Winter Haven Hospital Bostick Heart Center
Transcription
Winter Haven Hospital Bostick Heart Center
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, allowing our physicians to perform the latest minimally invasive procedures. Conveniently located on the campus of Florida Hospital East Orlando, the innovative facility features private patient bays and advanced multi-specialty operating rooms and interventional endoscopy suites. EAST-11-5388 Have your procedure close to home with one of our highly skilled physicians, by calling (407) 303-6580. OTOLARynGOLOGy (EnT) Michael Bibliowicz, DO David Rabaja, DO Lisa Waizenegger, MD PODIATRy Jay Bornstein, DPM Joseph Conte, DPM Thomas Fann, DPM Andres Perez-Gomez, DPM Luis Sanchez-Robles, DPM Anthony Saranita, DPM Amber Shane, DPM UROLOGy Daniel Cohen, MD Stephen Dobkin, MD Zamip Patel, MD Frank Troilo, DO 258 South Chickasaw Trail, Suite 100 | Orlando, FL 32825 | w w w.FloridaHospitalEast.com/Surger y 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 FROM THE THE PUBLISHER PUBLISHER FROM I ’m pleased bring a new of Florida MD. This is to animaganniversary Iam pleased totobring youyou another issue issue of Florida MD Magazine. It’s hard as the firstwho issue was February 2003. When I started nine ine anyone is not familiar with the March of Dimes and the workyears they ago, do to my goal was to create a magazine that would be useful, interesting and informative to always reinventing themselves create them new programs and services. up next physicians, one that could to benefit professionally and Coming personally. I have been month is the annual March for Babies. It’s a wonderful team-building opportunity for very fortunate to find local physician specialists and other professionals to write columns or articles about their respective specialty or profession. tions on how you and your family can join the march or how to form a team for your whole practice. hope to seeofsome of you there. It is hard to Ibe aware everything happening in the medical profession and doctors want to know more about new 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. Warm regards, Donald B. Rauhofer With the help and contributions of my columnists and the wonderful folks who Publisher/Seminar Coordinator work with me, we have created an award winning magazine and succeeded in our goal. Thank you all for being a part. Join more than a million people walking in March of Dimes, March for Babies and raising money to help give every baby a healthy start! Invite your family and friends Best regards, to join you in March for Babies, or even form a Family Team. You can also join with your practice and become a team captain. Together you’ll raise more money and share a meaningful experience. When Saturday, April 24th 7am Registration 8am Walk Where Lake Lily Park, Maitland Some keys to success: Ask your friends, Steps for New Users: Donald B. Rauhofer, Publisher family and colleagues to support you by 1. Go to marchforbabies.org 2. Click JOIN A TEAM 3. Search for your team name in the reason why people do not donate is that no one asked them to give (don’t be shy)! search box. Coming Next Month: cover features Emailing Our them is an easy story way to ask. 4. Click on your team name 5.Editorial focus is on Orthopaedics and Men’s Health. password for future reference. ADVERTISE ADVERTISE IN IN FLORIDA FLORIDA MD MD For For more more information information on on advertising advertising in in the the Florida Florida MD MD Central CentralFlorida FloridaEdition, Edition, call Rauhofer at at call Publisher Publisher Don Donald Rauhofer (407) (407) 417-7400, 417-7400, fax fax (407) (407) 977-7773 977-7773 