Spring/Summer 2016 1 - Volusia County Medical Society

Spring/Summer 2016
1
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Flagler County:
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Volusia County:
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the Stethoscope
Medical Bulletin of the Volusia County Medical Society
P.O. Box 9595 • Daytona Beach, FL 32120
Published Quarterly
Steve Sevigny, MD...........................................................Editor
Sami Bay......................................................... Managing Editor
2016 Executive Committee
Scott Klioze, MD........................................................ President
Joel Bautista, MD..............................Immediate Past President
Leslie Perla, MD, FACP...................................... President-Elect
Delicia Haynes, MD.................................................... Secretary
Andria Klioze, MD...................................................... Treasurer
Laura Yard, MD .......................................................... FMAPAC
Steve Sevigny, MD.................. Public & Professional Relations
Margorie Bhogal, MD............................................ Membership
Jonathan Treece, MD.................................... Young Physicians
Sarah Henry, MD............................East Volusia Representative
Joel Bautista, MD......................... West Volusia Representative
Lauren Powell, MD........................ HH Resident Representative
Michael Young, MD....................... HH Resident Representative
Rachel Rider................................. FSU Student Representative
Eric Brown.................................... FSU Student Representative
Samara Bay...................................................Executive Director
Table of Contents
President’s Message............................................................ 4
Money Sense....................................................................... 6
Full Circle............................................................................ 8
Cigarettes and Carcinoma.................................................... 9
Food for Thought............................................................... 10
E-Cigarettes and Vaping.................................................... 12
My Northern to Southern Transition.................................. 14
About the Cover
The Yellow-Eyed Penguin is one of the rarest penguins in the world maybe 4000 exist today – and unique to New Zealand. VCMS member,
Dr. Harry Moulis, captured this rare bird on film at Katiki Point, north of
Dunedin on New Zealand’s south island. Contrary to most people’s idea
of a penguin habitat, there’s not an iceberg in sight. This bird prefers
the privacy of secluded nest sites scattered in coastal forests, scrub or
dense flax and is an extremely shy bird, most often nesting well away
and out of sight of their neighbors.
Cover photographs and stories for the Stethoscope are gladly accepted from members of the Volusia County Medical Society. If you are interested in submitting a cover photograph or article, please contact
Sami Bay, Executive Director, 386-255-3321.
The opinions expressed in the Stethoscope are those of the individual authors and do not necessarily reflect policies of the Volusia County Medical Society, its committees or members. The Stethoscope reserves the right to edit all contributions for clarity and length, as well as reject any submitted material. We greatly appreciate our advertisers, however the inclusion of an advertisement does not imply endorsement.
CAMPUTARO & ASSOCIATES
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Daytona Beach, FL 32114
(386) 255-2511
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Bookkeeping and Accounting Services
Small Business Consulting
Spring/Summer 2016
3
President’s Message
-Scott D. Klioze, MD
ophthalmologists, corporate and defense
lawyers, family practice residents, family
lawyers, hospitalists and a radiologist. I
also learned that the majority of us shared
the same concerns regarding our families,
careers and the country in general. Most
importantly, I found that this small
-Aldous Huxley
representative sample of the counties’
doctors and lawyers was absolutely
On April 16th of this year, the Volusia
dedicated to both their communities and
County Medical Society and the Volusia
professions.
County Bar Association organized
Doctoring for nearly a quarter century,
and participated in a joint community
I know that I and most of my colleagues
service project.
Teaming up with
went into medicine to do the right
Habitat for Humanity, members of both
thing. Admittedly, the prospect of a
organizations met at the project site at
stable and prosperous career was an
0800 hours armed solely with gardening
enticing motivator to get us through the
gloves and boundless enthusiasm. After
tough times as we pursued our medical
filling out the requisite paperwork of
education. But that was just icing on
participation, the project manager and
the cake. The emotional high knowing
site supervisor gave us all an overview
another human being entrusted us with
of the day’s tasks and work goals as
their health and wellbeing, and more
well as a brief safety in-service – all the
importantly, procuring the knowledge and
while plying us with bottomless carafes
experience to deliver on that trust, was
of coffee and a seemingly endless supply
the true incentive to stay the course. And,
of Dunkin Donuts. Despite the fact that
despite the rapidly changing landscape
the most advanced piece of equipment
of healthcare delivery, I believe those
utilized that morning was a wheelbarrow,
same virtues and beliefs can be found in
I assumed that the over-caffeinated and
our most recent medical school
hyperglycemic condition
graduates as well.
of our bodies at the
Unfortunately, I can also sense
finale of the introduction
a growing frustration and distrust
justified the safety inof medical doctors from the
service to insure we didn’t
general public, accelerated by
kill each other with the
the bureaucratic demands of our
shovels and paint-rollers.
fledgling universal health care
At this point, the group
system which threatens to further
was voluntarily divided
undermine the already fragile
into 3 battalions – the
doctor-patient relationship. This
painters, the cleaners and
distancing of the patient from his
the landscapers. With my
doctor, in my opinion, creates a
steel-toed work boots,
knowledge gap of what’s known
black shorts and plain
and unknown of the medical
white t-shirt, I came to
profession and thus provides
A good time was had by all!
get dirty and thus, joined
opportunity for the general public
Participants were members of the VCBA and VCMS.
the manly ranks of the
to insinuate their own doors of
landscapers. With no real L to R: Judge Robert Sanders, Dr. Hannah Taft, Kelvin Daniels,
perception.
