AUGUST 2011 вЂў CENTRAL FLORIDA EDITION Nemours ChildrenвЂ™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 ChildrenвЂ™s Hospital and Health Campus Photos Provided by Nemours The 2012 opening of the Nemours ChildrenвЂ™s Hospital in Lake Nona Medical City increases the research and clinical care capabilities of Nemours ChildrenвЂ™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 FloridaвЂ™s families. Photos Provided by Nemours 12 The ABCвЂ™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 FROM THE THE PUBLISHER PUBLISHER FROM II am pleased to bring bring you youanother anotherissue issueofofFlorida FloridaMD MD. You donвЂ™t Iam pleased to Magazine. ItвЂ™shave hardtotolook imag-far to see theanyone economic on with around Central Florida losing ine whocrisis is notgoing familiar the us. March of Dimes andfamilies the workarethey do totheir jobs, their health benefits and their homes. There are programs and facilities in place to help these unfortunates, but sometimes lack new the ability to find The Unitedup Way has started always reinventing themselves they to create programs and them. services. Coming next 2-1-1, aisfree, 24-hourMarch information, referral crisis hotline describedopportunity below to help. month the annual for Babies. ItвЂ™s a and wonderful team-building for Please pass along this information to any of your patients you feel could benefit for this service. tions on how you and your family can join the march or how to form a team for your 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 B.toRauhofer Thanks a very generous community, Heart of Florida United Way (HFUW) is distributing nearly $15 million this year to local health and human service programs throughout Orange, Osceola and Seminole counties. From improving childrenвЂ™s health and lifting families out of poverty to providing Publisher/Seminar Coordinator warm, nutritious meals for seniors and mentoring at-risk teens, the programs вЂ’ 108 in all вЂ’ will serve more than 345,000 Central Floridians in need. Of the nearly $15 million, $6.25 million was funded under HFUWвЂ™s prevention-based model, Investing in Results (IIR), which awards competitive grants in four areas: Developingpeople Healthywalking Children and Families;of Building SafeMarch Communities through Education;When Improving Financial Stability; and Alleviating Join more than a million in March Dimes, for Babies and Hunger and Homelessness. Saturday, April 24th raising money to help give every baby a healthy start! Invite your family and friends This year marks the first time competitive grants were awarded for Developing Healthy Children & Families which focuses 7am (DHC&F), Registration 8am Walkon improving tothe join you inmental Marchand forsocial Babies, or of even a Family Team.that You can also join with physical, health localform families. вЂњWe know healthy individuals are the foundation for vibrant, productive communities,вЂќ said practice Dr. Ronald Piccolo, chair of United WayвЂ™s DHC&F cabinet associate professor for the Crummer Graduate School of Business at Rollins your andF. become a team captain. Together youвЂ™ll raiseand more money and share Where College. a meaningful experience. Lake Lily Park, Maitland вЂњThe opportunity for good health starts long before one needs medical care. Healthy living begins in our families, neighborhoods and schools. With a focus on prevention, these programs will address key health issues, such as low birth weight, obesity and chronic disease among youth and adults.вЂќ Some keys totosuccess: Ask your needs, friends, more on March Steps for focusing New Users: While on prevention, United Way is also responding urgent community according toFor Robert H. information (Bob) Brown, HFUW President/ family and colleagues to support you by for Babies please call: so many families struggling, more than 3,500 people per week are seeking assistance through 2-1-1, United WayвЂ™s information, referral and 1.CEO. GoвЂњWith to marchforbabies.org Phone: helpline,вЂќ he A said. вЂњIn July alone, more than 14,500 calls were received and housing and utilities вЂ“ basic human(407) needs 599-5077 were among the top requests. 2.crisisClick JOIN TEAM Fax: (407) 599-5870 Clearly our crisis of need is far from over.вЂќ 3. For Search for yourheteam name in the reason why people do notkicks donate Central Florida Division that reason, said the success of HFUWвЂ™s annual campaign, which off is inthat September, has never been more important. If youвЂ™d like noIfone to give (donвЂ™t bewho shy)! searchanbox. to make online donation, visit www.hfuw.org. youasked have athem patient or colleague needs help341 withN. any health and humanSuite service need, Maitland Avenue, 115 Emailing them is an easy way to ask. tell them to simply dial 2-1-1. Maitland, FL 32751 4. Click on your team name 5. YouвЂ™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 Center. Editorial focus is on Sports Medicine and fundraising! password for future reference. Robotic Surgery. ADVERTISE ADVERTISE IN IN FLORIDA FLORIDA MD MD For For more more