Nemours Childrens Hospital - FloridaMD

AUGUST 2011 • CENTRAL FLORIDA EDITION
Nemours Children’s Hospital
Opening in Fall of 2012
in Orlando
Welcome to a
hospital that will
never stop breaking
new ground.
The Neurosurgical Revolution is Coming.
NeurosurgicalRevolution.com
contents
AUGUST 2011
CENTRAL FLORIDA EDITION
4
COVER STORY
Coming to Orlando in 2012: Nemours Children’s Hospital and Health Campus
Photos Provided by Nemours
The 2012 opening of the Nemours Children’s Hospital in Lake Nona Medical City
increases the research and clinical care capabilities of Nemours Children’s Clinic in
downtown Orlando. Families will be able to access all of their services and specialists in
one place. Located on 60-acres, NCH represents added healthcare options for families,
economic growth and a collaborative approach that will only improve the future of
Central Florida’s families.
Photos Provided by Nemours
12 The ABC’s of Improving
Physician-Patient
Relations to Reduce
Infant Mortality
25 The Evaluation and
Treatment of the Patient
With a Chronic Cough
30 CURRENT TOPICS
DEPARTMENTS
2FROM THE PUBLISHER
3
FOR YOUR ENTERTAINMENT
8
MARKETING YOUR PRACTICE
10 PHARMACY UPDATE
11 WEALTH MANAGEMENT
14 Medical Malpractice Expert Advice
15 ORTHOPAEDIC UPDATE
16 PULMONARY AND SLEEP DISORDERS
18 FACIAL COSMETIC SURGERY
20 HOT TOPICS IN DERMATOLOGY
21 DIGESTIVE AND LIVER UPDATE
28 FERTILITY
FLORIDA MD - AUGUST 2011
1
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Best regards,
whole practice. I hope to see some of you there.
Warm
regards,
Donald
B. Rauhofer
Publisher
United Way to Distribute Nearly $15 Million to Help Fund Local Health and Human Service Programs
Donald
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Thanks
a very generous community, Heart of Florida United Way (HFUW) is distributing nearly $15 million this year to local health and human
service
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Publisher/Seminar
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warm, nutritious meals for seniors and mentoring at-risk teens, the programs ‒ 108 in all ‒ will serve more than 345,000 Central Floridians in need.
Of the nearly $15 million, $6.25 million was funded under HFUW’s prevention-based model, Investing in Results (IIR), which awards competitive
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focus on prevention, these programs will address key health issues, such as low birth weight, obesity and chronic disease among youth and adults.”
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You’re done! Your personal page has been
Coming Next Month: Our cover story features Lakeland Regional Cancer
created for you and you are ready to begin
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FOR YOUR ENTERTAINMENT
Orlando Philharmonic Opens Season with
Puccini and Verdi
The Orlando Philharmonic Orchestra promises a thrilling year of great music with popular favorites, timeless classics and new
discoveries throughout the 2011-12 Season. The season opens on Saturday, September 24, 8:30 p.m., at the Bob Carr Performing
Arts Centre. The program, Puccini e Verdi, features vocalists and orchestra giving a nod to these two composers in a selection of great
choruses and arias including Puccini’s O mio babbino caro and Nessun dorma and Verdi’s “Anvil” Chorus and the Overture to La forza
del destino – all timeless classics that music lovers are sure to enjoy.
Maestro Christopher Wilkins conducts the program which features the return of three vocalists to the Philharmonic stage – soprano
Janette Zilioli, tenor Yeghishe Manucharyan and baritone Timothy Mix. The concert also features the University of Central Florida
Choirs, Dr. David Brunner and Dr. Al Holcomb, directors, and the Florida Opera Theatre Chorus, Robin Stamper, music director.
American soprano Janette Zilioli is rapidly establishing herself as an exceptional artist with her talent as a dynamic, engaged singingactress with shimmer and brilliance to her voice. Central Florida resident and audience favorite, Zilioli was featured as a soloist in
Mahler’s Symphony No. 2 on last season’s opening concert “Resurrection Symphony.” She also appeared with the Philharmonic in the
role of MicaГ«la in the 2010 production of Carmen and as Musetta in the 2011 production of La Boheme.
Admired for his outstanding musical intelligence and
for the purity, power, and flexibility of his voice, Yeghishe
Manucharyan is quickly becoming one of the most soughtafter young tenors singing today. This is Manucharyan’s third
appearance with the Orlando Philharmonic. He was featured
in a past performance of Verdi’s Requiem and in the 2009-10
Season opening night concert “Ode to Joy,” as a soloist on
Beethoven’s Symphony No. 9 (Choral).
Recipient of a 2008 Richard Tucker Foundation Career
Grant, Timothy Mix is recognized for the beauty of his voice
and his compelling stage presence. He received critical acclaim
for his pivotal role as Edward Gaines in the New York premiere
of Richard Danielpour and Toni Morrison’s Margaret Garner,
in a new production by Tazewell Thompson, for which the
American baritone received New York City Opera’s 2008
Christopher Keene Award.
Mr. Mix makes his second appearance with the Philharmonic
having sang the role of Marcello in last season’s featured concert
opera, La Boheme.
Subscriptions are available now. Single tickets go on sale
August 22. Call the Orlando Philharmonic Box Office at
(407) 770-0071 or visit orlandophil.org. оЃ®
FLORIDA MD - AUGUST 2011
3
COVER STORY
Nemours Children’s Hospital
Opening in Fall of 2012 in Orlando
Construction of Nemours Children’s Hospital in
Orlando is underway at Lake Nona Medical City. The
hospital will open in October of 2012 and will expand
Nemours services in the area to meet rapidly growing
pediatric needs. Additionally, the Nemours Children’s
Hospital will enhance Medical City’s efforts to position
Orlando as a leading heath care region in the country.
Nemours has been recognized nationally with numerous
awards for providing technologically advanced, familycentered care. The unique design and management of
the hospital will promote a safe, efficient, family friendly
environment in which hospital specialists; referring doctors and families can work together to ensure Central
Florida children receive the best care possible.
Nemours History
In 1935, through the last will and testament of Alfred I. duPont, a trust was formed that would provide funding for The
Nemours Foundation. In 1936, The Nemours Foundation, a
non-profit organization devoted to the health of children was
established. Mr. duPont, a wealthy entrepreneur and philanthropist, adamantly believed “it is the duty of everyone in the world
to do what is within his power to alleviate human suffering.” Mr.
duPont’s words and his legacy of compassion have lived on for
more than 75 years through the care and services provided to
children and families at Nemours.
The Nemours Foundation began to deliver on the vision in 1940
when the Alfred I. duPont Institute, a pediatric orthopedic hospital in Wilmington, Delaware, opened its doors. Today, Nemours
has grown to become one of the nation’s largest integrated pediatric health systems, providing hospital- and clinic-based specialty
Photos Provided by Nemours
By Jennifer Roth Miller, Staff Writer
care, primary care, prevention and health information services,
as well as research and medical education programs aimed to improve the lives of children and families throughout the Delaware
Valley, Florida, New Jersey and Pennsylvania.
Since opening its doors, Nemours has devoted nearly $2 billion to enable a higher standard of care for more than two million children in medical need. That figure spans across Nemours’
health systems in four states and 25 locations.
In 2010, Nemours invested $75.1 million in Medicaid, charity
care for children without financial access and other public health
programs. Influencing children’s health is also a priority, evident
in the engagement of programs such as Nemours Health &
Prevention Services, Nemours Center for Children’s Health
Media and Nemours BrightStart! which are not exclusive to
Nemours patients.
By focusing on research, education and the training of health
professionals, bedside and exam room results have improved significantly.
Nemours in Central Florida; A Pillar in
Lake Nona Medical City
Leading up to the decision to build the new hospital in Central Florida, Nemours staffed several clinics throughout Florida
to bring Mr. du Pont’s vision to the Florida population. Clinics
are located in Destin, Jacksonville, Lake Mary, Orange Park, Orlando, Pensacola and Viera.
The 630,000 square foot facility will include 95 beds, while
the sixty-acre campus leaves plenty of room to grow. The pediatric population for the region is rapidly growing and is expected
to continue growing steadily, which will require increased pe4 FLORIDA MD - AUGUST 2011
COVER STORY
diatric services and resources. Nemours is ready to help fulfill
these needs.
Nemours is already leveraging its location within Lake Nona’s
Medical City to improve the care provided to children. Nemours
jointly recruited a physician with the University of Central Florida. Dr. Lisa Barkley will develop adolescent and sports medicine
programs at Nemours and will serve as an Assistant Professor of
Medicine at UCF. The growing partnership is expected to lead
to possible residencies, fellowships, clinical rotations as well as
research.
“This is already an incredibly valuable partnership and it has
just begun” said Dr. Lane Donnelly, Nemours’ Chief Medical
Officer and Physician-in-Chief. “I have no question there will
be additional collaboration with UCF and our other Medical
City partners which will improve healthcare and grow jobs in
Florida.”
Nemours is also working with the UCF College of Health and
All standard rooms in Nemours Children’s Hospital are identical in layout
and size, 330 square-feet. Double doors to each room create a six-foot
wide opening to easily bring equipment in and out of the rooms.
Photos Provided by Nemours
The strategic development and location of the Nemours Children’s Hospital will help attract the best life science and biotechnology organizations to the area that will assist the Lake Nona
Science and Technology Park in achieving the vision of becoming
an incubator for medical breakthroughs. The Nemours Children’s
Hospital will be an anchor tenant along with the University of
Central Florida’s Medical School the Veterans Affairs Medical
Center and the Sanford-Burnham Medical Research Institution.
LED lighting control will allow the young patients to choose whatever
color they desire. All rooms with be equipped with cardio respiratory
monitoring and support for varied levels of care.
Public Affairs and has initiated a new educational collaboration
that provides real world training to social work students. As part
of this educational affiliation, UCF social work students are on
site at Nemours Children’s Clinic in downtown Orlando. They
are working with doctors, nurses, social workers and staff as they
care for children with complex medical conditions, such as sickle
cell disease.
Concerning other partners, Nemours is actively exploring
multiple opportunities for collaboration with Orlando Veterans
Affairs Medical Center including simulation training, laboratory
services, continuing medical education and radiation oncology.
Nemours Children’s Hospital
Provides Family-Centered Care
Nemours is more than a children’s hospital. Everything they do
is dedicated to the care of children and their families. Nemours
delivers care differently, following a family-centered model.
Photos Provided by Nemours
Family-centered care {FCC) is an overarching philosophy of
family empowerment. FCC is driven by the notion that families are collaborative partners in the care of their child and this
collaboration involves all levels of Nemours associates. Parents
and other family members are experts on their children and they
are just as important as any other member of the medical team.
Families provide vital information that enhances the quality and
effectiveness of care.
In fact, Nemours involves parents in the execution of the organization’s mission through the Nemours Family Advisory Council
(FAC). The council is comprised of members of the community,
many of whom have children with health issues and have been
treated at Nemours. The council is significantly influencing decisions regarding both the design of the hospital and staffing.
The council regularly meets with the hospital architect and
other executives to provide feedback on the design and policies of
the hospital. For example, the input of the council impacted the
FLORIDA MD - AUGUST 2011
5
COVER STORY
design of the main entry by suggesting changes to the
valet and access in and out of the parking area. The
council also made suggestions that led to changes in
the type of furniture included in patient rooms.
Photos Provided by Nemours
Members of the council have also been trained
in interview techniques and are actively involved in
interviewing candidates for top executive positions
and the physician leaders within Nemours Children’s
Hospital. The comments from council members following interviews with candidates for Chief Administrative Officer were the deciding factor between the
final two candidates.
Family-friendly features at NCH will also include: a bilingual interactive way-finding
“It is truly a unique opportunity to have a voice
system, family concierge service, comfortable and spacious gathering rooms,
in selecting the doctors of tomorrow,” said Lynda
reception and lounge areas.
Griffin, who has been on the Family Advisory Council for the past three years. “We’ve had the chance to shape and
nature inspired decor promote a soothing sense of healing. The
improve the experience that patients and their families will have
hospital also offers access to two room top gardens which allow
when they visit the hospital for decades to come.”
children close access to the healing features of the natural envi-
Rooms at the hospital have been carefully designed through input from members of the FACto be as family-friendly as possible.
Each room is private and large enough for an entire family. They
feature plenty of seating and even a convertible couch that allows
a parent or sibling to spend the night, comfortably. Rooms have
large flat screen TVs, Internet access and KidsHealth.org programming. Each room has its own private bathroom large enough for
a family to share, complete with bathtub and shower. Furniture
has been thoughtfully chosen to be safe for young children. Sharp
edges and furniture with other hazards have been avoided. A family really could stay for an extended period of time in the room.
ronment. Studies have shown details such as these promote the
healing process.
Children also have the opportunity to customize their room.
They can select details such as the color of the lighting in the
room. Soothing blues and greens with fun oranges and patterns
are· incorporated into the hospital’s design. These soothing, childfriendly, fun and optimistic colors create an environment suited
for recovery. Details such as customizable “mood lighting” give
children a sense of control in a time that may seem out of their
control.
