Winter Haven Hospital Bostick Heart Center

Transcription

FEBRUARY 2012 • CENTRAL FLORIDA EDITION
Winter Haven Hospital
Bostick Heart Center
Making Sure Your Heart is in the
Right Place with Compassion,
Innovation and Trust
setting the standard
in Outpatient surgery
sURGERy CEnTER
PHysICIAns:
COLORECTAL
Sam Atallah, MD
Teresa deBeche-Adams, MD
Samuel DeJesus, MD
GAsTROEnTEROLOGy
Steven Feiner, DO
Keith Moore, DO
Mario Moquete, MD
Srikiran Pothamsetty, MD
Seela Ramesh, MD
Srinivas Seela, MD
Aniq Shaikh, MD
GEnERAL sURGERy
Ajmal Baig, MD
Joseph Bennett, DO
Kenley Davis, MD
Malcolm McDonald, DO
GynECOLOGy
Fernando Gomez, MD
Fernando Lopez, MD
OPHTHAMOLOGy
Mont Cartwright, MD
MyHanh Nguyen, MD
ORAL sURGERy
Scott Farber, DDS
Lincoln Taylor, DDS
ORTHOPAEDICs
Juan Agudelo, MD
M. Anwarul Hoque, MD
Brian Leung, MD
Sean McFadden, DO
The Florida Hospital Surgery Center combines the highest quality personalized care with state-of-the-art technology,
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OTOLARynGOLOGy (EnT)
Michael Bibliowicz, DO
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Lisa Waizenegger, MD
PODIATRy
Jay Bornstein, DPM
Joseph Conte, DPM
Thomas Fann, DPM
Andres Perez-Gomez, DPM
Luis Sanchez-Robles, DPM
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Amber Shane, DPM
UROLOGy
Daniel Cohen, MD
Stephen Dobkin, MD
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contents
FEBRUARY 2012
CENTRAL FLORIDA EDITION
4
COVER STORY
Photo: Donald Rauhofer / FLORIDA MD
Recognized as a national leader in cardiac care, the Winter Haven Hospital Bostick
Heart Center is earning accolades for quality of care, impressive outcomes and overall impact on community wellness. Since opening in 2005, Winter Haven Hospital’s
Bostick Heart Center has sustained a three-star rating from the prestigious Society of
Thoracic Surgeons, placing the Bostick Heart Center’s heart surgery program in the top
10-15% in the nation. Additionally, the open heart program was recently rated among
the top 50 in the United States by a leading consumer magazine. In an effort to ensure
excellent treatment regardless of growth, Winter Haven Hospital embraces an inspirational promise to it’s patients: Compassion, Innovation, Trust.
Photo: Mike Potthast/ Mike Potthast Photography
Cath Lab team performs a PCI at Bostick
Heart Center
30 CURRENT TOPICS
36 FOR YOUR ENTERTAINMENT
36 ADVERTISERS INDEX
DEPARTMENTS
2
FROM THE PUBLISHER
10 MARKETING YOUR PRACTICE
12 HOT TOPICS IN DERMATOLOGY
13 PHARMACY UPDATE
14 PULMONARY AND SLEEP DISORDERS
16 ORTHOPAEDIC UPDATE
18 Medical Malpractice Expert Advice
20 INPATIENT MEDICINE
22 WEALTH MANAGEMENT
24 DIGESTIVE AND LIVER UPDATE
FLORIDA MD - FEBRUARY 2012
1
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3
COVER STORY
Winter Haven Hospital Bostick Heart Center
Making Sure Your Heart is in the Right Place with
Compassion, Innovation and Trust
By Nancy DeVault, Staff Writer
“If you are seeking world-class medicine
with a hometown feel…come to Winter
Haven Hospital.”
Heart Disease is the leading cause of death in the United States
for both men and women, accounting for 26% of deaths —
more than one in every four, according to the Center for Disease
Control and Prevention (CDC). Winter Haven Hospital utilizes
the latest research and evidence-based practice to treat Coronary
Heart Disease, the most common type of heart disease, and delivers this care with compassion. Recognized as a national leader
in cardiac care, the Winter Haven Hospital Bostick Heart Center is earning accolades for quality of care, impressive outcomes
and overall impact on community wellness. Since opening in
2005, Winter Haven Hospital’s Bostick Heart Center has sustained a Three-Star rating (the highest ranking possible) from
the prestigious Society of Thoracic Surgeons (STS), the organization that tracks the quality data of the country’s most elite
open heart programs, placing the Bostick Heart
Center’s heart surgery program in the top 1015% in the nation. Additionally, the open heart
program was recently rated among the top 50
heart programs in the United States by a leading consumer magazine.
In addition to open heart surgery, non-invasive cardiology and
catheterization lab services, the Bostick Heart Center provides:
• A Cardiovascular Intensive Care Unit (CVICU) for care after
heart and vascular surgeries,
• A Cardiac Intensive Care Unit (CICU) reserved for patients
following interventional cardiac procedures such as stents as
well as patients with other serious heart problems,
• A Cardiovascular Unit (CVU) designed for patients with complex cardiac needs that do not require ICU care,
• A Cardiac Observation Unit (COU) available for patients
with potential heart conditions needing evaluation, and
• A Cardiac Rehabilitation center providing three-stage recovery after heart-related events.
David Dodd, M.D., A. Nicolas Fernandez, M.D., and David Evans, M.D.
“We remind ourselves of what we would
want and expect regarding medical care if the
roles were reversed, if we were the patient,” explained Edgar H. Willard III, M.D., F.A.C.P.,
F.A.C.C., F.C.C.P., a Bond Clinic cardiologist
and 30-year Winter Haven Hospital medical
staff veteran, adding that providing compassionate care for patients paired with award winning and innovative services naturally leads to a
trusting patient relationship.
4 FLORIDA MD - FEBRUARY 2012
Photo: Winter Haven Hospital
In 2011, the CDC released data stating that
U.S. hospital visits increased to more than 136
million in 2009, from the previously reported
123.8 million in the year prior. In an effort
to ensure excellent treatment, Winter Haven
Hospital embraces an inspirational promise to
it’s patients: Compassion, Innovation, Trust.
Employees of Winter Haven Hospital put this
promise into action.
COVER STORY
“We’re providing a high quality service
through the integration of clinical, interventional and thoracic disciplines. This
cohesion, paired with our outstanding
hospital administration, board and medical staff, allows us to achieve and surpass
national benchmarks,” said Dr. Willard.
Winter Haven Hospital’s cardiovascular facility is proudly named the “Bostick
Heart Center” in honor of the Bostick
family’s philanthropic gift that keeps on
giving — the most precious gift — the
gift of life. Guy Bostick founded Comcar Industries, Inc. in 1953. The business
evolved into one of the nation’s largest
trucking companies. With the same drive
and visionary approach to his philanthropic work, Bostick
served on both the hospital and hospital Foundation Boards.
A Heartfelt Charitable
Investment puts Core
Values in Motion
Dr. Edgar Willard addresses his patient’s cardiac concerns.
“Customer Focus” and Prayer
exemplifies Compassion
Memphis native David Dodd, M.D., cardiovascular and thoracic surgeon, was practicing in Georgia when he heard of an
opening in a newly established heart center in Winter Haven.
He felt compelled to explore the opportunity and soon began a
surgical partnership with David Evans, M.D. (the Bostick Heart
Center’s other cardiovascular surgeon) to offer cardiovascular
surgery options there. Prior to the opening of the
Bostick Heart Center, patients needed to travel
Drs. Dodd and Evans review images for a potential CABG (Coronary Artery Bypass Graft.)
miles away, often driving to hospitals in Gainesville or Orlando, for open heart surgery. The inconvenience of traveling for care often increased
already elevated levels of stress for patients — a
non-issue now.
With a growing demand for local cardiovascular services in
the Winter Haven area, Bostick made a significant commitment
of funds in 2005 that paved the way for the new state-of-theart heart center. The monumental leadership and vision of the
Bostick family remains today with son Mark Bostick currently
serving as Winter Haven Hospital’s Board Chairman.
Like many hospitals, Winter Haven Hospital’s cardiovascular team is staffed with highlytrained professionals with astounding lifesaving
skills. A unique feature of the Bostick Heart
Center, the physicians, nurses and technicians
are mindful of the spiritual aspect of healing and
offer to pray with patients and families. Hospital employees pray for each other’s strength and
continued ability, and for the well-being of their
patients.
Dr. Dodd explained that prayer is a unique
way for physicians to connect with their patients
who themselves are often praying for successful
treatments and speedy recoveries. “Sharing a
prayer makes us more human and helps to deFLORIDA MD - FEBRUARY 2012
5
COVER STORY
Dr. Dodd, who has participated in nearly 3,000 surgeries during his fifteen-year career as a cardiothoracic
surgeon, says that another contributing factor to the
compassionate environment is a unique system of care
founded on stability. The Bostick Heart Center has a
dedicated surgical team comprised of surgeons, anesthesiologists, physician assistants, perfusionists, nurses
and surgical techs, all focused on cardiovascular health.
The cardiovascular anesthesiologists embody a key role
for the team by managing patients care from the operating room through their entire stay in the intensive
care unit, offering a consistency of service to benefit
Dr. Zaheed Tai discusses using the radial artery approach and its many benefits.
the patients’ medical care and comfort level. The team’s
strategy has resulted in shorter patient stays in the critical care
the same precision can be found at five other Ocala Heart and
unit, with most patients transferring to the cardiovascular unit
Vascular Institute locations including Citrus Memorial Hospital,
after just one night.
Leesburg Regional Medical Center, Martin Memorial Medical
Center, Munroe Regional Medical Center and Venice Regional
Medical Center.
It’s that dedicated “customer focus” that patients remember;
paired with the successful cutting-edge procedures offered within their own community. “If you are seeking world-class mediInnovative Techniques, Training and
cine with a hometown feel…come to Winter Haven Hospital,”
Research
said Dr. Dodd.
Dr. Dodd and Dr. Evans are associated with the Ocala Heart
and Vascular Institute. Well-documented clinical outcomes with
Zaheed Tai, D.O.
Zaheed Tai, D.O., F.A.C.C., F.S.C.A.I., one of the interventional cardiologists practicing at the Bostick Heart Center, is
training other physicians, nurses and technologists on new innovative techniques. Winter Haven Hospital is now a national
training center for the Spectranetics laser and for Terumo
Corporation.
The Spectranetics® laser uses light energy from the ultraviolet
spectrum (similar to the light used in LASIK for eye surgery) to
dissolve and remove arterial plaque in order to improve blood
flow in blocked arteries. Action is taken to remove plaque buildup by advancing the excimer laser catheter to the top, or cap,
of the blockage of the artery and through the obstruction. The
catheter transmits short bursts of ultraviolet energy through the
flexible fibers of the tube. The ultraviolet energy penetrates the
plaque, vaporizing it into microparticles absorbed by the bloodstream. The process can facilitate stent delivery and expansion
into complex lesions.
Photo: Winter Haven Hospital
Terumo Corporation is one of the leaders in transradial
equipment and sponsors monthly courses in the transradial approach to catheterization. Dr. Tai has been using this as the default approach since 2003 and performs approximately 90-95%
of all coronary cases via this technique. Using this approach, a
catheter is inserted through the radial artery in the wrist rather
than the femoral artery located in the groin. The entire procedure is completed with this approach. Studies have shown
equivalent procedural success with this approach as compared
to the femoral approach with a lower risk of bleeding, improved
velop trust,” said Dr. Dodd. “God gave us these medical talents to help our patients heal. We rely on Him to
lead us with our lifesaving skills,” he added.
COVER STORY
“At least 50% of these cases are done via the radial approach,”
said Dr. Tai. The Cath Lab at the Bostick Heart Center performs approximately 2000 diagnostic caths and 700 percutaneous coronary interventions (PCI’s) per year.
“We are seeing a tremendous amount of interest from other
cardiologists in particular who want to learn transradial catheterization as well as laser atherectomy and who want to be able
to offer this approach to patients at their respective hospital,”
Dr. Tai said. “We are conducting radial training sessions on a
monthly basis for cardiologists from around the United States.