information information on on advertising advertising in in the the Florida Florida MD MD Central CentralFlorida FloridaEdition, Edition, call Rauhofer at at call Publisher Publisher Don Donald Rauhofer (407) (407) 417-7400, 417-7400, fax fax (407) (407) 977-7773 977-7773 or or info@floridamd www.floridamdmagazine.com www.floridamd.com Send Send press press releases releases and and all all other other related to: related information to: Florida Florida MD MD Magazine P.O. P.O. Box Box 621856 621856 Oviedo, Oviedo, FL FL 32762-1856 32762-1856 2 2 FLORIDA MD MAGAZINE - MARCH 2010 FLORIDA MD - AUGUST 2011 PREMIUM PREMIUM REPRINTS REPRINTS Reprints Reprints of of cover cover articles articles or or feature feature stories in Florida MD are ideal stories in Florida MD are ideal for for promoting promoting your your company, company, practice, practice, services andand medical products. Increase services medical products. Increase your brand exposure with high your brand exposure with high quality, quality, 4-color 4-color reprints reprints to to use use as as brochure brochure inserts, promotional flyers, direct mail pieces, and trade trade show show handouts. handouts. pieces, and Call Florida MD for printing Call Florida MD for printing estimates. estimates. Publisher: Donald Rauhofer Photographer: DonaldJoanne Rauhofer / FloridaMD Associate Publisher: Magley Contributing Writers: Jennifer Sam Pratt, Photographer: Tim Kelly / Tim Miller, Kelly Portraits, RPh, FIACP, David/S.Florida Klein,MD MD,Magazine Ross Clevens, Donald Rauhofer MD, Harinath Writers: Sheela, MD, Kevin De Boer, Contributing Joanne Magley, Sam DO, Matt Jennifer Thompson, Chuck Oliver, Pratt Gracey, RPh, Mitchell Levin, MD, Jennifer Sylvia M. Davis, MPH,Giuliano, Emily Garcia, Steven Thompson, Vincenzo MD, David S. Rosenberg, MD, Sijo Parekattil, MD Klein, MD, Stephen P. Toth, CLU, Jennifer Designer: Roberts Ana Espinosa Florida MD is published by Sea Notes Media,LLC, P.O. Box 621856, Oviedo, FL 32762. CallNotes (407)Medical 417-7400 for more Florida MD Magazine is published by Sea Seminars, information. ratesFL upon request. Postmaster: Please PA, P.O. Box Advertising 621856, Oviedo, 32762. Call (407) 417-7400 for send notices on Form 3579 to P.O. rates Box 621586, Oviedo, FL 32762.Please more information. Advertising upon request. Postmaster: Although every to ensure accuracy send notices on precaution Form 3579 isto taken P.O. Box 621856, Oviedo,ofFLpublished 32762. materials, Florida MD cannot be held responsible for opinions expressed or facts expressed by itstoauthors. Copyrightof 2011, Sea Although every precaution is taken ensure accuracy published Notes Media. All rights reserved.cannot Reproduction in whole orfor in part materials, Florida MD Magazine be held responsible without permission prohibited. opinionswritten expressed or facts is expressed by its authors. Copyright 2010, Sea Notes Medical Seminars. All rights reserved. Reproduction in whole or in part without written permission is prohibited. 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 PucciniвЂ™s O mio babbino caro and Nessun dorma and VerdiвЂ™s вЂњAnvilвЂќ Chorus and the Overture to La forza del destino вЂ“ 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 вЂ“ 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 MahlerвЂ™s Symphony No. 2 on last seasonвЂ™s opening concert вЂњResurrection Symphony.вЂќ 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 ManucharyanвЂ™s third appearance with the Orlando Philharmonic. He was featured in a past performance of VerdiвЂ™s Requiem and in the 2009-10 Season opening night concert вЂњOde to Joy,вЂќ as a soloist on BeethovenвЂ™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 MorrisonвЂ™s Margaret Garner, in a new production by Tazewell Thompson, for which the American baritone received New York City OperaвЂ™s 2008 Christopher Keene Award. Mr. Mix makes his second appearance with the Philharmonic having sang the role of Marcello in last seasonвЂ™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 ChildrenвЂ™s Hospital Opening in Fall of 2012 in Orlando Construction of Nemours ChildrenвЂ™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 ChildrenвЂ™s Hospital will enhance Medical CityвЂ™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 вЂњit is the duty of everyone in the world to do what is within his power to alleviate human suffering.вЂќ Mr. duPontвЂ™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 nationвЂ™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 NemoursвЂ™ 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 childrenвЂ™s health is also a priority, evident in the engagement of programs such as Nemours Health & Prevention Services, Nemours Center for ChildrenвЂ™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 PontвЂ™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 NonaвЂ™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. вЂњThis is already an incredibly valuable partnership and it has just begunвЂќ said Dr. Lane Donnelly, NemoursвЂ™ Chief Medical Officer and Physician-in-Chief. вЂњI 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.