Nemours has involved nurses, doctors and specialists in the
design of patient rooms to make them as safe as possible. Extensive research has lead to equipment being installed in the
same position in every room to eliminate user time and error.
All medical equipment in the new hospital will be housed on
the left side of each room. When a nurse, doctor or specialist
The design of the hospital promotes a soothing, healing envienters a room, the equipment is always on the left. This reduces
ronment. The hospital is built around a garden. Large floor length
opportunity for error and start time and increases performance.
windows bring the outdoors in while water features and other
In addition, rooms have been designed with enough space to
The new Nemours Children’s Hospital in Lake Nona will have five sensory
allow for conversion to intensive care unit capabilities. Spegardens and two rooftop gardens. NCH firmly believes in the evidence-based
cialized equipment can be brought in eliminating the need
research that proves interacting with nature aids in the healing process.
to move a patient when his or her status changes. This can be
life saving.
Rooms are also large enough to bring equipment to the patients,
allowing some testing and many procedures to be performed right
inside the room. This reduces stress and anticipation and in some
cases can be life saving.
Technology
Photos Provided by Nemours
Nemours is at the forefront of technological integration
in the care of patients thanks to the development and use
of NemoursOne, their comprehensive electronic medical
record system. In addition to unifying physicians, researchers
and clinicians across locations and specialties, they have
designed a system that connects referring physicians (through
Nemourslink) and patient families (through MyNemours), so
that every member of the care team can be informed at the
same time and contribute to improving the health of the child
at every step.
6 FLORIDA MD - AUGUST 2011
Dr. David Milov, Chief Medical Information Officer at
Nemours says, “Less than two percent of health institutions are
operating at this level and no other institutions are operating at
a level higher than Nemours.” In fact, Nemours was awarded the
prestigious HIMSS Davies Award in 2010, honoring excellence
in health information technology.
The award-winning electronic medical record system enables
Nemours to spend more time on direct patient care while being
more accurate and efficient. The system reduces duplication of
medical testing and the possibility for errors. It makes prescriptions safer by eliminating handwriting errors and electronically
checking for drug-to-drug interactions and drug allergies. Internal and external specialists can easily share crucial health information, such as test results and medication, safely and securely while
easily tracking quality of care and medical outcomes.
Nemours is exceeding standards of care and is a leading example of implementation of established methods when it comes
to electronic medical records.
Doctors and families have instantaneous access 24 hours a
day, seven days a week to the electronic medical record. The 70
Nemours clinically trained full-time medical information specialists utilizing the system truly believe in the power of the record.
This staff buy-in makes the program even more powerful. They
are highly trained on the system and have been using it for years.
In fact, Nemours began employing a primitive version of the system as far back as the 1980’s. Since, the records have evolved to
offer several highly specialized applications such as scheduling,
registration, Web services, referring physician and parent portals.
Nemours is a leader in electronic medical records. Through
their Community Connect program, they have offered general
pediatricians a version of the electronic medical record for use
in their own practices. Forty-five pediatricians have successfully
used the record over the last ten years, making Nemours an expert
resource in this area.
Kids Health.org
Another important resource provided by Nemours is KidsHealth.org, the number-one online destination for children’s
health and development information. This site helps take the
mystery out of childhood illnesses, infections, surgeries, emotions, behaviors, fitness, nutrition, development and the dozens
of other topics affecting the health of a child. Parents, kids and
teens can find thousands of doctor-reviewed, up-to-date articles
and tips, interactive images, games and animations on the site.
KidsHealth.org content is also accessible through MyNemours,
the secure, online patient record portal. Patients and parents can
find family-friendly explanations of clinical tests, diagnoses and
procedures (why they are necessary, what to expect), as well as
a drug database of prescribed and over-the-counter medications
specific to their medical record.
KidsHealth.org’s award-winning content includes more than
5,000 doctor-reviewed, up-to-date, and easy-to-read articles, interactive features, games, and video (in English and Spanish).
Recent accolades include a Parents’ Choice Gold Award for Best
Website for Kids, four Webby Awards for Best Family/Parenting
Photos Provided by Nemours
COVER STORY
Designed with the help of patient-families and health care
professionals, the new 95-bed hospital will be part of a 60-acre,
fully integrated health campus with plenty of room to grow within
the existing footprint.
Website and Best Health Website. KidsHealth also was selected
as one of the 30 Best Websites by U.S. News & World Report
and one of the 50 Coolest Websites by TIME. KidsHealth also
creates KidsHealth in the Classroom, a free website for educators
featuring standards-based health curricula, activities, handouts,
and more.
Economic Impact of the Hospital
Nemours has commenced the process for hiring more than 700
new employees in preparation for the 2012 opening of Nemours
Children’s Hospital in Orlando. Within the first two years that
the hospital is open, there will be approximately 1,900 jobs created providing $109 million in wages with a resulting economic
impact of $414 million. In a time of an uncertain economy, these
jobs and economic enhancement to the area is significant. Those
interested in applying for a position with Nemours, please visit
www.nemours.org/careers for a complete list of the current open
positions, the necessary qualifications and the benefits offered.
What Nemours Means to Referring
Physicians
Nemours is working to become the preeminent pediatric health
care provider in Florida. They are recruiting some of the best specialists in the country to work at Nemours Children’s Hospital
and are eager to grow partnerships with pediatricians and primary care physicians in the region.
“I have been interviewing doctors from the finest children’s
hospitals in America,” said Dr. Donnelly. “By the time we open in
the fall of 2012, I fully expect that Nemours will have assembled
a team of pediatric specialists that will truly elevate the care of
children in this community’’.
Nemours’ electronic health records will facilitate the referral
process by allowing referring physicians to have a far better understanding of the type of care provided by a Nemours specialist.
As the Nemours presence in Orlando grows, they look forward
to working with members of the medical community and child
care services on efforts to improve child health care and the lives
of children in Central Florida. оЃ®
FLORIDA MD - AUGUST 2011
7
Marketing Your Practice
Building an Email List and
Using it Effectively
By Jennifer Thompson, President of Insight Marketing Group
Without fail, one of the cheapest, most effective ways to market and grow your practice is through targeted email lists. These
lists, generally speaking, are developed by your office for the sole
purpose of informing recipients about what’s going on in your
practice. No matter what strategies you’re currently using in your
marketing mix, if you’re not collecting email addresses of current
and potential patients, you’re missing the boat. In fact, the boat
already sailed. We’re out at sea, waving at you landlubbers.
But don’t worry, here’s your life preserver: start collecting addresses now and read on as we sail through the basics of email
marketing.
Why Email Lists?
Essentially, these records provide you with the ability to create targeted lists of current and potential patients that you can
advertise to on a continual basis for only several dollars a month.
This creates a direct line of communication to them which can
increase sales, website visits, practice knowledge and word of
mouth advertising considerably. The key is to provide them with
relevant content they find interesting so they will not only open
your email, but will continue to read it and share it within their
social circles.
Emails are also useful because they can go viral, pushing the
campaign far beyond its initial reach as people share content. If
you’re linking to articles and content on your website, the added
boost in traffic is always a benefit. On top of that, the effectiveness of your campaign can be analyzed from a handy online dashboard, allowing you to instantly see what people are reading and
clicking, when they’re doing it and how often.
Types of Lists
There are several types of email lists to be aware of. The first is
what’s known as an opt-in list. This is a collection of addresses
gathered by a tool with the consent of the subscriber, either directly or indirectly. Think of a website you’ve seen that has a box
asking the reader to sign up for updates or to receive free offers.
That is an opt-in list.
Next up is the opt-out email list. These addresses are purchased
or sourced indirectly from group sites, such as telephone companies or email list brokers (yes, there is such a thing). The people
on these lists generally don’t realize they’re on a list until the first
email gets to their inbox. These lists are not highly recommended
as they can make people a little angry, or just plain confused.
8 FLORIDA MD - AUGUST 2011
Finally there’s the double opt-in list, widely considered the
most ethical way to build a list. Here, after collecting an email
address, the subscriber is then asked to confirm their subscription
again. This way you’re double sure they want to see your content,
increasing open rates and retention.
List Building Tips
Gathering Emails. The first thing you’ll want to do is create a
method to gather emails. This is as easy as adding a line to new
patient forms requesting they put their email down. When you
ask this question, be sure to let them know by writing an email
address down they’re consenting to receive occasional updates
from your office. For returning patients, you can ask that they update their contact info the next time they’re in the office. If you’re
at an event, create some type of incentive program, such as a free
visit or giveaway as a means to collect the data. Be sure to include
ways and incentives to join your list via social media as well.
Signing Up. Next, you’ll want to sign up with an email marketing company in order to create, distribute and schedule your
message to the addresses you collect. Most are affordable and offer dozens of free templates so you can give your message a professional, enhanced look without much work on your part. iContact
and Constant Contact are some of the best sites on the market
today to help you connect using email newsletters.
Segmenting Lists. One of the most important things you can
do is segment and organize your contacts. You want to be as specific as possible and drop each email into a “bucket,” essentially
breaking them down into relevant categories. This is highly effective and will ensure that the right patients are receiving the right
offers and information. For example, let’s say you offer cosmetic
procedures such as Botox as a part of your facial reconstruction
practice. Obviously you’d want a list of patients who are interested in the cosmetic side to promote special offers that you may
not send to the patients who are strictly seeing you for a reconstruction following an accident. This target allows you to get the
right message in front of the right people instantly.
Creating Your Email. Finally you’ll want to create your email.
It’s imperative you make the content important and relevant to
the recipients. Be sure to include several links to articles and/or
pages on your website. Include “exclusive” information or photos
a patient may only see if they open the email to make them feel
Marketing Your Practice
special too. It’s a good idea come up with a schedule now so you
aren’t emailing people twice a week for two weeks and then stopping for three months.
Just like that you’re already in the water, briskly catching up
to the email marketing cruise and you haven’t even finished the
article yet. As you swim toward your goal, be sure to prepare your
finances accordingly and be sure to find some time each week to
go over your email marketing plan, objectives and results to maximize your return on investment. Happy swimming!
Looking for more information?
Contact Jennifer Thompson today for a free consultation
and marketing overview at 321.228.9686 or e-mail her at
Jennifer@InsightMG.com.
About the Author: Jennifer Thompson is a Central Florida small business owner, serving as President of Insight
Marketing Group, a full-service marketing company focused on medical office marketing, community outreach
efforts, and grassroots public relations. In this capacity she
is responsible for developing and implementing the longterm strategic vision for the organization, which includes
publishing Insight Magazine, the company’s communitybased monthly news magazine, and hosting their weekly
small business networking/mentoring group, Coffee Club.
In November 2010, Jennifer was elected to the Orange
County Board of County Commissioners. оЃ®
Coming Next Month: Our cover story features Lakeland Regional
Cancer Center. Editorial focus is on Sports Medicine and Robotic Surgery.
Start Weight Sept. 2010: 207 lbS. • end Weight dec. 2010: 166 lbS.
Pathology Lab Results — Patient: SP Age: 63 Sex: Male
Before Diet
Lipid Panel
Result 08/28/2009
Ref Range Result
Cholesterol
H 278
(80-199)mg/dL
Triglycerides
H 199
(30-150)mg/dL
HDL Cholesterol
51
(40-110)mg/dL
LDL Cholesterol
H 187
(30-130)mg/dL
VLDL Cholesterol
40
(10-60)mg/dL
Risk Ratio(CHOL/HDL)
H 5.5
(0.0-5.0)Ratio
8/26/10:
9/24/10:
Tissue Fat %
26.3%
21.1%
Body Scan Results
Tissue (g)
83,019
78,045
Fat (g)
21,864
16,449
After Diet
09/20/2010
180
82
55
109
16
3.3
Lean Muscle (g)
61,155
61,596
Please Note: Gain of 441g of muscle and a fat loss of 5,415g in 30 days! Individual results may vary.
For information call 407-260-7002 or email Sam@makerx.com.
FLORIDA MD - AUGUST 2011
9
PHARMACY UPDATE
New Study: Type 2 Diabetes is
Reversible with Very Low-Calorie Diet
By Sam Pratt, RPh
A disease believed to be long-term and progressive in nature
has been shown to be reversible according to a UK study from
Newcastle University. All 11 of the study participants showed reversal of the disease at the end of 8 weeks, and 7 maintained that
reversal at a 12 week follow-up. The purpose of the study was to
test the hypothesis that a decrease of fat in the liver and especially
the pancreas allows for the normalization of insulin production.
Type 2 diabetes is characterized by insulin-resistance and the
inability to properly utilize insulin. The pancreas gradually loses
the ability to produce sufficient amounts of insulin to regulate
blood sugar. High blood sugar ensues and makes the blood more
viscous. This causes microvascular complications like blindness,
kidney failure, and neuropathy. High blood glucose also causes
macrovascular complications that result in the narrowing of the
arteries and puts individuals at greater risk of having a heart attack or stroke.