Laser atherectomy courses are offered quarterly depending on
demand. We recently demonstrated laser atherectomy use in
the periphery to some Japanese
colleagues. We hope to see interventionalists from hospitals
overseas coming here on a regular basis for this training.”
Winter Haven Hospital is
also looking to contribute to
advances in the medical community by participating in
clinical research trials. The Bostick Heart Center is currently
one of just 35 facilities participating in a study to evaluate
the safety and efficacy of the
Diamondback 360°® Orbital
Atherectomy System in treatKenneth Gibbs, M.D.
ing de novo, severely calcified
coronary lesions (ORBIT II), another effort lead by Dr. Tai. His
Bostick Heart Center colleague, Boris Nunez, M.D., is also conducting scientific studies, specifically evaluating the effectiveness
of antiplatelet medications.
Cath Lab Techs Jennifer and John assist Bostick Heart Center Interventional Cardiologist
Dr. Kenneth Gibbs with a PCI (Percutaneous Coronary Intervention)
Earning Patient Trust
The Winter Haven Hospital Bostick
Heart Center has conducted nearly 1,900
open heart procedures since opening its
doors in 2005. The Bostick Heart Center
also offers lung, esophageal, vascular and
pacemaker surgeries.
“The Center sees a diverse population of
patients, especially since we are able to cater to the needs of snowbirds in the need of
emergency cardiovascular care or continued rehabilitation,” said Dr. Willard. He
adds that in addition to retirees, Winter
Haven Hospital is noticing an increase in
younger patients in their 40s and 50s including women, a focus area of awareness
for the Bostick Heart Center as well as national organizations such as the American
Heart Association and the National Heart
Lung and Blood Institute.
High levels of patient satisfaction at the
Bostick Heart Center are due in part to
the consistency of compassionate and innovative approaches. Thus, many new patient referrals simply stem from word-ofmouth, especially for those seeking cardiac
rehabilitation options.
The Cardiac Rehabilitation program at
the Bostick Heart Center offers three levels. Phase I is devoted to inpatients recovFLORIDA MD - FEBRUARY 2012
7
Photo: Provided by Winter Haven Hospital
patient comfort and earlier ambulation. Once the procedure is
completed, patients are able to ambulate almost immediately
without prolonged bed rest or the need for someone to manually obtain hemostasis in the groin. Currently, it is estimated that
5-7% of procedures in the United States are performed via the
radial approach. Yet, this has now become the default approach
for the majority of physicians at the Bostick Heart Center.
ering after a cardiac event. This initial step includes evaluation, education (for the patient
and family) and limited supervised exercise.
Phases II and III provide monitored physical
activity sessions for outpatients with certified cardiac nurses. The program helps participants learn about their disease process and
the therapeutic lifestyle modifications they
should make to maintain a healthy heart. Additionally, Phase II and III assist cardiac patients in regaining strength, decreasing pain,
improving activity tolerance, reduction of risk
for future cardiac events and helping patients
make improvements in their overall quality of life. All cardiac rehabilitation patients
and family members are welcome to attend
monthly support group meetings which offer
education and guidance. The opportunity to
participate in an extensive cardiac rehabilitation program is another example of the Winter Haven Hospital Bostick Heart Center’s
focus on compassion, innovation and trust.
COVER STORY
Bostick Heart Center Cardiac Rehabilitation room.
“We care for you and about you (the patient),” explained Dr. Willard. “It’s more than
just healing the body – it’s about treating the
whole person.” 
Winter Haven Hospital
Bostick Heart Center
200 Avenue F, Northeast
Winter Haven, FL 33881
Phone: 863-292-4688
www.winterhavenhospital.org
Dr. Nicolas Fernandez, cardiovascular anesthesiologist, reviews post-op orders with Debi
Wolf, RN.
Photo: Mike Potthast/ Mike Potthast Photography
Winter Haven Hospital in Winter Haven, Florida.
RACE
AGAINST
CARDIOVASCULAR
DISEASE
SYMPOSIUM
2012
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9
Marketing Your Practice
The Need to Respond to
Patients in Real Time
By Jennifer Thompson, President of Insight Marketing Group
In the past, your patients had a voice. From praising your work
to complaining about your office staff, you can bet they were going to tell their friends and family. That was then. Today they can
tell millions of strangers in addition to their friends and family
with the press of a button.
It’s important to note that with the increased power in consumers (patients) hands that you need to react to them in real time.
You need to put out the flames and make sure they’re happy before the complaint spreads like a virtual wildfire – pun intended.
The simple fact of the matter is that if you don’t respond quickly,
it shows that you’re out of touch with your patients and that you,
in fact, really don’t care that it was too cold in your office.
Jokes aside, with 65 percent of adult internet users now saying
they use social networking sites (up 4 percent from one year ago)
according to Pew Internet Research, many of these users have
begun to leave comments and various spread status updates on
the nature of their service, both good and bad. Everyone from
the local convenience store to your practice has unknowingly put
their reputation on the line.
A recent study from eMarketer found that consumer reviews
were trusted 12 times more than descriptions supplied by offices
and manufacturers. For patients and consumers, the ability to see
performance and opinion-based reviews on services and products
they are considering purchasing is a huge benefit. For businesses
and offices just like yours, it can be a huge headache thanks to
largely subjective reviews, dirty competition and a whole host of
other factors. Let’s say one of these reviews makes it online – what
do you do?
Remember, the Glass is Half Full
The reviews are a good thing – both positive and negative. If
they’re positive, they let people know what a wonderful physician
you are while also boosting your search engine rankings, according to new research. The researchers analyzed search results for
roughly 150 small businesses and found that more than 80 percent of search results did not point to the websites of these small
businesses. Instead, it was pointing at review sites. Now if the
review is negative, there is still merit to be had. Not only do you
now have an idea of what your customers think of your business,
you have the opportunity to correct the problem, show you care
and want to be better. This can be a great asset in the eyes of a
jaded potential patient if you are making a valid, visible effort to
make a change.
Create a Game Plan
As I’ve mentioned in my eBook “Marketing Your Medical
Practice: A Quick Reference Guide,” a good game plan will start
with being proactive. If you believe a patient had a good experience, encourage them to go online and share that. If you are
perusing your Facebook page and you see you have a negative
review, take this opportunity to reach out to the individual and
address their concerns publicly. Remember not to take what they
say personal. How can you fix the problem realistically and immediately? Consider what you would want to hear if the shoe was
on the other foot. Then, write out what you want to say and have
someone else check it for accuracy and read it over to make sure
your point comes across clearly and in a friendly tone.
Reach Out to Them
According to BabyCenter LLC, 44 percent of moms use social
media for brand/product recommendations and a whopping 73
percent trust online reviews. That’s why it’s imperative that if a
review is there (especially a negative one) that you reach out to
the reviewer and attempt to put a positive spin on the situation.
That example is just for mothers, but trust that consumers of all
ages, sexes and backgrounds trust in similar levels.
This doesn’t have to mean you’re giving them something for
free, or even offering an apology. What it does mean is that you
have to accept that something was wrong and you will do your
very best to fix it. If there is an opportunity to give them something, consider it, but remember it isn’t required to control the
situation. Remember, there is a chance that the review could be
false or misleading so you don’t want to give away the bank if you
don’t have to.
After taking all of this into consideration and determining the
best answer for you and the given situation, reach out to them.
Post your response and welcome any additional comments with
open arms.
Damage Control
At this point it’s all about positioning for your image and your
reputation. Sometimes you simply can’t make them happy or fix
whatever they were complaining about. One thing you can do,
however, is show your sympathetic to their needs. You want to
show that you care and will do everything within your power
to stop the incident from happening again – whether it wasn’t
spending enough time answering questions or just a longer than
expected wait time – you will at least try to fix it. This is called
brand management and it’s incredibly important.
Marketing Your Practice
Get Talking
Now that you have an idea of what you should be doing and saying when something about you comes up online, the next step is to get
to it. Monitor your social sites and several of the most popular review sites and check to see if you are trending in a positive or negative
light. From there, use your game plan and take your online communication skills (and reputation) to a whole new level.
Marketing Your Medical Practice: A Quick Reference Guide
Are you ready to finally start marketing your practice? Visit www.InsightMG.com to get your copy of “Marketing Your Medical
Practice: A Quick Reference Guide” by Jennifer Thompson and Corey Gehrold. Encapsulating their real world medical marketing
knowledge and expertise, this easy-to-read eBook gives you all the tips and tricks you’ll need to start marketing your practice today
in a fast, fun and friendly format – just like the articles in this series. To learn more, visit www.InsightMG.com.
Looking for more information?
Contact Jennifer Thompson today for a free consultation and marketing overview at 321.228.9686 or e-mail her at Jennifer@
InsightMG.com.
About the Author: Jennifer Thompson is a Central Florida small business owner, serving as President of Insight Marketing
Group, a full-service marketing company focused on medical office marketing, community outreach efforts, and grassroots
public relations. In this capacity she is responsible for developing and implementing the long-term strategic vision for the organization, which includes publishing Insight Magazine, the company’s community-based 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. 
Start Weight Sept. 2010: 207 lbS. • end Weight dec. 2010: 166 lbS.
Pathology Lab Results — Patient: SP Age: 63 Sex: Male
Before Diet
Lipid Panel
Result 08/28/2009
Ref Range Result
Cholesterol
H 278
(80-199)mg/dL
Triglycerides
H 199
(30-150)mg/dL
HDL Cholesterol
51
(40-110)mg/dL
LDL Cholesterol
H 187
(30-130)mg/dL
VLDL Cholesterol
40
(10-60)mg/dL
Risk Ratio(CHOL/HDL)
H 5.5
(0.0-5.0)Ratio
8/26/10:
9/24/10:
Tissue Fat %
26.3%
21.1%
Body Scan Results
Tissue (g)
83,019
78,045
Fat (g)
21,864
16,449
After Diet
09/20/2010
180
82
55
109
16
3.3
Lean Muscle (g)
61,155
61,596
Please Note: Gain of 441g of muscle and a fat loss of 5,415g in 30 days! Individual results may vary.
For information call 407-260-7002 or email [email protected].
FLORIDA MD - FEBRUARY 2012 11
Hot Topics in Dermatology
Chronic Urticaria: A Rare and
Often Puzzling Phenomenon
By Erica Mailler-Savage, MD
Chronic urticaria is defined as hives that persist for greater than
6 weeks. It is a very rare condition, affecting approximately 1%
of the population. Middle-aged women are most often afflicted.
Presenting as wheals that individually last < 24 hours, chronic
urticaria can have a significantly negative impact on quality of
life due to severe itching. Angioedema is seen in up to 40% of
patients with chronic urticaria.
urticaria is often unresponsive
to antihistamines alone. In addition, approximately 85% of histamine receptors in the body are classified as H1 receptors with
the remaining 15% classified as H2 receptors. This explains why
antihistamines which target both receptors are often needed to
control hive activity.
Chronic urticaria should most importantly be differentiated
from urticarial vasculitis, an inflammatory vasculitis commonly
associated with connective tissue disease. Hives that individually
last > 24 hours, are associated with burning or stinging, or leave
pigmentation when they heal should be biopsied to determine if
vasculitis is present.
There are three main categories of chronic urticaria:
• Physical urticaria: hives induced by external physical stimuli
– Dermatographism (Figure 1), solar urticaria, delayed-pressure urticaria, cholinergic urticaria/heat-induced urticaria,
exercise-induced urticaria, cold-induced urticarial, aquagenic urticaria
• Autoimmune urticaria: caused by IgG autoantibodies to the
alpha subunit of the Fc receptor of IgE or less commonly antiIgE autoantibodies
• Idiopathic urticaria: no known etiology is found
The following lab studies may be helpful in determining an etiology for chronic urticaria. Not all studies need to be performed,
but should be selected based on history and suspicion of underlying cause:
• CBC with differential (elevated eosinophil count may signify a
drug reaction or parasitic infection)
• ESR
• Hepatitis B and C
• ANA (if urticarial vasculitis is suspected)
• Cryoglobulins (seen in cold-induced urticaria)
• Thyroid studies, including antithyroid microsomal antibodies
and peroxidase antibody titers (often seen in autoimmune urticaria)
• Chronic urticaria index (seen in autoimmune urticaria)
Understanding the complex pathogenesis of chronic urticaria
will lead to more effective treatment. Mast cell stimulation results in the release of histamines and prostaglandins which in
turn leads to vasodilation and erythema. Mast cells also release
chemoattractants for other cells (including neutrophils) that are
involved in the inflammatory response. These other players in
the inflammatory cascade are the explanation for why chronic
Figure 1: Dermatographism
Chronic urticaria is rarely permanent, lasting less than a year
in 50% of patients. In physical urticaria, avoidance of the triggers
in addition to antihistamines may be helpful. Nonsedating antihistamines during the day and sedating antihistamines at night
are the mainstay of treatment. Doubling the recommended daily
dose of antihistamines is not unusual to help control outbreaks.
