Cedar Valley Medical Specialists by Waterloo-Cedar Falls Courier

Comprehensive Medical & Surgical

SPECIALTY GUIDE

WORLD-CLASS CARE

Right Here At Home

Page 7

OVER 20 INDEPENDENTLY OWNED SPECIALTY CLINICS Page 3

OVER 85 SPECIALIZED PHYSICIANS and Advanced Practice and MidLevel Practitioners Page 6

CedarValleyMedical.com

Fall 2016

10REASONS you should choose

1 2 3 4 5 6 7 8 9

World-Class Care — Our specialists come from the most

prestigious names in medicine, including Harvard, The Mayo Clinic, Cleveland Clinic, Johns Hopkins, the University of Iowa and more.

Close To Home — Specialized care available at major health facilities outside our area is offered right here in the Cedar Valley. Over 20 Specialties — Over 400 dedicated staff, including over 50

specialized physicians and over 35 advanced practice and mid-level practitioners.

Dedicated Specialists — Physicians and providers are true specialists in their areas of expertise.

Patient-Focused — A professionally managed organization with

over 21 years of experience allows us to focus our full attention on the needs of the patients.

Savings On Health-Care Costs — Cedar Valley Medical

Specialists (CVMS) doesn’t have the same costly overhead that many hospitals and other organizations have, allowing CVMS to be the lowest-cost provider for the patient and their insurance provider for medical and other ancillary services.

No Referrals Needed — CVMS does not require referrals to see our specialists (some insurance providers may require a referral).

Independently Operated — Specialists operate independent of

area hospitals, but many have privileges to provide services at area hospitals, including ER consults, surgery and more.

Convenient Locations — Specialists are located at their

Specialized, Comprehensive Care In:

 Allergy and Immunology  Anesthesiology  Audiology  Bone Health  Breast Care

 Cardiology/Cardiothoracic Surgery  Facial Plastic/Reconstructive Surgery & Med Spa Services  Gastroenterology  General Surgery  Imaging Center  Nephrology  Neurology  Ophthalmology  Orthopedics  Otolaryngology/ENT and Sinus  Pain Management  Physical Therapy/Occupational Rehabilitation  Pulmonology  Radiology  Rheumatology  Sleep Center  Skin Cancer  XL Sports

individual clinics throughout Waterloo and the Cedar Valley — each with easy access and close parking. CVMS also has clinics in surrounding communities, and many specialists serve smaller hospitals in the greater Cedar Valley region.

Choose a Cedar Valley Medical Specialist Today

CedarValleyMedical.com

4150 Kimball Ave. Waterloo, IA 50701

World-Class Care, Close to Home.

Introduction 4

Advanced Diagnostic Imaging

Allergy and Immunology

Anesthesiology 12

History 5 Putting Patients First Q & A

6 7

Cedar Valley Cardiovascular Center

Cedar Valley Centers for ENT and Sinus, Facial Plastic Surgery, Hearing, Skin Cancer and Rejuvenation

Cedar Valley Gastroenterology

General Surgery

Nephrology 26 Neurology 30 Cedar Valley Eye Care

Cedar Valley Orthopedics

OrthoExpress 36 Cedar Valley Bone Health Institute

Cedar Valley Ear, Nose & Throat and Hearing Care 40 Pain Management

Cedar Valley Physical Therapy and Occupational Rehab

Pulmonology 46 Radiology 48

www.CedarValleyMedical.com

Mission Statement

Cedar Valley Breast Care Center

Rheumatology 50 Cedar Valley Sleep Center

XL Sports Acceleration Program

COURIER COMMUNICATIONS Project Manager Tara Seible

Editor Melody Parker

IMPACT MARKETING Writer Nancy Justis

Graphic Designer Amanda Hansen

Photos Brandon Pollock Matthew Putney Tiffany Rushing

Project Development James White

Editing/Project Management Kevin Hansen Joe Ehrich

Cover Design Austin Grote Andy Mullinex

Cedar Valley Medical Specialists, P.C.

Welcome

The future of healthcare in the Cedar Valley has never looked brighter. Cedar Valley Medical Specialists (CVMS) continues to invest in the best people, the best practices and the best medical technology available to ensure world-class health care is available locally for everyone.

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Thomas S. Gorsche, MD

Cedar Valley Medical Specialists’ organization has grown significantly to include a staff of more than 400 specialized physicians, advanced practice and mid-level practitioners and support staff. This growth reflects our commitment to bringing in the “best of the best” to meet the ever-changing medical needs of Northeast Iowa. Our physicians and medical staff are trained at some of the most respected institutions in healthcare, including The Mayo Clinic, the University of Iowa, Harvard, Johns Hopkins, Cleveland Clinic and many of the other top programs in the country. Unlike other specialists who only visit the area periodically, our physicians and staff choose to work AND live right here in the Cedar Valley — making CVMS the premier local provider of medical specialists. CVMS is the only major independently owned network of medical service providers in the area. We’re not owned by area hospitals, or any other health system. Because we’re independently owned and managed, CVMS is able to offer some of the most affordable services available — saving patients up to 50 percent or more in some cases — compared to other local options, which helps reduce the rising cost of healthcare. We hope you enjoy learning more about all the reasons why Cedar Valley Medical Specialists is the best choice for patients in the Cedar Valley today. If you have additional questions, feel free to visit our website at www.CedarValleyMedical.com, or contact us at (319) 235-5390. Sincerely,

Thomas S. Gorsche, MD President, Cedar Valley Medical Specialists, P.C.

Cedar Valley Medical Specialists

Mission Statement: To provide the highest-quality, most cost-efficient patient care in Northern Iowa through a community of specialty providers. Vision Statement: • To provide a mechanism for utilization review, continuous quality improvement, outcomes research, and practice guidelines to ensure the delivery of the highest-quality patient care. • To create an atmosphere of enhanced cooperation among the specialties in the area, including primary care.

• • • • •

To create practice opportunities for other fields and specialties in the area, and provide for greater subspecialization within existing specialties. To provide for a means of increasing patient education and public awareness of issues pertaining to health care, especially as it affects Northern Iowa. To promote cooperation, communication and coordinated care across all specialties. To earn the right to “remain” into the future — become indispensable to patients and their third-party payers (i.e., cost, quality, access). To serve patients better by remaining physician-owned and -governed and professionally managed.

World-Class Care, Close to Home.

Mission / Vision Statements

History

Cedar Valley Medical Specialists (CVMS) was established in 1995. Our goal was to create an independent group of medical specialists and resources for the Cedar Valley and surrounding areas. By taking on most of the administrative and practice management functions for physicians and specialists, we’ve freed up these professionals to concentrate all their efforts where they should be — on the patient. Over the past two decades, we’ve brought together the most qualified, most caring and most community-minded professionals and specialists. At the same time, we’ve led the way in helping these professionals embrace the latest innovative medical advancements in technology, techniques, treatments and breakthroughs. CVMS SPECIALTIES: • Allergy and Immunology • Anesthesiology • Audiology • Bone Health • Breast Care • Cardiology/Cardiothoracic Surgery • Facial Plastic/Reconstructive Surgery & Med Spa Services • Gastroenterology

We have great relationships with all the hospitals in and around the Cedar Valley; however, we are not owned by any hospital or any other organization. Cedar Valley Medical Specialists is a 100 percent independent, locally owned organization with a staff of more than 400, including specialized physicians, advanced practice and mid-level practitioners and support staff representing dozens of health-care specialties. Headquartered in Waterloo, all of our physicians, health-care centers, clinics, labs and diagnostic centers are located in and around the Cedar Valley to better serve our entire extended community.

• General Surgery • Imaging Center • Nephrology • Neurology • Ophthalmology • Orthopedics • Otolaryngology/ENT and Sinus • Pain Management

• Physical Therapy/Occupational Rehabilitation • Pulmonology • Radiology • Rheumatology • Sleep Center • Skin Cancer • XL Sports

Today, Cedar Valley Medical Specialists represents the finest medical staff, most comprehensive health-care specialty centers and the latest in advanced technology and procedures for patients. We help medical professionals put the patient first, which is a win-win for everyone.

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of Cedar Valley Medical Specialists

Cedar Valley Medical Specialists, P.C. www.CedarValleyMedical.com

We put patients first.

utting the patient first is what Cedar Valley Medical Specialists (CVMS) is all about. “What we do with all our decisions is to make our mission ‘patient first,’ ‘corporation second’ and 'the individual providers third,’ ” says Gil Irey, CEO of Cedar Valley Medical Specialists. “Patients appreciate the convenience that we offer them.” Operating since Jan. 1, 1995, CVMS is 100 percent locally owned and 100 percent locally governed. All board members are physician shareholders. There is no outside influence. CVMS had six specialties and 80 employees when it first began service. Now it has over 20 specialties, over 50 specialized physicians, over 35 advanced practice and mid-level practitioners and over 400 total employees. “Our role is to make the physicians’ lives as easy as possible with the non-medical aspects of operating their practices,” Irey says. “Practicing medicine today is burdened with tremendous efforts to comply with government regulations and federal, state and local insurances. We try to figure out everyday how we can make the providers' lives easier and keep them practicing medicine.” CVMS considers Black Hawk County and the seven surrounding counties its primary coverage area. It houses clinics at hospitals in Grundy Center, Waverly, Sumner, West Union, Oelwein and Independence. Some services are divided with other communities where a county may not have a hospital. There are aggressive outreach clinics in each of those communities, each with specific specialty practices offered. “There may not be a demand for certain specialties in some local communities,” Irey explains.

There are different operating models, but CVMS is unique across Iowa, particularly in how each specialty makes the decision concerning how to operate, staff, and where to locate its offices. “We have a strong central board that manages the overall business affairs of the organization, but each department operates in its own clinic within CVMS’ structure,” Irey says. “They are departments of the corporation, but they operate in the best interest of their patients and the primary care physicians they serve. There is not a central authority from the corporation on where a physician must locate.” Thus, all of CVMS’ departments are not located under one roof. Because CVMS currently does not include primary care, “people are coming to us for very specific reasons,” Irey explains. “If someone wants to go to breast care, they can be in a waiting room for just breast care issues. We really want to respect the privacy of the people who have more severe problems than general medical conditions. “The other thing we want is easy patient access. Our patients can park close to an entrance, not in a parking ramp. They don’t have to find a parking spot, or go up elevators or flights of stairs. We want to be in the community where people can find us,” Irey says. Though many of the offices are located at United Medical Park on West Ridgeway Avenue in Waterloo, other offices are off of that site. Cedar Valley Eye Care, Cedar Valley Cardiovascular Center and Advanced Diagnostic Imaging all are located in different parts of the community, for example. “Most of our clinics have drive-up canopies, which makes access easier in case of inclement weather,” Irey says. “Having different locations makes business more expensive for us because we don’t have one phone number, and we don’t have one reception desk. But it’s part of our philosophy to put the patient first.” CVMS attracts well-trained, world-class physicians to the community. Many have been trained at The Mayo Clinic, the University of Iowa, The Johns Hopkins Hospital, or Cleveland Clinic and many of the other top training programs in the country. “We’re bringing the latest and the greatest from these teaching programs to the community. That’s a huge benefit for our patients,” Irey says.

An additional benefit for patients being treated under CVMS’ umbrella is the cost savings. “Our cost structure within our clinic is significantly lower than that of hospital-based physicians,” Irey says. “On average it’s less expensive to see a nonhospital-based physician. Hospitals get paid more money than private physicians because of their past Medicare and insurance trends and cost structure for comparable services.” CVMS also is performing more and more procedures in-office because of technological advances. “Ten years ago a physician never would have done outpatient procedures in any place other than an outpatient location or a hospital. We can routinely do outpatient procedures in the physician’s office. This also is a cost savings — a valuable alternative,” Irey says. With other technological advances, CVMS’ outreach doctors can now travel to their out-of-town clinics, perhaps perform a surgery in that hospital rather than necessitating that the patient travel to the Cedar Valley, and then follow up from their home office with the aid of telemedicine. “We may have an orthopedic surgeon do a total joint replacement in Grundy Center,” Irey says. “That might mean a two-to-threeday stay in the hospital. Working with a local nurse or practitioner and primary care physician, the surgeon can follow up with the patient via telemedicine rather than physically having to drive back to the outof-town site. “It’s a video and voice hookup, much like Skype but higher quality, which can be rolled into the patient’s room. The camera will zoom in on the surgical site, the doctor will talk with the patient, the vitals will be shared, all things done as if the physician were there in person,” he says. CVMS has affiliations with other health systems that bring more advanced procedures and care to the Cedar Valley.

Is Cedar Valley Medical Specialists a part of area hospitals?

A: No, the physicians, advanced practice providers and employees of Cedar Valley Medical Specialists (CVMS) are independent of the hospitals. However, many of our providers do have privileges to provide services at area hospitals such as ER consults, in- and outpatient surgeries and interpretations of radiology studies, as well as other tests and treatments.

Why should patients consider using CVMS?

A: CVMS’ physicians and advanced practice providers are true specialists in their areas of expertise. If you’re having a sinus problem, many people prefer to see an ear, nose and throat (ENT) specialist first instead of a general practitioner — who often ultimately refers patients to see an ENT. Seeing a specialist at CVMS first often avoids two separate doctor visits, which saves the patient time and money, and helps reduce overall insurance costs.

What makes CVMS different from other providers?

A: Our specialists truly are specialists — offering advanced, specialized health-care services typically found at major medical centers. In fact, with CVMS, advanced health-care treatment doesn’t have to mean a long road trip to specialty clinics in Rochester or Iowa City. We’ve brought world-class experts right here to our area from the most prestigious names in the medical field.

Do patients need a referral to see one of CVMS’ specialists?

A: No referrals are needed for most patients. Appointments can be made directly with any specialist at CVMS. If you think your insurance might require a referral, check with CVMS and the staff will be happy to look into your individual situation.

What are the benefits of choosing CVMS vs. a major specialty clinic outside of our market?

A: CVMS has brought in the highly qualified medical experts that patients need. It’s very reassuring to know that whatever patients are facing, it can usually be addressed right here in the Cedar Valley. Handling all of your medical needs close to home has so many advantages. The convenience factor is huge, and it can also significantly reduce the amount of time, and, more importantly, the amount of stress that can arise when dealing with medical situations.

What medical services does CVMS offer?

A: CVMS continues to expand and bring on new specialists in the areas of: • Allergy and Immunology • Anesthesiology • Audiology • Bone Health • Breast Care • Cardiology/Cardiothoracic Surgery • Facial Plastic/Reconstructive Surgery & Med Spa Services • Gastroenterology • General Surgery • Imaging Center • Nephrology • Neurology • Ophthalmology • Orthopedics • Otolaryngology/ENT and Sinus • Pain Management • Physical Therapy/Occupational Rehabilitation • Pulmonology • Radiology • Rheumatology • Sleep Center • Skin Cancer • XL Sports

How can CVMS offer services with up to 50 percent savings in some cases — or more — to patients?

A: CVMS is a truly unique provider of medical services. We are not owned by any hospitals or health systems. We are the Cedar Valley’s premier independent source for patients. We don’t have the same costly overhead expenses that many hospitals have, meaning our costs are much lower. We pass those savings onto patients — which in some cases can be up to 50 percent or more.

How does CVMS offer such a high-quality health care experience for patients?