or or info@floridamd www.floridamdmagazine.com www.floridamd.com Send Emailpress pressreleases releasesand andall allother other related to: related information to: Florida MD Magazine [email protected] P.O. Box 621856 Oviedo, FL 32762-1856 2 2 FLORIDA MD MAGAZINE - MARCH 2010 FLORIDA MD - FEBRUARY 2012 For more information on March for Babies please call: Phone: (407) 599-5077 Fax: (407) 599-5870 Central Florida Division 341 N. Maitland Avenue, Suite 115 Orlando Orthopaedic Clinic. Maitland, FL 32751 You’re done! Your personal page has been created for you and you are ready to begin fundraising! PREMIUM PREMIUM REPRINTS REPRINTS Reprints Reprints of of cover cover articles articles or or feature feature stories in Florida MD are ideal stories in Florida MD are ideal for for promoting promoting your your company, company, practice, practice, services andand medical products. Increase services medical products. Increase your brand exposure with high your brand exposure with high quality, quality, 4-color 4-color reprints reprints to to use use as as brochure brochure inserts, promotional flyers, direct mail pieces, and trade trade show show handouts. handouts. pieces, and Call Florida MD for printing Call Florida MD for printing estimates. estimates. Publisher: Donald Rauhofer Associate Publisher: Magley Photographer: DonaldJoanne Rauhofer / FloridaMD; Photographer: Kelly / Tim Photography Kelly Portraits, Mike Potthast /Tim Mike Potthast Donald Rauhofer / Florida MD Magazine Contributing Writers: Nancy DeVault, Harinath Contributing Writers: Joanne Magley, Sheela, MD, Erica Mailler-Savage, MD,Sam Krishan Pratt RPh, Levin, Jennifer MD, Jennifer Nagda, MD,Mitchell Matt Gracey, Thompson, Thompson, Vincenzo MD, David Corey Gehrold, Tyson Giuliano, Smith, Anh-Dao Tran,S. Klein, MD, Stephen P. Toth, CLU, Jennifer PharmD Candidate Roberts Ana Espinosa Designer: Florida MD is published by Sea Notes Media,LLC, Florida MD Magazine is published by Sea Seminars, P.O. Box 621856, Oviedo, FL 32762. CallNotes (407)Medical 417-7400 for more PA, P.O. Box Advertising 621856, Oviedo, 32762. Call (407) 417-7400 for send information. ratesFL upon request. Postmaster: Please more information. Advertising upon request. Postmaster: notices on Form 3579 to P.O. rates Box 621586, Oviedo, FL 32762.Please send notices on precaution Form 3579 isto taken P.O. Box 621856, Oviedo,ofFLpublished 32762. Although every to ensure accuracy materials, Florida MD cannot be held responsible for opinions Although every precaution is taken ensure accuracy published expressed or facts expressed by itstoauthors. Copyrightof 2011, Sea materials, Florida MD Magazine be held responsible Notes Media. All rights reserved.cannot Reproduction in whole orfor in part opinions expressed or facts expressed by its authors. Copyright 2010, without written permission is prohibited. Sea Notes Medical Seminars. All rights reserved. Reproduction in Annual subscription rate $45. whole or in part without written permission is prohibited. One stop for better health. Dr. P. Phillips Hospital Outpatient Services At Dr. P. Phillips Hospital, a part of Orlando Health, we offer comprehensive outpatient services in one place. Combining state-of-the-art technology, convenience and extraordinary healthcare, our team of specialists ensures that your patients’ medical needs always come first. Outpatient Services at Dr. Phillips Hospital include: t*NBHJOH4FSWJDFT Expert radiologists providing easy access to quick and accurate exams using advanced technology such as 64-Slice CT and digital mammography. tć F$PNQSFIFOTJWF8PVOE$BSF$FOUFS An aggressive, multidisciplinary approach using advanced