Adding a leukotriene antagonist can sometimes be helpful. Patients who respond poorly to traditional antihistamine treatment,
or those who are known to a have a neutrophil-predominate form
of urticaria, may benefit from dapsone or colchicine. Patients with
autoimmune urticaria may respond to methotrexate or cyclosporine. Chronic systemic corticosteroids are not a recommended for
chronic urticaria.
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. 
PHARMACY UPDATE
Personalized Medicine: Future Drug
Therapy in Cardiovascular Disease?
By Anh-Dao Tran, PharmD Candidate and Sam Pratt, RPh
Heart disease is the leading cause of death for both men and
women in the United States. 60.8 million Americans have one
or more cardiovascular diseases.1 In 2011, it was estimated that
heart disease cost the United States $444 billion.2 In a 2003 study
by Wald and Law, the authors proposed that a once-daily medication combining six different drug components can reduce cardiovascular disease by more than 80%. Their strategy of achieving a large effect in preventing cardiovascular disease focused on
four cardiovascular risk factors: low density lipoprotein cholesterol, blood pressure, serum homocysteine, and platelet function.
Outcome measures included reduction in ischemic heart disease
events and strokes, life years gained, and prevalence of adverse
effects.3
Wald and Law combined six components in a single capsule
with a strategy to prevent cardiovascular disease: a statin for
lowering LDL cholesterol, three antihypertensive agents (a betablocker, a thiazide diuretic, an angiotensin-converting enzyme
inhibitor), folic acid for serum homocysteine reduction, and
low-dose aspirin for its anti-platelet ability. The proposed pill is
designed for patients with known cardiovascular disease and individuals aged 55 and older as this risk factor is not modifiable.
Regarding the pricing of the formulation, a plan was devised to
incorporate generic substitutions for each of the pill’s constituents
to reduce the cost for patients and to evade drug patent issues.
The idea of using once-a-day formulation for cardiovascular
disease seems promising. According to the American Heart Association, non-adherence to medications has been documented to
occur in more than 60% of cardiovascular patients. Additionally,
almost 60% of patients with regimens of 5 or more cardiovascular
agents are not taking their medications correctly.1 While causes of
non-adherence are multi-factorial, there is no question that polypharmacy and complex medication regimens play a huge role in
promoting non-adherence among these individuals. This oncedaily, one pill strategy can promote greater adherence in this population, leading to better health outcomes. Regarding the adverse
effect profile, the authors predicted an 8% to 15% incidence of
side effects in those individuals taking the medication through a
meta-analysis. They claimed that side effects from the antihypertensive agents are less likely to occur given their use of these drugs
at half of their standard doses. Of the adverse effects, aspirin
was the main contributor with no excess risk of fatal extra-cranial
hemorrhage. Wald and Law estimated that the combination pill
can reduce ischemic heart disease events by 88% and stroke by
80%. In addition, one third of these individuals can gain on average 11 years of life free of ischemic heart disease and stroke.3
A once-daily pill strategy is admittedly beneficial in this population. However, more should be implemented. Mass production
of fixed drug strengths is not ideal; the strengths and selection of
drugs should be customized to fit the individual patient’s health
needs. Drug induced nutritional depletion should be considered
and even added to the formulation at the request of the attending physician. There must be an open line of communication
and partnership between physicians and pharmacists to facilitate
the success of this medication. Patient education and persistent
drug monitoring should strongly be enforced as well. With the
approach of simplifying drug regimens and reducing pill burden,
the fight against heart disease seems extremely hopeful.
REFERENCES:
1. American Heart Association. 2011.
2. Heart disease facts. CDC. Updated 2010.
http://www.cdc.gov/heartdisease/facts.htm. Accessed on 1/24/12.
3. Wald NJ, Law MR. A strategy to reduce cardiovascular disease by more than
80%. BMJ. 2003 Jun 28;326(7404):1419.
Anh-Dao Tran, PharmD Candidate University of Florida
is currently on rotation at Pharmacy Specialists. 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 check with a clinical pharmacist for suggestions
and recommendations. For additional information please
call (407)260-7002, FAX (407) 260-7044, Phone (800)
224-7711, FAX (800) 224-0665. 
Looking to reach doctors by direct mail
or email broadcast? Call (407) 417-7400
or email [email protected]
PULMONARY AND SLEEP DISORDERS
CYSTIC FIBROSIS ADULT CARE...
2012 and Beyond
By Daniel T. Layish, MD
Cystic fibrosis (CF) is the most common fatal genetic disorder
in Caucasians. It is inherited in an autosomal recessive pattern.
The gene responsible for CF was discovered in 1989. Under normal circumstances, this gene codes for a chloride ion channel. In
people with cystic fibrosis this protein malfunctions, or is absent.
This leads to an inability to secrete water which then causes dry
airway secretions and thick mucus that is difficult to expectorate.
This predisposes to recurrent lung infections and bronchiectasis.
Respiratory failure causes 94 percent of all deaths from CF.
In 1970, the median predicted survival for people with cystic
fibrosis was only 16 years. It is now 39 years. For people with CF
born in the 1990s, the median survival is predicted to be over
40 years. At this time, there are approximately 30,000 people in
the United Stages with cystic fibrosis, almost half are adults. This
dramatic improvement in survival in CF is felt to be related to a
variety of improvements in treatment (to be detailed below).
Typically, cystic fibrosis is diagnosed early in life. It is estimated that approximately 4% of patients with CF are diagnosed in
adulthood. Typically, patients who are diagnosed as adults have
milder lung disease and are less likely to have exocrine pancreatic
insufficiency. Recently, in the state of Florida newborn screening
for cystic fibrosis was instituted. This should certainly dramatically decrease the number of patients who are diagnosed as adults.
The Cystic Fibrosis Foundation recommends that people with
CF receive their care in an accredited center. The Adult Cystic Fibrosis Center at the Central Florida Pulmonary Group has been
accredited since 1999. It is a multidisciplinary program including
pulmonologists, nurses, respiratory therapists, a dietician, and a social worker. This
center is one of a minority of Adult Cystic
Fibrosis Centers that are run by a private
practice. Dr. Daniel Layish and Dr.Francisco
Calimano are co-directors of the program,
and provide care to approximately one hundred adults with CF. The program is accredited jointly with the Pediatric Cystic Fibrosis
Center at Nemours, which is run by Dr. David Geller.
Patients with CF have a very complicated treatment regimen with need for airway
clearance, bronchodilators, inhaled antibiotics, and aggressive nutritional support on a
daily basis for maintenance. They also have
periodic exacerbations which often require
hospitalization for intravenous antibiotics
and more aggressive pulmonary care.
Pseudomonas aeruginosa is the most
common pathogen found in adults
with cystic fibrosis. However, atypical
Mycobacterial infections, Methicillin sensitive (and Methicillin
resistant) Staph aureus, as well as Aspergillus can also be seen as
well as other organisms. Many patients with cystic fibrosis require
maintenance therapy with inhaled antipseudomonal antibiotics.
Although azithromycin does not have direct anti-pseudomonal
antibiotic efficacy, it has anti-inflammatory properties which
make it an important adjunct for many CF patients in whom it is
taken three times/week as part of maintenance therapy. Recombinant human DNase has become an important cornerstone in the
management of CF airway clearance by decreasing sputum viscosity (by catalyzing extra cellular DNA into smaller fragments).
Cystic Fibrosis is truly a multisystem illness. Approximately
85% of patients with cystic fibrosis have exocrine pancreatic insufficiency and require enzyme supplementations with every meal
and snack. Most patients with cystic fibrosis are below their ideal
body weight and some adults will require gastrostomy tube placement. Fat soluble vitamin deficiency is common. Cystic fibrosis
related diabetes will affect approximately 15% of all patients with
cystic fibrosis who are age 35 and above. Cystic fibrosis related
diabetes is felt to be related to fibrosis and destruction of the pancreas and is more common in people who have had exocrine pancreatic insufficiency. CF related diabetes has been shown to have
components of insulin resistance as well as insulin deficiency. It
is a unique form of diabetes, distinct from either Type I or Type
II. Many patients with cystic fibrosis have chronic sinusitis and
PULMONARY AND SLEEP DISORDERS
will require sinus surgery. Osteopenia and osteoporosis are also quite prevalent in patients with cystic
fibrosis due to both decreased levels of osteoblasts
and increased levels of osteoclasts, as well as vitamin
D deficiency.
More and more people with cystic fibrosis are
themselves becoming parents. While men with
cystic fibrosis are almost always infertile, new techniques may allow some men with cystic fibrosis to
become biological fathers. Such techniques include
microsurgical epididymal aspiration of spermatozoa
with intracytoplasmic sperm injection into the oocyte. Women with cystic fibrosis who are pregnant
require careful coordination of care with a high risk
obstetrician. In 2000, there were 97 live births to
women with CF.
Because of the time required to comply with the
complex maintenance treatment regimen for patients with CF (and the increased care needs during
exacerbations) it can be difficult for people with CF
to maintain a steady income. This can compound the financial burden to patients with cystic fibrosis who require expensive medications. Therefore, the adult CF care center needs to be skilled at assisting patients with career planning, financial resources and disability
options.
Lung transplantation has become an option for people with end-stage lung disease due to CF. In general, it is recommended to refer a
patient with cystic fibrosis to a transplant center when their FEV1 gets to be below 30% of predicted. Patients with CF require bilateral
lung transplant. The median survival 5 years after a lung transplant (for any cause of end stage lung disease) is about 60 percent. If anything, patients with CF tend to do better after lung transplant than those with COPD, pulmonary fibrosis, etc.
A recent exciting development in the treatment of CF involves an oral medication called Ivacaftor. The results of a randomized study
on Ivacaftor were published in the New England Journal of Medicine in November 2011 by Dr. Bonnie Ramsey et al. The patients who
received Ivacaftor were 55% less likely to have a pulmonary exacerbation than those receiving placebo, their FEV1 went up by 10.6
percent, and they gained 2.7 kg (on average). Lung function improved after 2 weeks on the medication and the results were sustained
through 48 weeks. No significant adverse effects occured with Ivacaftor. This medication may be the first in a new era in the treatment
of CF with treatments chosen on the basis of genotype. Ivacaftor is a potentiator of the Cystic Fibrosis Transmembrane Regulator and
the patients who received this Medication had a drop in their sweat chloride levels. Thus, Ivacaftor would be the first therapy to impact
the core defect of cystic fibrosis. Currently, this medication is only known to be helpful in the approximately 4% of people with CF who
carry the G551D mutation. Studies in CF patients with other genotypes are ongoing. It is hoped that this medication will be approved
by the FDA later this year.
While the improved life expectancy in CF over the past twenty years has been dramatic, much work remains to be done. Research
cannot stop when the average life expectancy remains only 39 years. Hopefully, we will see the day soon when CF will stand for “Cure
Found.”
Daniel Layish, MD, graduated magna cum laude from Boston University Medical School in 1990. He then completed an
Internal Medicine Residency at Barnes Hospital (Washington University) in St.Louis, Missouri and a Pulmonary/Critical
Care Fellowship at Duke University in Durham, North Carolina. Since 1997, he has been a member of the Central Florida
Pulmonary Group in Orlando. He currently serves as Medical Director of the Intensive Care Unit, Respiratory Therapy and
Pulmonary Rehab at Winter Park Memorial Hospital.
Dr. Layish may be contacted at 407-841-1100 or by visiting www.cfpulmonary.com. 
