stimulate the thyroid (secondary hypothyroidism). In most healthy individuals, a normal TSH value means that the thyroid is functioning normally.

Because thyroid disease is so common, it can be challenging to determine exactly who needs to be screened, and when. “When something is so prevalent, you could easily say that everyone should be screened,” Dr. Lieb says. The United States Public Health Service Task Force argues there is insufficient evidence to screen anybody, while the American College of Physicians says every woman over 50 should be screened. The American Thyroid Association guidelines indicated screening for anyone at risk.

Additionally, Dr. Wheaton explains, the TSH number can fluctuate: “There are definitely things that can affect it, especially if the patient is sick. There’s an entire condition called euthyroid sick syndrome, which results in abnormal thyroid function tests during a nonthyroidal illness in patients without pre-existing hypothalamicpituitary or thyroid disorder.” When the patient recovers from the nonthyroidal illness, she says, the abnormalities resolve.

Similarly, in thyroiditis, when the thyroid is being destroyed by a viral infection, it will release a substantial amount of thyroid hormone because the cells are breaking apart as they’re dying, Dr. Lieb explains: “So these patients become hyperthyroid for a period of time, and then it peaks, and they come back to normal. But sometimes rather than remaining at normal levels, they can get too low and become hypothyroid, requiring thyroid hormone.”

There are other factors that can result in abnormal TSH results, as well – even a patient’s (non)compliance with a thyroid hormone replacement regimen before testing.

Fortunately, most thyroid diseases can be managed with medical attention.

Most of the time, once patients have thyroid disease, they have it for life; however, because it’s an autoimmune disease, it can sometimes resolve itself. “We more commonly see that in hyperthyroidism due to Graves’ disease,” Dr. Wheaton says, “and some patients with Graves’ can be treated for a year or two with medication to normalize their thyroid, and then go into a kind of remission with thyroid levels that will stay normal on their own.”

With hyperthyroidism, treatment options include anti-thyroid medications – propylthiouracil and methimazole – but because of their side effects, they are not recommended for life-long use, particularly at the higher levels. Another option is radioactive iodine ablation, which causes the thyroid gland to shrink and thyroid activity to slow down. One of the sequelae of radioactive iodine is that it can cause hypothyroidism, requiring treatment for that condition.

The standard treatment for patients with hypothyroidism, whether as a result of radioactive iodine for hyperthyroidism or of Hashimoto’s disease, is to replace the thyroid hormone the body can no longer make with a daily dose of levothyroxine. To ensure the patient is receiving the proper dose, levels are monitored after initiating treatment and whenever the dose is changed.

Jennifer Wheaton, DO Goiter is another presentation of thyroid disease that requires skill to diagnose. A patient can have a goiter with a normal TSH, or a goiter with hypothyroidism or a goiter with hyperthyroidism, or a goiter with several nodules that are inactive or a goiter with nodules that are producing too much thyroid hormone. In some cases, a patient with nodules and Graves’ disease may have a goiter so large that it interferes with swallowing or breathing. In this case, surgical removal of the thyroid is indicated.

There has been an increase in both the incidence of thyroid nodules and the incidence of thyroid cancer in the United States over the last five to 10 years. Thyroid nodules are generally incidental findings, as the majority are asymptomatic. They are usually diagnosed when a patient has a head or chest CT scan or x-ray. “Thyroid nodules are more common as patients age,” Dr. Lieb says. “In fact, if we did an

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Winter 2016 Hampton Roads Physician | 17

ultrasound on everybody in their 60s and 70s, at least half of them would have nodules.”

The determination at that point is how best to proceed, particularly in light of the fact that fully 90 percent of thyroid nodules are benign.

“We’ll do a biopsy to determine whether there is cancer,” Dr. Lieb says, “and do another ultrasound at six months to see if it’s changing. And we’ll check thyroid labs to see if it’s overactive, and treat accordingly.”

Thyroid cancer is one of the fastest rising cancers, especially in women, but mortality from thyroid cancer has not increased; the rate of death is actually very low. Of the four types of thyroid cancer – papillary, medullary, anaplastic and follicular – papillary is the most common, Dr. Wheaton explains. “The majority of patients with papillary cancer have their thyroid removed, maybe radioactive ablation afterward, and they do well,” she says, emphasizing that it always depends on the patient.

Medullary thyroid cancer is a more aggressive disease, with a higher mortality rate, tending to be a genetic cancer that has often metastasized before it’s found. Similarly, anaplastic thyroid cancer, which claimed the life of Supreme Court Justice William Rehnquist, is very aggressive and almost always fatal.

When Surgery is Indicated.

With a diagnosis of cancer, removal of the entire thyroid is indicated, as well as some of the surrounding lymph nodes, says Rebecca Britt, MD, a fellowship trained general and laparoscopic surgeon and associate professor at Eastern Virginia Medical School.

“From a recovery standpoint, most patients do extremely well with

18 | www.hrphysician.com

thyroid surgery,” Dr. Britt says. “Our most common complications are low calcium after surgery. In about three percent of surgeries, patients experience recurrent laryngeal nerve injury, or hoarseness, which is permanent less than one percent of the time.”

“It’s a very delicate operation,” explains Doris Quintana, MD, a general and endocrine surgeon with Riverside Surgical Specialists, who did additional training in thyroid and parathyroid. “Keen attention to the finest details really makes a difference in how the patient does, particularly because of the presence of the four small parathyroids that are crucial to survival.”

The surgery is traditionally done through a transverse incision across the front of the neck. Today, surgeons like Dr. Britt and Dr. Quintana can perform the operation with much smaller scarring than in previous years, but for some female patients, they both agree, there is a concern about any scar on the neck.

In some cultures, for instance, where any imperfection is considered to render a woman unmarriageable, some surgeons are doing the procedure endoscopically, with tiny incisions in the axilla or underarms, or even around Rebecca Britt, MD the areola of the nipple. “A

Doris Quintana, MD

tunneling device is then used to come up to the neck,” Dr. Quintana says. “It’s been done some in this country as well, but not extensively.”

Sometimes, Dr. Britt explains, the diagnosis of cancer isn’t easily made. “We do surgery because despite the workup we’ve done, we can’t tell for sure whether something is a cancer or not,” she says.

“Some patients have a nodule or nodules, and when we

colleagues have more to do than ever. For those physicians, and for interested patients, Dr. Lieb and the other contributors to this article recommend these websites:

The American Thyroid Association www.thyroid.org Thyroid Cancer Survivors’ Association www.thyca.org American Association of Endocrine Surgeons www.endocrinesurgery.org

biopsy them, they come back with follicular cells. Frequently those are not cancer, but in order to definitively diagnose, we have to take the whole lobe of the thyroid out and have a pathologist look at it.” If the pathology indicates cancer, the surgeon will then return to the OR to remove the remaining thyroid.

In the absence of cancer, when only one lobe of the thyroid is affected, surgeons can remove only the involved lobe. Patients can do quite well with one functioning lobe, Dr. Quintana says, “particularly because the residual lobe preserves parathyroid function, and the native gland is still potentially putting out enough hormone to sustain a normal level.”

The Connection with Breast Cancer.

A recent study suggested that women being treated for breast cancer have a higher than normal risk of developing thyroid cancer. “It’s vitally important for primary care physicians and anyone treating women to understand that connection,” Dr. Quintana says. “And women should not only be urged to have their screening mammograms regularly, but also to examine their necks for lumps that could indicate nodules.”

Final Thoughts.

The availability of ultrasound and other advanced diagnostic tools are largely responsible for the increase in the diagnosis of thyroid nodules and thyroid cancer.

“It’s always been there; we’re just better able to recognize it,” Dr. Lieb says. “As an endocrinologist, I feel like a part of my job is to stay on top on developments in the management of all aspects of thyroid disease, because our primary care physician

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Winter 2016 Hampton Roads Physician | 19

GOOD DEEDS

CHARLES

E. HORTON, JR., MD Recognizing physicians who are doing community service locally or outside the state or nation

P

hysicians for Peace, the international non-profit organization founded by Charles E. Horton, Sr., MD, was officially incorporated in 1989. Dedicated to delivering medical training and support to local healthcare teams across the developing world, Physicians for Peace has operated in more than 60 countries over the past 26 years, striving to achieve its vision of “a world where no one struggles with illness, disability or death due to the lack of quality local healthcare.”