modalities, such as Hyperbaric Oxygen Therapy, to heal your patients’ wounds and change their lives. t$BSEJPMPHZBOE$BSEJBD$BUIFUFSJ[BUJPO Providing state-of-the-art clinical care for both elective and emergent cardiac and peripheral vascular patients. The Catheterization Lab at Dr. Phillips Hospital maintains an average STEMI response time that is well below the national standard. t/VDMFBS.FEJDJOF4FSWJDFT Providing Hybrid SPECT/CT imaging with radiation dose reduction technology. t3FIBCJMJUBUJPO4FSWJDFT Bioness (wireless functional electrical stimulation) evaluations and trials now going on in our outpatient clinics. Three locations for more convenience: Multiple Sclerosis Comprehensive Care Center of Central Florida, Dr. P. Phillips YMCA and Sand Lake Commons. t/FVSPEJBHOPTUJD4FSWJDFT Identifying brain and nervous system disorders. For patient convenience, with system-wide linking, appointments are available at Dr. Phillips Hospital as well as at the downtown campus. t-BCPSBUPSZ4FSWJDFT Utilizing the most advanced leading-edge instruments, we provide quick turnaround times for your testing needs. We offer complimentary valet parking, and efficient service at our Patient Registration services desk located on the 2nd floor. For more information on Dr. Phillips Hospital outpatient services, call 407.851.8500 or visit drpphillipshospital.com. Dr. Phillips Hospital is located at 9400 Turkey Lake Rd., Orlando, FL 32819. 11ORD033 FLORIDA MD - FEBRUARY 2012 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. Photo: Donald Rauhofer / FLORIDA MD 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. Photo: Donald Rauhofer / FLORIDA MD 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 6 FLORIDA MD - FEBRUARY 2012 Photo: Donald Rauhofer / FLORIDA MD 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. Photo: Donald Rauhofer / FLORIDA MD “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. Photo: Donald Rauhofer / FLORIDA MD COVER STORY Bostick Heart Center Cardiac Rehabilitation room. Photo: Donald Rauhofer / FLORIDA MD “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. 8 FLORIDA MD - FEBRUARY 2012 RACE AGAINST CARDIOVASCULAR DISEASE SYMPOSIUM 2012 February 25, 2012 Daytona International Speedway Velocitorium Mark your calendars and start your engines for this one-day, one-of-a-kind educational event hosted by Halifax Health at the world famous Daytona International Speedway. Addressing the latest advances, trends and management of cardiovascular disease, the symposium will feature experts from Mayo Clinic, Oschner Clinic, William Beaumont Hospital, Duke University Medical Center and others. Attendees will also have the opportunity to enjoy part of the Nationwide Series Daytona 300 race going on during the event. LIMITED TO THE FIRST 250 TO REGISTER Register Today For registration and additional information visit halifaxhealth.org/cvsymposium Halifax Health is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Halifax Health designates this live program for a maximum of 6.0 AMA PRA Category 1 Credits.™ FLORIDA MD - FEBRUARY 2012 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. 