A: Our clinics are staffed by dedicated professionals ― specialists who are trained at the finest names in medicine, including Harvard, Johns Hopkins, The Mayo Clinic and the University of Iowa. They’re not distracted with administrative burdens or mandated requirements that other providers may experience. CVMS’ home office in Waterloo takes care of the business side of business, so our doctors and providers can do what they do best ― take care of patients.

Where is Cedar Valley Medical Specialists located?

A: Our corporate offices are located in Tower Park in Waterloo, and our specialists are located at their individual clinics throughout Waterloo and the Cedar Valley. Many of our doctors have additional clinic locations in surrounding communities, and maintain hours or serve smaller hospitals in the greater Cedar Valley region.

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Q&A

World-Class Care, Close to Home.

Cedar Valley Medical Specialists

Cedar Valley Medical Specialists, P.C. www.CedarValleyMedical.com

Del Donaldson

ADVANCED DIAGNOSTIC IMAGING A

dvanced Diagnostic Imaging (ADI) has been serving the Cedar Valley since 2005 and is the area’s leader in imaging services. ADI has convenient locations in both Waterloo at 4006 Johnathan St. and in Cedar Falls in the Cedar Valley Orthopedics office in the Jacobson Human Performance Complex on the University of Northern Iowa campus next to the UNI-Dome. ADI provides a comprehensive selection of imaging services, including

PET/CT scans, MRIs, CT scans, ultrasound and nuclear medicine, as well as X-rays. So what are the advantages of scheduling your imaging exams at ADI? “The advantage we have is that we bill as an office place of service, which means it’s less expensive for your insurance and you,” says Operations Manager Del Donaldson. “Also, there’s a convenience factor. The parking lot is a lot closer to the door. If you have to go somewhere else, you walk a lot further outside, and also

inside. We are more convenient and userfriendly, and we accept most insurance.” In addition to favorable logistics, ADI’s machines are accredited by the American College of Radiology. With multiple MRI machines, patients can get in to get their scans done quickly. With an on-site radiologist reading films, your doctor will get the results generally within 24 hours. ADI recently purchased a new, stateof-the-art 3 Tesla MRI scanner and is currently upgrading one of its other MRI

World-Class Care, Close to Home.

MEET OUR TEAM ADVANCED DIAGNOSTIC IMAGING 4006 Johnathan St. Waterloo, 319-236-2700 Cedar Valley Medical Specialists, P.C. at UNI 2351 Hudson Road, Ste. 001 Cedar Falls, 319-273-5275 Driss Cammoun, MD

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scanners. then fuses the images together. “They will have a large opening Nuclear medicine is a radiology for the patient, so that will help procedure that is able to image ease claustrophobia concerns,” the body on a functional level. It Donaldson says. “Images will be uses an injected tracer that gives of the highest-quality because off a small amount of radiation, of the newer software and allowing the scanner to image the computers.” body. Different tracers are injected A CT scan is a special kind to capture different functions of of X-ray imaging where a thin the body. X-ray beam rotates around the Nuclear medicine is used for patient, allowing cardiac stress physicians to see tests and bone highly detailed scans, and it is “With the old pictures. The performed to technology of one most commonly test a variety slice at a time, you ordered CT of other parts would have to hold scans are of of the body, your breath, the the head, chest, such as the picture would be abdomen and thyroid gland taken, then hold your pelvis, but CT and gallbladder, breath again, and it can be used on among other would take another literally every things. ADI picture,” Donaldson part of the body. also performs explains. “Now, in just ADI’s CT general X-rays. a few seconds, you is a 160-slice In addition can hold your breath scanner. It was to Dr. Driss and it’s done.” obtained about Cammoun, one year ago. It ADI’s fullhas all the software for radiation time radiologist, the office has dose reduction and provides seven MRI/CT technologists, the best image quality at the two nuclear/PET technologists lowest exposure. Years ago, this and three X-ray technologists, as technology was single slice. The well as other clerical and coding new one has increased speed. staff. All of the technologists are “With the old technology of certified by the American Registry one slice at a time, you would of Radiologic Technologists. have to hold your breath, the “We do a few procedures here picture would be taken, then hold that no one else does in the area,” your breath again, and it would Donaldson notes. “Before ADI, take another picture,” Donaldson people had to travel to Iowa City explains. “Now, in just a few or The Mayo Clinic to have these seconds, you can hold your breath tests done.” and it’s done. It’s a lot quicker for Call ADI at 319-236-2700 to the technologist and the patient. schedule your next radiology exam. In one breath we can scan from your chest to your pelvis. There is less chance of needing to redo something.” ADI offers the only PET/ CT technology in-house, which is unique to the Cedar Valley. It combines two scanning techniques: the PET scan shows different metabolic body functions, while the CT scan provides a detailed view of structural anatomy. The software technology

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David Redfern, MD

ALLERGY AND IMMUNOLOGY F

or those suffering from some form of allergy or immune disorder, Cedar Valley Medical Specialists (CVMS)’ Allergy and Immunology Department can not only provide relief for daily living, but also can be a lifesaver in rare instances. Allergy and immunology is a relatively small specialty in the world of medical care, with only about 4,000 specialists nationwide. In the Cedar Valley, CVMS’ Dr. David Redfern is just one of two. “I’ve been in town about 20 years, and

the (patient load) has been fairly steady for most of that time,” he says. “We’ve seen a general increase in the last couple of years, and this year we are experiencing another bump. “It’s difficult to know the reason why, because we are not seeing just seasonal increases. We’re just seeing more cases.” Dr. Redfern is seeing many people suffering from hives, a fair amount of dermatitis, and other issues. Chronic sinus problems “seem to be more and more

prevalent over time. “Allergies play a role in some of these and not others. But allergies are clearly worse over time. There are more food allergies, more airborne allergies,” he says. A number of theories have been introduced as to the causes. “Some center around exposure, some can even be from indoor exposures,” Dr. Redfern explains. “Some say our houses now are so tightly sealed that normal chemicals, for instance cooking fumes

World-Class Care, Close to Home.

appropriate candidates and the type and timing of introduction remain to be fully clarified. Another new way of treating pollen allergies is to place a tablet under the tongue that releases a lot of allergen. Some of the allergen is absorbed by the mouth lining. This can lead to desensitization to the allergen, like allergy shots cause. “But it’s a very different protocol,” Dr. Redfern says. “You start with a large dose, not building it up like with the shots. We tried the first ones a couple months ago. There have been some attempts with sublingual drops but those have not been shown to be effective.” The tried-and-true skin testing remains the fastest, most costeffective and most accurate way to test, he says. A new generation of blood tests has been introduced, with the newest that approaches skin testing. “Allergy specialists have to spend time with patients to figure out what they are exposed to and what is causing their symptoms,” Dr. Redfern says. “It’s more of a history-driven specialty. It’s not like we can do a CAT scan and say, ‘oh, you’ve got this.’ “It’s difficult for a primary doctor with 60 people on the schedule to try to discover the little things that might be a cause or to find the small exposure causing the problem. That’s where we come in.” Dr. Redfern’s staff includes four full-time nurses and medical assistants.

MEET OUR TEAM ALLERGY AND IMMUNOLOGY United Medical Park 1753 W. Ridgeway Ave., Ste. 106 Waterloo, 319-833-5982 David Redfern, MD

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and aerosol sprays, could be adding to the number of cases seen. Some believe super-clean indoor environments have left our immune systems with nothing to do. If the immune system goes awry, allergies are a consequence. None of these theories has been proven 100 percent.” Over the last 10 years, the number of peanut allergies has exploded, Dr. Redfern says, in addition to other food allergies. Some are serious enough to cause anaphylaxis. Others cause chronic swelling and development of scar tissue in the esophagus to the extent food won’t pass. “Some even call it asthma of the esophagus. It can be related to food allergies or to acid reflux,” Dr. Redfern explains. “The cells you find in the esophagus also are found in the lungs with those with asthma. I saw maybe four cases in two years when going through allergy training. Now it’s not unusual to see six cases in a month. It’s a huge increase.” Dr. Redfern’s office does not see as many sufferers of ragweed or other common allergies because there are many adequate over-thecounter medications. He says there have not been huge “leaps and bounds” in the treatment of allergy or immune system problems in the last couple of years, but more of an “incremental” change. There are many antihistamines available over -the-counter. Other medications are almost 15 years old. There are many types of inhalers, “but the mechanisms are fairly similar. “We have seen some injectable antibodies come out. We have treated some of our hive patients and asthma patients with these. One has been introduced that will block the allergy response. Some other new treatments have not come to market yet,” Dr. Redfern says. One of the new peanut allergy prevention protocols may include very early introduction of peanut protein. Details on selection of

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ANESTHESIOLOGY A

nesthesiology has come a long way from the days when a person took a swig of whiskey prior to a procedure to help dull the pain. Today’s anesthesiologist has an array of tools and medications to make the process easier for both patient and doctor. There is a much better understanding of the anatomy and physiology of the human body today, and how it interacts with various medications and procedures. “We have a huge role in taking care of patients in the pre-operative, intraoperative and post-operative stages,” says Dr. Matthew Grady, one of Cedar Valley Medical Specialists (CVMS)’ eight anesthesiologists. “We help patients get ready for surgery, we make sure they are

adequately managed prior to surgery and that they can be put under anesthesia safely. We treat pain, we keep patients asleep and we keep them alive.” Although you are asleep during a surgery, you still are able to feel pain. It is the anesthesiologist’s job to make the procedure tolerable to the body. They have control of your entire body. They can raise or lower your blood pressure as needed and adjust your oxygenation levels — actually breathe for you. “We have very good equipment, very good drugs and very good monitoring techniques,” Dr. Grady says. “Anesthesia is very safe today. The American Society of Anesthesiologists (ASA) has put together very good practice standards and

Matthew Grady, MD

guidelines.” A typical procedure uses the ASA’s monitors for checking the heart rate, the blood pressure, the pulse, the breathing, the temperature, and for making certain the carbon dioxide levels are adequate. Additional monitoring can be done, depending upon the need, to see how deeply you are anesthetized or to check the filling pressures in your heart. There are different types of pain management. Epidurals used for labor and delivery pain also can be used for post-surgical discomfort, for example, or nerve blocks in the neck can numb the arm. An anesthesiologist continues to monitor the patient until he or she is

World-Class Care, Close to Home.

MEET OUR TEAM ANESTHESIOLOGY Allen Hospital 1825 Logan Ave. Waterloo, 319-235-5390 United Medical Park Allen Ambulatory Surgery Center 1731 W. Ridgeway Ave. Waterloo, 319-235-5390 Keeran Ghandivel, MD, FACS Matthew Grady, MD Stephen Punke, MD Tahseen Husain, MD Karl Terwilliger, MD Lyle Stefanich, MD R. Vemulapalli, MD Paula McFadden, MD Scott Doyle, CRNA Jon Clinton, CRNA Sara Yoder, CRNA Kathryn Ogburn, CRNA Kate Nicholson, CRNA LenaMarie Johnson, CRNA Lisa Baker, CRNA

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moved from the recovery unit a certain criteria after they have or until the epidural has been been resuscitated,” says Dr. Karl removed. Terwilliger, CVMS’ expert in the Dr. Grady says one advance practice. “In order to preserve in anesthesiology has been the neurological function in patients introduction of direct video whose brains have not received laryngoscopes. These provide a oxygen due to their hearts consistently clear, real-time view stopping, we cool down their of the airway and tube placement, bodies to 33 degrees Celsius for enabling quick intubation in 24 hours. Then we re-warm the patients who patients over 17 might otherwise hours. have been “There is “We help patients get difficult to good data ready for surgery, we intubate. showing make sure they are “When we improved adequately managed put people outcomes in prior to surgery and under anesthesia these patients. that they can be put and we give Larger hospitals under anesthesia you muscle usually have safely. We treat pain, relaxation, this available. we keep patients essentially you Allen Hospital asleep and we keep can’t breathe on has been doing them alive.” your own,” Dr. it since 2013, Grady explains. with promising “We have to get success,” Dr. a breathing tube or some kind of Terwilliger says. device into you through your vocal CVMS has eight physicians chords in order to breath for you. and seven CRNAs in the With some patients, that’s very Anesthesiology Department. The difficult to do. physicians take all of the first “We used to use a long calls, including the overnight calls. fiberoptic scope, put it in the back The CRNAs work independently of your throat, look at your vocal in the OR and are a big help in chords, put in a breathing tube, providing care for the patients. and then put you under anesthesia. However, a physician is always in It’s not pleasant having a the hospital when anesthesia is breathing tube put in while you being delivered. are awake. It’s labor-intensive and Dr. Grady says he chose takes time. anesthesiology because he enjoys “About 10 years ago it doing procedures, the operating became standard to have a video room environment and the laryngoscope where we can look physiology of the specialty. at your vocal chords after you are “One of the things I enjoy about asleep. I think it’s made anesthesia this job is that every patient is safer,” he says. different,” says Dr. Grady. Medications also have improved “There are no hard and fast over the past 20 years. Halothane rules. What works for one person used to make people sick, but there may not work for the next. We are better-inhaled anesthetics now. have to be prepared for that.” Another recent advancement is the management of temperature. People who go into cardiac arrest have a higher risk of death and brain damage. “ ‘Code Chill,’ also known as hypothermia protocol post-cardiac resuscitation, is a treatment for patients who meet

Douglas Duven, MD, FACS

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Cedar Valley Medical Specialists, P.C.

r. Douglas Duven made the transition from full-time general surgeon to a practice devoted to breast care in 2003. He felt there was a need for increased coordination of care and longterm follow-up for breast patients. “Establishing the Cedar Valley Breast Care Center gives the patient a central contact point for routine follow-up, as well as nurses to contact starting at the time of diagnosis, surgery and follow-up treatments,” he says. “After participating with the American Society of Breast Surgeons in several conferences and meeting people there, I learned how to improve the quality and timeliness of care.” Dr. Duven is a strong proponent of one of the latest breast cancer screening technologies, digital breast tomosynthesis (DBT) or 3D breast imaging, which takes multiple images from different angles and provides a much clearer and more accurate image of breast tissue. Digital mammography allows manipulation by the radiologists to closely examine areas of interest or concern on the mammogram. Dr. Duven uses ultrasound examination to evaluate the breast tissue as needed. Ultrasound imaging visualizes the tissue differently than mammography, providing more information. He offers fine-needle aspiration biopsy as well as ultrasoundguided core biopsy at the Breast Care Center. Biopsies utilizing

mammographic tomosynthesis imaging are also available for abnormal findings that are not seen well by ultrasounds. Tissue biopsy reports are typically available in three business days. “Women have become more educated about their own breast health, and this has caused an increase in patients seeking care at the Breast Care Center for evaluations and education,” Dr. Duven says. The Cedar Valley Breast Care Center also sees patients who are at high-risk for breast cancer. These patients may qualify for genetic testing, which has improved as well, and now requires a simple saliva specimen. Some women who are at high-risk need close surveillance, which is offered and coordinated at the center. “Our cancer patients are provided with the information and education to make the best treatment decisions for themselves,” Dr. Duven says. “Treatment is individualized for the patient. We also like to remind the public that we are the Breast Care Center, not the breast cancer center. We do provide care for patients with benign (noncancerous) breast conditions.” The American Cancer Society’s statistics show that invasive breast cancer will develop in one in eight women during her lifetime, although men are not immune from the disease. Early detection provides the best opportunity for cure.