Researchers studied 11 people with a history of type 2 diabetes
to see what a very-low calorie diet would do to their pancreatic
function. The 11 participants were matched to a control group
of people without diabetes and then monitored over an 8-week
period. To be included in the study, participants had to have been
diagnosed with type 2 diabetes within the past 4 years, be between
the ages of 35 and 65, and have an HbA1c between 6.5 and 9.0.
Participants who were being treated with TZD’s (e.g. Actos), insulin, steroids, or beta-blockers were excluded from taking part
in the study, as were those with liver or renal problems. More research will be necessary to see if the same dramatic results can be
obtained in individuals who have had diabetes for a longer period
of time, and also to determine if the reversal is permanent.
The diet consisted of a liquid formula which provided 510
calories, and was supplemented with non-starchy vegetables to
complete the 600 calorie per day requirement. Participants were
also encouraged to drink 2 liters of water daily and to maintain
their normal levels of pre-study exercise. Participants were regularly contacted by telephone during the study to provide support
and encouragment.
After just one week, the participants had normal fasting blood
glucose levels. At the end of the 8-week study, participants lost an
average of 33 lbs, the average HbA1c fell from 7.4 to 6.0 (a value
which is similar to non-diabetics), and the average blood glucose
decreased from 165 mg/dL to 102 mg/dL. MRI scans revealed a
reduction of fat in the pancreas, and blood levels showed normal
insulin levels.
10 FLORIDA MD - AUGUST 2011
After the 8-weeks, participants were encouraged to eat healthy
foods, but were allowed to resume a normal diet. At a 12-week
follow-up, 7 out of the 10 people that were retested remained
diabetes-free.
The study is important and offers hope to many people with
diabetes. However, the diet is rigorous, and not everyone will be
able to follow it. Also, the researchers state that they are not recommending that people with diabetes adopt this diet, warning
that it should only be completed under medical supervision.
While more research is needed to test the breadth of this discovery, the suggestion that millions of individuals who are at risk
for diabetic complications can become diabetes-free is astounding and warrants much attention
I have personally seen Type II diabetes attenuated and reversed
with the low calorie, life style modification diet. As mentioned
above, these diets can be rigorous but the results are amazing as
I have witnessed many times. The reason it is a medically supervised program is to assist the prescriber in supervising and reducing the need for prescription medications. If you would like to
have a clinical pharmacist to help with the life style modification
program, you may call Jill at Pharmacy Specialists (407)260-7002
for further information.
References
Lim, EL, Hollingsworth, KG, Aribisala, MJ, et. al. Reversal of Type 2 Diabetes: normalization of beta cell function in association with decreased pancreas
and liver triacylglycerol. Diabetologia: June 9, 2011.
Currently, Sam Pratt, RPh at Pharmacy Specialists is the
only Full Fellow of the International Academy of Compounding Pharmacists in the Central Florida area. Call Pharmacy
Specialists to explore the possibilities of a clinical pharmacist. For additional information please call (407)260-7002,
FAX (407) 260-7044, Phone (800) 224-7711, FAX (800)
224-0665. оЃ®
WEALTH MANAGEMENT
Are You a “Tax Target”?
Best-Selling Author and Wealth Strategist Provides His Perspective
on the Impact of Proposed Tax Increases on Doctors and Their
Retirement Security
By Chuck Oliver
President Obama says he wants to target “millionaires, billionaires, corporate jet owners and hedge fund managers” as a way to
raise revenues to reduce the enormous Federal deficit. But individuals earning $200,000 a year and couples earning $250,000
annually could also lose money as well as their tax rates rise or
they are moved into a higher tax bracket.
Although Americans are paying the smallest share of their income
for Federal taxes since 1958, rest assured, higher taxes are on the
way! While many in Congress have pledged to not raise taxes, if
you’re like me, you’re pretty sure that taxes are going to be higher
in the future.
Among the current proposals that will result in higher taxes:
• Let the Bush era tax cuts expire for individuals earning over
$200,000 and couples earning over $250,000,
• limit itemized deductions to 28% of an individual’s gross income and
• change the way inflation is measured, causing individuals to
move to higher tax brackets more rapidly as their earnings increase.
According to the U.S. Bureau of Labor Statistics, physicians practicing in medical specialties earned an annual median income of
over $339,000, in 2008 (the most year for which statistics are
available). Self-employed physicians, that is, those who own or
are part owners of their medical practice, usually have even higher
median incomes than salaried physicians. What that means is,
medical professionals, with their higher than average individual
and joint earnings, are definitely wearing a tax target on their
collective chests.
If all three of the above proposals are implemented, the Tax Policy Center, a joint venture of the Urban Institute and Brookings
Institution, estimates that the annual income tax bill increase
for above average-earning Americans would increase by over
$18,500.00 - and that’s just for starters! Once the tax increases
begin, they are likely to continue until the government finally has
the deficit under control and who knows when that will happen
(if ever). Income tax rate reductions are rare and, when they do
occur, they are usually temporary.
If you’re worried about how the looming tax increases will affect
your current income, think about the effect these increases and
the others that are sure to follow, will have on your retirement in-
come. There’s a towering storm on the horizon. The government
is targeting you and their plans are threatening your retirement
safety and your future well-being. Wouldn’t it be great if there
was a way to secure your retirement by eliminating the income
tax on it?
Let me show you how our proven, safe-money solution, The
Medical Professionals Protected Pension Planв„ў can solve the
threats to your retirement. I’ll show you how to start up or catch
up your retirement and protect it from the ravages of an increasingly harsh tax code and from market volatility. We have helped
many medical professionals throughout Florida secure their retirement future with our unique tax-advantaged system. Now,
you can be one of those fortunate medical professionals!
To learn more about The Medical Professionals Protected Pension
Planв„ў download my free e-book at http://www.thehiddenwealthsystem.com/pdf/MedicalPension.pdf or review the short webinar
on the subject at http://www.thehiddenwealthsystem.com/medical-professionals-webinar. To schedule a no cost no obligation
Medical Professionals Protected Pension Planв„ў consultation
please contact our Client Concierge, Millie, at (866) 998-7699
or email her at millie@thechuckoliverteam.com.
People get a second opinion on their health; get a second opinion
on your wealth!
Charles “Chuck” Oliver is an industry recognized wealth
strategist and two-time best-selling author who works with
retirees, those who are about to be retired and their families. These are people whose concerns center on taxes, market risk, and the possibility of outliving their income.
Chuck Oliver’s Hidden Wealth System specializes in creating and preserving wealth. This helps clients to achieve financial independence and become immune from economic
down turns. Chuck and his Team educate clients on how to
increase their retirement income by 50% or more with little
or no tax and with no market risk. Chuck shows his clients
how to establish a tax free income for the rest of their lives;
an income that will transfer tax free to future generations.
To learn more about Chuck Oliver and The Hidden Wealth
System visit: http://www.TheHiddenWealthSystem.com or
call (407) 478-1599. оЃ®
FLORIDA MD - AUGUST 2011 11
The ABC’s of Improving Physician-Patient
Relations to Reduce Infant Mortality
By Sylvia M. Davis, MPH
Infant mortality (IM) has been a critical public health issue for
centuries. Historically, most babies never survived infancy and
women routinely died as a result of pregnancy related complications and childbirth. Although today’s IM rates pale in comparison to those of the past, the fight to combat infant mortality is
far from over.
Every year in the United States, thousands of infants die before
ever reaching their first birthday. Throughout the state of Florida,
there are approximately four infant deaths per day and about one
infant death per day in Central Florida. Even one infant death
can have a devastating impact on the community at large.
The five leading causes of infant mortality in Central Florida
are: congenital malformations, disorders related to short gestation, Sudden Infant Death Syndrome (SIDS), maternal pregnancy complications, and complications of placenta cord and
membrane. The IM rate is often used as a proxy measure for the
overall health status of a community. Healthier communities are
usually the ones with lower IM rates.
Whereas, advances in medical technology and public health
have led to significant reductions in infant deaths, the role of the
physician in further improving healthy birth outcomes should
not be overlooked. “We’ve seen huge improvements in the technological aspects of keeping low-birth weight babies alive once
they’re born, but we need improvement on the front end. It’s prevention. And that means increased access to good care and an
intentional focus on addressing the social determinants of infant
mortality.” Adewale Troutman, MD, Member, National Advisory
Committee on Infant Mortality (Association of Schools of Public
Health, Friday Letter, March 2011). Physicians are the critical
connection between the patient and a healthy birth outcome.
Language, cultural and socioeconomic barriers are often cited
as obstacles in the healthcare seeking behavior of high-risk populations and can potentially cause a strain in physician-patient relations. Non-English speaking populations and minority groups
(i.e. Blacks and Hispanics) typically experience higher rates of
IM and thus it is important that potential barriers to effectively
reaching these populations be addressed if further improvements
in infant mortality are to be realized.
The ABCs to reduce infant mortality mnemonic was developed
by the Orange County Health Department as a simple three step
12 FLORIDA MD - AUGUST 2011
approach to assist physicians in their efforts to ensure healthy birth outcomes
and reduce infant deaths among their patients. The A reminds
physicians to ask and advise their patients about their health and
other habits. The B stands for Back to Sleep and it encourage
physicians to teach patients the importance of the proper sleep
position for infants, and C represents the continuum of healthcare, and encourages physicians to advise their pregnant patients
to attend all of their prenatal care visits, and recommend to
their female patients of child-bearing age to have regular routine
check-ups.
Step 1: A- [Ask and Advise] patients about dietary habits, substance and alcohol use, and daily levels of physical activity. Once
the physician knows about the patients’ lifestyle and practices,
a plan of action can be developed to help the patient eliminate
or reduce habits such as, smoking, exposure to second-hand smoke, use of drugs
and alcohol while pregnant or engaging in
other unhealthy behaviors that place the
unborn child at risk. If necessary, patients
should be referred to cessation services
or other behavioral modalities for care.
Patients should be advised to maintain a
healthy weight, and monitor their dietary
intake.
Step 2: B- [Back to sleep] Physicians
should encourage new mothers to place
infants on their backs during sleep. Improper sleep positioning has been identified as one of the risk factors for SIDS.
“Placing babies on their backs to sleep
reduces the risk for SIDS” (Back to Sleep
Public Education Campaign, National
Institutes of Health, June 2010).
Data Source: Florida Department of Health, Bureau of Vital Statistics.
Sylvia M. Davis, MPH is a Researcher at the Orange County Health Department
with ten years of experience working with maternal and child health issues. She can be
reached at 407-858-1400 ext. 1222 or Sylvia2_Davis@doh.state.fl.us.
Be sure and check out our NEW and IMPROVED
website
www.floridamd.com!
fl-md-jewett-july_Layout
1 6/30/11at10:57
AM Page 1
Step 3: C [Continuum of healthcare]
The health of the mother before she becomes pregnant is important in ensuring
a healthy birth outcome because a healthy
baby starts with a healthy mother. “Since
over half of all pregnancies in the United
States are unplanned, women who might
be sexually active with male partners
should consider their health” (Preconception Care, Centers for Disease Control,
April 2006).
The ABC’s of Health is an easy to use
and helpful tool physicians can use during
visits with patients to help reduce infant
mortality. The mnemonic stresses the important aspects of healthy birth outcomes
as they relate to maternal and infant care.
Every child deserves to celebrate his or
her first birthday. Physicians play a significant role in ensuring that this becomes a
reality. Physicians should remain vigilant
in encouraging their female patients to
continually take care of their health, and
not just reserve these practices for pregnancy.
If you are interested in further community action to reduce Infant Mortality, please contact, the Orange
County Health Department, Infant
Mortality Task Force at (407) 858-1400
ext. 1217.
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407.206.4500
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A tradition of care powered by innovation
FLORIDA MD - AUGUST 2011 13
Medical Malpractice Expert Advice
Is Cheaper Really Better?
By Matt Gracey
Q: Many cheap malpractice-insurance offers are coming my way these days. How can I go wrong by
saving so much, particularly since my practice’s income is going down and my expenses are going up?
A: Florida doctors are now enjoying a very “soft” buyer-centered market cycle, although I believe this is
close to ending. Back in 2000 we were in a similar market cycle, which led to many insurers pulling out of the state and the others
dramatically increasing their malpractice-insurance rates a year or two later. My advice as we enter the end of this soft market is to find
a stable, well-funded, Florida-committed malpractice insurer so that you will lessen the chances of your coverage being cancelled by your
insurer when the going gets tough soon.
When deciding which insurer will handle your coverage, remember that not all malpractice insurers are created equal, by any stretch
of the imagination. This is contrary to what you might read and hear from slick marketing folks and what you might like to believe so
you feel can feel more comfortable and secure just price shopping. As with every important purchase decision, a risk/reward calculation
is useful. If a new, unrated insurer is promising great coverage and superb defense against claims, all for a price much below the rest of
the marketplace, then there is a very high probability that they are just luring you in with unsustainable marketing promises. In the last
malpractice-insurance crisis of the early 2000s, over 50 insurers stopped insuring Florida doctors and left many facing expensive “tail”
purchases, so choose very carefully as we come to the end of this buyers’-market part of the never-ending cycle.