10 FLORIDA MD - FEBRUARY 2012 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 12 FLORIDA MD - FEBRUARY 2012 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] FLORIDA MD - FEBRUARY 2012 13 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 14 FLORIDA MD - FEBRUARY 2012 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. FLORIDA MD - FEBRUARY 2012 15 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 16 FLORIDA MD - FEBRUARY 2012 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 FLORIDA MD - FEBRUARY 2012 17 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 18 FLORIDA MD - FEBRUARY 2012 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. FLORIDA MD - FEBRUARY 2012 19 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 20 FLORIDA MD - FEBRUARY 2012 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. Central Florida Pulmonary Group, P.A. Serving Central Florida Since 1982 Specializing in: x x x x x x x x Asthma/COPD Sleep Disorders Pulmonary Hypertension Pulmonary Fibrosis Shortness of Breath Cough Lung Cancer Lung Nodules Our physicians are Board Certified in Internal Medicine, Pulmonary Disease, Critical Care Medicine, and Sleep Medicine Daniel Haim, M.D., F.C.C.P. Syed Mobin, M.D., F.C.C.P. Tabarak Qureshi, M.D., F.C.C.P. Daniel T. Layish, M.D., F.A.C.P., F.C.C.P. Eugene Go, M.D., F.C.C.P. Kevin De Boer, D.O., F.C.C.P. Francisco J. Calimano, M.D., F.C.C.P. Mahmood Ali, M.D., F.C.C.P. Andres Pelaez, M.D. Francisco J. Remy, M.D., F.C.C.P. Steven Vu, M.D., F.C.C.P. Pranav Patel, M.D., F.C.C.P. Ahmed Masood, M.D., F.C.C.P. Ruel B. Garcia, M.D., F.C.C.P. Downtown Orlando: 326 North Mills Avenue East Orlando: 10916 Dylan Loren Circle Altamonte Springs: 610 Jasmine Road 407.841.1100 phone | www.cfpulmonary.com | Most Insurance Plans Accepted FLORIDA MD - FEBRUARY 2012 21 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. 22 FLORIDA MD - FEBRUARY 2012 ∙∙ 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. CYERON CORPORATION “Healthcare Finance Specialists” BUSINESS and PERSONAL Financial Health is one of the most important challenges facing today’s Healthcare Professionals. Our philosophy is simple to dedicate ourselves to the highest degree of quality and service by creating a wide variety of Flexible Financial Plans to meet your day to day needs. We are a DIRECT Source to today’s most aggressive Lenders. We offer: • Medical Working Capital Loans $25,000 to $450,000 (Business or Personal) (OAC) • Electronic Receivable Financing $10 K -1 MM (Credit score not required) • Equipment Leasing • Patient Financing (All Procedures/All Credits Accepted) • SBA Loans &Commercial Real Estate Financing 90% LTV • Practice Acquisition $100K – $5MM • Practice Refinancing /Debt Consolidation $100K –$ 5MM Our Programs Feature: Looking to reach doctors by direct mail or email broadcast? 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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. Central Florida’s Premier Center for Innovative, Advanced, Minimally Invasive Vein Care: $FOUSBM'MPSJEB7FJO7BTDVMBS$FOUFS INITIAL EVALUATION — Initial evaluation of patients with chronic HBV infection should include : • 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 24 FLORIDA MD - FEBRUARY 2012 Where results and patient satisfaction are the only things that matter. Specializing in Minimally Invasive Vein Therapy for Venous Disorders of Any Magnitude Non-Surgical Treatment of All Veins, Endovenous Laser Therapy- EVLT ◆ Ultrasound-guided Foam Sclerotherapy for Varicose Veins ◆ Spider Vein Sclerotherapy ◆ Nd:YAG 1064 nM Laser of surface veins ◆ High Definition Vascular Ultrasound Diagnostics and Therapeutics ◆ Practice 100% committed to Vein Care ◆ Most Vein Care authorized and covered by insurance ◆ ◆ The finest ultrasound guided therapeutics and vein care available anywhere Specialty Trained. Especially Caring. Kpio!E/!Ipspxju{-!NE! Gps!jogpsnbujpo!dbmm!518/3:4/6:55!¦!xxx/dgwfjo/dpn 8$PMPOJBM%S4UF 0DPFF0SMBOEP '-◆4BOE-BLF$PNNPOT#MWE4UF 0SMBOEP'- Digestive and Liver Update 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 Validated Quality International Academy of Compounding Pharmacists Central Florida’s ONLY PCAB-Accredited™ Compounding Pharmacy! 