Dr. Charles Horton, Jr., a pediatric urologist at Children’s Hospital of the King’s Daughters, was involved with Physicians for Peace even before its official incorporation. In fact, his first mission trip was in 1988, when as a junior resident at Harvard, he accompanied his father and a team of health care professionals to Jordan to perform a wide variety of reconstructive surgeries. Remembering that early trip and the many that followed it, Dr. Horton says, “It’s interesting, because some of the work that my father was best known for overlaps with what I do now as a pediatric urologist – reconstructive surgeries for boys with congenital defects: hypospadias, among others. My father pioneered some of those

techniques, and we did a lot of those surgeries together, in several countries. We were in Egypt quite a few times, and in Israel, China and Honduras.”

Dr. Horton recalls the last time he performed surgery with his father. “It was also the last time he ever scrubbed on a case,” he says. “It was in 2000, in the Dominican Republic, in a little town called Moca, 145 kilometers north of Santo Domingo. Our patient was a boy of about 12 who had had multiple attempted repairs, all of which had failed. We were able to successfully perform a salvage hypospadias repair for that young man.”

For the past decade, the Dominican Republic has remained the focus and the destination of Dr. Horton’s mission trips, and he has come to work very closely with the medical professionals in that country. His next mission is scheduled for the fall of 2016. “I take one other pediatric urologist and two other surgeons, as well as an anesthesiologist, a nurse anesthetist, one or two nurses and often a medical student,” Dr. Horton says. The team will stay for a week to 10 days, focusing not just on performing surgeries, but also on training health care providers in the Dominican Republic.

“The need is so great,” Dr. Horton explains, “and there is a great deal of pathology in the country that has been ignored, or improperly dealt with, largely because so many have not had the opportunity to be properly educated and trained.”

Today, Dr. Horton says, there are only four pediatric urologists in all of the Dominican Republic. It’s estimated that one pediatric urologist is needed for every 700,000 in population. The Dominican Republic has a population of 10.8 million people, so they are grossly understaffed.” So much so, in fact, that Dr. Horton and some of his colleagues are in the process of setting up a fellowship in the Dominican Republic. Beginning in 2016, and for the next two consecutive years, they will train one physician each year in reconstructive surgery and pediatric urology. They have identified the initial candidate, who will come to Virginia for part of the fellowship period to train with both pediatric urologists and adult reconstructive urologists.

It’s all part of the philosophy of Physicians for Peace: teach one, heal many. In other words, Dr. Horton says, “We have to teach them how to do what we do, independently of us. So basically, we’re trying to put ourselves out of business down there eventually.” 

If you know physicians who are performing good deeds – great or small – who you would like to see highlighted in this publication, please submit information on our website – www.hrphysician.com – or call our editor, Bobbie Fisher, at 757.773.7550.

20 | www.hrphysician.com

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Sleep Apnea Might Not Just Take Our Breath Away – It Can Also Take Our Sight

By Kapil G. Kapoor, MD

R

ecently, increasing evidence is highlighting the importance of good sleep hygiene for our visual health. Our eyes need sleep with uninterrupted REM cycles to allow a system restart. In sleep apnea, the tissues of the throat collapse and occlude the airway, causing repeated interruptions leading to rapid drops in oxygen levels. The brain responds by releasing compensating circulatory hormones that cause rapid blood pressure spikes.

The retinal blood vessels are extremely sensitive to these fluctuations, putting them at risk of micro-infarct or occlusion – the equivalent of mini-strokes. Even more concerning, obstructive sleep apnea may have a triggering role in cases of retinal vascular occlusions, which may explain why many patients with retinal vascular occlusions notice visual loss upon awakening.

Mini-strokes can affect the microcirculation surrounding the optic nerve as well, known as ischemic optic neuropathy.

A stroke at the level of the optic nerve undermines the main transmission pathway between the eye and the brain.

Research has linked oxygen and vascular irregularities secondary to sleep apnea as important risk factors for ischemic optic neuropathy.

Sleep apnea has also been associated with open-angle glaucoma, which puts the optic nerve at risk for damage due to elevated pressure within the eye. Chronically elevated intraocular pressure can lead to gradual loss of peripheral vision, and frequently goes undiagnosed until advanced stages.

The most classic ocular association with sleep apnea is floppy eyelid syndrome, almost universally present in apneic patients. The oxygen and breathing changes throughout the night lead to frequent positional shifts and repeated friction on the eyelids against pillows and blankets. This mechanical stress leads to a breakdown in the structural tissues of the upper eyelids, which are no longer able to provide the support the eyes need for maintaining tear film – leading to chronic dryness, irritation, and sometimes blurred vision.

Sleep apnea has been further linked with acceleration of other retinal vasculopathies – notably diabetic retinopathy.

Vascular damage inherent to retinal capillaries in diabetic retinopathy can be compounded by damaging factors released in obstructive sleep apneic episodes. These all accentuate hypoxia, a critical driving stimulus for diabetic macular edema and proliferative diabetic retinopathy, in which the retina produces new blood vessels to compensate for the decreased blood flow and oxygen levels. This neovascularization can be sight-threatening, potentially 22 | www.hrphysician.com

resulting in vitreous hemorrhages or tractional retinal detachments, often requiring an increased treatment burden to preserve sight.

While our treatments for preserving sight continue to advance, with multiple options of anti-VEGF intravitreal injections, focal or panretinal photocoagulation laser treatments, and the latest equipment for microincisional sutureless surgery, it’s clear that more attention needs to be shifted toward prevention. As we understand

Sleep apnea has been further linked with acceleration of other retinal vasculopathies – notably diabetic retinopathy. the risks of sleep apnea more, we need to improve patient screening and lower our threshold for patients who may be at risk. Patients should be asked about gasping or choking while sleeping, loud snoring, or daytime sleepiness. Also, it’s critical to engage a family member in the screening process, as patients are often unaware that they snore. Working together as a healthcare team will allow us to optimize treatment for these patients, preserve their sight, and give them all of the benefits of a good night’s sleep.

Kapil G. Kapoor, MD completed medical school at Ohio State University, residency at the University of Texas Medical Branch-Galveston and a fellowship at The Mayo Clinic.

Dr. Kapoor is a Board certified ophthalmologist specializing in vitreoretinal surgery. www.wagnerretina.com.

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PROMOTIONAL FEATURE

NO WONDER

WOMEN ARE SMILING

MonaLisa Touch® is quick, virtually painless, and effective therapy for postmenopausal dyspareunia

A

sk any woman “of a certain age” (i.e., menopausal and post-) what she dreads the most about getting older, and you wouldn’t be surprised if “Wrinkles!” were the first word she uttered. Close behind might be, “Sagging! Nothing is where it used to be!” Or the ever-higher number that seems to greet her every time she steps on the scales.

A more thoughtful woman might respond that the loss of independence, or her memory, or a loved one, was her greatest fear.

Or perhaps the possibility of loneliness.

Women have no trouble expressing these concerns about the aging process. They are, after all, part of life, and therefore, can be shared and discussed without embarrassment.

What women have been less inclined to talk about openly as they get older are the symptoms that accompany an aging female body, and their effects on a woman’s emotional and physical comfort.

Women can feel these symptoms are too embarrassing to mention, even to a gynecologist or other physician. They needn’t be, as they, too, are part of life – and neglecting them can lead to unnecessary discomfort.

and hydration of the cells of the vaginal mucosa. She may experience some or all of these symptoms: • thinning of the vaginal walls; • shortening and tightening of the vaginal canal; • vaginal dryness and/or burning; • vaginal burning (inflammation) • pain or burning with urination; • more frequent urinary tract infections.

Atrophic vaginitis.

The treatment has generally been prescription vaginal estrogen creams. Many women, however, concerned about the use of hormones and the threat of associated cancers, prefer not to use these.

The atophic vagina is thin, fragile, lacking elasticity, and above all, dry and unlubricated. Consequently, postmenopausal women often experience pain (sometimes severe) during intercourse, and may even notice some spotting blood after sex. These women learn to fear sexual intimacy, which is often mistaken for lack of sexual desire by an uncomprehending partner. The damage to these women’s self esteem – and to their relationships – can be devastating.

Until now, physicians have had little to offer these women.

Histology courtesy of Prof. A. Colligaro.