ORTHOPAEDIC UPDATE
Neck or Back Pain? Cervical Disc Arthroplasty
May Be the Answer
By Corey Gehrold
There’s no doubt that as technology continues to evolve, the
medical field will continue to evolve right along with it, adapting and developing innovative new procedures that are beneficial for both patients and physicians alike. One such innovation
comes in the form of a new spinal surgery known as cervical disc
arthroplasty, a new surgical alternative for patients with symptomatic herniated cervical discs. The procedure is designed to
provide nerve and spinal cord decompression through removal
of the herniated disc while preserving and/or restoring normal
motion to the cervical spine, which is a large advantage over the
traditional anterior cervical disc excision and fusion procedure it
can replace.
When patients are experiencing symptomatic neck and arm
pain, sometimes associated with numbness, tingling, or weakness
in the arm, there is a chance they have herniated cervical discs.
“Of course patients with these symptoms will be treated with
a variety of non-surgical treatment options first including oral
medications, physical therapy and possibly the use of therapeutic
spinal injections such as epidural steroids, among others,” says
Stephen R. Goll, M.D., a board certified orthopaedic surgeon
specializing in cervical & lumbar spine surgery and adult spinal
reconstruction at Orlando Orthopaedic Center. “However, if a
patient continues to experience symptoms and they do not respond to non-surgical treatment, surgery may be the best option
to provide relief.”
for surgery are still identical but
the results can be radically different. The first element of the procedure is exactly the same, as the
initial goal of both cervical disc
arthroplasty and anterior cervical
disc excision and fusion is comStephen R. Goll, M.D.
plete neurologic decompression
Board Certified in
or removing anything (discs, herOrthopaedic Surgery
Specializing in Cervical &
niated discs, or bone spurs) that
Lumbar Spine Surgery and
is creating pressure or pinching
Adult Spinal Reconstruction
the spinal cord or the nerves of
the spinal cord. “Cervical disc arthroplasty differs from anterior cervical disc excision and fusion
in that after neurologic decompression, the empty space created
is replaced by an artificial cervical disc instead of bone,” says Dr.
Goll. “Unlike an anterior cervical disc excision and fusion, cervical disc arthroplasty therefore preserves motion or movement at
the operative level. In contrast to a fusion procedure, this would
be considered a motion sparing surgical procedure.”
In other words, rather than undergoing a spinal fusion procedure, these patients may have a surgical procedure done that
allows for the restoration of normal motion at the injured cervical spine segment while providing a similar degree of nerve and
spinal cord decompression through removal of the herniated disc.
“This is a big advantage over anterior cervical disc excision and
In the past, the traditional surgical approach for patients with
herniated cervical discs has been a procedure
called anterior cervical disc excision and fuStephen R. Goll, M.D., a board certified orthopaedic surgeon specializing in cervical &
sion. In this procedure, performed through an
lumbar spine surgery and adult spinal reconstruction at Orlando Orthopaedic Center,
performs a cervical spine arthroplasty.
incision on the front of the patient’s neck, the
cervical spine is exposed and the herniated disc
is removed in its entirety including not only
the herniated disc material, but any associated
bone spurs or anything creating pressure on
the nerve roots or spinal cord at that particular
spinal level. “In an anterior cervical disc excision and fusion, the space that is created by
disc excision and decompression of the spinal
cord and nerve roots is then filled with a block
of bone,” says Dr. Goll. “This block of bone
eventually becomes incorporated into the vertebral level above and below the operated disc
space and that segment becomes fused. This
creates a permanent stability of the injured spinal segment.”
But that was then. Cervical disc arthroplasty
is now. In the new procedure, the indications
ORTHOPAEDIC UPDATE
fusion,” says Dr. Goll. “In patients who have undergone anterior
cervical disc excision and fusion, there are many instances where
we see years down the road these patients who have achieved a
solid fusion at the operated level now get symptomatic disc problems at the levels above or below a prior fusion. With cervical
disc arthroplasty, the chances of developing these adjacent level
or junctional disc problems are significantly reduced.”
An additional advantage of cervical disc arthroplasty is that
there is no need for any period of immobilization following disc
replacement surgery. Unlike anterior cervical fusion, where it is
important to allow the neck to rest or be still for several weeks
after fusion before starting physical therapy, the patient who has
undergone a cervical disc replacement or cervical disc arthroplasty
can enter into therapy and begin restoring strength and mobility
to the cervical spine in a much shorter timeframe when compared
to those who have undergone a fusion procedure.
Perhaps even better news for patients is that cervical disc arthroplasty is still in its early stages at this point. “I think as time
goes on more and more patients may choose to elect cervical
disc replacement in lieu of cervical fusion and more and more
surgeons may be comfortable in offering this as an alternative
to their patients,” says Dr. Goll. “At the present time, cervical
disc replacement is usually performed on just a single level of the
cervical spine, but as time goes on and further technologic devel-
opments occur, we may see the day when the patient is getting
cervical disc replacement done at multiple levels of the cervical
spine at the same surgical setting.”
To view a patient-centered video featuring Dr. Goll explaining the cervical disc arthroplasty procedure, please
visit www.OrlandoOrtho.com. For additional information please call (407) 254-2500. 
Coming Next Month:
Our cover story features Orlando Orthopaedic
Clinic. Editorial focus is on Orthopaedics and
Men’s Health
Be sure and check out our
NEW and IMPROVED
website at
www.floridamd.com!
Quynhanh H.T. Pham, MD, MBA, FACS
We’re expanding to
better serve your patients.
South Seminole Surgical Group is proud to welcome Quynhanh H.T. Pham, MD, MBA,
FACS, to our team of physicians. Board Certified in General Surgery, Dr. Pham performs
a range of minimally invasive procedures including laparoscopic cholecystectomies,
herniorrhaphies, Nissen fundoplications and colon resections. She is also proficient in upper
and lower endoscopies.
Dr. Pham joins general surgeon Jon Wiese, MD, FACS who has been caring for patients in
Seminole County for over 20 years. Both physicians are accepting new referrals.
Jon Wiese, MD, FACS
To refer patients to South Seminole Surgical Group, please call 407.767.5808.
South Seminole Surgical Group
521 W. State Road 434, Suite 301
Longwood, FL 32750
Phone: 407.767.5808
Fax: 407.767.5892
11ORS052
Medical Malpractice Expert Advice
How Should You Prepare for Florida’s
Malpractice Insurance “Hard Market”?
By Matt Gracey
Q: With a more difficult, “hard market” predicted to hit Florida’s
malpractice insurance market soon, what should we be considering in our medical practice to be prepared?
A:Just like creating hurricane plans before the fury of a storm
descends upon you, now is a good time to be positioning your
practice for the impending hard market in malpractice insurance that will be unfolding in the next few years, just at a time
when many practices are challenged by decreasing income and
rising expenses. The best strategy can be broken down as this:
1.Preventative: Focus yourself and your entire practice team on
risk management. Many times doctors overlook the importance
of including the staff in risk management discussions. Studies
show that the friendlier your whole practice environment is
the lower your risk of a lawsuit. Many higher end malpractice
insurers offer risk management assessments of your practice
including in-office observations and recommendations, all for
free. Alternatively many offer self-assessment tools. Take advantage of these free services!
2.Review your malpractice insurance coverage with an experienced specialist to make sure you are on “high ground” when
the storm unfolds. Beware of the many offers from small, new,
unrated insurance companies now offering coverage in Florida.
Ask your broker to shop your coverage to a number of rated
insurers and remember that in this market cycle just before an
upturn you will see many offers that are too good to last. The
few strong insurers have the ability to withstand the upcoming market pressures because they are not highly leveraged, are
not offering actuarially unsound rates, and have a long term
not short term philosophy. Find those and you will be much
better off when the high winds are pounding on your practice
windows!
3.Create negotiating power: Many medical societies, networks,
and hospitals have created malpractice insurance purchasing
groups to give even smaller practices the negotiating power of
larger ones. If you cannot find a suitable purchasing group then
consider creating one with your peers, now before the market
changes. Such groups are fairly simple to start, legal, and will
help you weather the next cycle of sharply increasing malpractice rates.
4.Make sure that your asset protection plans are up to date and
if you need to transfer assets around do so soon before many
more claims get filed against doctors after the much predicted
upcoming overturn of the 2003
caps on non-economic damages.
We at Danna-Gracey are here
to help if you need specific direction and recommendations on any
of these suggestions and would be
honored to become part of your
trusted team.
Matt Gracey, Jr. is a medical malpractice insurance specialist with Danna-Gracey, an independent insurance agency
based in downtown Delray Beach with a statewide team of
specialists dedicated solely to insurance coverage placement
for Florida’s doctors. To contact him call (800) 966-2120, or
email: [email protected]. 
FROM OPEN HEART
TO OPEN ARMS.
Cardiac Surgery Program given the Society of
Thoracic Surgeons’ highest “three-star” rating.
With a staff of legitimate cardiovascular pioneers and innovative
services, it’s no wonder so many of the region’s cardiologists are on
board with the high-level care and personal touch that only
Central Florida Cardiac & Vascular Institute’s team can deliver.
The Society of Thoracic Surgeons recently awarded
Osceola Regional Medical Center with the coveted “three-star”
rating, placing our Cardiac Surgery Program in the nation’s top 12
700 WEST OAk STREET
kiSSiMMEE, FL 34741
percent. By pioneering complex procedures such as minimallyinvasive valve replacement, our experts continue to be recognized
for new ways forward in cardiovascular care.
For more information, call 1-877-4-HCA-DOCS (1-877-442-2362).
Or, visit us at www.CentralFloridaCardiac.com.
INPATIENT MEDICINE
Extraordinary Communication Makes
the Difference in Driving Better Quality
Outcomes and Patient Satisfaction
By Dr. Krishan Nagda, MD
Much of a group practice’s success depends on the leadership
assumed by its individual physicians. As the largest hospitalist
group in the region, we at Central Florida Inpatient Medicine
(CFIM) asked ourselves, how can we engage our doctors to lead
by example in achieving better outcomes and patient satisfaction?
We determined that collaboration among all those involved in a
patient’s care is key, and we made achieving extraordinary communication one of our strategic goals. Our Medical Director Program is a prime example of how we put that goal into practice.
At each facility we serve, we’ve appointed a physician Medical
Director to provide leadership and to facilitate communication.
A 2010 workflow study of hospitalists demonstrated that doctors
actually spend more time communicating (26%) than they do
touching patients (18%). So, why not refine the avenues of communication with the hospital, specialists, primary care doctors,
patients, and importantly, amongst ourselves? CFIM already had
in place unique technology and office support platforms. Adding
the clinical and professional components of the Medical Director
role has taken the practice to the next level.
CFIM Medical Directors at each facility take a lead role on
clinical standards for the practice. They ensure that we have systems in place, such as oversight, training and education of practice physicians, to ensure consistent and reliable delivery of standards.
The Medical Directors also provide professional leadership and
serve as a bridge between the practice and the hospitals and facilities we serve. Most importantly, they help achieve alignment
between the practice and our constituents (primary care doctors,
specialists, hospitals, health plans and of course, our patients).
Based on their stewardship they bring their perspective to key
decisions at CFIM… from quality initiatives, to staffing, to long
term practice strategy.
We’ve found that the strengthened physician engagement galvanized by the Medical Director
Dr. Ivan Bolivar
Program has enabled us to forge
stronger, more satisfying relationships with our patients, helped us
respond to change more effectively
and has facilitated our practice’s
delivery of higher quality care as
gauged by across the board improvement in core measures.
CFIM Medical Directors posses varied backgrounds and a rich
mosaic of experiences, but they all share the goal of leading by
example.
Dr. Ivan Bolivar serves as the CFIM Medical Director at Florida
Hospital South. He completed his residency at the Department
of Internal Medicine and Pediatrics
Dr. Mohammed Merchant
at Cook County Hospital, in Chicago, Illinois. Dr. Bolivar serves on the
CFIM Peer Review Committee and
is instrumental in putting together
Quality and Performance Improvement initiatives at CFIM.
Dr. Mohammed Merchant serves
as the CFIM Medical Director at
Health Central. He attended Nova
Southeastern University in South
INPATIENT MEDICINE
Florida and completed his residency in Internal
Medicine at Loma Linda University Medical Center
in Loma Linda, California. He takes a very active
role in hospital operations, serving as the Chief of
Internal Medicine and as a lead physician for CPOE
at Health Central. Dr. Merchant also has responsibility for designing protocols for Core Measures.