Lou
Rossi,
Cassie
Rex,
Jow
Zwick,
Sara
Glover,
Ryan
Will,
personal
introductions
We as a medical community,
Homeowner
Mario
Figueroa
(kneeling),
Dr.
Kile
Cowell,
amongst the foot soldiers,
of
course, are not without blame.
Dr. Michael Young (orange T), Dr. Amanda Young,
we all set to work moving
Before
the federal government
excess fill dirt and sand Dr. Mike Makowski, Clay Meek, Dr. Andria Klioze, Dr. Scott Klioze
instituted
policies to reign in the
and Tracy Davis, Construction Supervisor.
“There are things known and
there are things unknown,
and in between are the
doors of perception”
4
the Stethoscope
from one project lot to the back of another
in preparation for sodding the latter
towards the end of the work day. And I’ve
got to be honest with you - the experience
was both enjoyable and surprisingly
educational! First of all, I learned that a
group of 7-10 dedicated and collaborative
adults can make a tremendous impact
on the regional landscape with the most
basic of implements. Shoveling the dirt
into 3 wheelbarrows, moving the same
to the back of the second lot and grading
both areas with simple hand-rakes was
accomplished in a mere 45 minutes.
Sodding the second lot took an additional
30 minutes. The problem was that the site
supervisor assumed that this entire effort
would be a solid 4 hour project! The
cleaning and painting crews were equally
efficient and, therefore, the morning was
a wrap before 10 am.
With the work day behind us and
feeling good about our accomplishments,
the mood amongst the volunteers became
notably congenial as we socialized
and posed for pictures memorializing
the day’s event. This is the time I
learned that my fellow volunteers were
ever rising and unsustainable cost of
healthcare, a number of our predecessors
were able to capitalize on the poorly
regulated reimbursement practices of
the CMS and its physician participants.
Some of the fiscally savvy specialists
physicians of the 70’s – 90’s were
living like rock stars once they figured
out the business model that maximized
reimbursement with minimal effort. And,
of course, there was the small segment of
our community who simply cheated the
system and stole untold millions from
CMS and private insurance companies.
While these individuals are in the
overwhelming minority, these stories are
the high-profile events promoted by the
lay press and the information the general
public utilizes to formulate and construct
their own doors of perception as they fill
in the blanks between the known and the
unknown regarding their physicians and
the healthcare industry.
From my own anecdotal experience,
I am confident our attorney colleagues
suffer the same fate with the majority
faithfully and enthusiastically utilizing
their training to responsibly uphold the
laws and litigate the events of our great
country. However, as in medicine, the
irresponsible minority become the de
facto face of the legal community shaping
the public perception of the industry.
In my opinion, the responsible majority
in both medicine and law are obligated
to inform the public, through direct
education and practical example, of the
true caring culture and professionalism of
both organizations. I would also propose
that this is best accomplished through
the efforts of the respective professional
societies/associations.
The sails of the once powerful and
influential local medical society and bar
association are a little defaced and partially
deflated but I don’t believe irreparably
damaged. April’s event was a great kick
start to possibly rejuvenate the once
respected inter-professional camaraderie
between the two organizations, marked
by regular games of softball and annual
socials. These events of the 90’s and
early 2000’s provided a neutral, social
environment to better understand the
culture of the other organization and
close some of our own distorted doors
of perception. We are continuing to
work with the bar association to find
meaningful and hopefully entertaining
ways to connect the two groups. All we
need is participation - your participation.
I would implore all of you reading this
article right now to look for and attend any
future joint events. More importantly, as
a sign of support and solidarity, bring 2-3
of our medical or legal colleagues along.
I assure you, they won’t be disappointed!
I witnessed firsthand what our two
organizations can accomplish through
teamwork and cooperation, knocking out
four hours of scheduled work in a fraction
of the time. While it was a simple task
of physical landscape manipulation,
I’m confident that the same enthusiasm
would be evident as we worked together
to educate ourselves, and the general
public, about the caring and professional
landscape of our respective professions.
Together we can effectively narrow the
gap between the known and unknown and
close those erroneous doors of perception.
Scott Klioze, MD
2016 VCMS President
William H. Johnson, III, M.D., F.A.C.S.
John B. Holt, M.D., F.A.C.S.
588 Sterthaus Drive, Ormond Beach, FL 32174
o
Phone: 386.672.9503
o
Fax: 386.672.0386
o
www.actsllc.org
It’s hard to believe we began practicing under our new name in August 2014! We haven’t skipped a beat! We want
to thank all of our colleagues for your continued referrals, and helping us continue to succeed.
Just a refresher for all of the new practitioners: We are a private practice group with 53 years of combined
experience in cardiac, thoracic and vascular surgery. Our services are provided to patients from all of Volusia
county, with many of our patients coming from Flagler county. There have been more than 15,700 heart surgeries
performed at Florida Hospital Memorial Medical Center alone, of which we were a big part. Our surgical services
also include endovascular intervention, thoracoscopic approaches, transcatheter valves (TAVR) and cardiac maze
and ablation treatments.