Matt Gracey is a medical malpractice insurance specialist with Danna-Gracey, Delray Beach, 800-966-2120; matt@dannagracey.com. Danna-Gracey offices are located in Delray Beach, Orlando/Tampa, Jacksonville, and Miami. оЃ®
Central Florida
Pulmonary Group, P.A.
Serving Central Florida Since 1982
Specializing in:
п‚·
п‚·
п‚·
п‚·
п‚·
п‚·
п‚·
п‚·
Asthma/COPD
Sleep Disorders
Pulmonary Hypertension
Pulmonary Fibrosis
Shortness of Breath
Cough
Lung Cancer
Lung Nodules
Our physicians are Board Certified in Internal Medicine,
Pulmonary Disease, Critical Care Medicine, and Sleep Medicine
Daniel Haim, M.D., F.C.C.P.
Syed Mobin, M.D., F.C.C.P.
Tabarak Qureshi, M.D., F.C.C.P.
Daniel T. Layish, M.D., F.A.C.P., F.C.C.P.
Eugene Go, M.D., F.C.C.P.
Kevin De Boer, D.O., F.C.C.P.
Francisco J. Calimano, M.D., F.C.C.P.
Mahmood Ali, M.D., F.C.C.P.
Kerlan Wolsey, M.D., F.C.C.P.
Francisco J. Remy, M.D., F.C.C.P.
Steven Vu, M.D., F.C.C.P.
Andres Pelaez, M.D.
Ahmed Masood, M.D., F.C.C.P.
Ruel B. Garcia, M.D., F.C.C.P. Peter L. Fort, M.D., F.C.C.P.
Downtown Orlando: 326 North Mills Avenue
East Orlando: 10916 Dylan Loren Circle Altamonte Springs: 610 Jasmine Road
407.841.1100 phone | www.cfpulmonary.com | Most Insurance Plans Accepted
14 FLORIDA MD - AUGUST 2011
ORTHOPAEDIC UPDATE
Hip Implants and Your Patients
By Emily Garcia
When a patient undergoes hip replacement surgery, they not
only expect to find relief from their pain, but they also expect the
implant to last for many years. However, a recent scare on the
manufacturing side of hip implants left many patients undergoing another surgery within a 24-36 months and many surgeons
shaking their heads and pointing fingers at the supplier.
Recent Problems
“One of the major issues concerning hip replacement implants
over the past several years has been the design and choice of the
bearing surface, that is the surface of the ball and socket, where
hip motion occurs,” says Jeffrey P. Rosen, M.D., a board certified orthopaedic surgeon specializing in joint replacement with
Orlando Orthopaedic Center.
The surface of the bearing has, in the past, consisted of a metal
head and a polyethylene (a very durable plastic) socket. In an effort to prolong the life of the implant beyond the traditional 15
year mark, two new bearing surfaces were developed for implantation: ceramic-on-ceramic and metal-on-metal.
After initial success with the metal-on-metal implants, “significant adverse outcomes have been reported with several of the
metal cups,” says Dr. Rosen.
Last August DePuy Orthopaedics began recalling two types of
hip implants because many patients required a second hip replacement after the company’s original implant had failed.
“The issue with the implants is an imperfection of the surface
[of the implant] which reduces the chances for adequate bone
ingrowth,” says Dr. Rosen. In other words, the implants were not
allowing for the bone of the pelvis to grow into the outer surface
of the implant and create the biologic bond that traditionally occurs after hip replacement surgery.
In addition, it has also been found that the metal-on-metal implants generate metal ions that are then released into the patient’s
bloodstream.
“While no adverse event has been shown in any patient as a result of the presence of these ions in the blood, there are concerns,
and there is no way to determine whether or not there could be
long-term adverse effects, such as the development of kidney or
liver problems, or perhaps even an increased risk of malignancies
years later,” says Dr. Rosen.
On top of that, the development of “pseudotumors” has become cause for concern in a small percentage of women who have
metal-on-metal hip implants. These large, fluid filled cysts grow
around the implant and require prompt surgical removal.
“As a result, [of all of these factors] the DePuy, and Zimmer
implants have been withdrawn from the market until further research can solve this problem,” says Dr. Rosen.
What’s the Next Step
for My Patients
Although these three types of imJeffrey P. Rosen, M.D.
plants have been recalled, that does
not mean that there are no options for
patients who require a hip replacement; the Smith and Nephew
Birmingham Hip Resurfacing System has not fallen prey to the
recalls and remains a viable option for younger, male patients.
Dr. Rosen recommends the use of a ceramic femoral head with
a titanium acetabular shell, and a highly cross-linked polyethylene liner between the ball and socket for his patients. This has
been shown to be one of the most effective, most used hip replacements on the market today.
If patients who have received a metal-on-metal hip implant begin to experience pain, Dr. Rosen says they should seek help from
their general practitioner, who can then refer them to a joint specialist with experience dealing with the issue. Oftentimes, general
practitioners are unaware of the recall and are not equipped to
treat such problems in their office.
Still, it may be better to be safe than sorry. Even if the patient
has not yet experienced problems with their implant, Dr. Rosen
recommends they see a specialist for annual monitoring to ensure
that either nothing goes wrong, or if it does, that it is treated
promptly, correctly and safely.
Dr. Rosen says that patients who are referred to him or any
qualified joint expert should expect an extensive work-up, full
exam and follow up in order to alleviate pain associated with faulty
hip implants. If deemed necessary, revision surgery is performed
in order to fully correct the problem plaguing the patient.
While revision surgery carries a higher risk than the initial
implant surgery, it is unfortunately the only option for patients
sometimes. Risks of the operation include infection, blood clots,
excessive bleeding and possible nerve damage, similar to the risks
during the initial operation. On average, patients report that revisions are 25 to 50 percent more painful than their first operation.
Dr. Rosen says that patients who do require a second surgery
to repair a faulty implant can rest assured that their problem will
be dealt with efficiently and thoroughly. “At Orlando Orthopaedic Center, we are fortunate to have two high volume hip replacement surgeons, both of whom have extensive experience in
all aspects of hip surgery, and both of whom have experience in
evaluating and treating the painful hip implant,” he says.
For additional information please call (407) 254-2500 or
visit www.orlandoortho.com. оЃ®
FLORIDA MD - AUGUST 2011 15
PULMONARY AND SLEEP DISORDERS
Pulmonary Hypertension in 2011
By Kevin De Boer, DO
Pulmonary hypertension is becoming a more widely recognized disease that commonly presents with dyspnea on exertion,
fatigue, and lethargy. As the disease progresses, symptoms of right
sided heart failure develop including lower extremity edema, and
later exertional chest pain and even syncope. Historically the disease was classified as primary pulmonary hypertension (idiopathic) or secondary pulmonary hypertension (related to other disease
processes). Recently the World Health Organization (WHO) has
reclassified the disease into five discreet categories based on the
causative etiology (Figure 1). In general WHO group 1 patients
are referred to as having pulmonary artery hypertension, while all
other WHO groups are referred to as pulmonary hypertension.
The normal mean pulmonary artery pressure at rest is ≤20
mmHg. Pulmonary hypertension is diagnosed when the mean
pulmonary artery pressure elevates ≥25 mmHg at rest. The predominant cause for pulmonary hypertension is an increase in the
pulmonary vascular resistance. Typically this occurs from chronic
vasoconstriction of the vascular bed (chronic hypoxia), decrease
in the area of the vascular bed (i.e. pulmonary emboli or pulmonary parenchymal diseases), or vasculopathy of the small pulmonary arteries or arterioles (i.e. connective tissue disease, HIV, or
medication induced). The remaining cases are typically associated
with left sided heart disease and elevated pulmonary artery occlusion pressures.
The diagnostic evaluation of pulmonary hypertension consists
of confirming the presence of pulmonary hypertension and attempting to identify the etiology causing the elevated pressures.
Often a chest radiograph and electrocardiogram are performed
early in the workup of the patient’s dyspnea. The chest radiograph
may reveal enlargement of the central pulmonary arteries and
“pruning” or attenuation of the peripheral vessels. This results in
oligemia of the lung fields. As the disease progresses, dilation of
the right ventricle and atrium can be seen with enlargement of
the right heart border. The chest radiograph may also suggest other pulmonary pathology that may contribute to the disease (i.e.
emphysema or fibrosis). The electrocardiogram may reveal right
ventricular hypertrophy or a right bundle branch block, typically
with right axis deviation. The P wave amplitude can also increase
(P pulmonale) with right atrial dilation.
When pulmonary hypertension is suspected, an echocardiogram with Doppler study is typically performed to estimate the
pulmonary artery pressure. The pressure is calculated based on
the severity of tricuspid regurgitation and the velocity of the regurgitation. It will also allow for evaluation for potential left sided
heart disease. When the pulmonary artery systolic pressure is >50
mmHg and the tricuspid regurgitant velocity is >3.4, pulmonary
hypertension is likely and further workup is indicated.
Other tests are directed according to the patient’s history, exam,
and other findings. Pulmonary function testing is performed to
identify any obstructive or restrictive lung disease, and to assess
16 FLORIDA MD - AUGUST 2011
for abnormalities of the diffusion capacity. V/Q scanning is performed to exclude venous thromboembolic disease.
Nocturnal trend pulse oximetry and
polysomnogram can reveal nocturnal
hypoxemia and sleep disordered breathing (predominantly obstructive sleep apnea). Baseline laboratory
testing should include evaluation for connective tissue diseases,
HIV screening, and liver function testing. Other laboratory testing may be indicated depending on your patient’s history such as
sickle cell disease, pro-brain natriuretic peptide, hypercoaguable
workup, and schistosomiasis in the appropriate settings. An assessment of the patient’s exercise capacity is also performed. In
the office this is most commonly performed as a 6 minute walk
test. Assessments of oxygenation and WHO functional class can
be obtained which also helps in monitoring the effectiveness of
treatment.
Once pulmonary hypertension is suspected, it must be confirmed with right heart catheterization. It is confirmed if the mean
pulmonary artery pressure is >25 mmHg. The test will also determine the pulmonary vascular resistance, and cardiac output. It
will also evaluate for the presence of left sided heart disease. Left
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PULMONARY AND SLEEP DISORDERS
sided heart disease is suggested if the mean pulmonary artery occlusion pressure (PAOP) is ≥15 mmHg. If the PAOP is elevated,
a left heart catheterization should also be performed to measure
the left ventricular end diastolic pressure (LVEDP) and confirm
elevated left sided pressures. A right heart catheterization can also
help in detecting the presence and severity of any intracardiac
shunt that may not have been noted on noninvasive testing. Occasionally the patient will perform exercise during the catheterization to assess changes in the pulmonary pressures during periods of increased cardiac output. Once pulmonary hypertension
is confirmed, the patient will also typically undergo a vasodilator
challenge to assess the responsiveness of the pulmonary artery
circulation to vasodilator therapy. During the challenge, patients
are usually given adenosine, nitric oxide, or epoprostenol. All of
the medications are short acting and allow for quick assessment
of the responsiveness, and improvement of the pulmonary artery
pressures, pulmonary vascular resistance, and cardiac output.
Patients that are identified as having pulmonary hypertension
should be treated as early as possible. As the disease progresses, patients are typically less responsive to therapies. Treatment
should always be initially directed at the underlying cause of the
pulmonary hypertension. Primary therapy typically includes
oxygen, diuretics, anticoagulation, and in some patients digoxin. All patients are encouraged to continue exercise. Treatments
specific to pulmonary hypertension include endothelin receptor antagonists, phosphodiesterase 5 inhibitors, prostanoids, and
rarely calcium channel blockers. These therapies are typically
used in patients with WHO functional class II, III, and IV that
have not responded to primary therapy. Pulmonary hypertension specific therapy is most commonly used in patients with
WHO group 1 disease, and select patients in WHO group 4
and 5. They are typically not indicated for patients with WHO
group 2 or 3 disease.
Historically, calcium channel blockers were the initial therapy
of choice, however trials have not definitively concluded that
there was improved survival with their use. Usually long-acting nifedipine or diltiazem are used. Patients intolerant to these
medications may be given amlodipine. Short acting medications
should be avoided because of the increased risk of systemic vasodilation and worsening ventilation-perfusion mismatch.
Prostanoids include epoprostenol, treprostinil, and iloprost.
Epoprostenol (Flolan) and treprostinil (Remodulin) can both be
given by continuous intravenous infusion. Treprostinil may also
be given by subcutaneous infusion, and is also available now by
inhalation (Tyvaso). Iloprost (Ventavis) is also available as inhalation therapy. The prostanoids are typically given to patients with
WHO functional class III or IV disease, and treatment is associated with improved functional status.
Endothelin receptor antagonists help to block endothelin-1
which is a potent vasoconstrictor in the pulmonary circulation.
Current agents include bosentan (Tracleer) and ambrisentan (Letaris). Both agents have shown improvement in exercise tolerance
and functional status in patients with WHO functional class II,
III, and IV. Hepatotoxicity is the most significant adverse side effect, and liver function testing should be monitored. Peripheral
edema is also common and is typically controlled with diuretic
therapy. Woman should adhere strictly to contraception as these
drugs are teratogenic.