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MEET OUR TEAM CEDAR VALLEY BREAST CARE CENTER United Medical Park 1753 W. Ridgeway Ave., Ste. 104 Waterloo, 319-833-6100 Douglas Duven, MD, FACS

www.CedarValleyMedical.com

CEDAR VALLEY BREAST CARE CENTER

Cedar Valley Medical Specialists, P.C. www.CedarValleyMedical.com

Kalyana Sundaram, MD

CEDAR VALLEY CARDIOVASCULAR CENTER S

ince 1982, UnityPoint Health-Allen Hospital, along with Cedar Valley Medical Specialists, has been providing the Cedar Valley and surrounding communities with full-spectrum cardiac care. This care has been provided by a team of board-certified cardiologists and cardiothoracic surgeons. Cedar Valley Cardiovascular Center is located at 419 E. Donald St. in Waterloo. At the center, which is under the direction of Dr. Kalyana Sundaram, area patients

experience the best in care with the latest technology and procedures, all with the center’s aim of keeping hospitalization and overall costs minimal. Allen Hospital was ranked one of the 2014 Top 50 Cardiovascular Hospitals in the United States by Truven Analytics for the last few years. Allen performs approximately 160 open heart surgeries and over 3,000 other cardiac procedures, including stent placements, each year. “We are not shy about taking credit

for Allen’s recognition because we are the exclusive cardiac care for Allen Hospital,” Dr. Sundaram notes. “It is a good partnership.” The Cardiovascular Center recently has completed an expansion of services, allowing for concise, patient-friendly outpatient cardiac care. There are five cardiologists, four of whom are interventional cardiologists, and one electrophysiologist, all of whom treat those with rhythm problems. The team

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MEET OUR TEAM

is supported by a board-certified cardiac surgeon who provides inpatient and outpatient care. Also on staff are seven boardcertified ARNPs who work closely with the physicians, three nuclear technologists, two pacemaker nurses, eight ultrasound sonographers, 10 nursing personnel, and seven support staff and billing specialists. The Cardiovascular Center includes a large pacemaker clinic for those who need to have devices checked on a routine basis, and an Enhanced External Counterpulsation (EECP) Department for those outpatients needing treatment for severe angina who are not candidates for stents or bypass surgery. “Functioning in one place makes logical sense,” Dr. Sundaram says. “We can keep all patients and care teams here so

we can focus and concentrate on all the needs of our patients. We operate as a group. We work well together as a team. If someone is sick, we can provide care right away. We have all the resources needed to provide the full spectrum of cardiac care with both outpatient care in our office and inpatient care at Allen.” Dr. Sundaram says his team deals with heart attacks and congestive heart failure, among many other conditions, along with the vascular system, which deals with the blood vessels going to and from the heart. Vascular medicine, just like heart medicine, treats the entire disease process, not just the symptoms. “Heart disease is one of the most common diseases in Western society,” he says, “but is declining in incidence rates because we as a society have done very well

Kalyana Sundaram, MD Joud Dib, MD Salam Sbaity, MD Himanshu Tandon, MD James Wright III, MD Sharad Bajaj, MD Kari Haislet, DNP, ARNP Erica Jensen, ARNP Lisa Maher, DNP, ARNP Abbie Schaa, ARNP Abbie Schrader, ARNP Jody Zolondek, ARNP Mattie Thompson, ARNP

www.CedarValleyMedical.com

CEDAR VALLEY CARDIOVASCULAR CENTER 419 E. Donald St. Waterloo, 319-236-1911

Cedar Valley Medical Specialists, P.C. www.CedarValleyMedical.com

in reducing the number of people who smoke. That is showing its effects on the incidence of heart disease. “Also, the medical community in general has done well in the treating of cholesterol. Still, heart disease is a burden on the system.” Dr. Sundaram says obesity and lack of physical exercise remain problems. “This country has not done a good job in terms of physical exercise and healthy eating,” he says. In addition to the more well-known heart-related diseases, the center is seeing many sleep apnea patients. Sleep apnea can have a large affect on the heart function. “People snore and they stop breathing for a period of time,” Dr. Sundaram explains. “That can directly lead to heart arrhythmia. It can lead to congestive heart failure and it significantly increases the risk of stroke. If a patient comes in and they have sleep apnea, unless you treat the apnea, you are not going to get the fibrillation better.” Dr. Sundaram says doctors have multiple roles to play. Saving lives is a top priority, but they also need to consider how the patient will be functioning three, five, or ten years later. Making an early diagnosis can be paramount. It’s also important to manage the disease well so it does not cause long-term disabilities.

“Our motto is not ‘just fix it when it’s broken,’ but ‘once you fix something, make sure they live well.’ We live long, but living long doesn’t matter if you don’t have a good quality of life. We do everything possible so patients live healthy lives and remain healthy. This will allow them to live as long as possible in their own homes. It’s less expensive, they’re happy and they’re self-sufficient,” Dr. Sundaram says.

“We live long, but living long doesn’t matter if you don’t have a good quality of life. We do everything possible so patients live healthy lives and remain healthy.” He says the national trend is to treat patients in their own environments. “Hospitals are good if you are very sick, but if you don’t need to be admitted, you get to stay where you are and get treated. Our practice has done that very well. We have consciously made an effort. Our role as cardiologists doesn’t stop in the cath lab. We feel heroic when the outcome is good, but we want to make sure patients live healthy lives so they do not need to be in the hospital. “We see the patient, we educate them. Seeing them in the office is very effective because we can address their lifestyles and all other health issues before they become severe. Outpatient care is very key in patient education,” he notes. Besides the quality of care and the cost of care, the providers with the Cedar Valley Cardiovascular Center also pay attention to access to care. They travel to Sumner, Grundy Center, West Union, Independence, Waverly and Oelwein to make it easier for patients. “It’s important to take care of patients on a periodic basis so we don’t wait for conditions to worsen,” Dr. Sundaram

explains. “If we wait until they need to be hospitalized, it could be too late.” Access to care also is addressed with the team of nurse practitioners who can treat a patient at certain levels. They have their own state licenses, and they have extensive training and experience in cardiology. Each doctor and each practitioner focuses on a particular niche, whether it be diet, EECP, devices like pacemakers or sleep apnea. Dr. Sundaram says medicine as a whole will be moving away from the hospitalbased system. Better coordination of care needs to come with that. “We’re good in specialized things in the U.S., but we haven’t been good in coordinating things well. It’s not something one physician can do alone. It is a team effort. “Sharing of information is important. Patients can be and will be monitored from home, take blood pressure from home — all the telemedicine advancements are done to improve the quality of care and life.” He says the future of cardiology is “very exciting.” A lot of gene research is being done, including gene therapy for high cholesterol. There will be tremendous advancements in the coming years. “As doctors, we don’t just treat heart attack patients. This is our community. We are a part of our community. Our goal is to study the community needs and do everything possible to make those in our community live long, healthy lives.”

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CEDAR VALLEY CENTERS FOR ENT AND SINUS, FACIAL PLASTIC SURGERY, HEARING, SKIN CANCER AND REJUVENATION W

hen it comes to hearing better, breathing better, looking better, and having better skin, Dr. David J. Congdon has it covered under one roof. His Cedar Valley Centers for Hearing, ENT and Sinus, Facial Plastic Surgery, Skin Cancer and Rejuvenation are located at United Medical Park on West Ridgeway Avenue

in Waterloo. A double board-certified surgeon, Dr. Congdon specializes in surgery of the head, neck and face. Heâ&#x20AC;&#x2122;s also boardcertified and fellowship-trained in facial plastic and reconstructive surgery. The list of procedures heâ&#x20AC;&#x2122;s experienced in is quite lengthy.

Within the Cedar Valley Center for Hearing, he works with patients on hearing loss prevention, hearing loss assessment, and provides specialized testing for young children. His staff and he help patients with customized hearing aid selection for optimal fit. The office supports assistive listening technology,

www.CedarValleyMedical.com

David J. Congdon, MD, MPH, FACS

Cedar Valley Medical Specialists, P.C.

MEET OUR TEAM CEDAR VALLEY CENTERS FOR ENT AND SINUS, FACIAL PLASTIC SURGERY, SKIN CANCER AND REJUVENATION United Medical Park 1753 W. Ridgeway Ave., Ste. 111 Waterloo, 319-833-5970 David Congdon, MD, MPH, FACS Meg Heatley, PA-C Crystal Wilken, ARNP Tricia Thompson, ARNP Deborah Rieks, AuD

CEDAR VALLEY CENTER FOR HEARING United Medical Park 1753 W. Ridgeway Ave., Ste. 110 Waterloo, 319-833-5968

www.CedarValleyMedical.com

Deborah Rieks, AuD

Rejuvenation

custom swim molds and hearing aid batteries and supplies. As an otolaryngologist, he provides all general ear, nose and throat care, including ear tube placement, earwax buildup, nosebleeds, tonsils, adenoids, outer ear infections and other conditions. In addition, Dr. Congdon says about half of his day revolves around full body screenings and treatments of skin cancer, including facial skin cancer reconstruction. “Facial plastic surgery is a subset of otolaryngology,” he explains. “We can rebuild a nose. We treat simple skin cancers as well as the larger skin cancers the dermatologist cannot treat. Patients don’t want to see multiple providers for one problem. We are a one-stop shop for skin cancer in this way.” Dr. Congdon also performs cosmetic procedures, including nasal surgeries, ear surgeries, facelifts, forehead lifts, Botox, fillers, lip augmentation, eyelid rejuvenation, chin and cheek implants, skin resurfacing and facial skin reconstruction. His medical spa treats spider veins and offers pigment treatments for sundamaged skin and laser treatments for acne scars, hair removal and rosacea. Dr. Congdon was one of the first physicians locally to perform balloon sinuplasty, one of the newest technological advances in the field. He teaches balloon sinus surgery at a biennial conference with others from The Mayo

Clinic and Europe. It is a safe and effective in-office procedure for chronic sinusitis patients who are seeking relief from uncomfortable and painful sinusitis symptoms and who may not be responding to medications. The procedure involves opening inflamed sinuses, much like a heart surgeon opens blocked arteries during balloon angioplasty. It is less invasive than traditional sinus surgery and does not involve removing bone or tissue. There is no bruising and no packing. “You used to have to have your nose packed and take 14 days off from work,” Dr. Congdon says. “People chose not to be treated and suffered because they didn’t have the time to take off. Balloon sinuplasty is not painful; the patient usually can go back to work the next day. It does not involve incisions, and the tissue does not scar shut. The patient experiences immediate relief. It can be done right here in the office and avoids a trip to the operating room.” Other conditions treated in the ENT office include snoring and sleep apnea, chronic coughs, ringing in the ears and dizziness and imbalance issues. Dr. Congdon’s staff includes Crystal Wilken, ARNP, Meg Heatley, PA-C, Tricia Thompson, ARNP, and Deborah Rieks, AuD. They share his goal of creating confidence and comfort throughout each procedure with their worldclass care.

Deborah Rieks, AuD

earing loss — missing parts of a conversation or turning up the sound on the television — can be more than just an unfortunate part of aging. “Scientific evidence is now beginning to surface associating hearing loss with poorer cognitive functioning and dementia,” says Deborah Rieks, AuD, one of Cedar Valley Medical Specialists (CVMS)’ two audiologists. “Hearing loss may be a risk factor for falls. Patients with diabetes have a significantly higher prevalence of hearing loss than those without diabetes.” Audiologists are trained to diagnose, manage and treat hearing and balance problems for persons of all ages, including newborns. Rieks practices within Dr. David Congdon’s Cedar Valley Center for Hearing, located at United Medical Park on West Ridgeway Avenue in Waterloo. A study published by the National Council on Aging found that hearing loss affects all aspects of life that depend on the ability to communicate with other people. It affects how we relate to family and friends, how we perform our jobs, how we are able to lead productive lives, and how we maintain our health through social connections.

“Digital hearing aids are working over thousands of times per second sampling the environment,” she adds. “They are designed so that soft sounds are amplified enough to be heard while loud sounds are heard but do not sound uncomfortably loud.” She says most of her patients tend to be older, “although they are getting younger. Today’s youth have had much more experience with technology. If there is something out there that is going to make their lives easier, they’re more readily seeking help.” Technology of course is changing at lightning-speed, and hearing aids are no exception. In the past, a new product would appear on the market every three or four years. “Now it’s every three to four months,” Rieks says. “Today’s smart hearing aids can be controlled by your smartphone — adjusting volume, changing programs, or locating a misplaced hearing aid. You can make phone calls or video calls with clear, feedback-free voices that are streamed directly to the hearing aids.” One of the newest trends in audiology is incorporating more-inclusive rehabilitation for hearing aid users. “We’re finding that keeping the brain active will help improve listening in noise and the kind of auditory processing that needs to take place with hearing aids,” Rieks says. “Counseling can be a major part of hearing aid acceptance and obtaining maximum benefits. Understanding that your biggest difficulty may be in a noisy environment, you will miss (hearing) some things. “The audiologist is a key component,” Rieks adds. “Someone that you trust, someone who is going to listen to you, someone who will treat your hearing loss with more than just a medical device.”

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“Benefits of treating hearing loss include improved relationships at home, giving people a sense of independence, feeling more socially engaged, and even unlocking earning potential — hearing your best helps you do your best at work,” Rieks says. “We do know that when you have a hearing loss you are spending a lot more time on lower-level cognitive processing. You are working so hard at hearing what people are saying that the higher cognitive processes may not be exercised. One study has shown that as we get older, our brains actually shrink. The parts of the brain that are responsible for speech and language have atrophied or shrunk more in the hearing-impaired. “The cochlea (our organ of hearing) is very vulnerable to a lack of oxygen or lack of good nutrients,” she says. Researchers are linking our hearing to cardiovascular, neural and metabolic health. “We also live in a noisy world, making our ears work harder. Sudden hearing loss is also on the rise. One third of those with sudden hearing loss just wake in the morning with hearing loss. “If this happens to you, you want to be treated immediately, within the first two weeks,” she adds, “for the best chance of getting your hearing back.” Audiologists also treat tinnitus or ringing in the ears, which often is correlated to hearing loss. Rieks says hearing aids can help bring in background noise that mask the ringing to a certain extent. There are many apps for smartphones that stream into hearing aids, providing nature sounds. “People are getting some relief,” she says. The electronic circuitry of today’s hearing aids has advanced significantly over the last few years. The aids are getting smaller and thus more cosmetically appealing and more comfortable.

www.CedarValleyMedical.com

CEDAR VALLEY CENTER FOR HEARING

Cedar Valley Medical Specialists, P.C. www.CedarValleyMedical.com

Ravindra Mallavarapu, MD

CEDAR VALLEY GASTROENTEROLOGY C

edar Valley Gastroenterology offers area patients an interdisciplinary approach in the diagnosis and treatment of a wide range of digestive disorders. Gastroenterology is the specialty dealing with all the organs associated with digestion, from the time we eat to the time the digested food leaves the body — the esophagus, stomach and colon. Disorders can happen because of any problems with digestion, either the movement, or the digestion itself, the elimination, or because of cancers or infections.