University of Pavia, Italy

As a woman ages and approaches menopause, she experiences a drop in estrogen that can lead to atrophic vaginitis, the lack of nourishment

Dyspareunia.

Before Vaginal, mucosa in the basal condition with a thinner epithelium.

24 | www.hrphysician.com

After Follow-up was at 2 months—2 weeks after 2nd treatment with the MonaLisa Touch.

While some of their fears might be unfounded, it can be an unsurmountable mental block. And breast cancer patients and survivors cannot use them at all.

Additionally, there are no generic options in this drug class, so all prescriptions are branded and tend to be very expensive. Even with co-pays, women can spend upwards of $50 to $100 every time she fills her prescription.

And then, there is the “ick factor.” Vaginal estrogen creams are messy, and unpleasant to administer, which far from enhancing pleasure, can actually diminish it. Women don’t like them, and are thus less likely to use them.

MonaLisa Touch® is a quick, virtually painless, and effective therapy for postmenopausal dyspareunia.

In December 2014 the U.S. Food and Drug Administration cleared a new laser therapy for gynecologic health. Developed in Italy, and named for one of Italy’s most enticing women, the treatment was introduced in the United States by internally renowned urogynecologist Dr. Mickey Karram, a clinical professor of obstetrics and gynecology, and urology, at the University of Cincinnati. Learning about the new treatment, Dr. Karram visited the manufacturer to observe the MonaLisa Touch® and evaluate its application for his own patients. So impressed was he with what he found that he acquired the laser from Cynosure and began to experience the same remarkable results in the United States.

The MonaLisa Touch® is based on a special fractional CO2 laser that was specifically created for the vaginal mucosa. The therapy both resolves and prevents estrogen drops in the vaginal tissue by re-activating the production of new collagen and reestablishing the conditions the vaginal mucosa once had.

In menopausal women, the lining of the vagina is about a millimeter thick. The laser acts on the vaginal lining through a special scanner, creating micro-lesions that trigger the production of new collagen, reorganizing and re-equilibrating the components of the vaginal mucosa. It is the body’s response – increasing blood flow and collagen to heal the wound inflicted by the laser – that allows the vagina to normalize.

The laser’s action reactivates and reestablishes the proper function of the relative urogenital structures, while also improving symptoms associated with urinary dysfunction (mild incontinence due to stress).

Quick, virtually painless and safe.

The treatment takes no more than five to seven minutes, and is performed in the office. There is no need for anesthesia, no need to insert a speculum.

Women report that the physical experience is very much like having a vaginal probe ultrasound – something almost every woman is familiar with. Some have reported a tingling sensation while the probe is in place.

To this point, thousands of women in America, Italy, Australia and throughout Europe have had the procedure. To date, not one case of adverse side effects has been reported. Some women note a small amount of irritation a day or two after the treatment, but that soon resolves.

Jeffrey Wentworth, MD

condition called lichen sclerosis, a chronic skin condition that may be caused by a too active immune system, almost like lupus. Lichen sclerosis in the genital area can create patches that left untreated can cause problems with urination or sex. There is also a very small chance that skin cancer may develop in the patches.

Truly a remarkable breakthrough.

For so long, we have seen our patients suffer the sequelae of menopause. The MonaLisa Touch® – a therapy that is effective and safe and proven – heralds a new age for gynecologists and the women they treat. 

The proof is in the results.

The therapy regimen consists of three treatments, six weeks apart. The tissue regeneration process lasts a number of weeks, but stimulation occurs immediately.

Women have reported experiencing significant improvement of their symptoms as early as days after first treatment with the MonaLisa Touch® - improvement that has translated into an invigorated, almost youthful approach to an activity they found painful just weeks before. Husbands and partners are thrilled, not just with a revitalized sex life, but also with the re-energized woman who has emerged.

The results are far-reaching.

Even beyond the bedroom, women are experiencing relief from virtually all of the vaginal symptoms of menopause. UTIs are resolved, the burning and itching that often accompany urination are gone. Additionally, the MonaLisa Touch® works very well in treating the vulva for a very specific non-hormonal

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Winter 2016 Hampton Roads Physician | 25

ADVANCED PRACTICE PROVIDERS

Janine B rown MS, RN, CFNP Honoring the Expanding Role of Nurse Practitioners and Physician Assistants

J

anine Brown’s career has been a series of firsts.

Her first job after completing her NP training in 1997 was at Sentara Norfolk General Hospital, where she was an outpatient heart transplant nurse practitioner – the first NP ever hired at Sentara in this role. It wasn’t her first choice, she says – she initially wanted to find a position with a family medicine practice, caring for folks in the community and helping them stay healthy. But in the late 90s, those jobs were few and far between locally. She could relocate to West Virginia or the Eastern Shore, but she wanted to live and work in Hampton Roads.

She had been a cardiac step-down nurse and also worked part-time during NP school in the heart transplant clinic, so when the opportunity arose to help craft a nurse practitioner role caring for heart transplant patients at Sentara, she took it. She remained with the program for three and-ahalf years, and during that time, established professional relationships with many physicians and surgeons, whose patients often overlapped with her own.

One of those physicians was Dr. David A. Johnson, a gastroenterologist with Digestive and Liver Disease Specialists (a division of Gastrointestinal and Liver Specialists of Tidewater), to whom she had referred several patients. After Brown left Sentara to care for her newborn daughter, Dr. Johnson called her at home and asked if she’d come to his office to talk with him. “He said he wanted to start something new,” she remembers, “and he said he wanted me to start it with him.”

Dr. Johnson’s idea was to utilize nurse practitioners in the hospital to support his GI practice. “No other GI practices in Hampton Roads were doing that,” Brown recalls. “There were nurse practitioners in the office, but they didn’t round on hospital patients.” Aware of her responsibilities to her family, Dr. Johnson offered her the opportunity to work six hours a day, twice a

week. “He asked if I could handle that,” she remembers. And indeed, she could.

In fact, she says, it was the perfect fit for her.

The learning curve from cardiology to gastroenterology, while huge, was eased by her innate ability to appreciate what was urgent and what wasn’t. Dr. Johnson describes the transition as “seamless, thanks to Janine’s strength of immediate assessment of acuity of illness.” She credits Dr. Johnson’s training – he dedicated two full months of working exclusively at Sentara Norfolk General to teach her – with helping her make the change.

Today, in addition to working four days a week at Norfolk General, she helps mentor medical students, NP students and residents. As part of the practice’s ongoing commitment to the students and residents at EVMS, she can often be found giving advice on presentations or the best ways to approach the diagnosis and therapeutic plans to be presented.

Brown says she was inspired by two exceptional women who served as her role models.

Her mother she describes as “the kind of nurse that every doctor wanted to work with,” adding with pride, “she gained a lot of well-deserved accolades throughout her career.” Her high school biology teacher was the spark that interested Brown in life science. She also credits Dr. John Herre and Dr. David Eich, both cardiologists, with mentoring her through her early days as a nurse practitioner.

“Janine has the foundation of family and faith to guide her,” Dr. Johnson says. Part of that foundation is reliance on the Golden Rule: “I try really hard to treat every patient the way I’d want to be treated,” she says.

If you work with or know a Physician Assistant or Nurse Practitioner you’d like us to consider, please visit our website – www.hrphysician.com – or call our editor, Bobbie Fisher, at 757.773.7550.

26 | www.hrphysician.com

PROMOTIONAL FEATURE

Rebecca English, PT, DPT

Bringing Sense of Balance to the Peninsula as New Director of Tidewater Physical Therapy’s Denbigh Clinic Balance Center Program

By Amanda Kerr, Freelance Writer, Consociate Media

T

echnically speaking, balance is the even distribution of weight that enables someone or something to remain upright and steady.

But in reality, in life, balance is much more than that.

It’s what enables a person to feel sure footed, to feel confident, to feel empowered.

When balance declines, it creates a range of symptoms and sensations such as dizziness or feelings of being faint or unsteady. A loss of balance can also cause dizziness which creates a false sense that a person or their surroundings are spinning or moving, typically referred to as vertigo.

Losing the confidence to move under their own feet can cause patients to doubt themselves and retreat from the world. Unfortunately, the causes of such symptoms can vary greatly and can easily mimic other conditions.

For many patients suffering from balance issues or dizziness, getting a correct diagnosis can be difficult.