Phosphodiesterase-5 inhibitors help to prolong the vasodilatory
effect of nitric oxide in the pulmonary circulation. Current available drugs include sildenafil (Viagra, Revatio), tadalafil (Cialis,
Adcirca), and vardenafil (Levitra). Although studies have shown
varying results in regards to onset of action and oxygenation,
these drugs are associated with improved functional status and
hemodynamics. These drugs are well tolerated, and frequently are
combined with the other above therapies for additional benefit.
These drugs are usually considered for patients with WHO functional class II or higher.
Patients on any therapy should be monitored frequently for
adverse effects, and to assess the response to therapy. Assessment
of the patient’s functional status should be performed with every office visit. In patients who have worsening functional status, reduced cardiac index <2.5 L/min per m2, failure to respond
to therapy, or rapidly progressive disease should be referred to a
transplant center for evaluation of lung or heart-lung transplant.
Early and aggressive therapy in the appropriate patient will improve their functional status and their quality of life. Hopefully as
further studies are performed, we will also begin to see improvement in the prognosis and mortality in our patients.
Kevin De Boer, DO, FCCP graduated from the University of Medicine and Dentistry of New Jersey (UMDNJ)
in 1999. He completed an Internal Medicine Residency
at Kennedy Memorial Hospital and Our Lady of Lourdes
Medical Center (UMDNJ) in Camden, New Jersey. He
completed a Pulmonary/Critical Care Fellowship at Kennedy Memorial Hospital (UMDNJ) and Deborah Heart
and Lung Center in Browns Mills, New Jersey. He is board
certified in Internal Medicine, Pulmonary Medicine, and
Critical Care Medicine. He joined Central Florida Pulmonary Group in Orlando in 2009. He currently serves
as the Pulmonary Chair for the American Osteopathic
Board of Internal Medicine. Dr. De Boer may be contacted at 407.841.1100 or by visiting www.cfpulmonary.
com. оЃ®
FLORIDA MD - AUGUST 2011 17
Facial Cosmetic Surgery
Teenagers and Rhinoplasty Surgery
By Ross A. Clevens, M.D.
According to the American Society for Aesthetic Plastic Surgery (ASAPS), rhinoplasty was the most popular cosmetic procedure for teens in 2009. In my facial cosmetic surgery practice
I perform several hundred nasal operations every year, and many
of these patients are young adults. As a general rule of thumb, the
earliest a female can undergo a rhinoplasty is on average 14 years
old and the earliest a male can undergo a rhinoplasty is 15 years of
age. There are exceptions to the above ages where rhinoplasty can
be performed earlier, if there is a gross deformity of the nose.
Rhinoplasty for teens involves different techniques than for
adults. Teens usually want a more dramatic change in the shape
and size of their nose than many adults are seeking. In addition, a
teens motivation to have surgery is usually fueled by the desire to
blend in, while an adult seeking surgery usually wants to distinguish themselves from the crowd. As a surgeon, I enjoy working
with young patients because they are often very specific in their
surgical goals and are usually very appreciative of the outcomes
we can achieve. I work closely with all of my rhinoplasty patients
to meet and exceed their expectations. A successful rhinplasty
surgery can transform a young adult and empower them with a
new found sense of self and self esteem that they had previously
not had.
Although many teenage patients seek rhinoplasty surgery for
cosmetic reasons, some seek surgery to correct functional breathing issues. A good percentage of my teen rhinoplasty patients are
athletes with a sports-related injury. These injuries to the nose
or a malformation of the nose can result in a crooked nose in
a teenager that results in difficulty breathing. These breathing
difficulties can be repaired with a septoplasty or a combination
septorhinoplasty.
In my practice I stress the importance of teenagers speaking
with their family and ensuring that the whole family is in agreement prior to proceeding with the rhinoplasty as the family is
Rhinoplasty Before and After
18 FLORIDA MD - AUGUST 2011
important as a support system after
the surgery. Psychological counseling may also be recommended to
evaluate the teenager’s motivations,
expectations, and maturity level.
Teenagers tend to heal more rapidly
after rhinoplasty and their nasal skin is more elastic so it shrinks
faster. I also offer all of my rhinoplasty patients platelet healing
gel and a nasal rapid recovery kit which contains medications to
be used before and after the rhinoplasty, which allow a more rapid
recovery, with less bruising and swelling.
Another common thread amongst teenagers seeking rhinoplasty surgery is that often times they seek to have rhinoplasty surgery
during school breaks and over the summer. Many teens decide to
have their rhinoplasty procedure between high school and college. Commonly, the teenagers will bring pictures of celebrities or
models in magazines which have noses they like. It is important
for the facial plastic surgeon to discuss what can realistically be
achieved for the specific teenager based on their skin type, facial
structure, chin position, etc. I always customize the new nose to
the patient’s face and do not just give one type of nose. Sometimes
i will use computer imaging to show the teenager what a possible
result may look like and this is a method of communicating and
understanding the teenager’s goals and motivations. Computer
imaging can also show any unrealistic expectations from the patient by noting their reactions to the newly imaged noses. If it
happens that the perspective patient does not like any of the imaged noses then the patient may have unrealistic expectations and
may not be a good candidate for the rhinoplasty.
A teen who is thinking about plastic surgery should be ready
- both physically and emotionally. Below are some topics I encourage parents to discuss with their teens before making such
a decision:
Rhinoplasty Before and After
Facial Cosmetic Surgery
• Why does he or she want surgery? Is it to put an end to teasing or to be more attractive to others? Is physical discomfort involved? Is
your teen taking it lightly because other family members have had it done?
• Is there another way? Less drastic measures - such as a new hairstyle, makeup or contact lenses - could boost confidence. Counseling
to improve self-acceptance is another option.
• Is your teen realistic? Does she expect to look totally different? Does he think he will feel like a new person overnight?
• Is your teen prepared for the recovery period? Not only will it be painful, but there may be swelling and bruising to deal with.
• Does he or she understand the risks? These can range from infection to bleeding and even death. Other times, surgery must be redone
to get the desired result.
Teens should talk honestly to both parents and doctors about what they expect from surgery. As a surgeon I am aware that I play
an important role- not just of fixing a physical imperfection- buy also being able to help teens and parents judge whether a teen could
benefit from rhinoplasty surgery and not make unreasonable promises about the results. Only when everyone is on the same page should
any cosmetic surgery go forward.
Ross A. Clevens, MD, FACS, is a Board Certified Facial Plastic and Reconstructive Surgeon having completed his undergraduate education at Yale University, his medical degree at Harvard Medical School and his M.P.H. in Health Policy and Management also at Harvard University. Dr. Clevens completed his residency in Head and Neck Surgery and an advanced fellowship in
Facial Plastic and Reconstructive Surgery at the University of Michigan where he also served as Chief Resident.
Dr. Clevens is a nationally recognized educator, author, lecturer; he has served as President of The Florida Society of Facial
Plastic and Reconstructive Surgeons, Chief of Staff at Wuesthoff Medical Center, President-Elect of the Brevard County Medical
Society, and has held numerous leadership positions with the American Academy and the American Board of Facial Plastic and
Reconstructive Surgery.
Dr. Clevens has been in private practice in Central Florida since 1996. At
the Clevens Center for facial Cosmetic
Surgery he has established a practice
grounded in patient-centered care.
Clevens states that his staff is his great
asset — knowledgeable professionals
who impart compassionate care with
exceptional customer service.
Dr. Clevens’ leadership and commitment to excellence transcends to
his philanthropic endeavors through
participating in numerous charitable
organizations in our community. Dr.
Clevens recently joined a humanitarian and medical mission trip to East
Africa. Having the opportunity to
affect profoundly the lives of others
through the application of his education, training and judgment proved to
be a deeply gratifying and humbling
experience.
He can be contacted by calling
(321) 727-3223 or by visiting www.
DrClevens.com or www.FloridaFaceAndBodySpecialists.com. оЃ®
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FLORIDA MD - AUGUST 2011 19
Hot Topics in Dermatology
A Dermatologist’s Tricks for Treatment of Warts
By Erica Mailler-Savage, MD
Warts are one of the most common dermatologic complaints
in pediatric patients, with approximately 10-20% of school-aged
children affected. There are several different types of warts found
in children including verruca vulgaris (common wart), plantar
warts, flat warts, periungual warts, mosaic warts (Figure 1), and
mymecia warts (deep palmoplantar warts).
Warts are benign proliferations
of the skin caused by human papillomavirus (HPV), with more than
150 subtypes identified. They are
spread by direct contact or autoinoculation with a latency of weeks
Figure 1: Mosaic wart
to years. The risk of spreading
warts is highest in wet, macerated skin, with communal showers
and wet pool decks being common places of transmission.
Warts can be self-limiting. It is estimated that approximately
80% clear spontaneously within 2 years. Patients seek treatment
when warts become painful, diffusely spread, or when the lesions
cause social embarrassment. Treatment options are numerous, including salicyclic acid, liquid nitrogen, cantharadin, podophyllin,
retinoids, intralesional chemotherapy, and laser.
For patients seeking treatment in my office, I have found the
most successful treatment regimen to be as follows:
(1) Pare down the keratotic
debris at the top of the
wart with a #15 blade
(Figure 2). Soaking the
warts in warm water
for 10-15 minutes in
the waiting room prior
to paring is best for hyperkeratotic lesions.
Figure 2: Paring the wart
(2) Freeze the warts with liquid nitrogen using a cotton-tipped
applicator. Wrapping extra wisps of cotton around the applicator tip helps to hold more liquid nitrogen in the cotton
(Figure 3). Freeze each lesion twice until a deep white color
is appreciated throughout
the wart and within a 1mm
margins around the wart
(Figures 4 and 5). Allow the
wart to fully thaw before applying the 2nd freeze. For
children, using a cotton applicator is less threatening
Figure 3: Extra cotton applied to
than using a cryogun.
cotton-tip applicator
20 FLORIDA MD - AUGUST 2011
(3) If a blister develops at the site of
treatment, have the patient lance
the blister at home with a sterile
needle to allow all the fluid out, being careful not to remove the blister
roof. Wash the area thoroughly after lancing. Allowing blisters to stay intact increases the risk for development of warts
around the initial lesion. Once the blister is lanced, keep a
band-aid over the treated area.
(4) Have the patient apply an over-the-counter
salicylic acid product
daily at home beginning 2-3 days after the
treatment. This allows
for sloughing of the
dead tissue and keratotic debris between treatments.
(5) Advise the patient to
return for retreatment
of the wart with paring and cryotherapy
no later than 2 weeks
from the initial treatment. Spreading the Figures 4 and 5: Freezing the wart
treatment cycles too far
apart will allow the viral-infected cells at the base of the wart
to re-proliferate the lesion. For patients who are compliant
with salicylic acid treatment at home, it is unusual to need
more than two treatments with cryotherapy.
(6) Warn the patient and their parents that warts are viral lesions
which always have a chance of recurring. Using a salicylic
acid based product at home as soon as a recurrent lesion is
noted, however, can prevent the need for further treatment
with cryotherapy in the office.
Erica Mailler-Savage, MD, is a board-certified Dermatologist and fellowship-trained Mohs surgeon specializing in skin cancer removal. Her practice, Comprehensive
Dermatology & Dermatologic Surgery, recently opened in
Winter Park, Florida. Prior to moving to Winter Park,
Dr. Mailler-Savage was a practicing physician and clinical instructor at the University of Cincinnati. She may be
contacted at (407) 339-7546 or by visiting www.comprehensivedermorlando.com. оЃ®
Digestive and Liver Update
What Causes GERD
in Infants and Children?
GERD (Gastroesopageal Reflux) can be present in all ages,
from infants, to adolescents and Adults. Most of the time, reflux
in infants is due to a poorly coordinated gastrointestinal tract.
Most babies outgrow infantile GERD.
In older children, the causes of GERD are often the same as
those seen in adults. Anything that causes the muscular valve between the stomach and esophagus (the lower esophageal sphincter, or LES) to relax, or anything that increases the pressure below
the LES, can cause GERD.
The burping, heartburn, and spitting up associated with GERD
are the result of acidic stomach contents moving backward into
the esophagus (called reflux). This can happen because the muscle
that connects the esophagus with the stomach (the esophageal
sphincter) relaxes at the wrong time or doesn’t properly close
The range of symptoms and complications of GERD in children vary with age.
Clinical manifestations and diagnosis
of GERD in children and adolescents:
Most episodes are brief and do not cause
symptoms, esophageal injury, or other complications. In contrast, gastroesophageal
reflux disease (GERD) is present when the
reflux episodes are associated with troublesome symptoms or complications. The term
“regurgitate” describes reflux to the oropharynx, and “vomit” describes expulsion
of the refluxate out of the mouth, but not
necessarily repetitively or with force. The
terms are not clearly distinguished in clinical practice. In this review, we will use the
term “regurgitate” to describe obvious gastroesophageal reflux, whether or not the refluxate is expelled from the mouth.