Dr. Victor Mikhael serves as the CFIM Medical
Director at Florida Hospital Winter Park. He comDr. Victor Mikhael
Dr. Kristin Minerva
Dr. Mark Bobek
pleted his residency at The Metro Health Medical
Center in Cleveland, Ohio. Dr. Mikhael is active
in hospital operations, serving as the Chair of the Healthcare and Spiritually Committee, Unit Advisor on two floors and as a member of
the Medical Division Leadership Board. Recently, Florida Hospital awarded him The Balance Award, which recognizes physicians who
successfully balance clinical practice with administrative responsibilities.
Dr. Kristin Minerva is the CFIM Medical Director at Florida Hospital Altamonte. She earned her medical degree and completed her
residency in Internal Medicine at the University of South Florida. Dr. Minerva serves as Florida Hospital Altamonte’s Chief of Medicine,
Medicine Secretary / Treasurer and as a Unit Medical Director. She also provides physician leadership at the hospital as a CPOE Leader
and as a member of the Patient Safety Committee.
Dr. Mark Bobek is the Medical Director for CFIM’s Skilled Nursing Division, which attends 23 Skilled Nursing Facilities in the
Central Florida region. He attended medical school at The University of Miami and completed his residency in Family Practice at St.
Vincent’s Medical Center in Jacksonville, Florida. As CFIM’s SNF Medical Director his responsibilities include collaborating on clinical
consultations alongside practice physicians, addressing complex patient and family concerns and writing and implementing compliance
program initiatives. One of his most important tasks is detecting patterns of infection within facilities and developing protocols to rid
the infection spread area. His communication between the SNFs administration and staff is also vital to our mutual success.
Krishan Nagda, MD is President / C.E.O. of Central Florida Inpatient Medicine.
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WEALTH MANAGEMENT
Financial Lessons From 2011
By Tyson Smith
The year-end performance of the broader markets last year was
anything but memorable and the whipsaw volatility throughout
was something most investors would rather forget. But a closer
look reveals a wealth of wisdom to be gained from observing how
events unfolded in 2011 and taking note of the way people and
investments responded.
What You Should Know:
1. Media headlines can be a short-term leading indicator. Savvy
investors have long viewed the media as a lagging indicator,
reasoning that – by the time most financial stories break – the
marketplace has usually priced in the news. However, the correlation between daily headlines and dramatic swings in market indices throughout the second half of 2011 was difficult
to ignore. Here are some important things to keep in mind
regarding media-driven volatility:
∙∙ Headlines are designed to be attention grabbing. They often
play on people’s fear and/or excitement to compel them to
read or pay attention. The psychological impact of such messages can also compel investors to react in extreme ways – such
as a dramatic reallocation or exiting the market entirely.
∙∙ The most universally agreed upon cause of volatility in 2011
was uncertainty. And the issues investors were most uncertain
about – political deadlock over the U.S. budget and deficit,
and sovereign debt issues in the Euro-zone – are not expected
to change substantially in the near term.
∙∙ Research reports issued by reputable analysts who study the
fundamentals underlying share prices are the best way to determine the prospective long-term value of an investment.
2. Volatility swings both ways. Investors tend to remember the
big drops, like the three larger-than-500-point declines the
Dow experienced in rapid succession during the first and second week of August last year. But the Dow also saw three days
with gains above 400 points and actually closed the year up
5.5%. Not a great year, but – depending on when (or if ) they
got back in – investors who pulled out in August may have
done much worse.
∙∙ Attempting to time market swings– particularly in a highly
volatile environment – can be extremely risky, requiring you
to be right twice, once about when to get in and once about
when to get out.
∙∙ Wholesale allocation or strategy shifts are rarely a good idea. It
is better in times of volatility to keep a portion of your portfolio flexible and nimble in the short term to capitalize on
opportunities that arise.
∙∙ The risks (in terms of lost potential return) of not being invested at all may
outweigh the risks of being invested on
a down day or through a secular bear
market.
3. Everything is connected but not necessarily correlated. The relationship between the U.S. and the rest of the world’s markets
was never clearer than in 2011, as political tensions here and
in Europe drove indices and incited downgrades of multiple
nations’ credit ratings. Similarly, on the days when markets
did swing, the effect was often widespread and impacted most
traditional investments the same way.
∙∙ Correlation, or the degree to which different investments behave similarly under certain conditions, has increased in recent years – particularly among stocks.
∙∙ While stocks were effectively flat in 2011, U.S. Treasuries
logged their best performance since 2008 and gold finished
the year up 10%.
WEALTH MANAGEMENT
∙∙ In volatile times, it may make sense to look beyond traditional investment asset classes like stocks, bonds and commodities and allocate
a minority portion of your portfolio to alternatives that are less or negatively correlated with other investments in your portfolio.
What You Should Do Now:
The U.S. Presidential election may provide a psychological boost – or at least some degree of certainty about the future – for investors
in November, but any fundamental changes to U.S. economic policy won’t take place until next January. Meanwhile, the majority of
economists don’t expect the Euro-zone to get its collective economic act together until 2013 at the earliest. So it appears the uncertainty
that fueled market volatility in 2011 will likely be with us for the bulk of 2012. You should talk The Tyson Smith Group about what
worked and what didn’t in terms of your investments so that together you can make an informed plan for this year.
Past performance is not a guarantee of future results.
The information contained in this communication
is being provided for informational and discussion
purposes only. All investments and investment strategies carry a degree of risk. Although alternative investments may be beneficial as a minority allocation
in a well diversified portfolio, they are historically
more volatile than traditional investments and are
not suitable for all investors. Please consult with
your Financial Advisor before implementing any
strategies.
Robert W. Baird & Co. does not provide tax advice. Please consult with your tax professional before
implementing any strategies.
Article provided by Robert W. Baird
& Co. for Tyson Smith, Vice President, Financial Advisor at the Orlando office of Robert W. Baird & Co.,
member SIPC. He has 12 years of financial services industry experience,
and can be reached at 407-481-8286
or 888-792-0098.
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Digestive and Liver Update
Overview of the Management of
Hepatitis B (Part 1)
By Harinath Sheela, MD
INTRODUCTION — The following topic review will summarize issues related to the management of hepatitis B.
Specific examples of cases are described at the end, which illustrate some of the issues that may arise when making treatment
decisions for patients with chronic hepatitis B. Clinical decisions
regarding individual patients should be based upon patient-specific clinical information and test results. Data supporting this
section are presented separately.
HEPATITIS B VIRUS — The hepatitis B virus (HBV) is a
double-stranded DNA virus belonging to the family of hepadnaviruses, which include duck hepatitis virus, woodchuck hepatitis
virus, and ground squirrel hepatitis virus.
HBV has traditionally been classified into eight genotypes (A
to H) based upon an inter-group divergence of 8 percent or more
in the complete nucleotide sequence. The prevalence of specific
genotypes varies geographically. Furthermore, genotypes may
correlate with clinical course and response to interferon. Genotype testing is not necessary in routine clinical practice, but it
may be indicated for HBeAg-positive patients who are considering interferon therapy since patients with genotype A have a
more favorable response.
in patients who are not known to be
immune.
• Evaluation for other causes of liver disease including hepatitis
C, hepatitis D, and hemochromatosis by obtaining anti-HCV,
anti-HDV (in injection drug users and persons from countries
where HDV is endemic, particularly Eastern Europe, Mediterranean countries, and the Amazon basin), iron, and TIBC.
• Screening for HIV infection in persons with risk factors such
as injection drug use, multiple sexual exposures, or men who
have sex with men.
• Screening for hepatocellular carcinoma if indicated.
• Liver biopsy may be considered for patients who meet criteria
for chronic hepatitis (ie, HBsAg positive for >6 months, serum
HBV DNA >10(5) copies/mL or >20,000 IU/mL, persistent
or intermittent elevation in ALT/AST levels). Liver biopsy is
most important for patients who do not meet current criteria for treatment but have serum HBV DNA 10(4) to 10(5)
copies/mL (2000 to 20,000 IU/mL) and ALT/AST levels that
are normal or mildly elevated (<2x upper limit); patients with
histologically active or advanced liver disease may benefit from
treatment.
EPIDEMIOLOGY — Hepatitis B virus infection is a global
• A normal serum ALT level alone in patients with active viral
public health problem. It is estimated that there are more than
replication does not predict mild or normal histologic find300 million HBV carriers in the world, of whom approximately
ings. One report found that up to 37 percent of patients with
500,000 die annually from HBV-related liver disease. Despite
the availability of HBV vaccines, the rate of
HBV-related hospitalizations, cancers, and
deaths in the United States have more than
doubled during the past decade.
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• A history and physical examination,
emphasizing risk factors for coinfection
with HCV and/or HIV, use of alcohol,
and family history of HBV infection and
liver disease.
• Laboratory tests: complete blood count
with platelets, liver biochemical tests
(AST, ALT, total bilirubin, alkaline phosphatase, albumin), prothrombin time,
and tests for HBV replication (HBeAg,
anti-HBe, HBV DNA). Testing for immunity to hepatitis A virus (HAV) with
HAV IgG antibody should be considered
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persistently normal ALT and HBV DNA levels >10,000 copies/mL (approximately >2000 IU/mL) had significant fibrosis
and inflammation on liver biopsy. On subgroup analysis, most
such patients had an ALT in the high range of normal and
were older than 40. By contrast, two studies in patients in the
immune tolerant phase of chronic HBV infection found that
despite high HBV DNA levels, most patients had no or minimal fibrosis ]. Considered together, these data indicate that
age or duration of infection is important in predicting severity
of liver injury in patients with high HBV DNA levels.
WHO SHOULD BE TREATED AND HOW — The rationale
for treatment in patients with chronic HBV is to reduce the risk
of progressive chronic liver disease, transmission to others, and other long-term
complications from chronic HBV such as
cirrhosis and hepatocellular carcinoma.
We recommend that treatment be considered in patients with HBeAg positive or
HBeAg negative chronic hepatitis. Patients
with compensated cirrhosis and HBV DNA
>2,000 IU/mL and those with decompensated cirrhosis and detectable HBV DNA
by PCR assay should be considered for antiviral therapy, regardless of the serum ALT
level.
Recommendations from the American Association for the Study
of Liver Diseases updated in 2009 suggest an approach and considerations for treatment.
HBeAg-positive patients — Treatment is recommended for
those with HBV DNA >20,000 IU/mL and ALT >2 x ULN in
patients without cirrhosis. As noted above, patients with compensated cirrhosis and HBV DNA >2,000 IU/mL and those with
decompensated cirrhosis and detectable HBV DNA by PCR assay should be considered for antiviral therapy, regardless of the
serum ALT level. Treatment should be delayed for three to six
months in newly diagnosed HBeAg positive patients with compensated liver disease to determine whether spontaneous HBeAg
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The following criteria for treatment were
suggested in a 2008 consensus conference
from the United States National Institutes
of Health.
• Patients in whom therapy is indicated:
acute liver failure, clinical complications
of cirrhosis, cirrhosis or advanced fibrosis
with high serum HBV DNA, or reactivation of chronic HBV after chemotherapy
or immunosuppression.
• Patients for whom therapy may be indicated: patients in the immune-active
phase who do not have advanced fibrosis
or cirrhosis (HBeAg-positive or HBeAgnegative chronic hepatitis).
• Patients for whom immediate therapy is
not routinely indicated: (1) Patients with
chronic HBV in the immune tolerant
phase (with high levels of serum HBV
DNA but normal serum ALT levels or
little activity on liver biopsy); (2) Patients
in the inactive carrier or low replicative
phase (with low levels of or no detectable
HBV DNA in serum and normal serum
ALT levels); (3) Patients who have latent
HBV infection (HBV DNA without
HBsAg).