“A lot of people struggle with dizziness and imbalance for years,” says physical therapist Rebecca English, PT, DPT. “They’ve been going to doctors for relief, but there is only so much they can do to treat the functional deficits that dizziness and balance disorders can create.”

It’s the mystery of such ailments that led English, who joined Tidewater Physical Therapy in late 2015, to become an expert in the treatment of neurological and vestibular disorders. Over the last 15 years, she has refined her diagnostic skills to hone in on potential causes of vestibular disorders (inner ear and brain deficiencies that affect balance) and the best methods for treatment. She also specializes in neurological and gait dysfunction as well as concussion management.

English comes to Tidewater Physical Therapy from Charleston, S.C., where she helped establish specialized balance services for Charleston ENT. English earned her degrees in occupational therapy and physical therapy from the Medical University of South Carolina in 1997 and 2000, as well as a master’s degree in rehabilitation. In Rebecca English works on dynamic balance with her patient

28 | www.hrphysician.com

2009, she received her Doctorate in Physical Therapy from A.T. Stills University.

She has also earned competencies from the Emory University School of Medicine in vestibular function testing and interpretation with an application in rehabilitation and in vestibular rehabilitation. She holds an advanced competency in the evaluation and treatment of complex balance disorders.

A nationally renowned speaker on balance and vestibular disorders, English is also an adjunct professor at the Medical University of South Carolina’s College of Health Professions, where she teaches coursework related to vestibular dysfunction in the Doctor of Physical Therapy and neuroresidency program.

It is that highly advanced training and skill that English brings to Tidewater Physical Therapy as one of the firstphysical therapists on the Peninsula to offer balance related therapy at this caliber. As a leader in her field, English is heading up Tidewater Physical Therapy’s new Denbigh Clinic Balance Center program, which serves patients with balance, dizziness and mobility issues.

The program can treat patients suffering from vestibular disorders and inner ear conditions, as well as neurological deficiencies due to stroke, Parkinson’s disease, Multiple Sclerosis or concussion. But patients don’t have to have a diagnosis to receive an evaluation.

“I may not be the final stop but I can help direct patients to the right type of care,” English said. “I’m meeting them where they’re at and getting them on the final road.”

Under English’s guidance, the Balance Center’s fall prevention and vestibular rehabilitation programwill treatpatients suffering from dizziness as well as recurrent falls through individualized treatment plans. The program is designed for patients with neurological disease or inner ear disorders suffering from symptoms of vertigo, poor balance and oculomotor disturbances.

Dizziness is the second most common complaint to primary care physicians and accounts for 11.3 million physician visits per year. A total of 40 percent of the population over 40 will experience a dizziness disorder at some point during their life, according to the National Institutes of Health.

Some conditions, such as vertigo or dizziness from concussion, may improve over time. But many balance patients, particularly those with neurological diseases or impairments, have to learn to live with their symptoms. For those patients, English says treatment must focus on their new reality, rather than recovery.

Photo courtesy Krystal Searcy

Under English’s guidance, the Balance Center’s fall prevention and vestibular rehabilitation program will treat patients suffering from dizziness as well as recurrent falls through individualized treatment plans.

English and her patient work on balance and coordination to increase vestibular queues

“We can’t correct the brain for someone with MS,” English says, “but we can help give them strategies and assisted devices to maintain their mobility and independence for as long as possible. There’s a lot of patient education and therapy in terms of functional mobility.”

The difference between treating balance patients and orthopedic patients, English says, is that physical therapy for balance patients isn’t about rebuilding strength or returning their mobility. It’s about giving them strategies to live their lives. 

For further information please visit:

www.TPTI.com

Rebecca English is accepting new patients at the Tidewater Physical Therapy Denbigh Clinic

757.874.0032 Winter 2016 Hampton Roads Physician | 29

Creating an Effective Employee

HANDBOOK What To Include

A

ny size medical practice can benefit from having an employee handbook.

An employee handbook tells employees what’s expected of them and what they can expect from the employer in regard to working hours, conditions, vacations, and other benefits.

By outlining in detail the employer’s policies and procedures, an employee handbook can help minimize disagreements and avoid legal disputes when it comes to discipline and dismissal policies. An effective employee handbook should cover certain core subjects.

Your handbook should include sections on your practice’s policies and rules regarding: • Payment schedules, work periods, and working hours • Lunch breaks, paid time off, vacations, sick leave, and time off for military service or jury duty • Unapproved absences and tardiness • Workplace conduct standards, including policies on workplace violence, harassment, and dress codes • The practice’s information security policies • The use of cell phones or other personal communication devices during working hours • Health and retirement benefits Have a lawyer review the handbook before printing to ensure it complies with applicable laws. After it’s approved and printed, make sure each employee receives a copy. Human resource professionals suggest each copy include a receipt that employees are required to sign and return to you. This confirms that they’ve read and understood the handbook.

Keep It Updated

Medicine is forever changing. With new laws and policies from federal and state regulators and constant shifts in the way medicine is practiced, an employee handbook may not stay legal, timely, or appropriate for long. The handbook should be reviewed annually and updated to reflect current conditions.  For more information please contact the McPhillips, Roberts & Dean Healthcare Team Leaders. mrdcpa.com/Industries/Healthcare

Jennifer Pagador, MD

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Copyright 2015 by DST. All rights reserved.

The general information in this publication is not intended to be nor should it be treated as tax, legal, or accounting advice. Additional issues could exist that would affect the tax treatment of a specific transaction and, therefore, taxpayers should seek advice from an independent tax advisor based on their particular circumstances before acting on any information presented. This information is not intended to be nor can it be used by any taxpayer for the purpose of avoiding tax penalties.

You’ve been asked to serve as an expert witness in a medical malpractice case – What it really means in terms of your commitment of time and energy

By Jessica Flage, Attorney at Law Goodman Allen Donnelly PLLC

Y

ou’ve been asked to review a chart and serve as an expert inconvenience to rearrange schedules and patients. Most often, trial witness in a case of medical malpractice. Do you understand dates in Virginia are scheduled at least eight months in advance, so the full extent of the commitment of time and energy you’re physicians and their offices should have ample notice of impending being asked to make? court dates.

It can be tempting to think of it as easy money: you review a chart Even then, it’s rarely possible to state definitively when an expert will and give your expert opinion about the care rendered, and the sequelae be called to testify. Lawyers make every effort to accommodate their of that care. But it doesn’t end there: at the very least, you will have experts’ calendars, but in malpractice cases, which in Virginia can last to meet with the lawyer to understand what is being alleged. You will a week to 10 days, flexibility is required on the part of every witness. have to educate the attorney about the medicine and what constitutes If you are asked to serve as an expert, be sure you understand the negligence in a particular medical setting. I can tell you that nothing is extent of the commitment. Your own attorney can be a vital resource more frustrating than sitting down with a physician who’s agreed to be in determining whether to agree.  an expert witness, but who has clearly not read the chart.

It’s essential to dedicate time for meetings, depositions, and other pre-trial preparations. A word about depositions: in a malpractice Jessica Flage earned her law degree in 2007 case, testifying is unlike what you may be familiar with from appearing at American University Washington College of as a treating physician. In those cases, you refer to the chart to explain Law. She focuses her practice primarily in the what you found and what you did. However, when you testify as areas of medical malpractice defense litigation, healthcare and product liability defense. www. an expert in a malpractice case, the attorney’s job on the opposing goodmanallen.com side is to attack your opinion, and make a jury feel your position is unfounded and unjustifiable. For physicians who are unaccustomed to being challenged by someone outside the medical field, these depositions can be very uncomfortable.

Before the designation of expert witnesses, you can expect the attorney who hired you to barrage you with questions about the case. Many of those questions will begin with the phrase, “Can you say that…” or “In this THANK YOU! The doctors and staff at Allergy & Asthma Specialists extend a particular instance, did the actions of heartfelt thank you to all the physicians and staffs in Hampton Roads who the physician result in…” refer their patients to us for allergy and asthma health care. We never lose sight of the fact that your referral is accompanied with a trust in us.

You must be prepared to be available to state your opinion and explain your answer, a week or days, or even the day of the designation. These events happen at a very fast pace, and on a very strict deadline.