Prevalence: Prevalence of GERD is
much more common in adults than infants
and children. Exceptions are children with
neuromuscular disorders such as muscular
dystrophy and cerebral palsy and children
with Down syndrome, who, for reasons that
are poorly understood, are at increased risk
for developing GERD and other esophageal
motor abnormalities. Such children also appear to be at increased risk for developing
respiratory complications related to GERD
and represent a significant proportion of
children referred for antireflux surgery. A
By Harinath Sheela, M.D.
study by Richter and a Gallup Organization National Survey estimated that 2540% of healthy adult Americans experience symptomatic GERD,
most commonly manifested clinically by pyrosis (heartburn), at
least once a month. Furthermore, approximately 7-10% of the
adult population in the United States experiences such symptoms
on a daily basis. Among adolescents, 3 to 5 percent complained
of heartburn or epigastric pain, and 1 to 2 percent used antacids
or acid-suppressing medication.
Natural history — Regurgitation in infants is common and
typically decreases or resolves during the first year of life. While
the problem usually resolves by the end of infancy, there is a weak
association with GERD later in life. As an example, frequent regurgitation during infancy and a history of GERD in the mother
(but not the father) both predict the risk of reflux-related symptoms during childhood.
CLINICAL MANIFESTATIONS — The most common
symptoms of GERD vary according to age, although overlap may
exist.
Treating Central Florida for over 25 years
Major Services include:
• Allergy Injections
• Allergy Testing
• Asthma Therapies
• Flu Shots (during Flu season)
• Pulmonary Testing
• Food Challenge
• Drug Challenge
• Exercise Challenge
Helping Patients with:
• Asthma
• Chronic Cough
• Drug, Insect and Food Allergies
• Eczema
• Hay Fever
• Hives
• Immunodeficiency
• Sinus Conditions
• And More!
Board Certified Allergy,
Asthma & Immunology
& Board Certified Pediatrics
Steven Rosenberg, MD
Carlos Jacinto, MD
Winter Park
407-678-4040
Altamonte Springs
407-331-6244
Dr. Phillips
Our physicians hold faculty appointments
at the Florida State University School of
Medicine and the University of Central
Florida School of Medicine and are
members of Florida Hospital Kid’s Doc’s
407-370-3705
Viera
407-678-4040
www.aaacfonline.com
FLORIDA MD - AUGUST 2011 21
Digestive and Liver Update
The most common symptoms are:
• Frequent or recurrent vomiting
• Frequent or persistent cough
• Heartburn, gas, abdominal pain, or colicky behavior (frequent
crying and fussiness)
• Regurgitation and re-swallowing
• Feeding problems
• Recurrent choking or gagging
• Poor growth
• Breathing problems
• Recurrent wheezing
• Recurrent pneumonia
Atypical symptoms of GERD — In patients with laryngeal
symptoms, severe or atypical asthma, or children who are nonverbal, esophageal pH monitoring can be useful to establish a
temporal correlation between symptoms and episodes of reflux.
Symptoms of GERD present during childhood are moderately
likely to persist to adolescence and adulthood. In a survey of 207
patients who were diagnosed with GERD through an endoscopic
examination in childhood (mean age 5 years), about one-third
had symptoms of significant GERD during early adulthood (approximately 15 years later). At least 10 percent had weekly symptoms of reflux. Among those responding to the survey, 30 percent
were currently taking either H2RA or PPI, and 24 percent had
undergone fundoplication. Other studies have shown similar
results, but the lack of prospective trials limits the reliability of
these observations.
EVALUATION
The differential diagnosis of GERD in children is broad, particularly when the principal complaint is regurgitation, vomiting,
or abdominal pain. As a general rule, the diagnosis can be narrowed based upon the pattern of symptoms and the age of the
child, supported by a thorough medical history.
Empiric treatment — An empiric trial of acid suppression is
often used as a diagnostic test, and is suggested for children with
uncomplicated heartburn. This is not a valuable diagnostic test
in infants and young children, in whom symptoms of GERD are
less specific. Studies in adults suggest that it may be a cost-effective approach in selected patients, although the applicability of
these results to children is uncertain.
Endoscopy and histology — Endoscopic evaluation of the
upper gastrointestinal tract is indicated for selected patients in
whom esophagitis or gastritis is suspected. These include children
or adolescents with heartburn or epigastric abdominal pain that
fails to respond to or relapses quickly after empiric treatment.
In addition, endoscopy may be valuable in the evaluation of patients with recurrent regurgitation after two years of age, dysphagia, or odynophagia. Upper airway symptoms such as hoarseness
or stridor may also be caused by gastroesophageal reflux, but are
22 FLORIDA MD - AUGUST 2011
usually evaluated with laryngoscopy rather than esophagoscopy.
Unlike esophageal pH monitoring studies, endoscopy permits
visualization of the esophageal epithelium as well as histologic
evaluation, to determine the presence and severity of esophagitis
and complications such as strictures or Barrett’s esophagus, and
to exclude other disorders such as allergic or infectious esophagitis. An esophagus that appears normal does not exclude the
presence of GERD. Sensitivity can be increased with mucosal
biopsies, which may reveal histologic findings consistent with
GERD. The proportion of children with symptoms of GERD
who have evidence of overt mucosal damage has not been well
established. Endoscopy can be performed in infants, toddlers,
and older children. Procedure-related complications of diagnostic
endoscopy and biopsy appear to be rare. An infant or child with
documented esophagitis should be treated with lifestyle changes
and acid suppression therapy. Patients with only mild esophagitis
can be assessed based upon the degree of symptom relief. Those
with erosive esophagitis should undergo a repeat endoscopy to
demonstrate healing.
Esophageal pH monitoring or impedance monitoring —
Esophageal pH monitoring permits the assessment of the frequency and duration of esophageal acid exposure and its relationship to symptoms. However, the results do not correlate consistently with symptom severity or objective findings on endoscopy.
Therefore, pH monitoring can raise or lower suspicion of GERD,
but is not a definitive diagnostic test, and is not useful in many
Digestive and Liver Update
clinical situations. In some children, distinguishing between
GERD and eosinophilic esophagitis can be difficult. In this case,
documentation of a normal intraesophageal pH monitoring or a
trial of sustained acid suppression is needed before the diagnosis
of eosinophilic esophagitis can be established.
Laryngeal symptoms that may be related to reflux include nocturnal stridor or cough. A dual-channel esophageal pH monitor,
with electrodes in both distal and proximal esophagus, is particularly valuable for evaluating patients with these symptoms.
However, no consensus exists on the pH criteria that should be
used for defining pathologic reflux in this setting. One study suggested that a pH decrease of more than 2 pH units in the pharynx, occurring during esophageal acidification, and reaching a
nadir of less than 4 units in less than 30 seconds was optimal for
distinguishing patients with suspected regurgitation from healthy
controls.
In patients with severe or atypical asthma, esophageal pH monitoring also can assess whether there is a temporal correlation between symptoms and reflux, particularly if asthmatic symptoms
are discrete and positional. However, empiric trials of vigorous
acid suppression also are used in this situation.
In patients with recurrent pneumonia, it is difficult to establish
whether esophageal reflux contributes to the problem. Abnormal
results from esophageal pH monitoring are neither highly sensitive nor specific in detecting whether aspiration pneumonia is
related to reflux, but patients with aspiration tend to reflux more
frequently into the proximal esophagus. Esophageal pH monitoring may help establish the diagnosis when combined with other
investigations, including videofluoroscopic swallowing evaluation, bronchoscopy, and/or endoscopy.
In nonverbal children (eg, those with autism) behavioral
changes or self-injurious behavior can be the only symptoms of
GERD. Esophageal pH monitoring can support or help to exclude GERD as a cause of the behavioral symptoms.
Reflux symptoms not responsive to medical or surgical
therapy — Esophageal pH studies can determine the adequacy
of acid suppression in children who remain symptomatic despite
being treated with a proton pump inhibitor, or after surgical treatment for reflux. If the pH study shows adequate acid suppression,
alternative explanations for the symptoms should be sought (eg,
allergic esophagitis or alkaline reflux). If there is marked acid reflux, acid suppressive treatment should be optimized.
Premature and newborn infants with apnea or an apparent life-threatening event — If infants have repeated episodes
of apnea, esophageal pH monitoring may be useful to determine
if these are triggered by GERD. However, the association can be
made only if performed simultaneously with polysomnography
or oxycardiorespirography, and if an event occurs during monitoring.
Barium contrast radiography — Barium studies of the esophagus are neither sensitive nor specific for the diagnosis of GERD.
Compared to esophageal pH studies, the sensitivity, specificity,
and positive predictive values have ranged from 31 to 86, 21 to
83, and 80 to 82 percent, respectively, in various reports.
Complications of GERD: including esophageal adenocarcinoma, are more common in individuals who had repair of esophageal atresia in the perinatal period as compared to individuals
without this congenital defect. GERD also appears to be relatively common in children with cystic fibrosis.
SUMMARY AND RECOMMENDATIONS
Gastroesophageal reflux is common in infants, as manifested
by regurgitation, and is generally not pathological. The regurgitation usually resolves by 18 months of age. Symptoms suggestive of pathological gastroesophageal reflux, or gastroesophageal
reflux disease (GERD) include recurrent regurgitation after two
years of treating GERD.
Treatment for GERD depends on the type and severity of the
symptoms.
In babies, doctors sometimes suggest lightly thickening the formula or breast milk with rice cereal to reduce reflux. Making sure
the baby is in a vertical position (seated or held upright) during
feedings can also help.
Older kids often get relief by avoiding foods and drinks that
seem to trigger GERD symptoms.
Doctors may recommend raising the head of a child’s bed 6
to 8 inches to minimize reflux that occurs at night. They may
also try to address other conditions that can contribute to GERD
symptoms, including obesity, alcohol consumption, smoking,
and certain medications.
FLORIDA MD - AUGUST 2011 23
Digestive and Liver Update
If these measures don’t help relieve the symptoms, the doctor may also prescribe medication, such as H2 blockers, which can help
block the production of stomach acid, or proton pump inhibitors, which reduce the amount of acid the stomach produces.
Medications called prokinetics are sometimes used to reduce the number of reflux episodes by helping the lower esophageal sphincter
muscle work better and the stomach empty faster.
In rare cases, when medical treatment alone doesn’t help and a child is failing to grow or develops other complications, a surgical procedure called fundoplication might be an option. This involves creating a valve at the top of the stomach by wrapping a portion of the
stomach around the esophagus.
Side effects from medications that inhibit the production of stomach acid are quite uncommon. A small number of children may
develop some sleepiness when they take Zantac, Pepcid, Axid, or Tagamet.
Harinath Sheela, MD moved to Orlando, Florida after finishing his fellowship in gastroenterology at Yale University School of
Medicine, one of the finest programs in the country. During his training he spent significant amount of time in basic and clinical research and has published articles in gastroenterology literature.
His interests include Inflammatory Bowel Diseases (IBD), Irritable Bowel Syndrome (IBS), Hepatitis B, Hepatitis C, Metabolic and other liver disorders. He is a member of the American Gastroenterological Association (AGA), the American Society
for Gastrointestinal Endoscopy (ASGE) and the American Association for the Study of Liver Diseases (AASLD) and Crohn’s
Colitis foundation (CCF).
Dr. Sheela is a Clinical Assistant Professor at the University of Central Florida School of Medicine. He is also a teaching attending physician at Florida Hospital Internal Medcine Residency and Family Practice Residence (MD and DO) programs.
Coming Next
Month IN
FLORIDA MD:
Our cover story
features Lakeland
Regional Cancer
Center. Editorial
focus is on Sports
Medicine and
Robotic Surgery.
24 FLORIDA MD - AUGUST 2011
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The Evaluation and Treatment of the
Patient With a Chronic Cough
By Steven Rosenberg, MD
It is not unusual for the physician, especially during the winter
months, to have a majority of patients, who present to his office
on any given day, having symptoms of a recurrent cough. In
the vast majority of these individuals, their cough is secondary
to a viral cold or upper respiratory tract infection, influenza, or a
mild case of pneumonia/bronchitis. Usually the cough will subside within several days. However, in a small
number of these individuals, rather than
subsiding, the cough will become chronic
in nature.
Cough is an important physiologic response of the body’s defense or immune
system in that it permits one to clear excessive secretions and foreign bodies from
the respiratory tract. However, one of the
most perplexing medical problems is the
patient who is presents with a cough which
has become persistent or chronic in nature. Chronic cough is defined as recurrent
coughing which persists for longer than 8
weeks in an adult, and 4 weeks in a pediatric
patient.
Chronic cough may impose much stress
on the patient, and in the case of our pediatric patients, on both the child and their
families. The patient is often concerned in
that he/she fears that the cough may be an
indication of a more severe clinical condition. Coughing often interferes with sleep
and the ability of the patient to function
throughout the day. Overall chronic cough
can have a severe impact on the patient’s
quality of life.
There is still much debate as to the proper
work-up for the patient who is presenting
with recurrent coughing. There is even more
debate as to how to treat such individuals.