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seroconversion will occur. Patients with chronic hepatitis whose
serum ALT is persistently below two times the upper limit of
normal can be observed, considering treatment if and when the
serum ALT becomes higher. Possible exceptions to this rule are
those who have recurrent hepatitis flares that fail to clear HBeAg,
patients with icteric flares, those with active or advanced histologic findings (such as moderate/severe inflammation or bridging
fibrosis/cirrhosis), and patients above the age of 40 who remain
HBeAg positive with persistently high HBV DNA levels.
nancy. Compared to adefovir, lamivudine has more rapid and
more potent virus suppression, but entecavir, telbivudine, and
tenofovir are superior to lamivudine in suppressing viral replication. The main disadvantage of lamivudine is the high rate of
drug resistance. The role of lamivudine in the care of HBV is
diminishing with the availability of new therapies which are associated with lower rates of drug resistance. Lamivudine may still
have a role in patients coinfected with HIV (in whom lamivudine
may be part of the antiretroviral regimen).
Treatment may also be indicated in patients with HBV-related
polyarteritis nodosa.
Adefovir — The main advantage of adefovir is its activity
against lamivudine-resistant HBV and a lower rate of drug resistance compared to lamivudine. However, virus suppression is
slow at the approved dose and up to 25 percent of patients experience minimal or no viral suppression. Adefovir at high doses
has been associated with nephrotoxicity. At the approved dose
of 10 mg daily, reversible increase in serum creatinine has been
reported in 3 to 9 percent of patients after four to five years of
treatment. Adefovir resistance was not detected after one year of
treatment but the rate of drug resistance has been reported to
be as high as 29 percent after five years of treatment. The most
important role of adefovir is in the treatment of patients with
lamivudine-resistant HBV, preferably in combination. With the
approval of tenofovir, which is more potent, the role of adefovir
is rapidly diminishing. In vitro data suggest that adefovir is also
effective in suppressing telbivudine- and entecavir-resistant HBV
but clinical data are scant.
Although treatment can lead to virus suppression in HBeAg
positive patients with normal ALT, the likelihood of HBeAg seroconversion is low. The benefits of long-term treatment in such patients, most of whom are young Asians with perinatally acquired
HBV infection, must be balanced against the risks of drug-resistance, side effects, and costs, particularly since some of these
individuals will undergo spontaneous HBeAg seroconversion and
remain in remission for many years afterwards, and since most
of these individuals will have very low rates of treatment-related
HBeAg seroconversion.
HBeAg-negative patients — Treatment may be initiated immediately once a diagnosis of HBeAg negative chronic hepatitis
(ALT >2 x ULN and HBV DNA >2000 IU/mL) is established
because sustained remission is rare in the absence of treatment.
Because of the fluctuating course of HBeAg negative chronic hepatitis, serial follow-up is needed to differentiate an inactive carrier
state from HBeAg negative chronic hepatitis. Liver biopsy should
be considered in HBeAg negative patients who have serum HBV
DNA levels >2000 IU/mL and normal or mildly elevated ALT to
determine if treatment is warranted.
Choosing among the available options — Treatment strategies for chronic HBV include interferon (standard and pegylated), lamivudine, adefovir dipivoxil, telbivudine, entecavir, and
tenofovir (in countries in which it is approved). The following
are general rules that can be considered when deciding upon an
approach in individual settings. Specific examples are presented
in the cases below:
Interferon — The advantages of interferon compared to the
other options are its finite duration of treatment, the absence
of selection of resistant mutants, and a more durable response.
On the other hand, side effects from interferon are troubling for
many patients, and (less commonly) can be severe. Furthermore,
interferon cannot be used in patients with decompensated disease. The main role of interferon is primarily treatment of young
patients with well compensated liver disease, who do not wish to
be on long-term treatment or are planning to be pregnant within
the next two to three years, and in whom drug resistance may
limit their treatment options in the future. Interferon is also an
attractive option for patients with HBV genotype A infection.
Lamivudine — The main advantages of lamivudine are its
lower cost compared to the other oral agents and the many years
of experience confirming its safety, including its use during preg26 FLORIDA MD - FEBRUARY 2012
Entecavir — The main advantages of entecavir are its potent
antiviral activity and a low rate of drug resistance. Entecavir has
a more important role in primary treatment of HBV than in patients with lamivudine-resistant HBV. Entecavir may also have an
important role in patients with decompensated cirrhosis because
of its potent antiviral activity and low rate of drug resistance but
its safety in this patient population has not been well studied.
Resistance to entecavir is rare among nucleoside-naïve patients
(approximately 1 percent with up to five years of treatment). By
contrast, resistance has been observed in up to 50 percent of lamivudine-refractory patients after five years of treatment. Studies
in rodents (that used 24 to 40 fold higher doses of entecavir than
in humans) have reported increased rates of tumors; the relevance
of these findings to humans is unclear.
Telbivudine — Telbivudine appears to have slightly more
potent antiviral effects compared with lamivudine and adefovir
but it selects for the same resistant mutants as lamivudine and is
more expensive. Thus, its role as primary therapy is limited. Furthermore, there have been rare cases of myopathy and peripheral
neuropathy.
Tenofovir — Tenofovir has more potent antiviral activity than
adefovir and is effective in suppressing wild-type as well as lamivudine-resistant HBV. Tenofovir may be used as first line treatment in treatment-naïve patients, and in patients with lamivudine, telbivudine or entecavir resistance, preferably as additional
treatment in these patients. Tenofovir can also be used to substitute for adefovir in patients who have inadequate viral response
to adefovir. However, its efficacy in patients with adefovir-resistant HBV is limited. Tenofovir will probably replace adefovir in
countries where it is approved because of its more potent antiviral
activity. Preliminary data indicate that resistance to tenofovir is
rare after up to four years of treatment.
Prediction of response HBeAg positive patients — For
HBeAg positive patients, the likelihood of response to lamivudine, adefovir, telbivudine, entecavir, interferon, and probably
tenofovir depends upon the degree of elevation of the serum
aminotransferases. As a general rule, treatment with any of these
drugs does not result in higher rates of HBeAg seroconversion
compared to no treatment in those who have a serum ALT ≤2 X
the upper limit of normal.
Prediction of response in HBeAg negative patients — For
HBeAg negative patients, prediction of response is less precise.
Because of the need for long-term treatment, therapy is recommended only for those with persistent or intermittent elevation
in ALT and/or substantial histologic abnormalities (moderate/
severe inflammation or bridging fibrosis/cirrhosis). Interferon,
adefovir, entecavir, or tenofovir are generally preferred because
long-term treatment with lamivudine or telbivudine is associated with diminishing response due to selection of drug-resistant
mutants. Advantages of entecavir and tenofovir are more potent
antiviral activity and lower rate of drug resistance compared with
adefovir.
Renal insufficiency — Entecavir may
be a better option than adefovir or tenofovir in patients with renal insufficiency
and in those who are at risk for renal insufficiency. While all of these medications
require dose reduction according to renal
function, entecavir has not been reported
to cause renal impairment.
Failed prior interferon therapy — Patients who failed to respond to prior interferon therapy can be treated with lamivudine, adefovir, telbivudine, entecavir, or
tenofovir with the expectation of a similar
response as treatment-naïve patients.
Breakthrough infection — Those that
develop breakthrough infection due to
antiviral drug resistance should be treated
with additional antiviral therapy. Salvage
therapy should be initiated promptly at
the time of virologic breakthrough, prior
to biochemical breakthrough, especially
those with worsening liver disease, decompensated cirrhosis, recurrent HBV after
transplantation, or immunosuppression.
The choice of therapy in patients who developed resistance to nucleotide/side analogue depends upon which drug was used
for initial treatment.
• Although data from a small study in patients with compensated liver disease showed that substitution of lamivudine for
adefovir was as effective in viral suppression as addition of adefovir, patients who stopped lamivudine were more likely to
have hepatitis flares during the first few months. In addition,
follow-up data found that adefovir resistance was detected only
in patients who stopped lamivudine but not in those who received combination therapy. These data indicate that lamivudine should be continued after the addition of adefovir.
• For lamivudine/telbivudine resistance, addition of adefovir or
tenofovir is a better option than entecavir since the likelihood
of entecavir resistance increases in patients who have preexisting mutations that confer resistance to lamivudine/telbivudine.
Preliminary data suggest that salvage with switch to tenofovir
monotherapy may be as effective as add-on tenofovir in suppressing HBV replication, but longer duration of follow-up is
needed to determine if the rates of resistance to tenofovir will
be equally low with these two approaches.
• For adefovir resistance, addition of lamivudine/telbivudine/entecavir is recommended. However, the durability of response is
unclear in patients with prior lamivudine resistance. Entecavir
is preferred in patients with prior lamivudine resistance. Case
series suggest partial cross resistance between adefovir and tenofovir.
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• For patients with entecavir resistance, we suggest the addition
of adefovir or tenofovir.
Compensated cirrhosis — In patients with clinically and biochemically compensated cirrhosis, interferon may be used with
caution but nucleosides/nucleotides are safer. Because of the need
for long-term treatment, entecavir or tenofovir is preferred.
Decompensated cirrhosis — Patients with decompensated
cirrhosis should be considered for treatment with lamivudine,
telbivudine, adefovir, entecavir, or tenofovir. Interferon is contraindicated in these patients. In view of the need for long-term
treatment, lamivudine and telbivudine are not optimal treatments unless used in combination with adefovir or tenofovir. If
adefovir monotherapy is used, HBV DNA levels and liver function should be monitored closely (monthly or more often) and
treatment modified by switching to tenofovir or adding lamivudine, telbivudine, or entecavir if virus suppression is slow or inadequate. Renal function (creatinine every one to three months)
should be monitored closely in patients receiving adefovir or tenofovir. Entecavir may be a preferred option. Although a case
series reported the occurrence of lactic acidosis in patients with
severe liver dysfunction, this is likely a class effect of nucleos/tide
analogs. Furthermore, several larger studies did not observe any
clinical cases of lactic acidosis, although lactate levels were not
monitored in those studies. Treatment of such patients should be
coordinated with a transplant center.
Chemotherapy or immunosuppression — Issues related to
patients undergoing chemotherapy or receiving immunosuppression are discussed separately.
Cost-effectiveness — The cost-effectiveness of various treatment strategies for chronic HBV is incompletely understood.
Although several cost-effectiveness analyses have been published,
all were conducted before approval of peginterferon, entecavir,
telbivudine, and tenofovir.
DOSES — The following are recommended doses of the specific drugs:
Interferon alfa — Interferon alfa is administered by subcutaneous injection.
For adults: 5 MU daily or 10 MU three times a week
• For children: 6 MU/M(2) three times weekly with a maximum
of 10 MU
• Treatment duration for HBeAg positive chronic hepatitis is 16
to 32 weeks
• Treatment duration for HBeAg negative hepatitis is 12 to 24
months
Peginterferon alfa-2a
• For adults: 180 microG once weekly
• For children: Not approved
• The manufacturer recommends 48 weeks of treatment for
HBeAg positive or negative chronic HBV. The Asian-Pacific
guidelines recommended 24 weeks treatment for HBeAg
positive HBV based on comparable responses obtained in the
phase II trial [1]. However, preliminary data from one trial
suggest that 48 week treatment is superior to 24 week treatment,
and 180 microG is superior to 90 microG for HBeAg positive
patients.
Lamivudine — Lamivudine is administered orally.)
• The recommended dose for adults with normal renal function
without concomitant HIV infection is 100 mg daily. Dose adjustment is required in those with decreased renal function.
• The recommended dose for children is 3 mg/kg per day with a
maximum of 100 mg/day
• The recommended dose for those who are coinfected with HIV
is 150 mg twice daily (along with other anti-retroviral drugs).
Adefovir — Adefovir is administered orally. The dose is 10 mg
daily. Patients with impaired renal function should have the dosing interval adjusted.
Entecavir — Entecavir is administered orally. The recommended dose is 0.5 mg once daily for nucleoside-naïve adults
and adolescents older than 16 while it is 1 mg daily for those
who have lamivudine resistance. The dose should be adjusted in
patients with a creatinine clearance of <50 mL/min.
Telbivudine — Telbivudine is administered orally. The recommended dose is 600 mg once daily.
Tenofovir — Tenofovir is given at a dose of 300 mg daily; the
dose needs to be adjusted in renal impairment.
Harinath Sheela, MD moved to Orlando, Florida after
finishing his fellowship in gastroenterology at Yale University School of Medicine, one of the finest programs in the
country. During his training he spent significant amount
of time in basic and clinical research and has published
articles in gastroenterology literature.