We have an on-site IAC Accredited ultrasound lab for vascular evaluation and surveillance of our surgical patients,
and we also treat for medically necessary varicose veins.
We schedule 99% of your patient appointments all without a lengthy phone call. Just fax the patient’s demographics,
diagnostic testing, office notes, insurance information and referral (if applicable), and we will contact the patient,
and make your office aware of the appointment via fax. We do not treat patients under the age of 18 years.
Spring/Summer 2016
5
Money Sense
Divorce, Remarriage and Their True Cost
Stacy Allred, Director,Wealth Structuring Group at Bank of America Merrill Lynch
Whether you’re getting divorced, recovering from one or watching it unfold for a friend or family member, consider these steps
for minimizing the financial consequences.
Take precautions
The single most effective divorce tool is a carefully drafted prenuptial agreement. Although entering a marriage with an exit
strategy may seem calculating, many couples can benefit from having one. “A prenup is generally good insurance,” says
Arlene Dubin, a matrimonial attorney. She recommends not only spelling out what would happen to key assets like real estate
and investment portfolios, but also outlining how to deal with debts incurred before and during the marriage.
Know what’s at stake
The first financial shock to face is the cost of the divorce itself. You’re already splitting assets; when you add a messy divorce
with high legal fees, it becomes a considerable financial and emotional drain. It’s vital to have someone on your side who has
a handle on a financial exit strategy that meets your needs.
Start with a complete inventory to help you understand what you’re entitled to receive or retain. Assets should include retirement plans, savings and checking accounts, properties and pensions, business interests, and inheritances. In addition, list
any financial obligations or debts that you and your spouse may have incurred. You should document each item by gathering
tax returns, paycheck stubs, wills, trust instruments, bank and credit card statements, insurance policies, property deeds, and
brokerage account documents. Financial housekeeping is essential during a divorce, arming you with the knowledge needed
to help make the right financial decisions.
Your fair share
Splitting the assets of your marriage will fall to the lawyers and the legal process. There are, however, tactical steps you can
take to prepare. “I tend to recommend splitting what you have across all assets as opposed to a scenario where you take the
house and I take the cash,” Dubin says.
If neither of you has an emotional attachment to the family home, selling it could be preferable, says Bill Hunter, director, IRA
Product Management at Bank of America Merrill Lynch. The proceeds can be split, used to pay down debt, or cover the cost of
the divorce itself. A sale of other shared, nonliquid assets may also be advisable.
Another important asset is health insurance. If you’re covered by your spouse’s plan, under federal law you can continue that
coverage for up to three years by enrolling in COBRA, although you’ll be responsible for making the payments.
Retirement accounts
Splitting IRAs and 401(k)s can prove problematic. If either of you has a retirement account, it’s vital that you sign a courtordered qualified domestic relations order (QDRO), which spells out exactly what percentage of the account each of you will
receive. This document allows you to roll over your agreed-upon share into another IRA without incurring early-withdrawal
taxes, as long as you do so within 60 days of receipt of the QDRO.
Try to avoid tapping your retirement accounts to pay for the divorce. Instead, consider taking a loan at today’s favorable interest rates.
Settlement aside
You need to update the beneficiaries in your will, as well as the person to whom you’re granting a power of attorney should
anything happen to you. “Review all your estate planning documents to make sure they reflect your current wishes,” says
Michael Liersch, director, Behavioral Finance at Bank of America Merrill Lynch.
Be sure to follow up on any debt you may have incurred during the marriage. Although the responsibility to pay may fall to
your ex-spouse, your name may still be tied to the account. This can have repercussions on your credit should he or she
default on payment.
Social Security can also come into play. If you were married to your spouse for over ten years, you can claim spousal benefits
even if your former partner remarries. But if you remarry, you can’t claim the benefits unless your new marriage ends in death
or divorce.
6
the Stethoscope
A new start
Once the divorce is finalized, the next chapter begins. Your Merrill Lynch Financial Advisor can help you review your financial
outlook and create a budget based on your new circumstances. Start with what you spent over the past year and try to forecast your new situation as to what would be a realistic budget. Your goal in the end is to have a new financial strategy — one
based on a new life chapter.
For more information, contact Merrill Lynch Wealth Management Advisors, Jeffrey Brok or Julian C. Lopez
Jr. in the Daytona Beach, FL office at 386-274-3025 or [email protected].
This article does not constitute legal, accounting or other professional advice.
Neither Merrill Lynch nor any of its affiliates or financial advisors provide legal, tax or accounting advice. You should consult
your legal and/or tax advisors before making any financial decisions.
Merrill Lynch makes available products and services offered by Merrill Lynch, Pierce, Fenner & Smith Incorporated
(“MLPF&S”) and other subsidiaries of Bank of America Corporation (“BofA Corp.”).
“Merrill Lynch” refers to any company in the Merrill Lynch & Co., Inc., group of companies, which are wholly owned by Bank of
America Corporation.
Bank of America Corporation (“Bank of America”) is a financial holding company that, through its subsidiaries and affiliated
companies, provides banking and nonbanking financial services.
Bank of America Merrill Lynch is a marketing name for the Retirement Services business of Bank of America Corporation
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Bank of America, N.A., member FDIC. Brokerage services are performed by wholly owned brokerage affiliates of BofA Corp.,
including Merrill Lynch, Pierce, Fenner & Smith Incorporated (“MLPF&S”), a registered broker-dealer and member SIPC.