For many years we have utilized numerous
antitussives for the treatment of cough, yet
today there is disagreement in regards to the
role of these agents, especially in the treatment of coughing in children.
Of paramount importance is a careful
and methodical history and physical examination of the patient presenting with a
chronic cough. The simple prescribing of
an antibiotic or antitussive should be
discouraged, at least until an attempt
is made to try to establish the cause of
the cough. Questions to be asked includes if the patient has a
current or past history of use of tobacco products. Individuals
who have recently discontinued smoking may actually present
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FLORIDA MD - AUGUST 2011 25
with an increase in coughing. Drugs such as Beta Blockers and
ACE inhibitors may cause an increase in coughing, especially in
individuals who have a history of clinical atopy (allergy) and/or
asthma. Coughing may be exacerbated by occupational exposure,
so evaluation should include the patient’s home, school, and work
environment.
Evaluation of the individual with chronic
cough should include:
A)Upper respiratory Tract: Rhinosinusitis can lead to a chronic
cough. In fact individuals presenting with cough secondary to
rhinosinusitis and post nasal drips are termed to have Upper
Airway Cough Syndrome.
B)Lower Respiratory Tract: Chronic lung disease can lead to recurrent coughing. There is still much debate as to whether an
individual who does not wheeze, but presents with a recurrent
cough has asthma. A new definition, Eosinophilic Bronchitis
is defined as an individual with recurrent coughing, unassociated with wheezing who has airway inflammation.
C)Gastroesophageal Reflux is thought to be another significant
cause of coughing. Interesting we do see individuals who have
an absence of symptoms suggestive of reflux, yet will respond
to treatment with anti-reflux agents such as Proton Pump Inhibitors (PPI’s) and H2 Histamine Antagonists.
D)Other causes: This will include Vocal Cord Dysfunction.
Psychogenic cough can also be seen, especially in children.
The History and Physical Examination of the
individual who presents with a chronic cough
should include:
A)Evaluation for the presence of allergy and sinus disease: Is
there a family history of allergy? Does the patient have symptoms of post nasal drip, and or rhinitis? Facial tenderness may
suggest sinusitis. Ocular pruritus, discharge and injection
may also suggest that the patient is bothered by symptoms of
allergy.
B)Lower Airway Disease: Is there a family history of both allergy and asthma? Does the patient have a history or symptoms
of wheezing, exercise intolerance or episodes of respiratory
distress.
C)GERD (Reflux): Does the patient have a history of frequent
heartburn, dyspepsia and/or chronic hoarseness.
D)Other: Especially in children the possibility of ingestion of a
foreign body should be considered. Also in children the suspicion of Cystic Fibrosis. A history of chronic lung disease
such as emphysema, bronchiectasis, occupational pneumonia or asthma, as well as alpha 1 antitrypsin deficiency. As
previously noted a history of tobacco use. The use of certain
medications such as Beta Blockers and ACE Inhibitors. Vocal
Cord Dysfunction is at time difficult to diagnosis, but may be
26 FLORIDA MD - AUGUST 2011
a cause of chronic cough. Finally when the diagnostic workup
in unrewarding, psychogenic cough may be considered.
There is also much debate as to what laboratory tests should be
included in the diagnostic work-up. The selection of such testing
should be based on conclusions reached during the history and
physical examination of the patient with a chronic cough.
Suggested laboratory tests will include:
A) Chest X-Ray: It is felt that the Chest X-Ray is the single most
important test obtained in the diagnostic workup. A negative
chest X-Ray may as important as obtaining a positive chest
X-Ray in the diagnosis.
B) Skin or RAST Testing: This is of importance to determine
if the patient has an allergic predisposition and may point to
possible triggering factors.
C) If upper airway disease is suspected a Computerized Tomogram or CT scan of the sinuses may be of benefit. Rhinoscopy
should also be considered,
D) If lower respiratory tract disease is considered a Computerized Tomogram Chest Scan should be considered. At times the
CT Chest Scan will pick up pathology which may be missed
by the conventional Chest X-Ray. Pulmonary Function testing
which may include Methacholine Challenge Testing as well as
Exercise Challenge Testing may be of benefit in ruling in or
out the diagnosis of asthma or reactive airway disease.
a patient, that consideration should be given to referral to an allergist. Allergists specialize in the management and treatment of
these individuals.
E) Reflux (GERD) Disease: Tests which may be of benefit will
include an esophagram or barium swallow. A newer assay for
evaluation of reflux is the use of a PH probe. If necessary, endoscopy with inspection of the trachea and vocal cords may
also be of useful. With proper diagnosis and treatment the patient presenting
with a chronic cough can have their symptoms brought under
clinical control.
While there is much debate in regard to the proper work-up of
the individual with a chronic cough, there is even more controversy about treatment. Treatment strategies may include:
Allergy and Asthma Associates of Central Florida has four
offices in the Greater Orlando Area including Winter Park,
Altamonte Springs, Orlando (Dr. Philips area) and introducing our newest office opening in the Melbourne/Viera area in
August 2011.
A) Upper Airway
1) Antihistamine/Decongestant Therapy, often used in combination. We prefer the second generation antihistamines because of the significant sedative properties associated with the
older first generation antihistamines.
2) Nasal Irrigation. This may be done with either isotonic or hypertonic saline solutions. We recommend the use of a device
such as the “Netti Pot.”
3) Nasal Corticosteroids. These are felt to be the “treatment of
choice” for individuals with rhinosinusitis.
B) Lower Airway
1) Both short and long acting beta agonists. With long acting
beta agonists extreme caution should and close monitoring of
the patient if these agents are used alone.
2) Inhaled corticosteroids. These are the “drugs of choice” for
the treatment of asthma. The combination of inhaled corticosteroids and long acting beta agonists (LABA’s) have been
shown to be of much benefit in the treatment of asthma, as
well as patients whose cough is secondary to asthma or reactive
airway disease.
Steven Rosenberg, MD, FAAAAI, has been practicing medicine in the Central Florida area for over 20 years, specializing
in the area of Allergy, Asthma, and Immunology. He received
the Doctor of Medicine from the State University of New York,
Downstate Medical Center. Dr. Rosenberg completed a residency in Pediatrics at the State University of New York at Buffalo and a Fellowship in Allergy, Asthma, and Immunology at
the University of Pittsburgh. Dr. Rosenberg has held positions
as President of the Central Florida Pediatric Society, at the
Florida Allergy, Asthma, and Immunology Society, and on the
medical staff at Florida Hospital. In addition, Dr. Rosenberg
has held the position of Chairman, Department of Pediatrics
at Florida Hospital and is a member of many local and national societies which include the American Academy of Allergy
& Immunology, the Florida Allergy and Immunology Society,
Florida Hospital Kid’s Docs and the Central Florida Pediatric Society. He holds faculty appointments at the University of
Central Florida Medical School and the Florida State University School of Medicine. For additional information please
contact him at 407.678.4040 or aaacf@embarqmail.com. оЃ®
3) Anticholinergics. Agents such as Ipratropium and Tiotropium have been shown to be of benefit in the management of
Asthma, Bronchitis and COPD
C) GERD
1) Proton Pump Inhibitors (PPI’s). These agents are the “drugs
of choice” in the treatment of reflux disease.
2)H2 Histamine Antagonists. They may be of benefit in that
they have a more rapid onset of action than the PPI’s
In individuals who do not respond to therapy the use of more
aggressive pharmacotherapy including the use of systemic corticosteroids as well as antibiotics may be of benefit. Such individuals should be closely monitored.
The individual with chronic cough can be a difficult medical
problem. We suggest that if the Primary Care Physician sees such
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FLORIDA MD - AUGUST 2011 27
FERTILITY
Male Infertility: Current Concepts and New
Robotic Microsurgery Treatment Options Now
Available at Winter Haven Hospital (Part 2 of 4)
By Sijo J. Parekattil, M.D.
What is Male Infertility?
Approximately 15% of all couples face infertility issues. Up to
50% of infertility in couples may be due to male factors. Male
infertility focuses on the male factors that may contribute to the
couples’ infertility issues. Infertility treatment is a team approach
involving female infertility and male infertility specialists with
one goal in mind - to help the couple have a child.
What causes Male Infertility?
A number of factors may lead to male infertility. These may
range from genetic and physiologic to environmental causes. The
careful evaluation and examination of male infertility patients is
geared to assess any of these possible causes and to rectify them
if possible.
What kinds of treatment options are
available?
Winter Haven Hospital in conjunction with the University
of Florida has developed a new center for urology and robotics institute with a serious commitment to the development of
new diagnostic and surgical treatment options for Male Infertility. The center is the leading program in the world performing
robotic assisted microsurgery to correct various types of male
infertility and testicular conditions – over 600 procedures have
been performed so far (the largest experience of this kind in the
world). This article is the first part of a 4 part series dedicated
to discussion of various unique treatment options offered at the
center:
1) Robotic assisted microsurgery for vasectomy reversal and
congenital obstruction repair (such as cystic fibrosis vasal obstruction)
2) Robotic assisted microsurgical varicocelectomy for the treatment of varicoceles in men
3) Robotic assisted microsurgical testicular sperm extraction
(Robotic Micro TESE) to detect and collect sperm from the
testicle in men who have no sperm in the ejaculate
4) Chronic testicular and groin pain – novel robotic assisted
microsurgical targeted neurolysis or denervation of the spermatic cord to treat this condition
This issue focuses on subtopic 2:
28 FLORIDA MD - AUGUST 2011
Robotic assisted subinguinal
microscopic varicocelectomy (RAVx)
In 2005, preliminary results on the advantages of robotic assisted laparoscopic intra-abdominal varicocelectomy were published. Since then, there have been a number of publications
that suggest microscopic subinguinal varicocelectomy (MVx)
may provide superior outcomes compared to intra-abdominal
varicocelectomy. A recent study comparing microsurgical to
RAVx found the robotic approach provided an added advantage of slightly decreased operative duration and near complete
elimination of surgeon tremor. These advantages may stem from
the 4th robotic arm allowing the surgeon to control one additional instrument during cases and therefore decreasing reliance
on the microsurgical assistant. Examples of how the fourth arm
provides this advantage are: 1) the simultaneous use of real-time
intra-operative Doppler mapping of the testicular arteries while
dissecting the veins, and 2) ability to cut sutures with the fourth
arm – obviating the need to switch the main left and right arm
instruments.
To further explore these findings, we performed a prospective
randomized control trial of MVx to RAVx in a canine varicocele model. 12 canine varicocelectomies were randomized into 2
arms of 6: MVV vs. RAVx. A fellowship-trained microsurgeon
performed cord dissection and ligation of 3 veins with 3-0 silk
ties. Procedure duration, vessel injury and knot failures were recorded. There were no vessel injuries or knot failures in either
group. There was no significant difference in setup duration between the robot and operative microscope. Based on these canine
trials there was a significant time duration advantage with robot
assistance (RAVx mean duration, 9.5min, MVV mean duration,
12min; p=0.04).
We recently reviewed our prospective clinical database of 97
RAVx cases (Figure 1 and 2) done from June 2008 to September
2010 (median follow up 11 months: range 1-27). Indications for
the procedure were the presence of a grade two or three varicocele and the following conditions: azoospermia (10), oligoospermia (42) and testicular pain with or without oligoospermia who
failed all other conservative treatment options (45). The median
duration per side was 30 min (10-80). Three-month follow up
was available for 81 patients: 75% with oligoospermia had a significant improvement in sperm count or motility, 1 with azoospermia was converted to oligoospermia and 92% of patients
FERTILITY
with testicular pain had complete resolution of
symptoms (targeted neurolysis of the spermatic
cord had been performed in addition to varicocelectomy). One recurrence or persistence of a
varicocele occurred (by physical and ultrasound
exam), one patient developed a small post-operative hydrocele, and two had small post-operative scrotal hematomas (treated conservatively).
Robotic assisted microsurgical subinguinal
varicocelectomy appears to be safe, feasible and
efficient. The preliminary human results appear
promising.
No solution is perfect, but our goal and dream
is to help each couple in achieving their fertility
goals using the most advanced and innovative
methods available.
Figure 1. View for the surgeon in the robotic console – this image shows one of the veins
being mapped with the micro-Doppler probe by the surgeon. The insert on the left lower
side is the view from the higher magnification optical camera.
Figure 2. Robotic assisted
microsurgery (the robot is used
instead of an operating microscope)
Sijo J. Parekattil, MD, is Director of Urology & Robotic Surgery for Winter Haven Hospital and University of Florida, Winter
Haven, FL, and is an Assistant clinical professor of Urology and an Adjunct professor of Bioengineering. He has dual fellowship training from the Cleveland Clinic Foundation, Cleveland in Laparoscopy/Robotic Surgery and Microsurgery and was an
Electrical Engineer prior to his medical training and thus has interests in surgical techniques incorporating technology, robotics
and microsurgery. Dr. Parekattil also runs a dedicated Male Infertility and Groin Pain/Testicular Pain Clinic at Winter Haven
Hospital, Winter Haven (863-292-4652 or www.roboticinfertility.com) As an infertility patient himself at one point, he is truly
dedicated to these patients. He may also be contacted at sijo.parekattil@winterhavenhospital.org.