It’s true that many cases never go Dr. Gary Moss Dr. Greg Pendell Dr. Craig Koenig June Raehll Lisa Deafenbaugh Cassandra L. Grimes to trial, but it is disheartening to NP-C FNP-BC PA-C engage an expert who then clearly We make it as easy as possible on the patient and referring physician by ACCEPTING MOST INSURANCES. demonstrates no desire to testify at trial, or who aggressively attempts to avoid Virginia Beach (757) 481-4383 • Chesapeake (757) 547-7702 • Norfolk (757) 583-4382 court. It can be even more stressful www.allergydocs.net when an expert insinuates that it’s an Winter 2016 Hampton Roads Physician | 31

TR EATING

IN THE OLDER PATIENT—

By Ali R. Jamali, MD, FACS, Sports Medicine & Orthopaedic Center

A

ccording to the Centers for Disease Control, at least 250,000 older Americans (defined as 65 and older) are hospitalized for hip fractures every year. The chances of a senior sustaining a hip fracture increase with every year of life, so much so that the National Institutes of Health predicts the number of hip fractures in the United States could total 840,000 by the year 2040.

Three-quarters of those fractures will occur in women, in part because of their increased risk for osteoporosis. Eight million American women have osteoporosis, which weakens bones and makes them more likely to break. In fact, the National Osteoporosis Foundation claims a osteoporotic woman’s risk of breaking her hip is equal to her combined risk of breast, uterine and ovarian cancer.

Unfortunately, the most troubling statistic comes from a study funded by the the National Institutes of Health and published in the Archives of Internal Medicine: women ages 65–69 who break a hip are five times more likely to die within a year than women of the same age who don’t break a hip.

The problem lies not so much with the hip fracture itself, but with the sequelae of the trauma.

When the body responds to such a trauma, it goes through a transformation and begins to excrete proteins and hormones that affect all of the organs in the body, the endocrine system, the gastrointestinal system, and the inflammatory and immune responses.

It is this multiple-organ pathological response to trauma that we need to take into consideration when we care for older patients, over and above correct-

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I­ t’s not just a question of orthopaedic expertise ing the original fracture, because elderly patients are often already suffering medical problems and diseases associated with age. For instance, diabetic patients may suddenly have trouble regulating their blood sugar after a hip fracture. A thyroid patient may have a similar experience with thyroid hormone. A patient with a queasy stomach may see that turn into an ulcer because of excess acid production. In short, many chronic conditions can be exacerbated by the trauma.

Surgery for the elderly patient.

When surgery is indicated for such patients, the type of procedure will depend on the nature and extent of the fracture, whether intertrochanteric, subtrochanteric or subcapital. No matter what the procedure, I consider it essential to have the safest possible anesthesia for my elderly patients, which is most often a spinal or a regional block – and I want the patient anesthetized for the shortest possible period of time. It can sometimes take an older patient a few days to shake

off the effects of anesthesia, and we watch them very carefully during their post-op recovery.

These older patients are especially vulnerable, and they face a long road ahead as other medical issues resulting from the trauma may impair their ability to heal and recover hip function. But paying attention to the whole patient, not just the fracture, can make all the difference.

Ali R. Jamali, MD joined SMOC in January 2016. He completed medical school at Tabriz University Medical School in Tabriz, Iran. He took post-graduate training in London, England and Seattle, Washington, and completed a combined orthopaedic residency training program at EVMS affiliate Children’s Hospital, Richmond, Virginia. smoc-pt.com

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Winter 2016 Hampton Roads Physician | 33

Chronic Pain and Sleep Distu

By Raj N. Sureja, MD and Jenny L. F. Andrus, MD

A

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s Interventional Pain Management Specialists, we frequently hear patients complain that they cannot fall asleep, or are awakened during the night by pain. Most practitioners know that lack of sleep can increase pain, and that restorative sleep can be the best medicine for relief. Our challenge is to break the cycle of sleep disruption, so our patients get the rest they need when pain is present.

Some statistics: • Pain is the number one medical condition to cause insomnia.

• A new study found that approximately two-thirds of all chronic back pain sufferers have sleep disorders.

• About 65 percent of those who report chronic pain experience non-restorative or disrupted sleep.

• The most prevalent complaint is difficulty falling asleep due to pain.

• Surveys revealed that waking too early due to pain (62 percent of respondents) and waking during the night (65 percent) are reported by chronic pain patients.

Many patients with chronic pain had sleeping problems before their pain started. The pain then turned a moderate sleep issue severe.

To help our patients sleep more deeply and efficiently, with fewer arousals and awakenings, we first determine which came first – the sleep disturbances or the pain. We address the older problem first, and handle each condition differently. If the predominate problem is pain, we address the painful process first; fixing the pain often corrects the impaired sleep. When sleep issues predate the pain, both issues must be addressed.

We start by counseling patients on proper sleep hygiene. We may suggest Cognitive Behavioral Therapy. If they adapt these behavior changes and still have difficulty, we may order a sleep study. A qualified sleep medicine physician can usually pinpoint the problem, whether sleep apnea, restless legs syndrome, periodic limb movement disorder or any other condition. Once a diagnosis is made, appropriate treatment can be recommended.

Sleep apnea is particularly important to diagnose. If severe, it can be dangerous, and is linked to many health problems, including chronic pain. We have seen patients with a chronic pain disorder become almost pain-free after their sleep apnea was addressed.

Additionally, sedative medications are riskier when used in a patient with under-treated sleep apnea. These drugs include narcotic pain medications, as well as some commonly-used prescriptions for sleep. It’s important to evaluate for sleep apnea before using these medications.

rbances: The Chicken or the Egg? We more commonly prescribe medications for sleep that have less risk to the patient and that may also address pain. These include some medications used for neuropathic pain.

For patients whose pain is causing the sleep disruption, we can treat the pain through a variety of techniques, including: • Interventional pain treatments like steroid injections or nerve blocks; • Pain medications, most typically non-narcotic; • Physical therapy; • Structured exercise to promote pain reduction and well-being; • Cognitive behavioral therapy; • Regenerative medicine techniques, including proliferant therapy, PRP, stem cell injections.

Managing pain involves much more than treating the pain generator. When sleep is impaired, pain worsens and patients don’t have the energy to deal with the important things in life, like their

family and work. An effective mullti-disciplinary pain management program addresses all aspects of pain – including sleep – so the patient can return to wellness.

Raj N. Sureja, MD and Jenny L. F Andrus, MD are fellowship-trained, Board-certified Interventional Pain Management Specialists and practice at Orthopaedic & Spine Center in Newport News, VA. osc-ortho.com

More than 40 million Americans suffer from chronic sleep disorders every night.

Many don’t even know it.

Whoever Said Counting Sheep Helps You Sleep

Should Be Put Out To Pasture.

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You know a good night’s sleep is essential to good health.

If your patients aren’t sleeping well at night, send them to Chesapeake Regional Healthcare for a sleep study.

We’ll handle the rest.

• The Sleep Centers at Chesapeake Regional Healthcare are fully accredited by the American Academy of Sleep Medicine.

• We also have all of the necessary equipment for pediatric sleep studies and provide accommodations for parents to stay the night with their child.

• For your convenience, appointments can be made in Chesapeake or at our Elizabeth City Sleep Center.

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1/15/16 9:49 AM Winter 2016 Hampton Roads Physician | 35

Benign Prostatic Hyperplasia

By Lawrence Volz, MD

V

oiding complaints are found in both sexes and all age groups, and can have a multitude of causes, or a combination of causes.

Classic urinary complaints include “irritative” symptoms of

frequency (urgency, urge incontinence, nocturia or nighttime urination) and “obstructive” symptoms (incomplete bladder emptying, slow stream, postvoid dribbling, and hesitancy.) Entire books have been written describing the pathophysiology, diagnosis, and treatment of urinary complaints.

One of the most common reasons for worsening urinary symptoms in men as they age is BPH (benign prostatic hyperplasia), more commonly known to the layman as “enlarged prostate.” That term can be somewhat misleading, however. Although it’s universally true that as most men age, their prostates enlarge, there’s more to the story. It is certainly the case that in general, the larger the prostate is, the more compression it will have on the outlet from the bladder. However, it’s not uncommon for some men with large prostates to have little or no urinary complaints, while others with smaller prostates may suffer greatly. The reason has been thought to be

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because some men may have smaller but more constrictive prostates, while other prostates may grow outward rather than inward as they enlarge, therefore minimally constricting the central channel.