Investment products:
Are Not FDIC Insured
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© 2016 Bank of America Corporation. All rights reserved.
ARFV7YLS
The things that are important to you are
what really matter. That’s why we’ll take
the time to understand life priorities like
your family, your work, your hopes and
dreams. Then we can help you get ready
for the future with a financial strategy
that’s just for you.
Where you’re going
is up to you.
Our job is to help
you get there.
Brok, Lopez & Associates
Jeff Brok, CFP ®
Wealth Management Advisor
386.274.3007 • [email protected]
Life’s better when we’re connected®
Merrill Lynch
1616 Concierge Boulevard, Suite 201
Daytona Beach, FL 32117
Merrill Lynch Wealth Management makes available products and services offered by Merrill Lynch, Pierce, Fenner & Smith Incorporated, a registered broker-dealer and Member
SIPC, and other subsidiaries of Bank of America Corporation.
Investment products: Are Not FDIC Insured Are Not Bank Guaranteed May Lose Value
The Bull Symbol, Life’s better when we’re connected and Merrill Lynch are trademarks of Bank of America Corporation.
Certified Financial Planner Board of Standards Inc. owns the certification marks CFP®, CERTIFIED FINANCIAL PLANNER™ and CFP® in the U.S.
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Spring/Summer 2016
7
Full Circle
Eric Brown, ENS, MC, USNR, Florida State University College of Medicine, Class of 2017
On December
30th, 2015, sometime around 10:00
AM, I learned that
one of my best
friends had lost
his grueling battle
with cancer. I felt
as bad as one can
feel when hearing
news like that. Worse still, there was no
way I would be able to make his funeral on
January 5th. However, I also realized that
this was one of the main reasons I went in
to medicine, to improve and prolong the
happiness in people’s lives. This is the
mindset I carried with me as I stepped into
the labor and delivery unit on the same
day as my friend’s funeral. As I stepped
through the door with my preceptor, I
learned that there would be four deliveries
today. Four?! I haven’t even seen one! We
made our rounds, broke their waters and
prepared them for the coming ordeal. We
finally settled on a lady who was choosing to do the entire process with absolutely
no painkillers. It was decided that based
on her progress, she would be the first to
deliver. She looked comfortable, or as
comfortable as one could be with a seven
pound creature inside of them fighting to
get out and what felt like everyone within five miles putting their fingers in her
to check size, station, readiness, etc. So
much for modesty, I suppose. Her husband
looked lost and panicky. A hard feeling,
I could imagine, wanting to help but not
being able to do anything. “Not so bad” I
thought, until my preceptor turned to me
and said “I’ve got to go back to the office to take care of some patients!” As my
preceptor walked out the main door, she
left me in charge with simple instructions:
“Call me when it’s time.” What does that
mean?! When will I know? What if one of
the other women give birth first?! Why are
these machines beeping?! What if I have
to deliver this baby, I have no idea what
I’m doing?! Luckily, several of the nurses
on the ward took me under their wing and
helped explain what was going on and reassured me that they would make sure my
preceptor was here. As we checked our
8
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main lady around 10:37 that morning, I
was informed that it was time. The doctor
was called and before I knew it the room
was filled with activity. Nurses read lines,
placed instruments and prepared. My
preceptor tried explaining things to me in
this rush, but I probably caught every 6th
word. I felt like the husband, lost, confused and excited. (Although much less
scared, if his face was any indication) Before I knew it, I was gowned and gloved,
sitting in front of this screaming woman
watching the head of her very first child
edge into sight. “You’re doing so good!”
we told her, “Keep pushing! Keep pushing! Don’t quit now!” Bit by bit came the
head. (As an aside, I would like to point
out that I don’t know how women do this
with no pain killers…) As the head came
forth, I went to grab it. “Flat hands! Over
the ears, grab it over the ears!” Someone
yelled at me. I pulled. Probably not hard
enough, as I was in mortal fear that I would
break its neck. I continued pulling. First
one shoulder popped out, then the other.
I made to grab the child but was caught
off guard by its slippery texture. As I tried
again, I looked up to see the feet leave the
vagina and without thinking twice I handed the child to mom. I’d tell people that
it was reflexive training taking over, but I
know that I was just petrified I would drop
the child and kill it. Probably an overexaggeration, but with my level of training I
was convinced that if I so much as sneezed
I would kill the poor thing. With the main
show over, the rest became routine. Have
the father cut the cord, extract the placenta, massage the fundu, all relatively
benign things compared to what had just
happened. The father was jubilant, taking
pictures and trying not to cry. The mom
looked ready to pass out from exhaustion.
I couldn’t blame her, either. However,
there was no mistaking the look of radiant
joy on her face upon seeing her lively, pink
little girl doing its best scream over every
other noise in the room. Two more deliveries followed that, both little girls, both
in the exact same manner. As I left that
day, it began to sink in. I had helped bring
about the beginning of life to three overjoyed families. I had helped them in a de-
fining and life changing event in their life
by bringing their children into the world.
I might have missed my friend’s funeral,
but I don’t think he would have been mad.