His interests include Inflammatory Bowel Diseases
(IBD), Irritable Bowel Syndrome (IBS), Hepatitis B,
Hepatitis C, Metabolic and other liver disorders. He is a
member of the American Gastroenterological Association
(AGA), the American Society for Gastrointestinal Endoscopy (ASGE) and the American Association for the Study
of Liver Diseases (AASLD) and Crohn’s Colitis foundation (CCF). Dr. Sheela is a Clinical Assistant Professor at
the University of Central Florida School of Medicine. He
is also a teaching attending physician at Florida Hospital
Internal Medcine Residency and Family Practice Residence
(MD and DO) programs. 
UCP of Central Florida’s
19th Annual Gala
2012
Saturday, March 10,
Hotel & Spa
Buena Vista Palace
p.m.
5:30 p.m. until 10:00
Prese nted by Prem ier Beve rage
Be a part of this star-studded
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ŵĂŐŝĐĂůĞŶƚĞƌƚĂŝŶŵĞŶƚ͘
^ƉĞĐŝĂůŚŽŶŽƌĞĞƐĨŽƌƚŚŝƐǇĞĂƌ͛Ɛ
ĞǀĞŶƚĂƌĞdŚĞDĂƌƟŶŶĚĞƌƐĞŶͲ'ƌĂĐŝĂ
ŶĚĞƌƐĞŶ&ŽƵŶĚĂƟŽŶĂŶĚƌ͘ŽŶĂůĚ
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Reserve your table:
hW'ĂůĂ͘ĐŽŵͮϰϬϳ͘ϴϱϮ͘ϯϯϱϮ
ƐƉŽŶƐŽƌƐŚŝƉƐΛƵĐƉĐŇ͘ŽƌŐ
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Dan Aykroyd and Emmy-Nominated
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UCP of Central Florida is serving over 2,400 children with and without disabilities, age birth to 21, embracing an inclusive educational environment.
Special thanks to our sponsors:
CURRENT TOPICS
Florida Hospital Receives Beacon Award
Florida Hospital’s VTICU Recognized As One of the Best Vascular Thoracic
Intensive Care Units in the Nation
Florida Hospital’s Vascular Thoracic Intensive Care Unit (VTICU) received the National Beacon Award by the American Association of Critical-Care Nurses (AACN). The Beacon Award
recognizes adult critical care, adult progressive care and pediatric
critical care units that exemplify nursing innovation, high quality patient outcomes, healthy work environments, commitment
to excellence, leadership and organizational ethics. This is the fifth
Beacon Award a Florida Hospital unit has received since 2009.
A team of eight of Florida Hospital’s VTICU nurses was inspired to submit their unit for the Beacon Award based on their
confidence that the unit excelled in the areas the award designates:
leadership, structure and systems, appropriate staffing and engagement, effective communication and collaborative practices with
physicians, knowledge management, best practices and patient
outcomes. The application and data reporting process took place
over a 10 month period and the unit was honored with the Beacon
award in December 2011.
Florida Hospital’s VTICU is a 20-bed adult critical care unit
that specializes in providing complex pre and post operative care
to vascular and thoracic, and other critically ill patients.
“Winning this award validates the hard work and dedication of
the entire team,” said Marie Desir, the nurse manager of VTICU.
“This journey has helped us to continue to learn, grow and improve in our ability to deliver the highest level of excellent patient
care which, of course, is the main objective of what we do.”
Hospitals earning the Beacon Award are both locally and nationally recognized for excellence in healthcare. The Beacon Award
affirms the VTICU’s passion to fulfill its promise of dedication to
the welfare of its patients and the community. 
Poinciana Medical Center Groundbreaking
A VIP groundbreaking ceremony for the Poinciana Medical Center, an affiliated facility of Osceola Regional Medical
Center and an HCA, was held
on February 7. The new facility
is located in Poinciana, about
ten miles South of Kissimmee,
corner of Cypress Parkway and
Solivita Boulevard. The first
phase of the Medical Center, a
Freestanding Emergency Department (FSE) is expected to
open its doors in early 2013. The
Emergency Department will be
11,000 square feet and house 12
exam rooms.
In addition, the facility will
include a 16-slice CT, radiography and fluoroscopy room, ultrasound, laboratory, and pharmacy. The structure will include an EMS entrance and helicopter pad for rapid
transport of critically ill patients to Osceola Regional Medical Center.
Poinciana Medical Center will be a two-story, 90,000 square foot building with 24 private medical-surgical beds and a six-bed ICU. In
support of both inpatient and outpatient care, the facility will provide a full range of acute care services including diagnostic imaging, inpatient and outpatient surgery, cardiac catheterization, laboratory, pharmacy, and a full range of support services. “We are eager to commence
the anticipated phased hospital for the Poinciana community” said Kathryn J. Gillette, Osceola Regional Medical Center CEO. “The opening of the first phase with its Freestanding Emergency Department will greatly enhance access to quality medical care for the community
and provide a positive economic impact to the surrounding communities,” added Gillette.
Poinciana Medical Center campus will house a freestanding medical office building with leasable space for physicians and other healthcare
providers. Approximate square footage and lease rates are to be determined.
HCA’s total investment in Poinciana Medical Center will be approximately $65 million. Once fully operational, Poinciana Medical Center will employ approximately 200 full time employees. 
CURRENT TOPICS
Florida Hospital Celebration Health Gynecologic
Doctor Invents New Surgical Device that Bears
His Name
Dr. Arnold Advincula created the Advincula Arch to aid
surgeons during minimally invasive procedures
Necessity is the mother of all invention: That is the reason behind the creation of the Advincula Arch. Dr.
Arnold Advincula, Medical Director of Benign Gynecologic Robotics at the Global Robotics Institute at
Florida Hospital Celebration Health, collaborated to create this device after seeing a need for better uterine access while performing a minimally invasive hysterectomy. The Advincula Arch is designed to increase uterine
visibility for the surgeon, increase patient safety and hopefully encourage more surgeons to offer a minimally
invasive approach to their patients.
“Two-thirds of hysterectomies today are still done with an open incision, and many of these patients are candidates for other less invasive
approaches,” said Dr. Advincula. “The Advincula Arch is designed to increase the visibility and safety of robotic and laparoscopic hysterectomies to give physicians even more confidence in these techniques.”
The Advincula Arch is the result of a five year collaboration between Dr. Advincula and Cooper Surgical, Inc., the device manufacturer.
Dr. Advincula wanted to create a more durable, safer and functional device with better access than other relatively similar devices that are
currently on the market. After several prototypes, the Advincula Arch is different from any other that currently exists.
Dr. Advincula unveiled the device at the American Association of Gynecologic Laparoscopists’s (AAGL) 40th Annual Global Congress in Minimally
Invasive Surgery, where it was well received by other gynecologic surgeons.
“I have been using the device in my operating room and it has revolutionized the way our team does hysterectomies on a variety of patients,” said Dr.
Advincula. “Other surgeons are intrigued as well and we are getting a lot
of inquiries about the device. I see it becoming a necessary surgical tool for
many gynecologic surgeons.”
To learn more about the device, contact Pete Arneson, Senior Product
Manager at Cooper Surgical, Inc. at (203) 601-9811. 
ORMC’s Bariatric Program, Medical Director Earns
Center of Excellence Designation
Program and doctor recognized for quality outcomes
The Weight Loss (Bariatric) Program at Orlando Regional Medical Center was recently designated as a Bariatric Surgery Center of Excellence® by the American Society for Metabolic and Bariatric Surgery (ASMBS). Muhammad Jawad, MD, the program’s medical director,
was also named an ASMBS Bariatric Surgery Center of Excellence designee.
“The designation reflects the demonstrated expertise and experience of our staff to provide patients with a program marked by high
quality care, good outcomes and safety,” said Dr. Jawad.
Established in 2004, the center of excellence program, administered by Surgical Review Corporation, was developed to advance the
safety, efficacy and efficiency of bariatric and metabolic surgical care. The center of excellence program uses objective requirements and
evaluation processes verified through a rigorous site inspection. Requirements for bariatric programs based in hospitals include: institutional commitment to excellence, surgical experience and volumes, responsive critical care support, appropriate equipment and instruments, patient support groups and long-term patient follow-up.
With its experienced clinicians – surgeons, nurses, dietitians, behavioral specialists and program coordinator – ORMC supports patients
before surgery through recovery and after discharge.
ORMC’s program offers Roux-en-Y gastric bypass surgery, laparoscopic sleeve gastrectomy, gastric banding (LAP-BAND® Surgery)
to help patients improve their health beyond weight loss to curing diseases such as type 2 diabetes, high blood pressure, sleep apnea and
polycystic ovary syndrome. The program also offers revision surgeries.
The center of excellence designation also improves access for patients as the program is now formally recognized by the Centers for
Medicare & Medicaid Services, which enables reimbursement from government and private health insurers. 
CURRENT TOPICS
Tampa Eye Surgeon Pioneers Blade-Free
Cataract Surgery Technique
Groundbreaking surgical technique invented, tested, and first offered by local
ophthalmologist T. Hunter Newsom, MD of Newsom Eye & Laser Center
Tampa, FL (January 24, 2012) –Cataracts affect nearly 22
million Americans age 40 and older every year, says the American Academy of Ophthalmology. With such a high prevalence,
continued industry advancements are critical. This is why Tampa’s own, T. Hunter Newsom, MD, founder of Newsom Eye &
Laser Center, works to remain at the forefront of ophthalmic
care. Newsom is the inventor of an innovative bladeless laser
cataract surgery technique, which he is now officially taking
public.
A pioneer in the field of ophthalmology, Dr. Newsom has
been the first in the country, and even the world, to achieve
noteworthy milestones in his field. In the treatment of cataracts, Dr. Newsom has once again achieved an industry first.
Over the past two years, Dr. Newsom carefully researched, tested, and developed a groundbreaking and exceptional new laser
cataract technique in-house at the AAAHC-accredited Tampa
Surgery Center.
Continued on page 33
Celebrating 40 Years
of Orthopaedic Excellence
Orthopaedic
Thank You for Allowing Us to Serve You and Your Family!
Foundation
Visit www.OrlandoOrthoFoundation.org
to see one of the many ways we
are thanking our community for 40 years
of success in Central Florida.
CURRENT TOPICS
The procedure is called ‘Newsom Bladeless Laser Cataract Surgery’ and it offers qualified patients the opportunity to experience cataract surgery without the use of bladed tools traditionally used to create the necessary surgical micro-incisions. Bladeless cataract surgery
utilizes what is referred to as “femtosecond” laser technology for the creation of those same incisions.“While the use of femtosecond laser
technology for cataract surgery is still in its infancy, the promise of the laser lies in improved safety, increased precision, and reproducibility
of results,” Dr. Newsom adds.
Dr. Newsom is now sharing his groundbreaking technique with his peers in the ophthalmology community. He has recently published
educational materials documenting his technique through the American Academy of Ophthalmology’s (www.aao.org) news and continuing education site. A site accessed by over 15,000 ophthalmologists nationwide. He is also scheduled to speak at the annual meeting of
the American Society ofCataract and Refractive Surgery (www.ascrs.org) this April in Chicago. Newsom states, “The response to our
technique has been overwhelming. We now have surgeons, from around the country, asking us how they can introduce our laser cataract
surgical technique into their own practices.” Newsom continues, “It’s encouraging to see that after two years of hard work perfecting this
technique our efforts are being validated as the ophthalmology community at large takes an interest in our laser cataract procedure.”
As a pioneer in the field of laser cataract surgery, Dr. Newsom feels obliged to
educate the ophthalmic community on the
Newsom Bladeless Laser Cataract Technique and share with them the promise of
early medical results. Newsom states, “Our
center’s extensive experience sets us apart
from surgeons who may simply purchase
this technology, right off-the-shelf, and defines us as authorities on the subject. With
all of the recent interest in this technology,
we are honored to be able to take a leadership role in the discussion and share our
knowledge with our peers and patients.”
Dr. Newsom welcomes any interest in
cataract surgery that the advancement generates and is proud of his role in providing the ophthalmology community with a
bladeless laser cataract surgery technique.