Diseases commonly treated include hepatitis B and C, reflux, Barrett’s esophagus, peptic ulcer, Crohn’s, ulcerative colitis, irritable bowel syndrome, pancreatitis and issues with nutrition. Dr. Ravi Mallavarapu, one of three gastroenterologists under Cedar Valley Medical Specialists (CVMS)’ umbrella, says three to four million Americans are infected by hepatitis C, a chronic infection of the liver. “It is contracted either through IV drugs, inhaled drugs or blood transfusions

before the testing came about,” he explains. “If it remains in the body, it can cause damage, such as cirrhosis, the scarring of the liver. The Centers for Disease Control and Prevention recommends persons 45 to 60 be tested for hepatitis C.” CVMS’ doctors are the primary providers in the Cedar Valley that treat hepatitis C. “Treating hepatitis C requires some experience first, and not everyone is interested. I had some background training in liver diseases that I brought with me here. The regimens are

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Most beneficial to patients is that the Cedar Valley Gastroenterology and the Allen Digestive Health Center offer full service, patient-focused satisfaction and customer service, he says. “We have a comprehensive range of services available that makes it highly unlikely that our patients will need to go outside the area for diagnosis and treatment. “Our primary care team has grown to include the highestquality care from world-class professionals, including Dr. Srinivas Kalala and Dr. Ana Huerta Alardin. We also have two outstanding nurse practitioners on our team. Barb Burkle, MSN, ARNP, FNP-BC, has been practicing digestive health for twelve years, and specializes in general gastrointestinal health, inflammatory bowel disease and liver disease. Tracy Elliott, ARNP, has been practicing digestive health for four years, and focuses on a holistic approach to patient care through nutritional education, exercise and natural supplementation,” says Dr. Mallavarapu. “We stay up to date. We have designed a new website to assist in educating patients regarding many aspects of their health care. We are the second line of care after the primary physicians and we collaborate with general surgery, radiology, and other disciplines.”

MEET OUR TEAM CEDAR VALLEY GASTROENTEROLOGY Allen Digestive Health Center 125 E. Tower Park Drive Waterloo, 319-234-5990 Srinivas Kalala, MD Ravindra Mallavarapu, MD Ana Huerta Alardin, MD Barb Burkle, MSN, ARNP, FNP-BC Tracy Elliott, ARNP

www.CedarValleyMedical.com

complex,” Dr. Mallavarapu says. Additionally, reflux is a common disease which affects quality of life for sufferers. “Reflux is a chronic condition that can put a person at risk for a condition called Barrett’s, which is a change in the lining of the esophagus that can lead to cancer. The treatment involves changes in lifestyle and medication. For example, reflux can be treated with medications, by losing weight, eating smaller meals, and not eating foods that trigger reflux, such as tomatobased sauces. The medications are really effective,” he says. “They have minimal side effects.” Inflammatory bowel diseases such as Crohn’s or ulcerative colitis can affect the lining of the gut, colon or small bowel. It is believed that an abnormal immune response is what results in the damaging inflammation of the digestive tract. If the immune system reaction can be controlled with medication, surgery may not be necessary. A number of digestive conditions can also be related to diet. People may be intolerant to gluten, lactose or fructose. A staff dietitian advises these patients, under the care of the provider. “We’ve made great strides in the detection of colon cancer, which may require the removal of pre-cancerous polyps. Also, the advancement in colonoscopy preparations requiring less liquid to be consumed is a great benefit to the patients,” says Dr. Mallavarapu. Other technological advancements include a camera inside a pill that can take pictures of the small bowel, and upgraded ways to control bleeding and open tumors using stents. In the near future, an instrument with a camera inside of another camera will allow viewing inside the bile duct. Dr. Mallavarapu’s practice recently obtained a new form of ultrasound that can tell if the liver is scarred.

Cedar Valley Medical Specialists, P.C. www.CedarValleyMedical.com

FRONT ROW: Laura Foote, Robin Engelking, Jennifer Laube, Julie Martin, Krystle Roberts BACK ROW: Joyce Schimmels, Paula Yount, Carmen Mundt, ARNP, Brian Gerrelts, MD, FACS, Paul Burgett, MD, FACS, Scott Houghton, MD, Jayson Gesme, MD, FACS, Debbie Schoephoerster

GENERAL SURGERY I

n today’s world of constantly changing technology and specialization, the need for general surgeons is still very important. Drs. Brian Gerrelts, Paul Burgett, Jayson Gesme and Scott Houghton are Cedar Valley Medical Specialists (CVMS)’ four general surgeons in the General Surgery Department. They recently have been joined by Carmen Mundt, an experienced surgical nurse who is now an ARNP and who will assist with daily tasks. In the past 10 years, statistics show that of about 1,050 surgeons who finish their training every year in the United States, more than one-half of them enter into subspecialties. Combining this with the retirements of older surgeons and a growing U.S. population means that every year, there are more patients for each general surgeon to cover. The field of general surgery has changed

over the years. General surgeons once performed almost every kind of surgery, with the exception of specialties such as heart or brain surgery. Over the past 40 to 50 years, with increasing subspecialization and advancing technology, general surgery has slowly evolved into a specialty itself. Although general surgeons still operate on a wide variety of body ailments and diseases, U.S. general surgeons now concentrate on a few main areas — abdominal surgery, hernia repair, trauma surgery, skin and soft tissue problems and endoscopy. Management of surgical diseases of the breast used to be done only by general surgeons, but it is becoming a specialty of its own. Two of CVMS’ surgeons maintain training and certification in breast surgery — Dr. Gesme and Dr. Douglas Duven, whose practice is entirely devoted to breast care. The biggest change in surgery recently

is the trend toward making incisions smaller, or “minimally invasive surgery.” This revolution can be traced back to the development of the laparoscopic cholecystectomy (removal of the gallbladder) in the 1980s. The benefits of minimally invasive surgery include less pain, shorteror-no hospital stays, reduced risk of complications, earlier return to functional status, and better outcomes. Many operations now are routinely done laparoscopically, including cholecystectomy, appendectomy, hernia repairs, weight-loss surgery and many bowel resections. All of CVMS’ general surgeons perform routine and advanced laparoscopic surgery. The newest development in general surgery is robotic surgery. Just as with laparoscopic surgery, several “ports” or small plastic tubes are placed by the

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answer you might get from most of their colleagues. “The beauty of our job is the spectrum of surgery that we perform, from removal of a little skin cancer in the office, to the straightforward cholecystectomy or appendectomy, to the sixhour-long repair of a complex abdominal wall hernia,” says one. “We get to correct a problem, small or large, and get the patient back on the path to wellness.”

MEET OUR TEAM GENERAL SURGERY United Medical Park 1753 W. Ridgeway Ave., Ste. 107 Waterloo, 319-833-5907 Paul Burgett, MD, FACS Brian Gerrelts, MD, FACS Jayson Gesme, MD, FACS Scott Houghton, MD Carmen Mundt, ARNP

www.CedarValleyMedical.com

surgeon into the abdominal cavity through which a camera and instruments are placed. Then, instead of the surgeon manipulating the instruments with his hands as in traditional laparoscopy, the instruments and camera are connected to arms on the robot. The surgeon then sits at a console and is able to control the camera and the instruments with his hands and feet. The advantages of this include better visualization and better control of the instruments. The view at the console is in 3D, as opposed to two-dimensional (like your TV) with traditional laparoscopy. The control of the instruments also is multidimensional, as the surgeon is able to perform “wristed,” or articulated, movements inside the abdominal cavity. Robotic surgery has proven applications such as in prostatectomy and some gynecologic surgery and is now proving itself more useful in other procedures such as colon resections and some hernia repairs. It is likely that robotic surgery will become more of a routine part of general surgery in the future. Robotic surgery is offered by Drs. Gerrelts and Gesme in the appropriate situations. While minimally invasive surgery offers many advantages, and new applications are always being developed, there still are times when surgery has to be or is best done with a traditional incision. This is often because of the urgent nature of some surgeries, anatomical constraints, or when laparoscopies cannot be performed safely. Fortunately, all of CVMS’ general surgeons are well-trained, experienced with minimally invasive surgery, and also have years of experience, making them comfortable with open surgeries when necessary. Why do doctors become general surgeons? Drs. Gerrelts, Burgett, Gesme and Houghton echo the

Cedar Valley Medical Specialists, P.C. www.CedarValleyMedical.com

Vinay Kantamneni, MD

NEPHROLOGY Y

ou don’t have to be a doctor to know that diabetes and high blood pressure are on the rise in the United States. Those two conditions can lead to kidney disease. Kidneys filter your blood and get rid of extra water and waste. They also release vital hormones that your body uses. If your kidneys become damaged and cannot perform these important functions, you may develop chronic kidney disease that then can lead to even more severe health issues. It is estimated that 26 million Americans have chronic kidney disease, which usually happens slowly over a long period of time. A nephrologist takes care of kidney disease, which includes kidney failure,

dialysis and preventing patients from having to go on dialysis. Dr. Vinay Kantamneni is one of Cedar Valley Medical Specialists’ two nephrologists. Also practicing in the Nephrology Department are Dr. Tarek Daoud, Jan Davis, ARNP, three RNs and two LPNs. “By far the most common cause of kidney disease is diabetes,” Dr. Kantamneni says. “Other causes can be high blood pressure, genetic conditions and kidney stones. Blood vessels are being affected, some can be blocked, and circulation in the kidneys can be a factor. Also, lack of exercise, diet and all of the sugar products we are consuming are contributing factors.”

Dr. Kantamneni says diabetes is the cause of kidney disease for around 40 percent of dialysis patients. Lupus and other autoimmune diseases also can affect the kidneys. “As we’re all aging you are going to see some wear and tear on our organs. The longer you live, organs are going to be affected. The population is living longer. Medications can also play a part,” he says. “In other parts of the world, medications are a bigger problem because they are not as regulated as they are in this country. Pain medication like ibuprofen can affect the kidneys.” One cause of kidney stones is not drinking enough liquids, in particular,

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in Waterloo. Most of Dr. Kantamneni’s and Dr. Daoud’s patients are older. They see about 170 dialysis patients locally. Dialysis machines are much more advanced today. Dr. Kantamneni says 20 years ago it would not be uncommon for a patient to be on dialysis for up to eight hours. Today, the same treatment can be finished in half the time. “Anti-rejection medications have come a long way, also,” he says. “They are less toxic and more easily tolerable. There is a lot more research being done into the prevention of kidney disease.” If patients need transplants and their names are selected, they are sent to Iowa City or The Mayo Clinic, since no transplants are performed here. But Dr. Kantamneni’s practice does care for the patients post operatively. “We try to shoot for at least 10 percent of all dialysis patients at one time to be transitioned into transplantation,” he says. “So if we’ve got 200 patients in this community, 20 of them are being evaluated for transplant. Everyone who is on dialysis is a potential transplant candidate. “Age is not the determining factor. Up to about age 70, patients are accepted without any question. After 70, other conditions are looked at, such as heart disease and cancer. We do encourage our patients to get evaluated early in order to get into the system and on the transplant list.”

MEET OUR TEAM NEPHROLOGY United Medical Park 1753 W. Ridgeway Ave., Ste. 105 Waterloo, 319-833-5940 Tarek Daoud, MD Vinay Kantamneni, MD Jan Davis, ARNP

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water. “We consume just about everything else but not enough water,” Dr. Kantamneni says. “Water is the best. Tea has oxalic acid which causes problems. The Southeastern part of the country sees a lot more of these stones because people drink more tea. One to two cups is not terrible. Twenty ounces three times a day is not good.” Nephrologists are detectives, looking for reasons why the kidneys aren’t working. They perform blood tests and urine tests and conduct ultrasounds of the kidneys. They also perform kidney biopsies. In cases where the kidneys fail, patients then are transitioned to dialysis or transplantation. The waiting period in Iowa for a transplant is three to five years. Dialysis acts as a bridge. There are two types of dialysis — hemodialysis and peritoneal dialysis. The first is done three times weekly, with each session taking about four hours. Blood is pumped through the dialyzer, extra water and waste are removed, and the blood is then pumped back into the body. Peritoneal dialysis is where a fluid called dialysate is put into the peritoneum, a space in the abdomen. The dialysate stays there for several hours. The waste products and water move through the peritoneal membrane into the dialysate, which is then drained away and replaced with fresh dialysate. “Some people want to have their independence, so we train them to do the peritoneal dialysis from home,” Dr. Kantamneni says. “Home hemodialysis requires intensive training and puts more responsibility on the patient.” When Dr. Kantamneni came to the Cedar Valley 18 years ago, there was only one dialysis clinic. Now there are clinics in Independence, Grundy Center, West Union and Waverly, in addition to two locations

METRO LOCATIONS 1

ADI Building

Advanced Diagnostic Imaging

Cedar Valley Bone Health Institute

Pulmonology

Cedar Valley Orthopedics

4006 Johnathan St., Waterloo

4006 Johnathan St. Ste. B, Waterloo

OrthoExpress

4006 Johnathan St. Ste. B, Waterloo

Anesthesiology

Radiology

Allen Hospital 1825 Logan Ave., Waterloo Allen Hospital 1825 Logan Ave., Waterloo

Allen Professional Building 212 W. Dale St., Ste. 203, Waterloo

United Medical Park 1661 W. Ridgeway Ave., Waterloo

Allen Hospital 164 W. Dale St., Waterloo

Dialysis Services (not afďŹ liated with CVMS) DaVita Black Hawk Dialysis Covenant Medical Center 3421 W. 9th St., Waterloo

Cedar Valley Medical Specialists, P.C. Administration 4150 Kimball Ave., Waterloo

Dialysis Services (not afďŹ liated with CVMS) DaVita Cedar Valley Dialysis

Cedar Valley Eye Care

909 E. San Marnan Drive, Waterloo

United Medical Park

Pain Management

Cedar Valley Gastroenterology

Cedar Valley Cardiovascular Center

Cedar Valley Eye Care

1753 W. Ridgeway Ave., Waterloo Allen Hospital Center for Pain Medicine 3630 W. 4th St., Waterloo Allen Digestive Health Center 125 E. Tower Park Drive, Waterloo 419 E. Donald St., Waterloo

1409 W. 1st St., Cedar Falls

12 11 2

VIKING RD.