I know I wasn’t. I like to think that he’d
be overjoyed that instead of being mired in
grief by his family’s side, I was celebrating
his legacy by introducing three more lives
into the world and helping three families
open a new, wonderful chapter into their
lives even as my friend’s short and untimely chapter was closed. After all, that’s why
I’m here in the first place.
About the Author…
I was born at Eglin AFB in Okaloosa
County, Florida. I spent a large portion
of my childhood and early teenage years
moving from state to state because of
my family’s military background. This
allowed me to experience many different cultures and towns I otherwise would
never have known and opened my eyes
to different ways of life, from downtown
Las Vegas to the more secluded Niceville,
Florida (which is a real town), where I
spent most of my later childhood. While
saving up enough money to move to a state
university via working at a nearby marina,
I attended the local community college
known as Northwest Florida State College. I graduated from there with an A.A.
in criminology in 2009 and transferred to
FSU to study law. I experienced several
life-changing events during this time, including the death of a family member that
pushed me out of the realm of law and into
studying medicine. I eventually graduated
from FSU with a B.S. in international affairs and earned a spot in the FSU College
of Medicine Class of 2017. I am currently
enrolled in the Navy’s Health Profession
Scholarship Program and aspire to practice medicine within the military, although
I’m still not quite sure what kind of doctor I wish to be. I married my better half,
Rachelle, on Dec. 20, 2014, in my hometown of Niceville. Since then we have acquired a pet dog named Dude who, while
of questionable intelligence, remains a
never-ending source of amusement.
Cigarettes and Carcinoma
By Sam Cromartie, M.D.
In 1980 I published an article in
The Annals of Thoracic Surgery entitled “Carcinoma of
the Lung: A Clinical Review” in
which I reviewed
the charts of 702
patients with carcinoma of the lung.
One finding stood out. Over ninety percent of the patients whose smoking status
was known were smokers. Many subsequent investigations have found similar
results, confirming the fact that cigarette
smoking causes cancer of the lung.
The risk of developing cancer of the lung
does not go away when an individual stops
smoking. One study by Ernst Wynder and
Stephen Stellman in Cancer Research 37
showed that male smokers are thirty-two
times more likely to get squamous cell,
large cell, or small cell lung cancer than
nonsmokers. This risk actually increases
to 54 times as likely during the first one to
three years after an individual stops smoking. After four to six years, the relative
risk gradually decreases, but even at 16
years the relative risk is five times that of
nonsmokers. The risks are also increased
with adenocarcinoma but to a lesser degree.
Exposure to radiation, to asbestos, or to
environmental or occupational pollutants
can also lead to carcinoma of the lung but
the incidence is small when compared to
tobacco inhalation.
The 2014 surgeon general’s report lists
other organs that experience increased
cancer development in smokers. These
include the oral cavity, larynx, esophagus,
bladder, liver, colon and rectum.
Smoking causes COPD and worsens
asthma in adults. It also has a causal relationship to cardiovascular disease, agerelated macular degeneration, diabetes,
erectile dysfunction, rheumatoid arthritis,
and ectopic pregnancy. Smoking during
pregnancy can lead to orofacial clefts in
infants, and evidence is suggestive that it
may cause other congenital defects as well
as spontaneous abortion and attention deficit hyperactivity disorder.
It also leads to an increased risk of tuberculosis and it compromises the immune
system.
The number of deaths per year caused by
smoking in the United States at this time is
estimated to be approximately 480,000.
In 1964, 42 percent of adults smoked
cigarettes. This percentage had dropped
to 18 percent by 2012. At the time that
men were quitting, women increased their
use of cigarettes until the 1980s when their
use also began to decline. These changes
have changed the demographics of lung
cancer. At the time of my study, squamous
cell was the dominant histologic type. Adenocarcinoma has now supplanted it.
Improved education, taxation, and governmental regulation have proved to be effective in decreasing the use of cigarettes,
but cigarette smoking remains the leading
cause of preventable death in the United
States. If tobacco were introduced into
our culture in 2016 instead of during colonial times, it would certainly be a controlled substance like narcotics are. Much
remains to be done in the area of education
and assistance to patients to break the addiction with emphasis in preventing young
people from taking that first puff.
Congratulations Dalton Price!
2015-2016 VCMS Biomedical and Health Sciences Special Award Category Winner
2015-2016 Tomoka Regional Science and Engineering Fair
January 30, 2016
Mr. Price was chosen from nearly one dozen high-achieving students to receive the
VCMS Certificate of Achievement along with a $250 check. A student at Spruce Creek
High School, Mr. Price’s area of interest is in biochemistry.
Project Synposis: The aggregation of amyloid beta (Aβ) protein in the brain is hypothesized to elicit a pathological cascade leading to Alzheimer’s disease (AD). The
ubiquitin proteasome pathway (UPP) is a major cellular process that is associated with
protein degradation via the proteasome. The TRIM21 gene encodes for a protein that
functions as an E3 ubiquitin ligase and tags proteins with an ubiquitin molecule, which
functions as a signal for degradation. Single chain variable fragments (scFv) have been
Rachel Rider, FSU College of
Medicine and Scott Klioze, MD, shown to be ideal mechanisms for anti-Aβ immunotherapies due to their safe applications
served as judges for the special and economic reliability. A transgenic AB9 scFv utilizing TRIM21
award category
DNA was designed to target and direct amyloid beta to the pro(seen here with Dalton Price,
teasome in pursuit of alleviating the neurotoxic effects seen in
award recipient)
AD. After successful construction, the DNA was transfected into
human embryonic kidney 293 (Hek293) cells and a western blot
was performed but the desired protein was not expressed. Possible causes of this failed expression
are currently being investigated and the principle of combining mechanisms of the UPP and AB9
scFv is being examined in regards to another neurotoxic protein, hyperphosphorylated tau.