вЂќ Nemours is also working with the UCF College of Health and All standard rooms in Nemours ChildrenвЂ™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 ChildrenвЂ™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 ChildrenвЂ™s Hospital will be an anchor tenant along with the University of Central FloridaвЂ™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 ChildrenвЂ™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 ChildrenвЂ™s Hospital Provides Family-Centered Care Nemours is more than a childrenвЂ™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 organizationвЂ™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 ChildrenвЂ™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 вЂњIt is truly a unique opportunity to have a voice system, family concierge service, comfortable and spacious gathering rooms, in selecting the doctors of tomorrow,вЂќ said Lynda reception and lounge areas. Griffin, who has been on the Family Advisory Council for the past three years. вЂњWeвЂ™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.вЂќ 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 areВ· incorporated into the hospitalвЂ™s design. These soothing, childfriendly, fun and optimistic colors create an environment suited for recovery. Details such as customizable вЂњmood lightingвЂќ 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 ChildrenвЂ™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, вЂњLess than two percent of health institutions are operating at this level and no other institutions are operating at a level higher than Nemours.вЂќ 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 1980вЂ™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 childrenвЂ™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.orgвЂ™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 ParentsвЂ™ 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 ChildrenвЂ™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 ChildrenвЂ™s Hospital and are eager to grow partnerships with pediatricians and primary care physicians in the region. вЂњI have been interviewing doctors from the finest childrenвЂ™s hospitals in America,вЂќ said Dr. Donnelly. вЂњBy 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 communityвЂ™вЂ™. NemoursвЂ™ 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 whatвЂ™s going on in your practice. No matter what strategies youвЂ™re currently using in your marketing mix, if youвЂ™re not collecting email addresses of current and potential patients, youвЂ™re missing the boat. In fact, the boat already sailed. WeвЂ™re out at sea, waving at you landlubbers. But donвЂ™t worry, hereвЂ™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 youвЂ™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 theyвЂ™re doing it and how often. Types of Lists There are several types of email lists to be aware of. The first is whatвЂ™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 youвЂ™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 donвЂ™t realize theyвЂ™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 thereвЂ™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 youвЂ™re double sure they want to see your content, increasing open rates and retention. List Building Tips Gathering Emails. The first thing youвЂ™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 theyвЂ™re consenting to receive occasional updates from your office. For returning patients, you can ask that they update their contact info the next time theyвЂ™re in the office. If youвЂ™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, youвЂ™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 вЂњbucket,вЂќ 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, letвЂ™s say you offer cosmetic procedures such as Botox as a part of your facial reconstruction practice. Obviously youвЂ™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 youвЂ™ll want to create your email. ItвЂ™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 вЂњexclusiveвЂќ information or photos a patient may only see if they open the email to make them feel Marketing Your Practice special too. ItвЂ™s a good idea come up with a schedule now so you arenвЂ™t emailing people twice a week for two weeks and then stopping for three months. Just like that youвЂ™re already in the water, briskly catching up to the email marketing cruise and you havenвЂ™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 [email protected]. 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 companyвЂ™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. вЂў end Weight dec. 2010: 166 lbS. Pathology Lab Results вЂ” 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 [email protected]. 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 TZDвЂ™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 вЂњTax TargetвЂќ? 