The cause of the obstructive symptoms is self-explanatory. As the urethral channel narrows and the stream slows, it may take longer to initiate urination, and men may be unable to empty the bladder fully. The irritative symptoms are thought to possibly result from the bladder having to generate higher pressures to empty. As with any muscle having to work harder, the bladder wall thickens over time, becomes less “stretchable”, and therefore holds a lower volume of urine before needing to empty, causing frequency and urgency.

All treatments for BPH-related voiding complaints ultimately focus on reversing the obstruction of the urethra from the prostate. In general, a stepwise progression of treatments should be pursued, moving from least aggressive to most aggressive. These include the medication class of alpha blockers such as tamsulosin (Flomax) which relax constriction of the prostate channel. These medications work on both large and small prostates, and symptom improvement is quick, typically as early as two-to-four weeks.

The other class of medication, “5 alpha reductase inhibitors,” is used to shrink the enlarged prostate. However, it may take 4-6 months to see the beginning of symptom improvement. These medications also tend not to have significant effect on smaller constricted prostates, but have been shown to reduce a man’s long-term risk of urinary retention and the need for future prostate surgery.

Lastly, there are many surgical options, all of which aim to open the prostate channel.

This includes the very effective transurethral resection of the prostate or “TURP” that has been performed for years, now with recently improved equipment and technique.

Prostate vaporization and laser treatments are available, along with a recently FDAapproved minimally invasive procedure that “pulls” the prostate channel open without removing or destroying tissue.

Patients should be reassured that effective treatment options exist, from well-tolerated daily medication to minimally invasive and more permanent treatments.

Lawrence Volz, MD has returned to Williamsburg. He is seeing patients in the new Urology of Virginia Williamsburg location. He earned his medical degree from the University of Pennsylvania. He completed his urologic residency at the Hospital of the University of Pennsylvania after two years of general surgery training at that institution. urologyofva.net

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in the news Atlantic Orthopaedic Specialists is pleased to announce that Blake E. Moore, MD, a surgeon with the group, has published an article in The Journal of Bone & Joint Surgery. The article reports on a study that looked at how three of the most common operations to relieve foot pain worked, and yielded insights that could help both orthopaedic surgeons and their patients decide which of the nearly 100 metatarsal procedures will work best to relieve their foot pain.

Atlantic Orthopaedic Specialists is pleased to announce their second “OrthoNow” office opened in Virginia Beach.

Bon Secours DePaul Cancer Institute – Kathy L. Brooks, RTT, radiation dosimetrist and manager for the Radiation Therapy Department within the Bon Secours DePaul Cancer Institute, has been named the winner of the 2015 All Hope Cancer Award. The award was presented at the Bon Secours Cancer Summit.

Bon Secours DePaul Medical Center’s team of urologists and fellows, lead by Dr. Michael Fabrizio, Dr. Shaun Wason and fellows Dr. Ashley Brandon and Dr. Arjun Poddar, have been awarded first place by the Endourological Society & the Journal of Endourology in their annual essay contest. The team’s paper entitled, “Novel use of an image enhance-

ment device to reduce fluoroscopic radiation exposure during ureteroscopic lithotripsy: randomized prospective clinical evaluation of Lessray®,” was presented at the 33rd World Congress Meeting in London, United Kingdom.

Bon Secours DePaul Medical Center in Norfolk was recently recognized with an “A” Hospital Safety Score by The Leapfrog Group. The Leapfrog Group is an independent national nonprofit run by employers and other large purchasers of health benefits. The A score was awarded in the latest update to the Hospital Safety ScoreSM, the A, B, C, D or F scores assigned to US hospitals based on preventable medical errors, injuries accidents, and infections. The Hospital Safety Score was compiled under the guidance of the nation’s leading experts on patient safety.

Bon Secours DePaul Medical Center has opened three Tranquility Rooms designed to help employees manage stress, as part of the hospital’s goal to provide innovative methods for enhancing its employees’ quality of life while at work. Tranquility Rooms provide a peaceful retreat so employees can manage their stress and return to work re-energized. In addition, Bon Secours DePaul Medical Center is pursuing accreditation by the American Nurses Credentialing Center as a Pathway to Excellence hospital. This accreditation recognizes hospitals that create a supportive environment in which nurses can develop professionally and maintain a positive, balanced lifestyle.

Urology of Virginia has a New Location!

Urology of Virginia is pleased to announce Lawrence Volz, MD will return to practice in Williamsburg. Dr. Volz earned his undergraduate degree in Chemistry from The Johns Hopkins University and his medical degree from the University of Pennsylvania. He completed his Urologic residency at the Hospital of the University of Pennsylvania after 2 years of General Surgery training at the same institution. Dr. Volz is board certified in Urology and is a Fellow of the American College of Surgeons. He has a special interest in erectile dysfunction, stone disease, prostate cancer and benign prostate disease.

Dr. Volz is seeing patients in our new location:

Geddy Outpatient Center 400 Sentara Circle Suite 310 Williamsburg, VA 23188 Appointments may be made by calling 757.345.5554 38 | www.hrphysician.com

www.urologyofva.net

Bon Secours Mary Immaculate Hospital announced that Helene Drees, RN, MSN, CNML, was recently accepted into the Society of Gastroenterology Nurses and Associates (SGNA) Scholars Program. Drees is the Endoscopy Nurse Manager at Bon Secours Mary Immaculate Hospital, and is one of just nine nurses nationwide who have been selected for the 2016 session of the program. The purpose of the SGNA Scholars program is to educate and train appropriately prepared GI/endoscopy nurses in order to build a repository of evidence applicable to the GI/endoscopy setting. Scholars will receive in-person systematic review training utilizing the TCU Center for Evidence-Based Practice and Research: A Collaborating Center of the Joanna Briggs Institute.

Drees will travel to Fort Worth, Texas, in June 2016, for SGNA Scholars training.

Bon Secours Maryview Medical Center announced that Helena Walo-Bates, MSN, RN has joined as the facility’s Administrative Director for Nursing Services. Prior to joining Bon Secours, she served in several clinical nursing and progressive management roles at Medical University Hospital of South Carolina.

She brings 24 years of progressive acute care nursing experience across all areas of practice.

Bon Secours Maryview Medical Center announced that Cheryl Hewlett, PhD, MBA, MSN, RN, NEA-BC has joined as the facility’s new Director for Professional Practice, Quality Wound Care and Infection Prevention.

Dr. Hewlett possesses a Doctorate in Nursing Health Policy, along with a Master’s in Business Administration and Nursing.

Bon Secours Maryview Medical Center is the first hospital in Hampton Roads and one of very few hospitals in the United States to use the Diamondback

360 Coronary Orbital Atherectomy System (OAS). This technology is the first evidence-based treatment approved by the US Food and Drug Administration for severely blocked coronary lesions. Interventional cardiologist Jayaraman Venkatesan, MD, FACC, with Cardiology Associates, a Bon Secours Medical Group specialty practice, successfully completed the region’s first procedure last month.

Bon Secours Virginia was recently named as one of the 2016 Best Places to Work in Virginia. The annual list is created by Virginia Business and Best Companies Group. This statewide survey and awards program is designed to identify, recognize and honor the best places of employment in Virginia,

Bayview T/C

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Winter 2016 Hampton Roads Physician | 39

in the news benefiting the state’s economy, workforce and businesses. The 2016 Best Places to Work in Virginia list is made up of 100 companies.

Bon Secours Virginia Health System - As part of Bon Secours’ mission to improve community health through prevention and education, more than 120 employees volunteered their time to give out 1,700 free drive-up flu shots to the Hampton Roads community. Bon Secours was the first local

health system to offer drive-up flu shots beginning in 2008 and continued the tradition of removing barriers to preventive care by being the first local health system to offer free shots in 2012.

Bon Secours Virginia Medical Group has opened its first Bon Secours FastCare location in the Farm Fresh Supermarkets in Chesapeake, and a second location, Bon Secours FastCare, in Virginia Beach. Bon Secours FastCare provides convenient, affordable patient care for those in need of non-emergency medical services including vaccinations, screenings and minor illness visits on a walk-in basis.

• Custom compounding for individualized care • Medications for: skin care, hospice needs, pain management, hormone replacement therapy & more...