Spring/Summer 2016
9
Richard Rhodes, M.D.
DE LA VEGA
“Celebrate life with food, wine, community and healthy living” is how De La Vega
portrays their wonderfully modern Latin fusion restaurant in downtown Deland. Chef
Nora and her brother Manny (who handles the business end of the restaurant) have hit
the bullseye when it comes to unique and creative cuisine. Their large menu ranging
from meat dishes to vegan or gluten-free will amaze you.
The De La Vega family came from Mexico City to Florida years ago. Chef Nora has
long had a passion for cooking and states most of what she learned was from her mom.
Her husband is from Costa Rica and Manny’s wife is from Venezuela. The many rich
and varied cuisines of these countries are also blended into Chef Nora’s cuisine.
The restaurant itself is tastefully decorated. One can choose to eat either outside or
inside. Our dining partners for the evening were Doug and Lois. Tonight, we opted for inside dining. Chef Nora escorted us to our
table by a window overlooking Woodland Blvd. Our extremely friendly server Nicoletta brought us our menus. We were then given
a sample of their latest wine. Aroma Reservado, a delicious semi sweet Chilean wine costing only $31/bottle, is a steal. However,
as there were so many options of beverages, we chose to sample others. I had their superb homemade red sangria which is served
2-for-1 after 4 PM for $7 per 16 oz glass. Lisa and Lois chose wonderfully tasty Hibiscus Margaritas while Doug enjoyed a Strawberry Margarita. These were served in tall sugar rimmed glasses over crushed ice.
Sangria Margarita
Chilean Wine
Strawberry Margarita
The menu itself is unique. It starts with Modern Tapas, which are small shareable portions. We chose four to share. First came
their famous Hibiscus Tacos. Corn tacos stuffed with this delectable edible flower rich in vitamin C and minerals. Containing
green and Spanish onions, cilantro, garlic, mozzarella, and topped with a sensational red pepper sauce; they were incredible. The
Aspirinas de Chorizo (take 2 and call me in the morning) were exquisite. They consisted of corn dough patties topped with chorizo,
beans, tomato, onion, cheese and sour cream. They were gone in a flash. So too were the divine Nopalitos. This dish is described as
“char-grilled cactus layered with cubes of cheese, sweet grilled pineapple, red bell pepper, and guajillo pepper. The Chicken Mole
Rice Balls were simply heavenly. These were made from balls of mixed rice, mozzarella cheese, chicken, topped with cilantro and
served over a savory mole sauce. I must say that their mole sauce is the finest in Florida. (You all know I love chocolate).
Next came our main courses. We decided to split three between us. Doug chose a Chipotle Glazed Salmon, which is usually
served on a bed of red pepper rice with a chipotle glaze topped with sweet mango chutney covered with crispy onions and garnished
with cilantro. As Doug cannot eat cilantro, they graciously accommodated him by switching sauces to the savory red pepper sauce
that pleased him immensely and he devoured every bit of it. Lois opted for the Enchilada Combo, which consisted of a chicken
enchilada roja, cheese enchilada verde, chicken enchilada with bean sauce, and cheese enchilada covered with mole sauce. All of
them were delightfully tasty. I picked the Chilango Con Carne. This was a savory dish consisting on strips of juicy tender sirloin
and caramelized red onion covered in a creamy white wine sauce, topped with an ancho pepper that was stuffed with Spanish cho10
the Stethoscope
rizo and refried black beans served on a bed of crispy yucca. Yummy!
Dessert? Who had room? For the sake of this article we forced ourselves to order the dessert sampler. We were not disappointed
and ate every drop. The sampler consisted of a portion of the most incredible flan any of us had ever sampled, an extremely luscious
piece of tres leches cake, and churros served with a bowl of scrumptious chocolate sauce and whipped cream for dipping! WOW!
De La Vega is an incredible restaurant that one should make every effort to try. The only criticism I have is that one should not
order bread for their table unless they don’t mind getting charged $1.75 for 2 small pieces. Otherwise, I give this establishment 5
stethoscopes for quality of food, 4 for ambience, 5 for service, and 4 for value.
De La Vega is open Tuesday through Sunday for lunch and dinner. Reservations are recommended. They have a wonderful web
site : delavegart.com. Check it out. They are located at 128 N Woodland Blvd, Deland, FL 32720, Telephone number is 386 7344444.
Chilango Con Carne
Salmon with Black Beans
Aspirinas
Hibuscus Tacos
Napolita
Rice Balls
Enchiladas
Dessert Trio
De La Vega
128 N. Woodland Blvd., DeLand, FL
Ambience:
Value:
Quality:
Service:
Spring/Summer 2016
11
E-Cigarettes
and Vaping
Since the inception of the modern e-cigarette in 2003 and arrival into the US market just several years later, these devices
continue to go unregulated at the federal level except for those that make specific health claims. A lack of regulation has led
to the proliferation of vape stores and for the first time since the 1970s, nicotine is being advertised on TV and the radio, often
with ads promoting liquid nicotine flavors appealing to youth along with unsubstantiated health claims.