“As with any vision correcting surgical
procedure, there is no one-size-fits-all solution. Any patient interested in laser cataract
surgery should seek the consult of a qualified surgeon to determine if the procedure
is right for them,” states Dr. Newsom.
Newsom Eye is located at 13904 N.
Dale Mabry Highway in Tampa, at 3205
Physicians Way in Sebring, and at 1023
US Hwy 27 South in Avon Park. 
Looking to reach doctors
by direct mail or
email broadcast? Call
(407) 417-7400 or email
[email protected]
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CURRENT TOPICS
Florida Hospital DeLand Awarded Joint
Commission Certification in Total Hip and
Knee Replacement Surgery
Florida Hospital DeLand has earned The Joint Commission’s Gold Seal of Approval™, Disease-Specific Care Certification in Total Hip
and Total Knee Replacement Surgery by demonstrating compliance with The Joint Commission’s national standards for health care quality
and safety in disease-specific care.
This certification award recognizes Florida Hospital DeLand’s dedication to continuous compliance with The Joint Commission’s stateof-theart standards. 1 6/30/11 10:57 AM Page 1
fl-md-jewett-july_Layout
Florida Hospital DeLand underwent a
rigorous on-site survey in November 2011.
A team of Joint Commission expert surveyors evaluated the Florida Hospital DeLand
Orthopaedic Center of Excellence for compliance with standards of care specific to the
needs of patients and families, including infection prevention and control, leadership
and medication management.
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A tradition of care powered by innovation
“In achieving Joint Commission certification, Florida Hospital DeLand has demonstrated its commitment to the highest level
of care for its patients undergoing Total Hip
and Total Knee Replacement Surgery,” says
Jean Range, M.S., R.N., C.P.H.Q. executive
director, Disease-Specific Care Certification,
The Joint Commission. “Certification is a
voluntary process and I commend Florida
Hospital DeLand for successfully undertaking this challenge to elevate its standard of
care and instill confidence in the community
it serves.”
Florida Hospital DeLand is the only Orthopaedic Center of Excellence in the area
and is comprised of a multidisciplinary team
representing surgery, anesthesia, nursing,
pharmacy, quality, physical therapy, occupational therapy, dietary, and case management.
This team approach enhances the individualized, patient-centered care delivered at every stage – from scheduling, pre-admission,
and pre-operative care — to surgery, postoperative care, discharge and rehabilitation.
Additionally, Florida Hospital DeLand has
recently been nationally recognized for being in the top 10 percent for quality in joint
replacement surgery.
Along with the hospital team, the physicians who work with the Orthopaedic Center
of Excellence perform more than 400 joint replacements a year, with Dr. Mark Hollmann
being the top performing knee replacement
surgeon in Central Florida, according to floridahealthfinder.gov. They also continually seek
CURRENT TOPICS
new approaches for various cases, such as the new direct anterior approach to hip replacements as performed by Dr. Royce Hood. All while
maintaining a consistently low infection rate.
“With Joint Commission certification, we are making a significant investment in quality on a day-to-day basis from the top down. Joint
Commission accreditation provides us a framework to take our organization to the next level and helps create a culture of excellence,” says
Randy Surber, Florida Hospital DeLand Chief Operating Officer. “Achieving Joint Commission Disease-Specific Care Certification in Total
Hip and Total Knee Replacement Surgery for our organization is a major step toward maintaining excellence and continually improving
the care we provide.”
The Joint Commission’s Disease-Specific Care Certification Program, launched in 2002, is designed to evaluate clinical programs across
the continuum of care. Certification requirements address three core areas: compliance with consensus-based national standards; effective
use of evidence-based clinical practice guidelines to manage and optimize care; and an organized approach to performance measurement
and improvement activities.
Founded in 1951, The Joint Commission
seeks to continuously improve health care
for the public, in collaboration with other
stakeholders, by evaluating health care organizations and inspiring them to excel
in providing safe and effective care of the
highest quality and value. The Joint Commission evaluates and accredits more than
18,000 health care organizations and programs in the United States. The Joint Commission also provides certification of more
than 1,700 disease-specific care programs,
primary stroke centers, and health care
staffing services. An independent, not-forprofit organization, The Joint Commission
is the nation’s oldest and largest standardssetting and accrediting body in health care.
Learn more about The Joint Commission
at www.jointcommission.org. 
NEW AD FOR FLORIDA HOSPITAL DOCTOR
About The Joint Commission
FHD Ortho: Florida Hospital DeLand Physical
Therapist Assistant Norman Shepherd performs
gait training with a patient who had a Total
Knee Replacement on the hospital’s dedicated
orthopaedic wing. Together, they are reviewing her performance on the ambulation board,
which allows patients to see how far they
are walking after surgery compared to other
joint replacement patients, creating a spirit of
friendly competition and camaraderie between
patients, which aids in their recovery.
FOR YOUR ENTERTAINMENT
The Orlando Philharmonic Presents Verdi’s
Classic Opera, Rigoletto
The Orlando Philharmonic Orchestra continues its opera programming with a concert staging of Giuseppe Verdi’s Rigoletto. Performances are on Friday, March 2, at 8:00 p.m. and Sunday, March 4, at 2:00 p.m. at the Bob Carr Performing Arts Centre, located at
401 W. Livingston Street, Orlando.
Once again, the Philharmonic collaborates with Florida Opera Theatre. Frank McADVERTISERS INDEX
Clain, who directed past Philharmonic productions Porgy and Bess, Guys and Dolls
and La Bohème to critical acclaim, serves as director. Joel Revzen, conducts. The title
role is performed by Mark Walters. Russell Thomas is cast as The Duke of Mantua,
Central Florida
Maureen O’Flynn is Gilda and John Cheek is Sparafucile.
Pulmonary Group. . . . . . . . . . . . . 21
A stellar cast in two heart-wrenching
performances of Verdi’s beloved opera
“From its premier in Venice in 1851,” explains conductor Joel Revzen, “Rigoletto
has proved to be one of Verdi’s most thrillingly popular masterpieces. Even Verdi
is quoted as having thought of this creation as something quite special. Why? One
reason is that the musical ideas unfold very quickly and powerfully. The opera maintains a huge dramatic sweep from the opening chords, and the musical scenes change
quickly every couple of minutes, holding the audience in rapt attention until the very
last second. Also, the story is filled with believable characters, and their relationship
to one another is one to which audiences today can relate; a father’s devotion and desperate love for his daughter, an abusive, self obsessed Duke who feels that because of
his power he can have any woman he desires, and a young innocent girl who has been
sheltered throughout her childhood, allowing her to fall prey to the Duke’s charm
when he approaches her disguised as a student. Our hearts are torn to pieces by pity
in the opening act for a deformed court jester, Rigoletto, who is constantly tormented
by the vile courtiers, and we are horrified at the end of the opera, when Rigoletto, in a
desperate act of vengeance towards the Duke, hires an assassin to do his bidding, and
the result is something that in his worst nightmare he could not have imagined.
“We have assembled a stellar cast, all of whom have performed this opera throughout the world. Together with the marvelous Orlando Philharmonic Orchestra and
Chorus they will bring this powerful opera to life in two heart-wrenching performances.”
The Philharmonic’s opera performances have the orchestra performing on stage
rather than in the orchestra pit. This places greater emphasis on the musical expression of the drama rather than on sets, costumes, and movement. As a musical organization, this fits the Philharmonic’s mission completely. With minimal sets, audiences
are more likely to focus on and enjoy the music. In all other respects, the costumed
singers come on and off stage and interact in the same way they do in a traditional
production. Lighting plays an even more crucial role in these productions than it does
in traditional opera stagings because it is the primary agent for creating mood and
establishing spatial relationships.
Central Florida Vein &
Vascular Center. . . . . . . . . . . . . . 24
Comprehensive Dermatology. . . . . 20
Cyberon Corporation Medical
Financial Services . . . . . . . . . . . . 23
Danna-Gracey. . . . . . . . . . . . . . . 27
Digestive & Liver Center
of Florida. . . . . . . . . . . . . . . . . . . 18
Dr P. Phillips Hospital. . . . . . . . . . . 3
Dr. ???? . . . . . . . . . . . . . . . . . . . 35
Florida Hospital Cancer
Institute. . . . . . . . Inside Front Cover
Florida MD 2012 Editorial
Calendar. . . . . . . Inside Back Cover
Halifax Health . . . . . . . . . . . . . . . . 9
Jewett Orthopaedic . . . . . . . . . . . 34
Last Diet ad. . . . . . . . . . . . . . . . . 11
Medicare Preventative
Services . . . . . . . . . . . . . . . . . . . 33
Michael Lowe, PA. . . . . . . . . . . . . 22
Orlando Orthopaedic Center. . . . . 32
Osceola Regional
Medical Center. . . . . . . . . . . . . . . 19
Pharmacy Specialists. . . . . . . . . . 25
Tickets are priced from $15.75 to $75. Students with a valid ID can purchase half-price tickets in select sections. To purchase tickets or for more information, phone the Orlando Philharmonic Box Office at 407-770-0071.
Tickets are also available online at www.OrlandoPhil.org. 
South Seminole Hospital . . . . . . . 17
United Cerebral Palsy Gala. . . . . . 29
Winter Haven Hospital . . Back Cover
2012
EDITORIAL
CALENDAR
Florida MD is a four-color monthly
medical/business magazine for physicians in
the Central Florida market.
It goes to 3,500 physicians, at their offices, in the
eleven-county area of Orange, Seminole, Volusia,
Osceola, Polk, Flagler, Lake, Marion, Sumter, Hardee and
Highlands counties. Cover stories spotlight extraordinary
physicians affiliated with local clinics and hospitals.
Special feature stories focus on new hospital programs
or facilities, and other professional and healthcare
related business topics. Local physician specialists and
other professionals, affiliated with local businesses
and organizations, write all other columns or articles
about their respective specialty or profession. This local
informative and interesting format is the main reason
physicians take the time to read Florida MD.
It is hard to be aware of everything happening in the
rapidly changing medical profession and doctors want
to know more about new medical developments and
technology, procedures, techniques, case studies,
research, etc. in the different specialties. Especially
when the information comes from a local physician
specialist who they can call and discuss the column with
or refer a patient. They also want to read about wealth
management, financial issues, healthcare law, insurance
issues and real estate opportunities. Again, they prefer
it when that information comes from a local professional
they can call and do business with. All advertisers have
the opportunity to have a column or article related to
their specialty or profession.
JANUARY –
Digestive Disorders
Diabetes
FebRUARY –
Cardiology
Heart Disease & Stroke
MARCH –
Orthopaedics
Men’s Health
ApRil –
Surgery
Scoliosis
MAY –
Women’s Health
Advances in Cosmetic Surgery
JUNe –
Allergies
Sleep Disorders
JUlY –
imaging Technologies
interventional Radiology
AUgUST –
Sports Medicine
Robotic Surgery
SepTeMbeR – pediatrics & Advances in NiCU’s
Autism
OCTObeR –
Cancer
Dermatology
NOveMbeR – Urology
geriatric Medicine / glaucoma
DeCeMbeR – pain Management
Occupational Therapy
Please call 407.417.7400 for additional materials or information.
T H E M O S T A D V A N C E D H E A LT H C A R E I S B A S E D O N T R U S T.
Nationally recognized heart care
is right here.
That’s the Bostick advantage.
Winter Haven Hospital’s Bostick Heart Center is recognized
by The Society of Thoracic Surgeons as being in the top
10 percent of Heart Programs in the United States, and
ranked one of the nation’s Top 50 Heart Centers by a
leading consumer advocacy magazine. We give our heart
patients every possible advantage by combining the best
clinical experts with the latest technologies and the most
effective rehab services available. And it’s all backed by
the hospital you trust, Winter Haven Hospital.
Learn more at www.winterhavenhospital.org
or call 863-292-4688.
Compassion. Innovation. Trust. We’re your family’s choice.
AN AFFILIATE OF THE UNIVERSITY OF FLORIDA
COLLEGE OF MEDICINE AND SHANDS HEALTHCARE
FIND A BOARD CERTIFIED DOCTOR CLOSE TO HOME:
Call the Winter Haven Hospital Physician Referral Line. 800-416-6705.

Winter Haven Hospital Bostick Heart Center

Transcription

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