Candice Carroll, MBA, BSN, RN has joined Riverside Regional Medical Center as Nurse Executive. She holds an RN/ADN from the Jefferson College of Health Sciences and a BSN in Nursing and MBA from Grand Canyon University. She has a broad background in Nursing and Nursing Leadership, having held positions in several specialty areas including VP, CNO, COO, Clinical Success Team, Forensic Nurse Examiner and Critical Care Administrator.

• Superior facilities and staffing • Special dosage forms such as ointments, creams, gels, injections, suspensions, etc.

We Moved!

4001 Virginia Beach Blvd., Suite 110 Virginia Beach, VA 23452 (757)934-0533 Toll Free: (877) 873-9564 Fax: (757) 228-3991 Other locations include: Jamestown, NY • Erie, PA Houston, TX • Greenville, SC

Chesapeake Regional Healthcare (CRH) and Atlantic Shores Retirement Community in Virginia Beach have joined forces to integrate CRH’s award-winning healthcare services at Atlantic Shores’ Seaside skilled nursing facility, and The Wellness Clinic at Atlantic Shores. Through this partnership, Atlantic Shores’ healthcare staff will be able to utilize CRH’s electronic medical records, technologies and additional resources. Directorlevel specialists from Chesapeake Regional Healthcare will also provide on-site guidance for quality, infection control and discharge planning. CRH will work directly with Atlantic Shores Medical Directors Dr. Daniel McCready and Dr. Paul Johnstone in managing all provided services.

Chesapeake Regional Healthcare has been named a Screening Center of Excellence by the Lung Cancer Alliance. With this designation, the organization, which has a comprehensive Thoracic and

40 | www.hrphysician.com

Lung Health Program, has been added to the Alliance’s national network of programs that commit to following particular standards for screenings and follow-up care. “We designed our Thoracic and Lung Health Program and early detection lung cancer screening process to provide innovative and excellent patient care,” said, Peter F. Bastone, Dr.PH, president and CEO of Chesapeake Regional Healthcare, “so it is truly exciting to be recognized nationally for those achievements.”

Chesapeake Regional Healthcare, in conjunction with its Thoracic and Lung Health Program’s multidisciplinary team and advanced technology, is now offering affordable lung cancer screening that could be vital in the early detection of the number one cancer killer of both men and women.

Chesapeake Regional Healthcare (CRH) is the 32nd organization in the United States, and the only healthcare organization in the state of Virginia, to receive the International Association for Healthcare Security and

Safety (IAHSS) Program of Distinction recognition for security department accreditation. The IAHSS Program of Distinction acknowledgement recognizes security programs where 70 percent of the officers, managers and directors are IAHSS certified. CRH’s security department was recognized with 100 percent of its 20 officers certified through IAHSS: Patrick Lewis, manager of safety, security and telecommunications, and immediate past president of the IAHSS Virginia Chapter, completed his Certified Healthcare Protection Administrator (CHPA) certification; and Darryl Lazar, lead security officer, received his Certified Healthcare Security Supervisor certification. CRH’s security department is composed of former law enforcement officers with a wide range of specialized training and experience including criminal drug investigators, helicopter pilots, federal corrections safety officers, hostage negotiators and more.

David Levi, MD, of APM Spine & Sports Physicians, along with fellow APM researchers Scott Horn, DO and Sara Tyszko, PA, recently performed a study of a new treatment for discogenic lower back pain. The team’s preliminary results were enthusiastically received at the annual meeting of the Spine Intervention Society. Their study has also been accepted for publication into the prestigious Pain Medicine Journal and is the first of its kind to be published. Their groundbreaking treatment modality may offer renewed hope to patients who have tried other options.

Trusted names in the latest sight saving technology and treatments.

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Kapil Kapoor, MD

Alan Wagner, MD, FACS

Diabetic Eye Disease • Macular Degeneration • Retinal Vascular Disease Ocular Oncology • Uveitis • Basic Science & Clinical Research

[757] 481.4400 • WagnerRetina.com Norfolk • Virginia Beach • Chesapeake • Suffolk • Hampton • Kilmarnock • Portsmouth • Elizabeth City • Eastern Shore Winter 2016 Hampton Roads Physician | 41

in the news Jennifer Pagador, MD, medical director of Seriously Weight Loss, LLC has joined REVITA Medical Wellness, a medical group specializing in Bio-identical Hormone Replacement Therapy.

HROSM Physical Therapy Center would like to welcome Chad Carlson, DPT: Newport News

Tidewater Physical Therapy would like to welcome Jennifer Pagador, MD

Orthopaedic & Spine Center, has announced that Erin Lee, PA-C, is competing for The Leukemia & Lymphoma Society’s (LLS) “ Woman of the Year” title.

Her candidacy was based on her fundraising efforts on behalf of LLS blood cancer research. Erin will be competing as a Virginia nominee with others from across the county. Every dollar counts as one vote and the titles are awarded to those with the most votes at the end of ten weeks. The top local fundraisers in the country win the national titles.

Dana Baratz, PTA: GREAT BRIDGE

Brandi Working PT, DPT: BATTLEFIELD

Janeil Stehr, PT, DPT, Katherine Graber, PTA: Rebecca English PT, CSCS: KEMPSVILLE DPT, MSR: DENBIGH NORGE

Melinda Marchlewski, Staci Fredrick, PTA: PTA: WILLIAMSBURG REDMILL

James-Michael Tayo, PTA: KEMPSVILLE

If you have News you would like to share with our readers in the Spring edition, please contact the publisher at 757-237-1106 or email: holly@hrphysician.com Deadline for submissions is March 29th.

Taking Nominations for the

Spring 2016 edition

We are looking for physician leaders who specialize in

Behavioral Health

BEHAVIORAL HEALTH Deadline for Nomination Submissions

March 1st

Nomination forms are available on www.hrphysician.com (click nominate tab) or by emailing a request to holly@hrphysician.com 42 | www.hrphysician.com

The Benefits of Microprocessor Knee Technology By: John Robb, CPO Reach Orthotic & Prosthetic Services

I

n recent years, there has been a lot of media publicity around computer controlled prosthetic devices. These devices are quite controversial, both in the health insurance industry and health care community alike. Paired with this improved technology is an increased price tag. Rising healthcare costs across the healthcare continuum fuel discussions as to whether or not these devices improve function consistent with that higher price tag. As a result, microprocessor controlled knees for transfemoral amputees are carefully examined, since they utilize this costly technology.

While it is a reality that microprocessor controlled knees are expensive, they can significantly the improve quality of life for the amputee.

A prosthesis incorporating this technology can cost between $40,000-$120,000, depending on the type of knee and components chosen to complement the knee. There are a variety of these devices on the market, and while most are quality products, each has nuances that make it unique and specific to the patient.

they may be of the most benefit to the amputee whose goals are simply to be efficient while using a cane.

There are questions that remain in all of healthcare. Who are the improving technologies appropriate for, and who’s going to pay for those technologies? In the meantime, prosthetic technology is making great strides in restoring mobility to our patients.

John Robb, CPO is certified by the American Board for Certification in Orthotics & Prosthetics. He has been practicing in orthotics & prosthetics since 1990. He regularly speaks for medical professionals. He currently serves on the board for the Virginia Orthotic & Prosthetic Association and is a member of the medical operations committee for Physicians for Peace. reachops.com

What does this technology do?

The integrated computer helps the prosthesis react to the many different conditions the amputee is exposed to when walking throughout the day. For example, the able-bodied person takes for granted the ability to deal with changing conditions while walking. However, for the amputee, things like carpet, steps, slopes (even subtle), grass, gravel, and crowds can present significant challenges. Conventional prosthetic devices are unable to change and react to these changing environments, creating a problem, since the efficiency with which the knee swings through, and weight bearing, are critically important. The computer, by analyzing data in the knee in real time, predicts what is going to happen on the next step and adjusts the knee resistances accordingly. For the amputee, this superior functionality increases trust in the prosthesis to perform reliably in various conditions.

This technology will not help the amputee who is severely physically debilitated or only uses the limb to ambulate in the home on consistent and level surfaces. These devices are generally not designed for high-impact sporting activities, such as running or water sports. However, this device can make a substantial difference in the life of an amputee who regularly walks in the community or has to deal surface changes regularly.

Regardless of whether the amputee uses a walker, cane, or other assistive device, it can be the difference in making the transition to an increased level of independence. The literature backs up the benefits of these devices.

What’s the issue?