16 15 14

8 7

9 1

5 10

13 13a 13b 13c

14 15 16

Cedar Valley Medical Specialists, P.C. at UNI Cedar Valley Orthopedics

2351 Hudson Road, Ste. 001, Cedar Falls

Advanced Diagnostic Imaging

2351 Hudson Road, Ste. 001, Cedar Falls

Cedar Valley Physical Therapy Northeast Iowa Physical Therapy - UNI 2351 Hudson Road, Ste. 164, Cedar Falls

Cedar Valley Sleep Center

2413 W. Ridgeway Ave., Ste. 1, Waterloo

Cedar Valley Occupational Rehab

7024 Nordic Drive, Ste. 200, Cedar Falls

XL Sports Acceleration Program

SATELLITE/ OUTREACH CLINICS Waverly Health Center

Covenant Clinic

Grundy County Memorial Hospital

Mercy Hospital

Advanced Family Eye Care

Satellite/Outreach Clinic Dialysis Services (not afﬁliated with CVMS) DaVita West Union Dialysis

312 9th St. SW, Waverly

201 E. J Ave., Grundy Center

1310 1st St. W., Independence

Buchanan County Health Center

(also: Dialysis Services ((not afﬁliated with CVMS)) -

129 8th Ave. SE, Oelwein 201 8th Ave. SE, Oelwein

DaVita Buchanan County Dialysis)

405 Highway 150 N., West Union

Palmer Lutheran Health Center

Dialysis Services (not afﬁliated with CVMS) DaVita Cedar Valley Waverly Dialysis

1600 1st St. E., Independence 112 Jefferson St., West Union

Community Memorial Hospital

220 10th St. SW, Waverly

909 W. 1st St., Sumner

3109 Venture Way, Cedar Falls

UNITED MEDICAL PARK Allergy and Immunology

Cedar Valley Ear, Nose & Throat

Anesthesiology

Cedar Valley Physical Therapy

Ste. 106

Allen Ambulatory Surgery Center Entrance 1731

Cedar Valley Center for Hearing Ste. 110

Cedar Valley Hearing Care Ste. 108

Cedar Valley Breast Care Center Ste. 104

Cedar Valley Center for ENT and Sinus Ste. 111

Cedar Valley Center for Facial Plastic Surgery Ste. 111

Cedar Valley Center for Rejuvenation Ste. 111

Ste. 108

Entrance 1731

General Surgery Ste. 107

Nephrology Ste. 105

Neurology Ste. 112

Cedar Valley Orthopedics Ste. 103B

Radiology

Entrance 1731, Ste. 101

Rheumatology Ste. 105

Cedar Valley Center for Skin Cancer Ste. 111

Cedar Valley Medical Specialists, P.C. www.CedarValleyMedical.com

Ivo Bekavac, MD, PhD

NEUROLOGY D

r. Ivo Bekavac is a happy man. He has a great family, he loves people, he loves the Cedar Valley, and he loves his job. Heâ&#x20AC;&#x2122;s not going anywhere. A neurologist, Dr. Bekavac practices in Cedar Valley Medical Specialistsâ&#x20AC;&#x2122; Neurology Department. Neurology is the branch of medicine that deals with the anatomy, functions and organic disorders of nerves, muscles and the nervous system. A neurologist diagnoses and treats disorders affecting the brain, spinal cord,

muscles and nerves. A native of Croatia, Dr. Bekavac completed medical school in Croatia at the University of Zagreb. Following this, he went to McGill University in Montreal, Canada, where he started his postdoctoral studies in neuroscience. These studies were completed in Philadelphia at Hahnemann University in 1994. Upon completion of his research, which according to Dr. Bekavac broadened his medical knowledge and, most importantly,

helped him to develop very critical thinking skills, he went to the Cleveland Clinic in Ohio, a top-five hospital, to start his residency in neurology. Upon completing his residency in 1998 from the Cleveland Clinic Foundation, Dr. Bekavac was about to start his academic career at the University of Cincinnati when he was contacted by a colleague and friend about an opportunity to join him in Iowa. He was so impressed with the hospitality during the interview that

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MEET OUR TEAM NEUROLOGY United Medical Park 1753 W. Ridgeway Ave., Ste. 112 Waterloo, 319-833-5954 Ivo Bekavac, MD, PhD

www.CedarValleyMedical.com

he decided to join Cedar Valley disease, Alzheimer’s disease and Medical Specialists and planned multiple sclerosis (just to mention to make his home in the Cedar a few) — the bond you create with Falls/Waterloo area. After five your patients is a lasting one. He years here, his colleague moved says, “We become like a family. south and asked him to join him It is all about trust. The trust in relocating. you earn with your knowledge, "I said, 'Forget it. I’m staying. your work and your passion. The My first job was here, and patients know that.” He adds, hopefully it’s the last one until I “One of the most important retire,’ ” Dr. Bekavac says. “I love measures of the quality of your my job, I love work is the my community, percentage of and I enjoy your patients “We become like a every single that come family. It is all about moment being back to see you trust. The trust able to help my again, and we you earn with your patients.” are extremely knowledge, your work Besides being proud of our and your passion. The board-certified numbers.” patients know that.” in neurology, When Dr. Bekavac asked about is also boardhis staff, Dr. certified in vascular neurology, Bekavac says teamwork is electrodiagnostic medicine (EMG) invaluable, moreso than in any and neuroimaging. He’s just other field. Without his office one of two neurologists in Iowa, staff, his accomplishments would and 140 in the country, who are not be possible. He pointed out board-certified in neuroimaging. that what it comes down to is the With strong roots in academics, quality of care, and knowledge and he also continues to publish and passion for the patients. teach. Dr. Bekavac recently was Besides his job, he also is appointed as adjunct associate involved in sports, in particular professor in neurosurgery at the soccer. He and his team of “old University of Iowa in Iowa City. people” have played together As to whether there is an for the past 17 years. On top impact and prevalence of of having fun and enjoying technology in his field, Dr. friendship, they have won many Bekavac says, “Yes, technology is championships, not only in Iowa, a huge aid in medical diagnostics; but in other states as well. this includes MRIs, CT scans, He is a proud husband and EMG, PET scans, EEG and proud father of four girls: one spinal taps.” He believes that is a recent graduate from the the most important part of his University of Northern Iowa, daily clinical work is face-to-face the second is a UNI senior, discussions with his patients, and and the youngest ones are in the time spent with patients and elementary and junior high school, their families. respectively. “The most important thing is the history (of the patient),” he says. The medical technology is significant, but a patient’s personal history and a clinical exam is paramount. Every patient is unique. For some chronic conditions — such as Parkinson’s

Cedar Valley Medical Specialists, P.C. www.CedarValleyMedical.com

Thomas Petrie, DO

CEDAR VALLEY EYE CARE C

edar Valley Eye Care (CVEC) offers one-stop shopping for your family’s eye care, ranging from routine eye care from three optometrists, to specialized treatment and surgery from three ophthalmologists and one retina specialist. It’s all under one roof in several convenient locations. CVEC has prided itself on always being in the forefront, using the latest technology in performing cataract surgery,

corneal transplants and LASIK surgery, along with offering contact lenses, general eye examinations, eyelid surgery, retina care and other optical services. Eye care no longer entails just vision correction surgery or prescription eyewear. Dr. Thomas Petrie is one of the newest additions to CVEC’s staff. He earned his undergraduate degree at the University of Northern Iowa, attended medical school at Des Moines University, and

completed his ophthalmology residency in Columbus, Ohio. “One reason why I came back to join this practice, and something that I take pride in now as a part of it, is that the practice is always in the forefront and the providers are always looking for ways to not only improve the care provided, but to improve outcomes as well," he says. Dr. Petrie says there is a huge demand for retina care with the aging population,

CVEC also was the first area clinic to perform laser vision correction surgery using the VISX laser correction system operated by the most experienced nurses and technicians. Dr. Petrie says cataract surgery is the most commonly performed surgery the practice handles. CVEC also offers specialty intraocular lenses so a patient can decrease dependence on glasses. Other services include corneal topography that maps the curvature of the cornea. The Humphrey Field Analyzer tests

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peripheral vision and aids in the treatment for glaucoma. The selective laser trabeculoplasty (SLT) is an office laser procedure meant to lower intraocular pressures as an option for glaucoma treatment. Most people are unaware that an ophthalmologist can also perform Botox treatments. Dr. Petrie himself is dedicating onehalf day monthly, and perhaps one full day in the future, to cosmetic or medical Botox treatments at the Cedar Falls office. The injectable treatment relaxes the muscles in the face. Having an ophthalmologist perform Botox treatment can help to ensure the safety of the eyes and vision because the specialist is most familiar with all aspects of the eyes, including the muscles and structures surrounding them. “By grouping all the patients in one day, it allows me to offer perhaps the most competitive prices in town,” he says. Additional services include pediatric eye care, such as muscle surgery, eyelid procedures, and treatment for skin cancers around the eyelids. “Ophthalmology is a field that is always advancing from a technological standpoint,” Dr. Petrie says. “It’s always a very groundbreaking specialty.” All of CVEC physicians are board-certified. Other credentials held by the providers include memberships in the American Academy of Ophthalmology, the American Society of Cataract and Refractive Surgery, the International Society of Refractive Surgery, and the American Optometric Association.

MEET OUR TEAM CEDAR VALLEY EYE CARE 909 E. San Marnan Drive Waterloo, 319-233-2020 1409 W. 1st St. Cedar Falls, 319-268-2020

Daniel Miller, MD Michael Puk, MD Brendan Girschek, MD, FRCSC, FACS Thomas Petrie, DO Suzanne Smith, OD Bradley Johnson, OD Lucas Cook, OD

www.CedarValleyMedical.com

from macular degeneration, to diabetic retinopathy, to retinal detachments. CVEC uses the only excimer laser in the Cedar Valley and the most up-to-date technology, including Custom-Cap treatment for irregular patterns of astigmatism. The LASIK surgery can be performed without using any blades. CVEC also was the first area clinic to offer the new 3D eye-tracking laser. It allows the laser to use active radar to follow any eye movement during the LASIK procedure, eliminating the possibility of laser pulses being applied in an incorrect spot. This increases safety by removing less tissue and utilizing a larger optical zone. Used during LASIK surgery, CustomVue Wavefront technology captures the unique imperfections in a person’s vision that could not have been measured and corrected previously, providing treatment options that are individualized. It produces a map of the eye, much like a fingerprint, and provides 25 times more precision than previous options.

Cedar Valley Medical Specialists, P.C. www.CedarValleyMedical.com

Jim Crouse, MD, FACS

CEDAR VALLEY ORTHOPEDICS O

rthopedics is the branch of medicine that treats the bones, joints, muscles and tendons and associated tissues. The eight orthopedic surgeons at Cedar Valley Orthopedics care for patients with broken bones, sports injuries, arthritic or worn-out joints, sprains, strains, cuts and bruises, as well as diseases and congenital problems involving the musculoskeletal system. 34

The most common procedures done include joint replacements of the hip, knee, shoulder and ankle, care for broken bones and joint dislocations with splints, casts or surgery, arthroscopic joint surgery, carpal tunnel surgery, and trigger finger release surgery in the hand. Dr. Jim Crouse says the majority of the cases have to do with injuries and arthritis. “Statistically, there are more people with

arthritic hips and knees,” he notes. “The population is aging and people are tending to be heavier, putting more stress on their joints, which causes increased wear. With age comes aches and pains from arthritis, bursitis and tendonitis.” As uncomfortable and inconvenient as any of these conditions or injuries may be, there have been advancements in the instruments and diagnostic and

have special interests in sports medicine and work closely with the University of Northern Iowa Department of Athletics and other organizations. Dr. Arnold Delbridge is experienced in spinal surgery. Joint replacement procedures are of particular interest to Drs. Thomas Gorsche and Robert Bartelt.

MEET OUR TEAM

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developed polyethylene (plastic). For bone ingrowth surfaces, titanium is the material of choice because of its closer similarity to real bone. “Bone can grow into it and bond more easily,” he says. Medical research is constant. In the forefront is stem cell research concerning regeneration of cartilage, skin and tendons. The hope is to have normal cartilage rather than metal in replacement surgery. Small areas of cartilage loss have been treated with various procedures, including taking cartilage from a knee, sending it to a laboratory to grow, and re-implanting the cartilage. However, as with most breakthroughs, the practice is expensive, time-consuming and still being perfected. Cedar Valley Orthopedics is also very focused on doing its part to keep costs as reasonable as possible. “Modern medicine is expensive, and we want to provide value for what we do,” says Dr. Crouse. Many of their surgeries are performed as outpatient procedures in United Medical Park’s Surgical Center on West Ridgeway Avenue in Waterloo. “It’s more convenient and is aimed at healthy patients who don't require major surgery and who can go home the same day, although overnight stays are possible. Most often this involves hand and foot surgeries, such as carpal tunnel and trigger finger release, and arthroscopic surgeries,” Dr. Crouse says. “As time goes on, I believe these procedures done in the Surgical Center will only increase. We now do partial knee replacement as an outpatient procedure.” The orthopedic surgeons at Cedar Valley Orthopedics travel to surrounding communities for clinical visits, including Waverly, Independence, Grundy Center, West Union and Sumner. In some cases they can perform outpatient surgery locally, but most of the inpatient operations are done at UnityPoint HealthAllen Hospital. Cedar Valley citizens are fortunate that in the more rare and complicated cases, patients may be transferred to the University of Iowa or The Mayo Clinic; they both have a close relationship with CVMS. The orthopedic physicians at Cedar Valley Orthopedics have special niches. Drs. Jeffrey Clark and Todd Johnston

CEDAR VALLEY ORTHOPEDICS Allen Hospital 164 W. Dale St. Waterloo, 319-833-5381, 319-233-6448 Robert Bartelt, MD Thomas Gorsche, MD Arnold Delbridge, MD

Cedar Valley Medical Specialists, P.C. at UNI 2351 Hudson Road, Ste. 001 Cedar Falls, 319-273-5275 Jeffrey Clark, DO Brenda Cooper, ARNP

United Medical Park 1753 W. Ridgeway Ave., Ste. 103B Waterloo, 319-833-5922 Jim Crouse, MD, FACS Roswell Johnston, DO, FAAOS Todd Johnston, MD, FAAOS Benjamin Torrez, DO, MPH Elizabeth (Liz) Hoy, ARNP

OrthoExpress

www.CedarValleyMedical.com

treatment techniques. Physicians are better-equipped to evaluate and treat bone and joint problems, leading to quicker and less-painful recovery times. Improved techniques and materials also offer a new hope of living more normally for people faced with fractured or degenerated joints, including the elderly, for whom a broken hip can lead to a sudden decline in lifestyle and overall health. “One of the biggest advancements is the development of arthroscopy for joints,” Dr. Crouse says. “It’s a major tool used now, particularly for shoulder and knee cases. There are still cases that need open surgical procedures, but more are done with a scope. The surgery is often easier to do this way and means quicker recovery for the patient. It’s also more cost-effective because it can be done as an outpatient.” This ties in with the trend of patients returning home sooner after hospitalization. Rather than needing to stay two weeks after a hip replacement, as was once the case, people may return home as early as the next one or two days. There is a movement to perform more replacements as outpatient procedures, which Dr. Crouse says requires a “concerted effort in getting people prepared and working with the family, physical and occupational therapists and others in managing post-operative care.” He explains that the instruments used for arthroscopy and joint replacement continue to be refined. MRI and CT scans are used for improved diagnosis and treatment. Materials continue to be refined for joint implants as we learn over time what works and what does not work so well. “We used to tell patients that a joint replacement would last maybe 10 years,” Dr. Crouse says. “Now, we say that most are going to last a lifetime. As a result, we are seeing much younger people with injury or stress to the joints having replacements, understanding they are more likely to have wear and loosening, which may require revision, as well as the possible complications associated with any procedure.” Dr. Crouse explains that cobalt chrome materials and ceramics, which are very hard and don’t wear, are generally used for joint surfaces along with a highly

(Located in the ADI Building off San Marnan Drive)