What is the current law in Florida?
State law prohibits the sale of any “nicotine dispensing device” to those 18 and under as well as underage possession. The
penalty for first-time offenders is a $25 civil fine, or 16 hours of community service and anyone under the age of 18 who is
caught three times risks losing a driver’s license. The law makes it a misdemeanor to sell vapor smoking devices to minors and
requires stores to post signs warning of the ban.
What is the difference between an e-cigarette and a vaporizer?
Both are battery operated devices that heat a liquid cartridge to produce a vapor of various particulates and toxins rather than
traditional smoke. E-cigarettes create a vapor by using a heating element to heat the liquid and vaporizers create a vapor by using warm air to heat the liquid. E-hookah, e-pipes, and e-cigars are other electronic devices that also resemble the e-cigarette
delivery method.
How are they being used?
Both devices are being used to vaporize liquid nicotine or BHO marijuana (a high potency liquid extraction of THC, the active
ingredient in marijuana). Vaporizing masks the pungent odor associated with smoking marijuana.
Concerns:
• A study published in the 2015 Pediatrics Journal found that vaporizing marijuana using e-cigarettes was common
among lifetime e-cigarette users and lifetime marijuana users. 15.4% of e-cigarette users reported using e-cigarettes
to vaporize hash oil, 10% reported using them to vaporize wax infused with THC and 19.6% reported using portable
electronic vaporizers to vaporize dried cannabis marijuana leaves.
• The same survey found among lifetime e-cigarette users, top locations in which they used e-cigarettes were in their
homes (50.5%), schools (24.6%), and public places where smoking is not allowed (24.1%).
• In addition, the same study found that “the THC concentrations of vaporized hash oil and waxes can exceed that of
dried cannabis by 4 to 30 times” and high school students who were surveyed, were 27 times more likely to use ecigarettes to vaporize cannabis than their adult counterparts.
• Adolescents are exposed to unregulated advertising for e-cigarettes in multiple channels, and approximately half had
tried e-cigarettes or intend to try them in the future.
• There are toxicological concerns over the concentration levels of some flavor chemicals used in e-cigarette fluids.
• E-cigarettes use among high school and middle school students TRIPLED from 4.5% in 2013 to 13.4% in 2014 and high
schoolers used more e-cigarettes than both hookahs and traditional cigarettes.
• A recent study of young adults found that the use of alternative tobacco products, such as e-cigarettes, is associated
with a 2.5 times increase in later cigarette use.
Recommended Actions:
State law does not fully address product placement in stores, zoning of vape stores and their proximity to schools or business
licenses for retail shops. Vaping is not currently addressed in the Florida Clean Air Indoor Act. More than two dozen local communities in Florida have passed local ordinances to address some of these issues not covered by the state or FDA.
12
the Stethoscope
1. Check to see if your city or county has a local ordinance that addresses where e-cigarettes can be used and where retail
vaping shops can be located. A local ordinance should define these products as “electronic chemical delivery devices.”
2. Make sure that your school has adapted its Tobacco Free policy to include e-cigarettes and vaporizers in the existing
definition of tobacco use policy.
3. Talk to your county officials about establishing Tobacco Retail Licenses. This would allow the county to regulate Vape
shops to ensure they are following rules associated with product placement, advertising and zoning while also keeping
a check on drug paraphernalia as it relates.
i High School Students’ Use of Electronic Cigarettes to Vaporize Cannabis, Meghan E. Morean, Grace Kong, Deepa R. Camenga, Dana A. Cavallo, and Suchitra Krishnan-Sarin, Pediatrics
peds.2015-1727; published ahead of print September 7, 2015, doi:10.1542/peds.2015-1727
ii High School Students’ Use of Electronic Cigarettes to Vaporize Cannabis, Meghan E. Morean, Grace Kong, Deepa R. Camenga, Dana A. Cavallo, and Suchitra Krishnan-Sarin, Pediatrics
peds.2015-1727; published ahead of print September 7, 2015, doi:10.1542/peds.2015-1727
iii High School Students’ Use of Electronic Cigarettes to Vaporize Cannabis, Meghan E. Morean, Grace Kong, Deepa R. Camenga, Dana A. Cavallo, and Suchitra Krishnan-Sarin, Pediatrics
peds.2015-1727; published ahead of print September 7, 2015, doi:10.1542/peds.2015-1727
iv Nina Parikh, et al, EXPOSURE TO ADVERTISING FOR E-CIGARETTES AND PRODUCT TRIAL AMONG U.S. ADOLESCENTS, presentation at the 2015 Society for Research on Nicotine & Tobacco
conference. Accessed online at https://www.srnt.org/SRNT_2015_Abstracts_WEB.pdf on October 20, 2015.
v Tierney PA, Karpinski CD, Brown JE, et al. Tob Control Published Online First: [April 15, 2015] doi:10.1136/tobaccocontrol-2014-052175
vi 2014 National Youth Tobacco Survey
vii Stephen M. Amrock, MD, SM; Michael Weitzman, M. Alternative Tobacco Products as a Second Front in the War on Tobacco. JAMA, October 2015 DOI: 10.1001/jama.2015.11394
Spring/Summer 2016
13
My Northern to Southern Transition
By Lauren Powell, MD, Halifax Health Family & Sports Medicine
One week after my
graduation from Medical
School I married the man
of my dreams. In one
short week I went from
“Ms.” to “Dr.”, to “Mrs.”!