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). The MacGyvers of Compounding! • Now accepting your toughest patient or medication challenge • Personalized Medicine • Community Clinical Pharmacy • A Drug Shortage Resource For more information please call 407-260-7002 or 800-224-7711 or visit us at 393 Maitland Avenue, Altamonte Springs, FL 32701 www.makerx.com FLORIDA MD - FEBRUARY 2012 25 Digestive and Liver Update 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 Digestive and Liver Update 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. )SNTITTIMEYOUCALLED THEMEDMALEXPERTS $ANNA'RACEY IS A BOUTIQUE INDEPENDENT INSURANCE AGENCY WITH A STATEWIDETEAMOFSPECIALISTSDEDICATEDSOLELYTOINSURANCECOVERAGE PLACEMENTFOR&LORIDASPHYSICIANSANDSURGEONS 7ITH OFlCES LOCATED THROUGHOUT &LORIDA $ANNA'RACEY WORKS ON BEHALFOFPHYSICIANSWELLBEYONDMANAGINGTHEIRINSURANCEPOLICY "Y SPEAKING WRITING FREQUENTLY PUBLISHED ARTICLES AND LOBBYING IN 4ALLAHASSEEWEHOPETOEFFECTPOSITIVECHANGE INTHEHEALTHCAREINDUSTRY &OR A NOOBLIGATION MEDICAL MALPRACTICE INSURANCEQUOTECALL$AN2EALEAT Delray Beach: 800.966.2120 • Orlando: 888.496.0059 • Miami: 305.775.1960 • Jacksonville: 904.388.8688 [email protected] • www.dannagracey.com FLORIDA MD - FEBRUARY 2012 27 Digestive and Liver Update • 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 28 FLORIDA MD - FEBRUARY 2012 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 ĞǀĞŶŝŶŐďĞŶĞĮƟŶŐƐƵƉƉŽƌƚ͕ĞĚƵĐĂƟŽŶ ĂŶĚƚŚĞƌĂƉLJƉƌŽŐƌĂŵƐĨŽƌĐŚŝůĚƌĞŶ ƐŚŝŶŝŶŐĂƚhWŽĨĞŶƚƌĂů&ůŽƌŝĚĂ͘ 'ƵĞƐƚƐǁŝůůĞŶũŽLJĂŐŽƵƌŵĞƚ ĨŽƵƌͲĐŽƵƌƐĞŵĞĂůƉĂŝƌĞĚǁŝƚŚǁŝŶĞ ĂŶĚƐƉŝƌŝƚƐ͕ďŝĚŽŶŝŶĐƌĞĚŝďůĞƐŝůĞŶƚ ĂƵĐƟŽŶŝƚĞŵƐĂŶĚĞdžƉĞƌŝĞŶĐĞ ŵĂŐŝĐĂůĞŶƚĞƌƚĂŝŶŵĞŶƚ͘ ^ƉĞĐŝĂůŚŽŶŽƌĞĞƐĨŽƌƚŚŝƐLJĞĂƌ͛Ɛ ĞǀĞŶƚĂƌĞdŚĞDĂƌƟŶŶĚĞƌƐĞŶͲ'ƌĂĐŝĂ ŶĚĞƌƐĞŶ&ŽƵŶĚĂƟŽŶĂŶĚƌ͘ŽŶĂůĚ ĂŶĚDƌƐ͘ŝŶĚLJŝĞďĞů͘ Reserve your table: hW'ĂůĂ͘ĐŽŵͮϰϬϳ͘ϴϱϮ͘ϯϯϱϮ ƐƉŽŶƐŽƌƐŚŝƉƐΛƵĐƉĐŇ͘ŽƌŐ ,ŽƐƚĞĚďLJŵŵLJͲǁĂƌĚtŝŶŶŝŶŐĐƚŽƌ Dan Aykroyd and Emmy-Nominated ĐƚƌĞƐƐ Cheryl Hines͘ 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: FLORIDA MD - FEBRUARY 2012 29 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. 30 FLORIDA MD - FEBRUARY 2012 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. FLORIDA MD - FEBRUARY 2012 31 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. 32 FLORIDA MD - FEBRUARY 2012 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] MediCARe PReveNtive BeNefitS PAy! How Many Medicare Patients Do You See Daily or Annually? OPTIMIZE $$$ Office Visits for Medicare Preventive Services! Generate Over $300 Per Patient Annually! 500 Medicare Patients = $150,000! • • • • • • • • Medicare Preventive Services Templates No Co-Pay Patient Services Waiting Room Screening Forms Health Risk Assessment (HRA) Template Annual Visits, Benefits and Screens User-Friendly — Any Staff Member Can Perform CMS Coding and Reimbursement Guidelines Sixty to Ninety (60-90) Minute Training Available Start Generating Additional Revenue NOW! Call 407-417-7400 or email [email protected]. FLORIDA MD - FEBRUARY 2012 33 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. "Jewett made my family feel like we were part of their family." Go to www.jewettortho.com and see the O’Lenick’s full story Jewett has a WALK-IN to make your summer easy and stress free! No appointment necessary! Monday - Thursday: 7:30am - 8:00pm Friday: 7:30am - 4:00pm Saturday: 9:00am - 3:00pm Stirling Center 701 Platinum Point On Rinehart Road Lake Mary, FL 32746 407.206.4500 www.jewettortho.com 34 FLORIDA MD - FEBRUARY 2012 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. FLORIDA MD - FEBRUARY 2012 35 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. 36 FLORIDA MD - FEBRUARY 2012 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.