4006 Johnathan St., Ste. B Waterloo, 319-233-0222 Mary Nading, PA-C

Cedar Valley Medical Specialists, P.C. www.CedarValleyMedical.com

Mary Nading, PA-C

ORTHOEXPRESS O

rthoExpress is a division of Cedar Valley Medical Specialists, and is the area’s only walk-in urgent care clinic specializing exclusively in orthopedics. The clinic is dedicated to sports, recreation and work injuries related to muscles, ligaments, bones and joints. For patients, that means strains, sprains, breaks or fractures no longer have to mean a costly trip to the emergency room. “A lot of patients go to the ER for a

twisted ankle or other injuries related to sports, falls or other mishaps,” says Dr. Roswell Johnston of OrthoExpress. “Depending on the injury, a referral may be made to see an orthopedic specialist, and it may take a while to schedule and get an appointment. We saw an opportunity to change and streamline that whole process, and that sparked the idea for OrthoExpress.” Dr. Todd Johnston explains that when

patients come to OrthoExpress, they can walk in with no appointment during normal business hours (currently Monday through Friday from 12 p.m. to 7 p.m.) — just like they would at the emergency room. The big difference is that they get to see a specialist first — a provider specializing exclusively in orthopedics. “Because patients don’t have to delay orthopedic evaluation and treatment, this can often lead to faster recovery times,”

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MEET OUR TEAM ORTHOEXPRESS

(Located in the ADI Building off San Marnan Drive)

4006 Johnathan St., Ste. B Waterloo, 319-233-0222 Mary Nading, PA-C

Consulting Orthopedic Specialists: Robert Bartelt, MD Jeffrey Clark, DO Jim Crouse, MD, FACS Arnold Delbridge, MD Roswell Johnston, DO, FAAOS Todd Johnston, MD, FAAOS Benjamin Torrez, DO, MPH

www.CedarValleyMedical.com

he says. the emergency room is still the When comparing the cost of place to visit first. “Patients should an emergency room visit to a use their best judgment. For true, walk-in clinic visit, the savings trauma-related and other serious can be huge. Dr. Benjamin Torrez injuries, the emergency room is emphasizes, “The difference can definitely appropriate. For most be hundreds of dollars or more, other injuries where you’re not depending on what you are being sure if it’s a sprain, strain, break seen for.” or fracture, Another OrthoExpress' advantage orthopedic “Because patients OrthoExpress specialists don’t have to delay offers is its can evaluate orthopedic evaluation relationship with and treat you and treatment, this ADI (Advanced quickly and can often lead to Diagnostic effectively.” faster recovery times.” Imaging). In fact, “We see OrthoExpress is people for torn actually located ligaments; in the ADI Building, just off painful, swollen and injured joints; San Marnan Drive in the Tower muscle and back pain; and foot, Park complex in Waterloo. Dr. ankle, shoulder, knee, hand and Jeffrey Clark says, “Working wrist injuries,” says Dr. Robert with ADI is a real benefit to our Bartelt. “Basically anything sports, patients. If imaging or scans are play, and work-related.” needed, our imaging partner is right there in the same building. ADI is widely known as one of the area’s leading imaging experts, but many are surprised to learn their services are typically offered at some of the lowest costs in the area for CT scans, X-rays, MRIs and ultrasounds — which saves OrthoExpress’ patients even more.” Dr. Arnold Delbridge emphasizes that for some injuries,

Cedar Valley Medical Specialists, P.C.

Jay Ginther, MD, CCD

www.CedarValleyMedical.com

CEDAR VALLEY BONE HEALTH INSTITUTE

fter 35 years as an orthopedic surgeon, Dr. Jay Ginther made a decision to try to prevent the conditions that often were sending his patients to the operating room — osteoporosis and poor bone health. “Traditionally, people have worried about treating osteoporosis, but frankly, preventing osteoporosis is a lot more helpful,” he says. “Medical professionals should be taking care of bone health in patients before they get to the orthopedic surgeon.” As a result of his “epiphany,” Dr. Ginther earned over 300 hours of continuing education credits specifically in bone health and opened the Cedar Valley Bone Health Institute, located in the ADI Building at 4006 Johnathan St. in Waterloo. It is the only center in the state devoted strictly to bone health. The primary care physicians are the first line of defense in the prevention of osteoporosis. Dr. Ginther uses himself as an example.

“In fairness to primary care, they’ve had other things to do,” he explains. “It took me three years to get my primary care physician to test for my vitamin D level. Because by the time we got done talking about my blood pressure and finished talking about my adult-onset diabetes, my cancer history, and a couple of other things, my time was long since up. When you get good bone health (care) is when you set aside a separate visit just for that.” As a surgeon, he says he got tired of placing screws into “an English muffin, hoping for good results. I got (bone) mush at best” when operating. Dr. Ginther says that if you don’t start worrying about your bones until you are out of high school, “it’s mostly over. If you don’t worry about your bones until you’re past 30, it's definitely over and all you’re trying to do is mitigate the downward slide that’s inevitable for the rest of your life. “You grow your bones primarily during adolescence. For women, you reach your

maximum bone density a bit before the age of 30; for men, a bit after 30. At that point, women lose up to one-half percent a year until they reach menopause. During menopause, some women lose as much as 20 percent of bone density. And after menopause, women typically lose one to two percent a year. Also, about one quarter of the osteoporosis patients are men. “An average person is currently living close to age 87. That’s another 20 years on one to two percent of lost bone density compounded every year. And it’s worse if you are not getting enough calcium and vitamin D,” he says. Dr. Ginther stresses that bone health is a matter of lifestyle. “As a kid, you should be running for at least a half hour five days each week. That’s going to build up good bones in your legs and back. But today, we are skipping physical education. “In terms of what is going to influence the rest of your life, physical education is probably more important than any of the

MEET OUR TEAM CEDAR VALLEY BONE HEALTH INSTITUTE

(Located in the ADI Building off San Marnan Drive)

4006 Johnathan St., Ste. B Waterloo, 319-233-2663

Jay Ginther, MD, CCD Jonathan Hennings, MN-FNP

World-Class Care, Close to Home.

hip, there’s almost a 20 percent chance you will never return home. If you are a male, there’s a 30 to 35 percent chance you will die of complications from that hip fracture. If you fall from a standing height and something breaks (not just because of ice or concrete), there’s a problem.” Dr. Ginther’s first step in caring for his patients is to improve their vitamin D, calcium and magnesium levels, along with their diets, during the first year. “We can tweak a lot of things first. Quite often, I have patients who will improve their bone density for three to five years by overcoming long-term calcium deficiencies. Then if a problem arises again, we can start thinking about medications as well.” He recently upgraded his DEXA machine to one that allows the patients to remain on their backs. Rather than trying to place patients on their sides to get a picture of the lateral spine (also known as a verbal fracture assessment or VFA), the machine rotates instead. Dr. Ginther says the addition of the VFA reading has increased the number of diagnoses of clinical osteoporosis. Dr. Ginther and his staff are doing more and more public appearances to educate about prevention and treatment of osteoporosis and bone health in general. They have spoken to church groups, prostate cancer support groups and celiac disease support groups. They also are beginning educational programs for student-athletes, particularly female athletes.

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academic classes.” Though the diagnosis and treatment of osteoporosis is mandated by the federal government, Dr. Ginther says it’s not being paid for by the government. The reimbursement for DEXA (a bone density test) has been cut by 75 percent over time. “We’re in a situation where less than half of the women in the country will get a DEXA,” he says. “As a diabetic, I am entitled to have an hour-long consultation with a nutritionist. As a patient with calcium and bone issues, I am not.” Dr. Ginther explains that if a person has had one previous fracture, they are more than twice as likely to experience another anywhere on the body. And if you’ve had two previous fractures, you are more than five times as likely to have another. “Many people have spinal fractures and never know it,” he says. “Eighty percent of upper spine fractures are unnoticed and are picked up incidentally by the DEXA machine, or on a chest X-ray if the radiologist happens to notice it. A lot of times they are looking for something else and are not focusing on what might be hiding there. “If you’ve lost height by more than one-half inch, there’s a reasonable chance you’ve got deterioration. If you’ve lost height by one-and-a-half inches, you should get evaluated.” Dr. Ginther’s frustration lies in the fact that bone health could be one of the biggest preventative specialties. Hip fracture is one of the leading causes of death in the United States. “It’s not listed as the cause of death. What’s listed is the congestive heart failure, the pneumonia, the pulmonary embolism — all complications of the hip fracture," he adds. "But if you are a woman age 70 or older and you break your

Cedar Valley Medical Specialists, P.C. www.CedarValleyMedical.com

Joseph Hart, MD, FACS

CEDAR VALLEY EAR, NOSE & THROAT AND HEARING CARE M

ost doctors enter the medical field because they want to help others. For Dr. Joseph Hart, the reason is more personal. When Joe Hart, his uncle and a physician himself, died of cancer of the tongue, it had a profound impact on him. “That’s what motivated my brother and I to specialize in ENT (ear, nose and throat),” says Dr. Hart. “We deal with anything from the clavicle up, in newborns to the very elderly.” Dr. Hart is one of Cedar Valley Medical Specialists’ two otolaryngologists. He is located at United Medical Park on West Ridgeway Avenue in Waterloo. Dr. Hart is a general otolaryngologist and his Cedar Valley Ear, Nose & Throat and Hearing Care offices perform sinus surgery; treat

pediatric ear, nose and throat patients; and treat hearing loss, nasal obstructions, chronic sinusitis, tonsils and adenoids, snoring and sleep apnea — in addition to treating such simple ailments as ear infections, sore throats and ears that need cleaning, and assisting patients with hearing aid fittings. “We deal with a lot of chronic problems,” Dr. Hart explains. “We also deal with acute conditions, which means they appear all of a sudden. We see patients who might have a problem for a very long period of time or lifelong concerns. A significant condition we see a lot of in Iowa is hearing loss.” Dr. Hart is very active at the national level through the American Academy of

Otolaryngology-Head and Neck Surgery (AAO-HNS). “My main effort was more patient advocacy when the state of Iowa presented a challenge for some insurers and physicians,” he explains. “That’s when I got involved, because those challenges can make physicians not want to practice in Iowa. So I got involved, first at the local level with both hospitals. I’m also a former state society president for ENT and a former board member of the Iowa Medical Society.” He’s currently a consultant to the AAO-HNS’s Board of Governors Governance & Society Engagement Committee. He’s appeared on Capitol Hill in the last 15 years advocating for patients and easier access to the health

-care system. “I’ve had electronic medical recordkeeping since I’ve been here (beginning 20 years ago),” Dr. Hart says. “That experience has made us somewhat more savvy, which is an advantage in our practice because it’s now such a huge part of our day-to-day environment. Technology is always changing. Instrumentation is constantly being updated in order to perform procedures more effectively. Some can even be less invasive than they were previously.” With a shortage of ENTs practicing in the state, the Cedar Valley is fortunate. “You should be able to access us and be able to have the vast majority of your needs met locally,” he says. “We are welltrained, have a lot of experience and we love our community.”

CEDAR VALLEY HEARING CARE

Hearing affects how we relate to our family and friends, how we perform our jobs, how we are able to lead productive lives and how we maintain our health through social connections. Audiologists are trained to diagnose, manage and treat hearing and balance

problems for persons of all ages. Stacy Wolf, AuD, can be found in the Cedar Valley Ear, Nose & Throat and Hearing Care offices of Dr. Joseph Hart. Wolf performs comprehensive diagnostic hearing and middle ear evaluations, and also performs specialized otoacoustic emissions testing on newborns. In addition to helping adults with hearing loss, she also sees a lot of children with middle ear fluid or infections. Some types of hearing loss can be treated medically or surgically by Dr. Hart, so it is important that these types of hearing losses be ruled out before hearing aids are considered. “Hearing aids have changed dramatically even from when I began practicing 19 years ago,” Wolf says. “Now they are more discreet in appearance, they are very comfortable and are very sensitive in adjusting to the patient’s listening needs. The biggest component of recent technological advances is that hearing aids can have wireless/Bluetooth connectivity." Newer hearing aids can be streamed to televisions, tablets, and computers. “Patients can be more satisfied in more challenging listening environments. They can have options for making adjustments to their hearing aids using their

MEET OUR TEAM CEDAR VALLEY EAR, NOSE & THROAT AND HEARING CARE United Medical Park 1753 W. Ridgeway Ave., Ste. 108 Waterloo, 319-833-5972 (Ear, Nose & Throat) 319-833-5975 (Hearing Care)

World-Class Care, Close to Home. www.CedarValleyMedical.com

Stacy Wolf, AuD

cell phones.” Phones can be turned into remote controls and adjusted for volume, used to change programs or even locate a misplaced hearing aid. Phones can also be turned into mini-microphones and placed in the middle of the table during a meeting; they pick up the voice and route it directly to the hearing aids. “Hearing aids aren’t perfect, they don’t restore normal hearing, but with these assistive devices you can really improve the quality of conversation,” Wolf says. According to several research studies by Johns Hopkins University, older adults with hearing loss are more likely to develop dementia and Alzheimer’s disease compared to their normal-hearing peers. “Hearing enriches relationships and connects you to the world. Your ears and brain work together as a system. Hearing plays a vital role in brain health,” Wolf says. “A key in treating hearing loss is the patient’s motivation to do something about it. If he or she waits too long, it’s more difficult for the brain to adapt to a hearing device.”

Joseph Hart, MD, FACS Stacy Wolf, AuD

Cedar Valley Medical Specialists, P.C. www.CedarValleyMedical.com

LEFT: Ashar Afzal, MD, RIGHT: Frank Hawkins, MD

PAIN MANAGEMENT N

ext to the common cold, back pain is the second most common reason for people to visit a primary care physician. Physicians specializing in pain management have seen patients accessing their services at an increasing rate for a multitude of pain-related problems. The elderly are afflicted with wear- and tearrelated issues to their joints and spines. Younger patients also seek their services for sports-related injuries and other recreationally or occupationally related injuries. As pain management has become a recognized specialty in the field of medicine, primary care physicians and providers are more readily referring patients for chronic pain issues. “Pain management is getting more recognized,” says Dr. Ashar Afzal, who, along with Dr. Frank Hawkins, provides full-time pain

management through the Allen Hospital Center for Pain Medicine, located at 3630 W. 4th St. in Waterloo. “I think there’s a lot more research into the mechanisms, biology and pharmacology of how to effectively manage pain,” Dr. Afzal adds. Pain is defined by the International Association for the Study of Pain as an unpleasant sensation associated with actual or perceived physical or psychological trauma. Dr. Afzal explains that pain is not always linked together with something that has happened physically, but with how a person perceives pain. 10 to 15 years ago, pain was actually recognized as the “fifth” vital sign, along with temperature, pulse, blood pressure and respirations. “People have different psychological structures,” Dr. Afzal comments. “People perceive pain differently and manage

pain differently. Pain and depression are very closely linked. We try to assess this as a contributing factor to their pain complaint. We then incorporate the use of antidepressant medications to primarily manage their chronic pain but potentially to have the added benefit of helping with their underlying depression.” Dr. Hawkins says treating pain — either acute or chronic — begins with a thorough evaluation, and conducting a history of the pain location and its intensity, characteristics and possible precipitating events. A physical examination is performed to determine from where the pain may be originating. Diagnostic studies are then utilized, if available, to help confirm the diagnosis of the source of the pain. “If we can determine the nature of what is causing the pain, then we can

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in 2007. As the practice grew, it was no longer feasible to provide both anesthesiology services and pain management. They began practicing full-time pain management approximately four years ago. Both physicians express the advantages of practicing under the umbrella of a medical group such as CVMS and the relationship that they have with UnityPoint Health-Allen Hospital. Allen Hospital provides the support staff to allow the clinic to run efficiently. This includes the clerical staff, radiology technicians, medical assistants and nurses that provide exceptional care to the clinic's patients. “We have the resources in regard to a referral network within CVMS and UnityPoint Health where we can have confidence that we are sending our patients to colleagues who we respect and who we are certain will provide the best care to our patients,” notes Dr. Hawkins. “Being under this umbrella of these organizations allows us to provide our patients with the quality care they deserve.” “CVMS also gives us an identity,” Dr. Afzal adds. “Cedar Valley Medical Specialists is a recognized name in the community and statewide. We are affiliated with an organization that has a highly trained network of physicians. We can rely on the resources it has, whether it be orthopedics, physical therapy, radiology or any other department that we may call upon to help us care for our patients.”