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 вЂњmillionaires, billionaires, corporate jet owners and hedge fund managersвЂќ 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 youвЂ™re like me, youвЂ™re pretty sure that taxes are going to be higher in the future. Among the current proposals that will result in higher taxes: вЂў Let the Bush era tax cuts expire for individuals earning over $200,000 and couples earning over $250,000, вЂў limit itemized deductions to 28% of an individualвЂ™s gross income and вЂў 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 thatвЂ™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 youвЂ™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 income. ThereвЂ™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. WouldnвЂ™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. IвЂ™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 [email protected]. People get a second opinion on their health; get a second opinion on your wealth! Charles вЂњChuckвЂќ 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 OliverвЂ™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 ABCвЂ™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 todayвЂ™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. вЂњWeвЂ™ve seen huge improvements in the technological aspects of keeping low-birth weight babies alive once theyвЂ™re born, but we need improvement on the front end. ItвЂ™s prevention. And that means increased access to good care and an intentional focus on addressing the social determinants of infant mortality.вЂќ 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 patientsвЂ™ 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. вЂњPlacing babies on their backs to sleep reduces the risk for SIDSвЂќ (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 [email protected]. 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. вЂњSince over half of all pregnancies in the United States are unplanned, women who might be sexually active with male partners should consider their healthвЂќ (Preconception Care, Centers for Disease Control, April 2006). The ABCвЂ™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. оЃ® "Jewett made my family feel like we were part of their family." Go to www.jewettortho.com and see the OвЂ™LenickвЂ™s full story Jewett has a WALK-IN to make your summer easy and stress free! No appointment necessary! Monday - Thursday: 7:30am - 8:00pm Friday: 7:30am - 4:00pm Saturday: 9:00am - 3:00pm Stirling Center 701 Platinum Point On Rinehart Road Lake Mary, FL 32746 407.206.4500 www.jewettortho.com 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 practiceвЂ™s income is going down and my expenses are going up? A: Florida doctors are now enjoying a very вЂњsoftвЂќ 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 вЂњtailвЂќ purchases, so choose very carefully as we come to the end of this buyersвЂ™-market part of the never-ending cycle. Matt Gracey is a medical malpractice insurance specialist with Danna-Gracey, Delray Beach, 800-966-2120; [email protected]. 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 вЂњOne 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,вЂќ 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, вЂњsignificant adverse outcomes have been reported with several of the metal cups,вЂќ says Dr. Rosen. Last August DePuy Orthopaedics began recalling two types of hip implants because many patients required a second hip replacement after the companyвЂ™s original implant had failed. вЂњThe issue with the implants is an imperfection of the surface [of the implant] which reduces the chances for adequate bone ingrowth,вЂќ 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 patientвЂ™s bloodstream. вЂњWhile 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,вЂќ says Dr. Rosen. On top of that, the development of вЂњpseudotumorsвЂќ 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. вЂњAs 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,вЂќ says Dr. Rosen. WhatвЂ™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. вЂњAt 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,вЂќ 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 в‰¤20 mmHg. Pulmonary hypertension is diagnosed when the mean pulmonary artery pressure elevates в‰Ґ25 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 patientвЂ™s dyspnea. The chest radiograph may reveal enlargement of the central pulmonary arteries and вЂњpruningвЂќ 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 patientвЂ™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 patientвЂ™s history such as sickle cell disease, pro-brain natriuretic peptide, hypercoaguable workup, and schistosomiasis in the appropriate settings. An assessment of the patientвЂ™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 The Hidden Wealth Systemв„ў Your вЂњPrimary CareвЂќ Advisor Build Your Own Personal Protected Pension Planв„ў Unique Medical Professionals Wealth Creation & Preservation Strategies: вЂў Tax Protection вЂў Market Loss Protection вЂў Asset Protection Chuck Oliver Best-selling Author & CEO (407) 478-1599 214 S. Park Ave. Ste. B Winter Park, FL 32789 [email protected] Prepare to Be Shocked! Watch the retirement money make over video: http://www.TheHiddenWealthSystem.com/MedicalPensionSolution Discover and Uncover Your Hidden Wealth PULMONARY AND SLEEP DISORDERS sided heart disease is suggested if the mean pulmonary artery occlusion pressure (PAOP) is в‰Ґ15 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 patientвЂ™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 teenagerвЂ™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 patientвЂ™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 teenagerвЂ™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 вЂў 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? вЂў 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. вЂў Is your teen realistic? Does she expect to look totally different? Does he think he will feel like a new person overnight? вЂў Is your teen prepared for the recovery period? Not only will it be painful, but there may be swelling and bruising to deal with. вЂў 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 вЂ” knowledgeable professionals who impart compassionate care with exceptional customer service. Dr. ClevensвЂ™ 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® )SNTITTIMEYOUCALLED THEMEDMALEXPERTS $ANNA'RACEY IS A BOUTIQUE INDEPENDENT INSURANCE AGENCY WITH A STATEWIDETEAMOFSPECIALISTSDEDICATEDSOLELYTOINSURANCECOVERAGE PLACEMENTFOR&LORIDASPHYSICIANSANDSURGEONS 7ITH OFlCES LOCATED THROUGHOUT &LORIDA $ANNA'RACEY WORKS ON BEHALFOFPHYSICIANSWELLBEYONDMANAGINGTHEIRINSURANCEPOLICY "Y SPEAKING WRITING FREQUENTLY PUBLISHED ARTICLES AND LOBBYING IN 4ALLAHASSEEWEHOPETOEFFECTPOSITIVECHANGE INTHEHEALTHCAREINDUSTRY &OR A NOOBLIGATION MEDICAL MALPRACTICE INSURANCEQUOTECALL$AN2EALEAT Delray Beach: 800.966.2120 вЂў Orlando: 888.496.0059 вЂў Miami: 305.775.1960 вЂў Jacksonville: 904.388.8688 [email protected] вЂў www.dannagracey.com FLORIDA MD - AUGUST 2011 19 Hot Topics in Dermatology A DermatologistвЂ™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 doesnвЂ™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 вЂњregurgitateвЂќ describes reflux to the oropharynx, and вЂњvomitвЂќ 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 вЂњregurgitateвЂќ 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 вЂ” 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 вЂ” The most common symptoms of GERD vary according to age, although overlap may exist. Treating Central Florida for over 25 years Major Services include: вЂў Allergy Injections вЂў Allergy Testing вЂў Asthma Therapies вЂў Flu Shots (during Flu season) вЂў Pulmonary Testing вЂў Food Challenge вЂў Drug Challenge вЂў Exercise Challenge Helping Patients with: вЂў Asthma вЂў Chronic Cough вЂў Drug, Insect and Food Allergies вЂў Eczema вЂў Hay Fever вЂў Hives вЂў Immunodeп¬Ѓciency вЂў Sinus Conditions вЂў And More! Board Certiп¬Ѓed Allergy, Asthma & Immunology & Board Certiп¬Ѓed 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 KidвЂ™s DocвЂ™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: вЂў Frequent or recurrent vomiting вЂў Frequent or persistent cough вЂў Heartburn, gas, abdominal pain, or colicky behavior (frequent crying and fussiness) вЂў Regurgitation and re-swallowing вЂў Feeding problems вЂў Recurrent choking or gagging вЂў Poor growth вЂў Breathing problems вЂў Recurrent wheezing вЂў Recurrent pneumonia Atypical symptoms of GERD вЂ” 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 вЂ” 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 вЂ” 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 BarrettвЂ™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 вЂ” 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 вЂ” 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 вЂ” 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 вЂ” 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 childвЂ™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 donвЂ™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 doesnвЂ™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 CrohnвЂ™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 оЃ® The Difference is in the Details. More Than 39 Years Serving Central Florida 17 Physicians Specializing in all Orthopaedic Issues MRI Services at 2 Locations State-of-the-art Outpatient Surgery Center Physical Therapy Available at Every Location Saturday Hours Available www.orlandoortho.com вЂ“ 407.254.2500 5 Convenient Locations: Downtown Orlando вЂў Winter Park вЂў Sand Lake вЂў Lake Mary вЂў Oviedo 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 bodyвЂ™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 patientвЂ™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 You would not consider using a non-accredited hospital... Then why use a non-accredited compounding pharmacy? 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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 patientвЂ™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 (PPIвЂ™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 вЂњNetti Pot.