Not only did I change
my name, I also followed
my heart back to his hometown in Florida,
thereby changing not only my geography,
but learning different traditions, mannerisms, and the way of life in the south.
July 1st was my first day of work at
Halifax Health. A week prior to moving,
I had packed my belongings into one suitcase and jumped on a plane from Detroit to
Daytona Beach. Goodbye snowy and cold
winters; hello sunshine and beaches. No
more heating up my car 30 minutes prior
to leaving my house and driving another
30 minutes to get to my destination. Welcome to no traffic and living 5 minutes to
the place I would spend 70 hours a week. I
had just gotten married and would no longer be doing the long distance commute.
To say the least, I was ecstatic about moving to Florida. I mean after all, Mickey
Mouse lives in Florida. What’s not to love?
I woke up extra early on my first day
of work. My first rotation was inpatient
medicine and my first day was a call day.
This meant that my team, which consisted
of me, the intern, and a second year senior
resident, would be responsible for admitting patients from the ER to the hospital.
My morning was slightly simplified by the
black scrubs we were expected to wear, so
I didn’t have to plan an outfit. But what
I couldn’t wait to put on, was a crisp,
freshly starched and pressed, long white
coat. I was excited to never wear that
short white coat with the awkwardly wide
coat pockets. Those pockets were huge,
I could fit my iPad, four 3-5 page journal articles, a reflex hammer, a note pad,
a sandwich, and two protein bars in those
14
the Stethoscope
pockets. Anyway, I remembered while
getting dressed, that hospitals are always
cold temperature-wise. It doesn’t matter
if you’re in the newborn nursery or in the
hospice care center, the air conditioning is
constantly on, and it’s always uncomfortable. I’m prepared this time! I purchased
long-sleeved cotton shirts to wear under
my scrub tops. I put my Estee Lauder dry
skin moisturizer on and straightened my
hair. My husband wished me well and I
jumped in my convertible Chrysler 200 that
I gave to myself as a medical school graduation gift, perfectly suited for the Florida
weather. I arrived to the hospital and reported for duty, only to learn that our white
coats were on backorder. So I was given
a men’s size medium white coat to wear.
I’m less than 5 feet tall, so the fit was a bit
awkward, but it was still a white coat and it
was mine! I was handed a code pager and
the work day began. With each admission,
we walked from the residency lounge taking a short cut by exiting the air condition
into the high noon sun, across the parking
lot, to the ER, then back to the lounge to
complete our notes, until the next admission. We did this approximately 7 times
throughout the day. It was hot. Not just a
little hot, the uncomfortable hot that makes
you wish it was cold outside. I had on this
long sleeved shirt under my scrubs and a
white coat that almost reached my ankles.
As I walked through the hallway, people looked at me and said, “Hello how are
you?” The first time this happened, I just
stared at them. People who didn’t even
know me smiled and spoke to me. This
was completely new to me. I went to the
restroom towards the end of my shift. My
face looked like someone rubbed butter
on it and my hair was no longer straight.
The humidity had shrunk my hair and had
given my face a mini facial. My first day
at work had finally reached an end. As I
walked to my car, I noticed that the earlier
clear blue sunny skies had turned quickly
to grey. By the time I put my seat belt on,
a rain storm like I’ve never seen before
erupted. That 5-minute drive home was
treacherous, and for a minute I wished I
was driving in snow. I guess no convertible top today.
All these events led me to draw one realization: The transition from the north
to south is exactly that, a transition. And
while my husband is a Floridian, there are
many things that he did not prepare me for
that I think anyone moving to the south
should know1.People say hello to you, whether they
know you or not. They don’t want
anything from you and you don’t have
anything on your face. People are just
genuinely nice.
2. Florida is beautiful, but the summers are
rough. They’re hot and uncomfortable
and it rains almost daily. So if you want
to show your city off to your family and
friends, don’t invite them down during
the summer.
3.The moisture in Florida is remarkable. If
you had dry skin up north, your skin will
likely change when you move to the Sunshine state. Hold on the thick daytime moisturizer until you give yourself a test run.
4.Depending on your texture, no matter
how much time and product you spend
on your hair, by the end of the day it
will not look how it started. I call it
the “growing effect.” My hair literally
grew a nest on the inside from the humidity causing my hair to frizz. There
are specific hair styles that work well for
the Florida weather, but no matter what
always have a hair tie that can be used to
contain the wild beast!
5. Transitions can be scary, but if you’re
willing to face the challenge, the reward
is great. I’ve met amazing people, I’ve
developed new and improved hairstyles,
and I’ve fallen in love with this new
place I call home.
Spring/Summer 2016
15
P.O. Box 9595
Daytona Beach, FL 32120-9595
PRESRT STD
U.S. POSTAGE
PAID
PERMIT #178
DAYTONA BEACH, FL