MEET OUR TEAM PAIN MANAGEMENT Allen Hospital Center for Pain Medicine 3630 W. 4th St. Waterloo, 319-235-7246 Ashar Afzal, MD Frank Hawkins, MD

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decide if the patient may need the assistance of physical therapy, chiropractic care, a psychological evaluation, injections, or medications. We might incorporate over-the-counter medications or prescription medications to help in their recovery,” Dr. Hawkins adds. “The ultimate objective is to help reduce their pain to allow them to recover and be more functional with less pain. We take patients from evaluation, to treatment, to hopefully positive outcomes,” says Dr. Hawkins. With advancements in pharmacology that allow the medications to better target the pain receptors, Dr. Hawkins and Dr. Afzal incorporate the latest advancements in medication delivery. These medications may be delivered orally, topically, transdermally and spinally via pump technology. They also provide injection therapy to the spine and joints. Additional services include spinal cord stimulation and certain spine fracture management procedures. Drs. Afzal and Hawkins were both trained as anesthesiologists. Dr. Afzal completed a fellowship in pain medicine at the University of Iowa Hospitals and Clinics and is board-certified in anesthesiology with a subspecialty certification in pain medicine. Dr. Hawkins became interested in pain management after completing his residency training in anesthesiology over 23 years ago. He incorporated this discipline into his clinical practice beginning in 1993. He is board-certified in anesthesiology and certified by the American Board of Pain Medicine. Dr. Afzal joined Cedar Valley Medical Specialists (CVMS) in 2002, and he, along with two other physicians, started the pain management practice for CVMS. Dr. Hawkins joined CVMS in 2004 and began practicing pain management along with Dr. Afzal

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TOP ROW FROM LEFT TO RIGHT: Makenze Mobley, PTA, Dave Fricke, M.S. ATC, LAT, Charlotte Strub, PT, ATC, Laurie Gibson, Ray Harrington, PT, Rebecca Jost, PTA, Jacob Westphal, PTA, Steffanie Merchant, PTA, Brenda Harrington BOTTOM ROW FROM LEFT TO RIGHT: Craig Thielen, PT, ATC, Monica White, PT, DPT, Guia Palma, PT, Kristin Lutz, PTA

CEDAR VALLEY PHYSICAL THERAPY AND OCCUPATIONAL REHAB T

he goal of the staff at Cedar Valley Physical Therapy (CVPT) is to restore or facilitate function and movement following an injury or other medical condition. The goal is for the patient to continue with a home exercise program and manage the continuation of his or her own recovery, thus diminishing the need to return for future therapy or medical care. CVPT provides a wide range of services and specialties in two convenient locations. The first is a 10,000-squarefoot facility at United Medical Park on West Ridgeway Avenue in Waterloo. The second facility is at the University of

Northern Iowa Wellness Center and uses the HydroWorx therapy pool. The pool’s floor raises and lowers to make it easier for patients to enter for therapy and helps treat individuals who require weightbearing rehabilitation. Using manual mobilization, exercise, special range of motion, modalities and patient education, CVPT works with a wide variety of orthopedic acute and chronic patients. Their staff treats a large range of post-surgical conditions such as joint replacements, joint reconstructions, trauma, sports injuries, multiple spine conditions, and many other joint surgeries. Many patients also suffer weakness

resulting from chronic degeneration of specific joints. CVPT helps set up specific exercise programs to help manage their conditions. “We also have seven athletic trainers that provide coverage to area high schools,” says Ray Harrington, physical therapist. “It’s nice to have them on the field at both practices and games. They are good communicators with both parents and the injured athletes. They may have to make a referral to an orthopedic surgeon or physician in the area.” Additionally, therapist Guia Palma is a vestibular balance specialist. There are two vestibular conditions, one caused

“There is another avenue for treating these urological conditions, and we have two people on staff who have a passion for working with these patients. They have had excellent results.” The staff at Cedar Valley Occupational Rehab (CVOR) assist workers and companies in the area of occupational health, and perform pre-offer employment testing, which is a functional test that determines the strength of the overall body. “It’s a matter of matching the functional lifting level of a potential employee to the job description,” Harrington says. “It’s also a way to determine if a person is functionally able to return to work after surgery or an injury. Are they producing adequate strength to be able to perform functional tasks?” In addition, CVOR can visit actual job sites and conduct ergonomic analyses to determine the job description task level or to make suggestions on how to make a job more safe. “We've expanded these services into the new CVOR clinic,” Harrington adds. CVOR is located at 7024 Nordic Drive, Ste. 200 in Cedar Falls. “Our staff is constantly being trained in new evaluation, treatment, mobilization, and specific exercise techniques for an array of problems. We’re always receiving continuing education on new techniques and rehab. “We have good communication with the physicians in our group,” he adds. “If a surgeon attends a conference and learns of new procedures or protocols, that information is forwarded to us. We can develop new protocols as they are developed on the surgical side. “Our growth is a reflection of how we’ve served the needs of the Cedar Valley, specializing in patient care for over 30 years.”

Ray Harrington, PT Guia Palma, PT Charlotte Strub, PT, ATC Craig Thielen, PT, ATC Monica White, PT, DPT Stefanie Swinton, PT, DPT Mitch Fonley, MPT Katie Niebuhr, DPT, ATC Rebecca Jost, PTA Kristin Lutz, PTA Steffanie Merchant, PTA Erin Renn, PTA Jacob Westphal, PTA Makenze Mobley, PTA Allyson George, ATC, LAT Melissa Fernau, ATC, LAT Joe Bahnsen, ATC, LAT David Fricke, M.S. ATC, LAT Pete Watters, ATC, LAT Scott Lockard, ATC, LAT

Cedar Valley Medical Specialists, P.C. at UNI Northeast Iowa Physical Therapy-UNI 2351 Hudson Road, Ste. 164 Cedar Falls, 319-273-5265 Katie Niebuhr, DPT, ATC Mitch Fonley, MPT Mandi Denner, ATC, PTA

CEDAR VALLEY OCCUPATIONAL REHAB 7024 Nordic Drive, Ste. 200 Cedar Falls, 319-859-3895 Ray Harrington, PT Mitch Fonley, MPT David Fricke, M.S. ATC, LAT

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by the central system (brain and brainstem) and one from the peripheral (inner ear and pathways to the brainstem). “Guia is certified to work with individuals that suffer from dizziness or other vertigo problems,” Harrington says. “The number one problem with people over 60 is falling. It could be from an orthopedic weakness or a vestibular problem. If Guia can make you dizzy (in the diagnosing phase), she can make you better. She can prescribe specific body positions to correct the dizziness.” Other geriatric conditions such as arthritis or weakness can be treated as well. CVPT also treats a wide variety of pelvic and urological conditions in both females and males. Most people are surprised to learn a physical therapist can treat symptoms of urinary urgency, incontinence, pelvic organ prolapse and symptoms associated with pregnancy and postpartum. Monica White is one of only three pelvic specialists in Iowa certified by the American Physical Therapy Association who has received specialized training in this area. “We’ve developed a nice program in this area. Over the past six months, Guia and Monica have treated more than 100 patients,” Harrington says. The treatment involves educating the patient with specific exercises on how to control the flow. If this fails, biofeedback may be an option to help in the exercise and training process to successfully treat the condition. Biofeedback is a tool that is used to help patients visualize how they are using their muscles. “People think urination problems are a part of getting older, and they think there is no help for them,” Harrington explains. “As people age, they expect to get more out of life. If they can learn to control the issue, they are going to have a more positive outlook on life.

CEDAR VALLEY PHYSICAL THERAPY United Medical Park 1731 W. Ridgeway Ave. Waterloo, 319-833-5900

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James Cafaro, MD

PULMONOLOGY M

any medical specialties evolve over time. Diseases evolve, medications evolve, technologies change. The field of pulmonology is no different. A pulmonary specialist, or pulmonologist, is a physician who possesses specialized knowledge and skill in the diagnosis and treatment of lung conditions and diseases. Pulmonology is a subspecialty of internal medicine. Because of the variety of clinical conditions seen by a pulmonologist, expertise in a myriad of specialties is needed. A pulmonologist treats asthma,

bronchitis, chronic coughs, chronic obstructive pulmonary disease (COPD), cystic fibrosis, emphysema, hemoptysis (coughing up blood), lung cancer, obstructive sleep apnea, pleural effusion (excessive build-up of fluid around the lungs), sarcoidosis (organ inflammatory disease affecting primarily the lungs), and tuberculosis, to name a few conditions. Dr. James Cafaro has been practicing pulmonology in the Cedar Valley for 37 years and is the only pulmonologist in Cedar Valley Medical Specialists' Pulmonology Department. He has seen

the prevalence of diseases change over the years, as has the technology in treating these diseases. “The most common conditions we see (locally) are COPD, asthma and lung cancer,” he says. “Bronchiectasis (chronic damage to the bronchial tubes) is not as common as it used to be because people are treated earlier with antibiotics. We’re not sure why asthma is becoming more common. In kids, it’s usually because of allergies.” Dr. Cafaro explains the primary cause of COPD is smoking, but it also can be

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other computerized machinery that allows us to see lesions that we may not have been able to biopsy before.” Dr. Cafaro says there are several new drugs to aid in the treatment of pulmonary fibrosis where previously there was no treatment at all. “For lung cancer, we have medications and markers that can target, or narrow down, the types of drugs that would be helpful in treating a certain person. Targeting is only going to get better and better.” Patients needing inhalers for asthma, emphysema and COPD have numerous options to choose from. They work faster because the medicine goes directly into the lungs, unlike pills. Another treatment option is portable oxygen. There are newer, smaller concentrators on the market that allow patients to get out for longer periods of time. The older tank oxygen units are unwieldy and don’t last as long. Pulmonology has several crossover diseases. For instance, pulmonologists help to diagnose sleep disorders, including sleep apnea. Neurologists and ear, nose and throat (ENT) specialists become involved once the diagnosis has been confirmed. Dr. Cafaro says more people are becoming aware they have pulmonary conditions. Studies are always being conducted in efforts to treat or control pulmonary conditions. “They are still doing research, but the important focus should be on preventive care,” says Dr. Cafaro.

MEET OUR TEAM PULMONOLOGY Allen Professional Building 212 W. Dale St., Ste. 203 Waterloo, 319-235-3518 James Cafaro, MD

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associated with exposures. 15 percent of patients with COPD have no smoking history or exposure. “Hog farmers can develop chronic bronchitis from hog dust. It’s pretty common in the Midwest,” Dr. Cafaro notes. Farmers also have concern with chemicals used in the fields, for example. The simple cure was to avoid the exposures that bothered them, but that can be a difficult answer for people earning their livelihoods. “We see less of these kinds of conditions,” Dr. Cafaro says. “The University (of Iowa) has a program devoted to the risks of agricultural work. Farmers are more educated and know they should wear masks when working in grain bins. The cabs on the tractors and combines are so much cleaner and airtight now. Farmers are not exposed to the pesticides as much now. “The exposures in factories have lessened a lot as well,” he explains. “Even though many companies have systems to clean the air, certain chemicals still may be present that can cause breathing problems. It’s pretty hard to avoid because some things are just part of the job. But not all people are bothered by the same exposures.” Pulmonology is a specialty of diagnosis. Dr. Cafaro says the biggest advancement in his effort to diagnose a condition correctly and quickly has been the introduction and improvement of CAT scans. “CAT scans of the chest show many more things that you couldn’t see with just X-rays in the clinical exam,” he says. “We now can do biopsies with needles that required surgery before the availability of CAT scans. They are much faster and show finer detail. That has been very helpful.” He also says the bronchoscopy technique (looking into the lungs with a tube) has become more sophisticated. “We now have ultrasound with the procedure and

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Rajeev Anugu, MD

RADIOLOGY R

adiology is the medical specialty that includes the diagnosis and treatment of certain conditions through the interpretation of images taken with various imaging technologies. Those technologies include ultrasound, CT scans, nuclear medicine, PET scans, X-rays and MRIs. “Radiologists expedite the diagnosis and ensuing treatments,” Dr. Rajeev Anugu says. He’s one of seven radiological specialists in Cedar Valley Medical Specialists (CVMS)’ group, all of whom work in the offices of the Radiology Department or Advanced Diagnostic Imaging (ADI). “One of my instructors said it best when he called us

‘consultants to consultants’. We interpret the images so other physicians have a better understanding of what is going on with a patient.” There are subspecialties to radiology. For example, a colleague of Dr. Anugu, Dr. John Halloran, is an interventional radiologist, meaning he performs medical procedures, which are usually minimally invasive, in almost every organ system with the guidance of imaging technologies. Many conditions, like abscess drainage, that once required surgery can now be treated non-surgically by interventional radiologists. CVMS also has the only pediatric radiologist in the area in Dr. Murali

Surnedi. Pediatric radiology involves the imaging of infants, children, adolescents and young adults. The specialty has to take note of the varying dynamics in developing bodies and the radiation differences between adults and children. Children are more radiosensitive than adults and live longer, which may increase the risk of too much exposure to radiation. Dr. Anugu is a neuroradiologist and focuses on the brain and spine. All physicians in the group are fellowshiptrained or have special interests. As mentioned above, radiologists do not just interpret the images obtained through the technologies, but also perform procedures. They conduct diagnostic

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From my office, I can read an X-ray of a patient who lives in Grundy Center without having to physically drive to Grundy Center. Patient care is instantaneous.” Dr. Anugu and his colleagues’ focus always has been, and always will be, “patient care first.” When intervention is needed, if complications arise after a surgery, they can address the problem to help prevent sending the patient back to surgery. Much of radiology is preventative medicine as much as diagnostic. Mammography is preventative if an abnormality is caught in the early stages. CT colonography has not been used as often as the usual colonoscopy, partially because radiation is involved. With improving technology to reduce radiation, this might be utilized more in the future, Dr. Anugu says. CVMS’ radiologists are located at Allen Hospital, United Medical Park and ADI at the Cedar Falls and Waterloo locations.