Because of the cost and moniker of “advanced technology,” most insurances, including Medicare, only make these devices available to the most functional and active amputees. This is unfortunate, because

Photo courtesy of Ottobock

Who is it right for?

Winter 2016 Hampton Roads Physician | 43

WELCOME TO THE COMMUNITY Nicole Donaldson, MD has joined Fort Norfolk Plaza Medical Associates. Dr. Donaldson received her medical training at the Wayne State University School of Medicine. She earned a BS in Biology at Virginia Tech and her Masters in Anatomy at Case Western Reserve University.

She is Board certified by the American Board of Family Medicine.

Sherie Horvath, MD and Brian Tyler, MD have joined CHKD’s Courthouse Pediatrics in Gloucester. They join the practice’s veteran physician, Anne Howard, MD, in providing comprehensive primary care to children. Dr. Horvath earned her medical degree from University of Alabama and completed her pediatrics residency at University of Virginia Children’s Hospital. Dr. Tyler holds a medical degree from Medical University of South Carolina and served his residency in pediatrics at East Carolina University. Both physicians are Board certified by the American Board of Pediatrics.

Laura Kerbin, MD has joined Riverside Shore Cancer Center on the Eastern Shore. She is co-founder of Riverside Shore Cancer Center’s Breast Health Center and founder of the High Risk Oncology Clinic. She is also Medical Director of Hospice of the Eastern Shore. Dr. Kerbin earned her medical degree from EVMS and completed a Hematology and Oncology Fellowship at VCU. Christina Rice, DO has joined Lakeview Medical Center in Suffolk. Dr. Rice received her medical degree from the Edward Via College of Osteopathic Medicine and completed her Obstetrics and Gynecology internship and residency at Riverside Regional Medical Center, where she served as Chief Resident. Dr. Rice offers comprehensive obstetric and gynecologic care to women of all ages.

Lawrence Volz, MD has returned to Williamsburg. He is seeing patients in the new Urology of Virginia Williamsburg location. He earned his undergraduate degree in chemistry from The Johns Hopkins University and his medical degree from the University of Pennsylvania in

Keeping your finances healthy

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757.640.7190 | 150 Boush St. Suite 1100 | Norfolk, VA 23510 | mrdcpa.com 44 | www.hrphysician.com

Philadelphia, graduating “Top of the Class” in 1989. He completed his urologic residency at the Hospital of the University of Pennsylvania after two years of general surgery training at that same institution.

Frank C. Westmeyer, MD has joined Tidewater Physicians Multispecialty Group (TPMG). He earned his medical degree from St. Louis University School of Medicine, and completed his residency in internal medicine and emergency medicine at Cleveland Clinic Foundation.

Shannon Andy, PAC has joined Hampton Roads Orthopaedics & Sports Medicine. She previously attended Averett University where she earned her Bachelor of Science in Athletic Training. After graduating she became a certified Athletic Trainer, she currently maintains her NATA certification. She received her Master of Science in Physician Assistance at EVMS. Shannon is licensed by the State of Virginia and is a member of the American Academy of Physician Assistants and the Virginia Academy of Physician Assistants.

Sean Hindman, PA-C has joined Hampton Roads Orthopaedics and Sports Medicine.

Sean is a graduate of James Madison University where he earned a Bachelor of Science double majoring in Psychology and Anthropology.

He received his Master of Science degree in Physician Assistant Studies from Eastern Virginia Medical School. He is a member of the American Academy of Physician Assistants and Physician Assistants in Orthopedic Surgery.

Lo Lumsden, ANP, GNP, EdD has joined Tidewater Physicians Multispecialty Group (TPMG) She has over 30 years experience and holds Board certifications in Adult

Nurse Practitioner, Gerontological Nurse Practitioner, Diplomate of the American Board of Forensic Nursing, American College of Forensic Examiners and Homeland Security Certified.

We would like to welcome your new physicians, NP’s and PA’s Please contact us at 757-237-1106 or email: holly@hrphysician.com Deadline for submissions for the Spring edition is March 29.

RadiosuRgeRy in easteRn ViRginia

Located on the campus of Riverside Regional Medical Center, advanced Gamma Knife technology treats brain tumors, malformations and neurologic dysfunctions; Synergy S treats benign and malignant tumors of the body.

Benefits: • Non-invasive treatment in an outpatient setting • Preserves healthy tissue surrounding the target area • Exceptional clinical outcomes with minimal side effects appointments and referrals: 757-534-5220 or email us at gammaknife@rivhs.com

The only radiosurgery center in Eastern Virginia since 2006 riversideonline.com/gamma Winter 2016 Hampton Roads Physician | 45

Awards

Accolades

Celebrating the Accomplishments of Those Who have Received Major Honors Bon Secours Hampton Roads Health System is pleased to announce the recipients of the 2015 Dedicated Service Award.

Winners are chosen by a team of managers who base their decisions on how well nominees meet the selection criteria, which include support of the mission of Bon Secours, personal development, and accomplishments in activities reaching beyond the recipient’s basic job description. The Winners are: Jason Hann, RN, Bon Secours DePaul Medical Center; Travis Jacques, MPT, Bon Secours InMotion Physical Therapy; Lucy Kooiman, RN, BSN, MSA, Bon Secours Maryview Medical Center; and Deborah Malliarakis, RN, BSN, MS, CIC Bon Secours Mary Immaculate Hospital.

Jason Hann

Lucy Kooiman

46 | www.hrphysician.com

Travis Jacques

Deborah Malliarakis

Jeffrey R. Carlson, MD, of Orthopaedic & Spine Center, was once again named by Becker’s Spine Review as a Spine Surgeon to Know for 2016. In this national recognition, the achievements of nine Virginia spine physicians were acknowledged, with Dr. Carlson being one of two spine specialists recognized outside of Northern Virginia. Among his many Jefferey R. Carlson, MD achievements, Dr. Carlson is known for his role in pioneering many outpatient spine procedures using Less Exposure Surgery (LES) techniques and instrumentation.

Dr. Allen R. Jones, Jr. owner of Dominion Physical Therapy & Associates, and Dominion Pediatric Therapy has been elected Vice President of the Virginia Board of Physical Therapy. Dr. Jones also received the Distinguished Public Service Award from the Virginia State University Alumni Association, Peninsula Chapter.

David Darrow, MD, Professor of Pediatric Otolaryngology and Director of the Center for Hemangiomas and Vascular Birthmarks at Eastern Virginia Medical School and the Children’s Hospital of the King’s Daughter’s, was recently elected President of SENTAC (Society of Ear, Nose and Throat Advances in Children). SENTAC is a multi-specialty organization composed of Otolaryngologists, Pediatricians, Audiologists, Speech Pathologists, Pediatric Nurse Practitioners, and Physician Assistants who care for children with communication disorders and complex otolaryngology medical issues.

SAY “ YES”

TO LIFE WITHOUT LIMITS C ALL US TODAY TO SCHEDULE AN APPOINTMENT

757-547-5145

Chesapeake | Suffolk | Belle Harbour

smoc-pt.com

“

LUIS VEL AZQUEZ :

Foot and Ankle Reconstruction

The goal was to adjust my ankle to a level that was mostly straight, and try to get my arch back. They fixed the alignment of my ankles, as well as my toes. Now, I actually have an arch in my feet again! And my toes are aligned with my ankles. Now, I have no pain when I walk, at all.

Before these surgeries, it was so bad that I would wake up in the morning and just stand, trying to get over the pain and tolerate it enough to move. Now, I can just get up and go. And I can do more with my daughter Lourdes—I can play ball with her, ride bikes with her. I could never have done that before.

After living my whole life in pain, SMOC has helped me “Say YES” to life for the first time!

I finally have the freedom to do what I want to do. I can walk again. It’s been a major success.

&

”

Dr. Uosife Alfahd Orthopaedic Surgeon Dr. Uosife Alfahd is an orthopaedic surgeon with specialties in orthopaedic trauma and limb reconstruction. He performs many advanced surgeries including primary and revisional joint surgery, trauma surgery, partial knee replacement, knee arthroscopy and shoulder arthroplasty.

MEET YOUR NEW NEIGHBOR 757-673-5680 930 W. 21st St., Ste.100, Norfolk, VA 23515 virginiaorthopaedicspecialists.com

BON SECOURS ORTHOPAEDIC INSTITUTE

YOUR HOME FOR GOOD HEALTH