вЂќ 3) Nasal Corticosteroids. These are felt to be the вЂњtreatment of choiceвЂќ 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 вЂњdrugs of choiceвЂќ for the treatment of asthma. The combination of inhaled corticosteroids and long acting beta agonists (LABAвЂ™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 KidвЂ™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 [email protected]. 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 (PPIвЂ™s). These agents are the вЂњdrugs of choiceвЂќ 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 PPIвЂ™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 Be sure and check out our NEW and IMPROVED website at www.floridamd.com! 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 couplesвЂ™ 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 вЂ“ 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 вЂ“ 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 вЂ“ 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 вЂ“ 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 [email protected]. 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. LeeвЂ™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 ChildrenвЂ™s Hospital Medical Center. Dr. Lee also held the position of director of the pediatric epilepsy fellowship program at the Cincinnati ChildrenвЂ™s Hospital Medical Center, and was also an associate professor in the department of neurology and pediatrics at the University of CincinnatiвЂ™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. вЂњWe 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,вЂќ said Marla Silliman, administrator of Florida Hospital for Children. вЂњDr. LeeвЂ™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.вЂќ оЃ® 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. вЂњWeвЂ™ve known for a long time that you can use antibodies to capture viruses and that nanoparticles have different traits based on their size,вЂќ said study co-author Ralph Tripp, Georgia Research Alliance Eminent Scholar in Vaccine Development in the UGA College of Veterinary Medicine. вЂњWhat weвЂ™ve done is combine the two to create a diagnostic test that is rapid and highly sensitive.вЂќ 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. вЂњThe test is something that can be done literally at the point-of-care,вЂќ said Driskell, who worked on the technology as an assistant research scientist in TrippвЂ™s lab. вЂњYou take your sample, put it in the instrument, hit a button and get your results.вЂќ Gold is often thought of as a costly metal, but the new diagnostic test uses such a small amountвЂ”less than what would fit on the head of the pinвЂ”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 canвЂ™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 stateвЂ™s economy. вЂњThis test offers tremendous advantages for influenza, but we really donвЂ™t want to stop there,вЂќ Tripp said. вЂњTheoretically, 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.вЂќ 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 вЂњoвЂќ 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 patientвЂ™s anatomy during surgery, which allows surgeons to view any part of the patientвЂ™s skeletal anatomy, from head to toe. Florida Hospital Memorial Medical Center has taken the advanced technology to the next level by integrating MedtronicвЂ™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 patientвЂ™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. вЂњThis is a significant investment by Florida Hospital Memorial Medical Center to improve spinal surgery in this region,вЂќ said Christopher S. Kent, MD, Neurosurgeon at Florida Hospital Memorial Medical Center. вЂњWhile 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.вЂќ 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. вЂњEven in the best of hands, screws can be placed less than optimally when using fluoroscopy,вЂќ said Dr. Kent. вЂњThe O-arm clearly shows us the patientвЂ™s anatomy and helps us determine the best trajectory for placing screws during a spine fusion surgery.вЂќ 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 ADVERTISERS INDEX Allergy Asthma Associates of Central Florida. . . . . . . . . . . . . 21 Central Florida Pulmonary Group. . . . . . . . . . . . . 14 Clevens Center for Facial Cosmetic Surgery. . . . . . . . . . . . . . 3 Distinguished Lecture S E R I E Comprehensive Dermatology. . . . . 22 S Danna-Gracey. . . . . . . . . . . . . . . 19 Florida Hospital invites you to Florida Hospital ChildrenвЂ™s Health Summit Digestive & Liver Center of Florida. . . . . . . . . . . . . . . . . . . 12 Presented By Alan Hinman, MD Florida Hospital Distinguished Lecture Series. . . . . . . . . . . . . . . 32 Larry Pickering, MD 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 ChildrenвЂ™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 Dinner will be provided Pharmacy Specialists. . . . . . . . . . 25 Werner Auditorium вЂ“ Florida Hospital Orlando 601 East Rollins Street | Orlando, FL 32803 RSVP with the Florida Hospital Friends and Family Helpline at (407) 303-1700 32 FLORIDA MD - AUGUST 2011 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. 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