MEET OUR TEAM RADIOLOGY Allen Hospital 1825 Logan Ave. Waterloo, 319-235-3390 Rajeev Anugu, MD Gopi Kota, MD John Halloran, MD Murali Surnedi, MD

United Medical Park 1731 W. Ridgeway Ave., Ste. 101 Waterloo, 319-833-6001 Lawrence Liebscher, MD, FACR Greg Raecker, DO

Advanced Diagnostic Imaging 4006 Johnathan St. Waterloo, 319-236-2700 Cedar Valley Medical Specialists, P.C. at UNI 2351 Hudson Road, Ste. 001 Cedar Falls, 319-273-5275

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biopsies on discovered masses with the aid of ultrasounds, or the draining of abscesses under local anesthesiology in perhaps an outpatient setting so the person can return home the same day. If a person has difficulty swallowing, a barium exam may be required. Radiologists can drain fluid from the chest or abdomen. If a fall has occurred, radiologists may insert a needle into the spine for an injection of cement and the patient can return home in about four hours. Under appropriate conditions, radiologists even can remove a clot in the brain of a stroke patient. Allen Hospital is a primary stroke center and can have an image of the brain within 30 minutes of a stroke-alert person entering the hospital door. Tomosynthesis is used in 3D mammography in order to create a three-dimensional image of breast tissue for better examination. CVMS’ physicians use this technology at United Medical Park to aid Dr. Douglas Duven and the Cedar Valley Breast Care Center. Dr. Anugu says this technology should be the standard of care. “Radiology has advanced a lot because of technology,” Dr. Anugu says. “CT scans used to be nothing but an X-ray that showed the body in one slice. It took too long to get a picture of the entire body while the patient had to lay perfectly still. Now, we have CT scans that have 128 slices, and an entire scan can be done in 10 to 15 seconds. “Right now, a lot of the focus is on reducing the amount of radiation on the patient. We have to determine what is right for the patient and what is right for the condition,” says Dr. Anugu. “Our CT scans have a lower dose of radiation but we don’t want to go so low that the imaging is not useful. We have to find the right balance,” Dr. Anugu says. “Years ago we read X-rays from film. Now everything is digital.

Driss Cammoun, MD

Cedar Valley Medical Specialists, P.C. www.CedarValleyMedical.com

Claro Palma, MD

RHEUMATOLOGY D

r. Claro Palma is the only rheumatologist in the Cedar Falls/ Waterloo area. His office in Cedar Valley Medical Specialists' Rheumatology Department is located at United Medical Park on West Ridgeway Avenue in Waterloo. Rheumatology is a subspecialty of 50

internal medicine. A rheumatologist undergoes an additional two to three years of training in order to be able to diagnose and treat the various disorders associated with musculoskeletal diseases and systemic autoimmune conditions commonly referred to as “rheumatic diseases.” These diseases can affect the joints, muscles and

bones and cause pain, swelling, stiffness and deformity. “The autoimmune conditions occur when the immune system sends inflammation to areas of the body when it is not needed, causing damage or other symptoms,” Dr. Palma says. The diseases also can affect the eyes, skin, nervous

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signals are increased in specific conditions. So if you can block a signal with antibodies assigned to only interact with that particular signal, then you can block the inflammation. The antibodies are usually given via injection,” Dr. Palma says. Still, some conditions have not had antibodies assigned or the antibodies still don’t work as well as some of the old medications, such as chemotherapy drugs, which are used for certain types of vasculitis. “Over the past 10 to 15 years, we have identified more than a dozen of these specific signals produced by different cells,” Dr. Palma says. “Progress is being made, and we have more options for treatments.” Science continues to look for more treatment options. Dr. Palma says a lot of genes are being identified as risk factors for certain conditions. “We might be able to use genetic testing to identify conditions ahead of time,” he says. Dr. Palma encourages his patients to work closely with physical therapists or at least to participate in a recreation program or some other exercise program offerings. His patients also might need to have consultations with pain doctors or orthopedists. “If you keep moving, you do better,” he says. “It’s not a cure, but you will feel better.”

MEET OUR TEAM RHEUMATOLOGY United Medical Park 1753 W. Ridgeway Ave., Ste. 105 Waterloo, 319-833-5940 Claro Palma, MD

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system and internal organs. “Causes also may include bad lifestyle choices or injuries. The conditions may include osteoarthritis, tendon injuries, tendonitis, nerve problems due to pinched nerves, and immune disorders like lupus and scleroderma. Some other conditions are gout, vasculitis and inflammation of the blood vessels — depending upon what organ is involved, you can have lung inflammation, heart inflammation or brain inflammation,” adds Dr. Palma. He explains that diagnosis involves visiting with the patient, discussing symptoms, getting a family history, and interpreting the information in order to make a reasonable assessment. “Additional testing includes testing of the blood and ordering X-rays or MRIs, and sometimes requesting tissue biopsies, depending upon what organ might be involved,” he adds. “Certain features will be identifiable in the biopsy, resulting in a diagnosis.” Rheumatologists do not perform surgery, though certain complications of a condition can lead to surgery. Joint deformities or inflammation in the breathing passages, for example, can lead to further invasive treatments, such as dilating the trachea or esophagus if the passageways have narrowed. Non-surgical care involves the use of antibodies. “There are a lot of new antibodies that identify rheumatoid arthritis,” Dr. Palma says. “There now are more specific tests for diagnosing lupus. The testing is easier to quantify. Testing previously was done on cell cultures. Now it’s an antibody test. “The treatments have changed a lot in that we now have developed monoclonal antibodies. The antibodies are engineered to target specific signals that the body uses to trigger certain inflammations in an abnormal way. These

Cedar Valley Medical Specialists, P.C. www.CedarValleyMedical.com

Francis Connelly

CEDAR VALLEY SLEEP CENTER S

leeping next to a snorer can be irritating. If you don’t fall asleep first, you could be lying there for an extended time before being able to fall asleep yourself. You toss and turn. You nudge your partner hoping the change in position will stop the annoyance. It’s not just the annoyance that can be a problem. Snorers can be putting their health at risk. There are approximately 88 sleeping disorders. Sleep apnea is the primary condition, along with insomnia. The disorders can increase the risk for high blood pressure, heart disease, heart attack, stroke, or driving- or work-related accidents. Diabetics left untreated for sleep apnea can record higher sugar levels in the morning. Treated, the sugar levels may be in normal range. In children, sleep

apnea can cause hyperactivity and affect development. As a rule, children should not snore. Obstructive sleep apnea (OSA) afflicts about 20 million adult men and women in the U.S. Only about 10 to 15 percent have actually been treated. The result is repeated breathing cessation during sleep because the airway collapses. This may be due to anatomical factors like a large tongue, extra tissue in the airway, or decreased muscle tone holding the airway open. Weight can be another cause. “Weight does have an impact,” says Francis Connelly of the Cedar Valley Sleep Center, a partner of Cedar Valley Medical Specialists (CVMS). “Gravity pushes down on the airway if you have a lot of tissue. But I have seen significant

sleep apnea in people that are quite slim. Each person’s anatomy is different, especially in the throat and with the tongue. Some people may have big tonsils that can cause snoring.” The Sleep Center and CVMS have been in partnership since 2014. Connelly is a registered EEG technologist and registered polysomnographic technologist. Electroencephalography is a monitoring method to record electrical activity of the brain. Connelly worked at Mercy Medical Center-North Iowa in Mason City for 24 years. It was one of the few hospitals in the state that performed sleep testing in 1986, when the specialty was in its infancy. “I got involved with it really early,” Connelly says. “I took a liking to it because it changes peoples’ lives,

can be quite expensive. We’re the only independent facility in the local area.” Connelly says the CPAP therapies will continue to improve because of the technological advances. More dentists will become involved because of the improvements and advancements of oral appliances. More sleep testing will be home-based because of technological advances. Sleep labs still will be needed, however. The number of patients being tested will increase because of better awareness of the problem by both patients and physicians. Testing will become less expensive because there will be more facilities like the Cedar Valley Sleep Center. “Sleep apnea is a treatable condition,” Connelly says. “Losing weight may improve or correct the problem, but again it depends upon the anatomy, how large the airway or how thick your tongue is. ENT (ear, nose and throat) specialists can perform laser procedures to shrink the palate or remove tissue to open a small airway. “The older you become, the better chance you have of developing sleep apnea. Males tend to have more sleep apnea issues, but women have equally as much sleep apnea after menopause. The first step is to get diagnosed, then the right treatment plan can be explored for you.”

MEET OUR TEAM CEDAR VALLEY SLEEP CENTER 2413 W. Ridgeway Ave., Ste. 1 Waterloo, 319-505-2896

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fitting of a mask and initiating a CPAP machine that the person wears each night when they go to bed. The mask provides a continuous stream of air pressure to keep the airway open. A bilevel PAP machine may be prescribed for certain situations and gives two levels of pressure, while an auto-PAP machine adjusts the pressure while the person sleeps according to the person’s needs. A Servo-Ventilation machine is similar to a ventilator but is non-invasive. Each time the machine senses the person is not breathing, it kicks on automatically and breathes for the patient until they begin breathing on their own. Extreme cases may require surgery such as a tracheotomy. Other corrective measures include changing sleeping positions, or fitting the person with an oral device to help keep the airway open. As a result of more awareness on the parts of physicians and sufferers, sleep testing is becoming more accepted. Cardiology is one of the specialties that refers patients for sleep testing. “Sleep apnea creates a stress, and if you have heart problems, the stress becomes more serious,” Connelly explains. “Cardiologists believe the sleep problem should be addressed quickly before they start treating other conditions. For example, hypertension medications may be reduced or possibly eliminated due to the correction of the sleep apnea.” Concerns regarding sleep apnea have arisen in other areas as well. The U.S. is the last developed country to implement sleep testing for truck drivers. A large number of accidents annually have been attributed to sleep apnea or driving drowsy behind the wheel. The Sleep Center can perform four to six studies per night. It currently performs 60 to 80 studies per month. The monitoring technicians are respiratory therapists or are registered in sleep therapy. In 2017, everyone performing sleep tests in Iowa must be a registered sleep technologist and be licensed. The Cedar Valley Sleep Center is an independent diagnostic testing facility, meaning it treats patients in an outpatient environment. “This is a true advantage for our patients,” Connelly says. “Hospital-based sleep testing

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sometimes almost immediately. “I’ve done tests on people who have bad sleep apnea, put them on a CPAP (continuous positive airway pressure) machine and they wake up the next morning and say, ‘oh, my gosh, I haven’t slept this good in 20 years.’ They didn’t realize how tired they were, how disruptive this can be to their daily lives.” Sleep disorders are broken down into disorders of excessive somnolence (sleepiness) and disorders initiating and maintaining sleep. Parasomnias are the bizarre sleep or unusual sleep disorders, such as REM behavior disorders, sleep terrors, sleepwalking and sleep eating. “Some people get up in the middle of the night, eat food and not even know they are doing it,” Connelly explains. “They’ll eat dog food or cigarettes.” When a person dreams, the body paralyzes itself, a preventative mechanism so the dream is not acted out, like jumping out of a window, running into walls or striking your bed partner if the dream is about being chased or held. If the person has REM behavior disorder, this mechanism isn’t working for some reason, whether because of a previous stroke, medications or a brain tumor. Connelly says this condition is not very common and generally affects males in their 60s. When adolescents and adults have an apnea event there is a protective mechanism in the brain to arouse the person so they take another breath. It is believed babies who have SIDs may not have that preventative mechanism in place. When they stop breathing, they don’t recover. If a person is suspected of having a sleep disorder, they are referred to a sleep lab such as the Cedar Valley Sleep Center. The center is located at 2413 W. Ridgeway Ave. in Waterloo. The patient is hooked up to various monitors and allowed to go to sleep. The patient is made as comfortable as possible in a home-type atmosphere. The monitoring provides answers as to what kind of sleep disorder or disorders the person suffers from. “If the condition is severe enough, we try to fix the problem in one night,” Connelly says. The “fix” most often includes the

Francis Connelly

Cedar Valley Medical Specialists, P.C. www.CedarValleyMedical.com

LEFT: Travis Hansen, RIGHT: Armand McCormick

XL SPORTS ACCELERATION PROGRAM X

L Sports Acceleration Program began about 10 years ago on the University of Northern Iowa campus. Since, the membership has grown by leaps and bounds. The training space has gone from about 4,800 square feet to over 11,000 square feet. It now is located at 3109 Venture Way in the Cedar Falls Industrial Park. XL Sports is designed to improve an athlete’s ability to win. Athletes develop skills such as explosiveness, speed, agility, jumping and mental skills. All coaches are certified and experienced.

“We train athletes mostly from middle school and high school,” says Director Armand McCormick. “We do have a lot of college athletes who come back during the summer. We’ve been pretty successful with our high school athletes. We just had a class of six who went off to play college sports.” No other gym in town does what XL Sports does. Coaches take a multi-tiered approach to increasing performance and maximizing potential. The bronze level, at XL Sports, for example, teaches technique and builds

strength while developing coordination and speed. It is built for athletes who may not be beginner athletes but are beginners to advanced in their training. The silver level coaches speed, power and strength. This intermediate level helps athletes become more familiar with specific weightlifting techniques and advancement to moderate intensity plyometrics. It is designed for athletes who have previously participated in, and who have completed, the bronze level, or who have been assessed by XL staff. The gold level coaches power and

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McCormick says most of the kids who started in the youngest age group have continued on to the higher levels. XL is not designed to be a program for post-surgical athletes. McCormick says they still should attend the physical therapy sessions as advised by their doctors. “PTs (physical therapists) do a lot more with measurable data as far as knee range of motion and other post-surgery measurements,” he adds. “We do a lot of data collection with numbers as far as jumping, running — the progress numbers. “What we really want to do is get the athlete into an athletic pattern again. We want to bring them back to the ability to get back into sport — putting them back on the field.” McCormick says athletics “any more is very one-dimensional. In other words, if I play football, I play football. So you have a lot of kids who just get beat up yearround by sports. Their joints aren’t strong enough to take the activity they are doing.” XL Sport provides outreach training to area high schools. McCormick and Hansen traveled to La Porte City, Waverly and Denver during the summer, assisting with the schools’ weightlifting programs by teaching proper form and technique and providing a workout schedule. Other programs offered by XL Sports include military career preparation and general adaptation training. The former is an intensive six-week course which prepares an individual for military service. Activities include rope climbing, hiking, push-ups, pullups and fireman carries. The latter class is based on the principles and philosophy of CrossFit for adults. It is meant to tax the body’s energy systems with each workout.

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explosive speed and strength. Athletes work to improve their overall explosive technique. They should be familiar with Olympic lifts and have a strength base that allows them to participate in the highest-intensity plyometrics. This level is designed for athletes who participated in the previous two levels. Training regimens at XL Sports are sport-specific, whether it be football, volleyball, basketball or wrestling, which makes the given program very relevant to the athlete. Also included in the training is the opportunity to learn about proper nutrition. Reaching full potential requires adequate fuel. The food an athlete eats — the quality, the quantity, the carbto-protein ratio — is important. XL views diet as another facet of training. A newer addition to XL Sports is CrossFit Kids, a version of adult CrossFit but meant for kids and teens. It’s a strength and conditioning program meant to help develop a lifelong love of fitness. No other gym begins training kids as early as XL Sports. McCormick and Coach Travis Hansen have developed three levels of CrossFit Kids, beginning with preschool ages three to five. “We teach real basic movements,” Hansen says. “It’s more just to get the kids in here. Their parents were bringing them in while they worked out, and you could tell the kids wanted to do something too. “The classes are only 30 minutes long because it’s difficult to keep them engaged for 10 minutes, let alone 30. We work on things like somersaults and simple squats.” There also are classes for ages six to nine and for ages 10 to 12. “Each class gets progressively harder,” Hansen explains. “We work on the foundations of CrossFit and fitness in general while playing games and incorporating simple movements.”