оЃ®
FLORIDA MD - AUGUST 2011 29
Current Topics
Pediatric Epileptologist Joins Walt Disney Pavilion
at Florida Hospital for Children to Launch
Comprehensive Pediatric Epilepsy Program
Pediatric epileptologist Dr. Ki Hyeong Lee recently joined the
Walt Disney Pavilion at Florida Hospital for Children as the medical director of the Pediatric Epilepsy Program. Under Dr. Lee’s
leadership, the team at Florida Hospital will provide comprehensive patient care by offering most advanced diagnostic tools and
full array of treatment options for children with difficult to treat
epilepsy.
Dr. Lee and his highly trained team of specialists will launch
a comprehensive program for epilepsy to provide personalized,
expert care to patients in Central Florida. Dr. Lee and his team
specialize in treating drug-resistant epilepsy with alternative treatments including ketogenic diet, which involves eating a high-fat
diet to control epilepsy, and brain surgery using the latest, most
advanced technology available. Under the expertise of Dr. Lee,
the team at the Walt Disney Pavilion at Florida Hospital for Children hopes to not just diagnose and manage epilepsy, but cure
epilepsy.
Dr. Lee earned his medical degree from Seoul National University. He then completed his residency in adult neurology at the
Seoul National University Hospital. Dr. Lee had his epilepsy research fellowship at the Mayo Clinic, as well as his child neurology
residency from the Medical College of Georgia. Prior to joining
the Walt Disney Pavilion at Florida Hospital for Children, Dr. Lee
was the director of clinical neurophysiology and epilepsy surgery
program at Cincinnati Children’s Hospital Medical Center. Dr.
Lee also held the position of director of the pediatric epilepsy fellowship program at the Cincinnati Children’s Hospital Medical
Center, and was also an associate professor in the department of
neurology and pediatrics at the University of Cincinnati’s College
of Medicine.
Dr. Lee was granted the National Epifellows Foundation Research Grant Award in 2001, and in 2002, received the Young
Investigator Award from the American Epilepsy Society. He has
given numerous national and international lectures on a variety of
pediatric topics, authored many articles as well as a book chapter
on epilepsy and is a member of several scientific and professional
societies such as the American Epilepsy Society and the American
Academy of Neurology.
“We are thrilled about the addition of Dr. Lee to our medical
staff, as we continue to establish Florida Hospital for Children as
a leader in advanced surgical services and patient experience,” said
Marla Silliman, administrator of Florida Hospital for Children.
“Dr. Lee’s leadership and specialized experience in pediatric epilepsy will help to enhance our neuroscience program at Florida
Hospital for Children to better serve the Central Florida community and beyond.” 
UGA Researchers Use Gold Nanoparticles to Diagnose Flu in Minutes
Arriving at a rapid and accurate diagnosis is critical during flu outbreaks, but until now, physicians and public health officials have had
to choose between a highly accurate yet time-consuming test or a rapid but error-prone test.
A new detection method developed at the University of Georgia and detailed in the August edition of the journal Analyst, however, offers the best of both worlds. By coating gold nanoparticles with antibodies that bind to specific strains of the flu virus and then measuring
how the particles scatter laser light, the technology can detect influenza in minutes at a cost of only a fraction of a penny per exam.
“We’ve known for a long time that you can use antibodies to capture viruses and that nanoparticles have different traits based on their
size,” said study co-author Ralph Tripp, Georgia Research Alliance Eminent Scholar in Vaccine Development in the UGA College of Veterinary Medicine. “What we’ve done is combine the two to create a diagnostic test that is rapid and highly sensitive.”
Working in the UGA Nanoscale Science and Engineering Center, Tripp and co-author Jeremy Driskell linked immune system proteins
known as antibodies with gold nanoparticles. The gold nanoparticle-antibody complex aggregates with any virus present in a sample, and
a commercially available device measures the intensity with which the solution scatters light.
Driskell explained that gold nanoparticles, which are roughly a tenth of the width of a human hair, are extremely efficient at scattering
light. Biological molecules such as viruses, on the other hand, are intrinsically weak light scatterers. The clustering of the virus with the
gold nanoparticles causes the scattered light to fluctuate in a predictable and measurable pattern.
“The test is something that can be done literally at the point-of-care,” said Driskell, who worked on the technology as an assistant research scientist in Tripp’s lab. “You take your sample, put it in the instrument, hit a button and get your results.”
Gold is often thought of as a costly metal, but the new diagnostic test uses such a small amount—less than what would fit on the head
of the pin—that the cost is one-hundredth of a cent per test.
The researchers noted that the current standard for definitively diagnosing flu is a test known as PCR, for polymerase chain reaction.
PCR can only be done in highly specialized labs and requires that specially trained personnel incubate the sample for three days, extract
Continued on page 31
30 FLORIDA MD - AUGUST 2011
the DNA and then amplify it many times. The entire process, from sample collection to result, takes about a week and is too costly for
routine testing.
The alternative is a rapid test known as a lateral flow assay. The test is cost effective and can be used at the point-of-care, but it can’t
identify the specific viral strain. It also misses up to 50 percent of infections and is especially error-prone when small quantities of virus
are present, Driskell added.
By overcoming the weaknesses of existing diagnostic tests, the researchers hope to enable more timely diagnoses that can help halt the
spread of flu by accurately identifying infections and allowing physicians to begin treatment early, when antiviral drugs, such as Tamiflu,
are most effective.
Tripp and Driskell are planning to compare the new diagnostic test with another that Tripp and his colleagues developed that measures
the change in frequency of a laser as it scatters off viral DNA or RNA. Tripp also is working to adapt the new technique so that poultry
producers can rapidly detect levels of salmonella in bath water during processing. Poultry is the largest agricultural industry in Georgia, he
pointed out, so the technology could have a significant impact on the state’s economy.
“This test offers tremendous advantages for influenza, but we really don’t want to stop there,” Tripp said. “Theoretically, all we have to
do is exchange our anti-influenza antibody out with an antibody for another pathogen that may be of interest, and we can do the same
test for any number of infectious agents.”
To learn more about the UGA Nanoscale Science and Engineering Center, see http://nano.uga.edu. оЃ®
Hospital Purchases New Equipment to Improve Spine
Surgery Care
Florida Hospital Memorial Medical Center O-armВ® Surgical Imaging System provides less
invasive, yet more effective, neurosurgical care
Florida Hospital Memorial Medical Center is the only hospital
in Volusia and Flagler counties to offer the O-armВ® Surgical Imaging System to patients undergoing neurosurgery.
The O-armВ® Surgical Imaging System closes around a patient
to make an “o” shape. It takes a 360-degree X-ray image and develops it into either a 2- or 3-D image, similar to a CT scan. This
technology provides real-time, high-quality images of a patient’s
anatomy during surgery, which allows surgeons to view any part of
the patient’s skeletal anatomy, from head to toe.
Florida Hospital Memorial Medical Center has taken the advanced technology to the next level by integrating Medtronic’s
StealthStationВ® surgical navigation systems, enabling neurosurgeons to perform less invasive procedures and confirm the precision of advanced surgical procedures while in the Operating Room.
This has the added benefit of reducing a patient’s X-ray exposure,
increasing safety for patients.
The O-armВ® Surgical Imaging System is a nearly $900,000 investment in Volusia County neurosurgical care and can be used in
any spine fusion procedure.
“This is a significant investment by Florida Hospital Memorial Medical Center to improve spinal surgery in this region,” said
Christopher S. Kent, MD, Neurosurgeon at Florida Hospital Memorial Medical Center. “While spine surgery will never be riskfree, the O-arm allows us to reduce the risk, increase patient safety,
and increase the accuracy of surgical screws and other implants.”
Prior to the O-arm, neurosurgeons would obtain these necessary
images via fluoroscopy, which only gives two views of the patient:
a lateral (side) view and an anterior/posterior (front/back) view.
From this, the surgeon would determine the best trajectory of surgical screws for a spine fusion.
“Even in the best of hands, screws can be placed less than optimally when using fluoroscopy,” said Dr. Kent. “The O-arm clearly
shows us the patient’s anatomy and helps us determine the best
trajectory for placing screws during a spine fusion surgery.”
About the Center for Neurohealth
Sciences at Florida Hospital Memorial
Medical Center
Opened in July 2007, the Center for Neurohealth Sciences at
Florida Hospital Memorial Medical Center offers patients the latest in minimally invasive surgical treatments. The neurosurgeons
at The Center are experts in surgical, non-surgical and rehabilitation treatment for all spine and brain issues and injuries. If surgery
is deemed necessary, they are experienced in the latest minimally
invasive spine surgery techniques. To learn more, call (386) 2313540 or visit www.FloridaBrainAndSpine.com. оЃ®
Dr. Eric G. Bonenberger was recognized as a Gold DOC
by The Arnold P. Gold Foundation in July. The nomination is
given when a patient pays tribute publicly to their physician
when they feel the care they received demonstrates
exemplary skill, sensitivity and compassion.
FLORIDA MD - AUGUST 2011 31
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Florida MD 2011 Editorial
Calendar. . . . . . . Inside Back Cover
Mark Rosenberg, MD
FloridaMD.com. . . . . . . . Back Cover
Emory University
Department of Global Health Vaccines
Senior Advisor to the Director of the National Immunization Program
Pediatric Infectious Diseases
Emory University
Executive Director of the Taskforce for Child Survival and Development
Pediatric Injury
The Hidden Wealth System. . . . . . 16
Charles Homer, MD
Jewett Orthopaedic . . . . . . . . . . . 13
Associate Professor, Department of Society, Human Development and Health
National Initiative for Children’s Healthcare Quality
Harvard School of Public Health
Pediatric Health Care
Last Diet ad. . . . . . . . . . . . . . . . . . 9
Steven Hirschfeld, MD PhD
Michael Lowe PA . . . . . . . . . . . . . 26
Associate Director, Clinical Research
National Institute of Child Health & Human Development, NIH
Neuroscience Institute at Florida
Hospital Orlando . Inside Front Cover
Save the Date
Wednesday, September 7, 2011
Orlando Orthopaedic Center. . . . . 24
3:30 pm Registration & Refreshments | 4 pm - 9 pm Lectures
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Werner Auditorium – Florida Hospital Orlando
601 East Rollins Street | Orlando, FL 32803
RSVP with the Florida Hospital Friends and Family Helpline
at (407) 303-1700
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DLS-11-3024
This program is approved for
AMA PRA Category 1 Creditв„ў.
Coming Next Month:
Our cover story features Lakeland
Regional Cancer Center. Editorial
focus is on Sports Medicine and
Robotic Surgery.
2011
EDITORIAL
CALENDAR
Florida MD is a four-color monthly
medical/business magazine for physicians in
the Central Florida market.
It goes to 4,000 physicians, at their offices, in the
thirteen-county area of Brevard, Flagler, Hardee,
Highlands, Indian River, Lake, Marion, Orange, Osceola,
Polk, Seminole, Sumter and Volusia counties. Cover
stories spotlight extraordinary physicians affiliated
with local clinics and hospitals. Special feature stories
focus on new hospital programs or facilities, and other
professional and healthcare related business topics.
Local physician specialists and other professionals,
affiliated with local businesses and organizations, write
all other columns or articles about their respective
specialty or profession. This local informative and
interesting format is the main reason physicians take
the time to read Florida MD.
It is hard to be aware of everything happening in the
rapidly changing medical profession and doctors want
to know more about new medical developments and
technology, procedures, techniques, case studies,
research, etc. in the different specialties. Especially
when the information comes from a local physician
specialist who they can call and discuss the column with
or refer a patient. They also want to read about wealth
management, financial issues, healthcare law, insurance
issues and real estate opportunities. Again, they prefer
it when that information comes from a local professional
they can call and do business with. All advertisers have
the opportunity to have a column or article related to
their specialty or profession.
JANUARY –
Digestive Disorders
Diabetes
FebRUARY –
Cardiology
Heart Disease & Stroke
MARCH –
Orthopaedics
Men’s Health
ApRil –
Surgery
Scoliosis
MAY –
Women’s Health
Advances in Cosmetic Surgery
JUNe –
Allergies
Sleep Disorders
JUlY –
imaging Technologies
interventional Radiology
AUgUST –
pediatrics & Advances in NiCU’s
Autism
SepTeMbeR – Sports Medicine
Robotic Surgery
OCTObeR –
Cancer
Dermatology
NOveMbeR – Urology
geriatric Medicine / glaucoma
DeCeMbeR – pain Management
Occupational Therapy
Please call 407.417.7400 for additional materials or information.
Visit Our New Website at
FloridaMD.com
Your Medical Business Resource
Practice Management Advice
Financial Information
Pod Cast Interviews with
Specialists and Professionals
Medical Classifieds
Back Issues with
Informative and
Interesting Stories
For Information Please
Email: info@floridamd.com
or call 407.417.7400