Florida md april 2015

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The Spine & Scoliosis Center

Delivering Next-Generation Care with Compassion

Florida Hospital is ranked the #1 hospital in the state of Florida for the second year in a row. And ranked nationally in ten specialties.


Cardiology & Heart Surgery

Diabetes & Endocrinology

Gastroenterology & GI Surgery




Neurology & Neurosurgery



We thank you for trusting us with your care. We thank our clinicians for their commitment to excellence.

FloridaHospital.com/USNews MKTGPR-13-16418 MKTGPR-13-16418_Florida MD September 2014 US News.indd 1

8/7/14 10:03 AM





am pleased to bring you another issue of Florida MD. If you think about it, breathing is something we take for granted. We don’t consciously think about every breath we take. This is not the case for people with cystic fibrosis who struggle for each breath. The Cystic Fibrosis Foundation works to assure the development of the means to cure and control cystic fibrosis (CF) and to improve the quality of life for those with the disease. Please join me in supporting this wonderful organization and their mission to better the lives of millions of Americans. Best regards, Donald B. Rauhofer Publisher

Coming UP Next Month: The cover story focuses on Gateway at Lake Nona. Florida Hospital and UCF Health joined forces to create Gateway at Lake Nona, an innovative and collaborative model of health care that brings a range of new providers and services to Medical City. Editorial focus is on Women’s Health and Advances in Cosmetic Surgery.

Cystic Fibrosis Foundation is Making an Impact The Cystic Fibrosis Foundation is the world’s leader in the search for a cure for cystic fibrosis. The Foundation funds more CF research than any other organization, and nearly every CF drug available today was made possible because of Foundation support. Based in Bethesda, Md., the Foundation also supports and accredits a national care center network that has been recognized by the National Institutes of Health as a model of care for a chronic disease. But what is Cystic Fibrosis? The genetic disease affects the lungs and digestive systems of tens of thousands of young people. One in 31 Americans, more than 10 million people, is an unknowing, symptomless “carrier” of the defective CF gene. Each time two carriers conceive, there is a 25 percent chance that they will have a child with cystic fibrosis. Good news is on the horizon though, as the first approved cure for cystic fibrosis, Kalydeco, was approved by the FDA in 2012 and expanded to another 6 mutations in February of 2014. Although the outlook for a child born with CF today has improved tremendously over the years, it is not good enough. That’s why the CF Foundation holds fundraising events throughout the year to make sure momentum in CF research continues. This fall, the Central Florida Chapter of the CF Foundation will host several events: CF Climb – Saturday, September 26, 2015 (climb.cff.org) CF Cycle For Life – Sunday, October 4, 2015 (Orlando.cff.org/cycleforlife) Apopka Great Strides Walk – Saturday, November 7, 2015 (greatstrides.cff.org) For more information on these events, please contact Paul Gloersen (407) 339-2978 or pgloersen@cff.org. The Central Florida office of the Cystic Fibrosis Foundation is located at1850 Lee Rd, Suite 111, Winter Park, FL 32789.



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Publisher: Donald Rauhofer Photographer: Donald Rauhofer / Florida MD Contributing Writers: Heidi Ketler, Daniel T. Layish, MD, Sajid Hafeez, MD, Arnold B. Etame, MD, Udayakumar Navaneethan, MD, Shyam Varadarajulu, MD, Christopher M. Ramsey, PhD, Robert Stanton, MD, Marni Jameson, Jennifer Thompson, Kathleen Summo RN, Corey Gehrold Art Director/Designer: Ana Espinosa Florida MD is published by Sea Notes Media,LLC, P.O. Box 621856, Oviedo, FL 32762. Call (407) 417-7400 for more information. Advertising rates upon request. Postmaster: Please send notices on Form 3579 to P.O. Box 621856, Oviedo, FL 32762. Although every precaution is taken to ensure accuracy of published materials, Florida MD cannot be held responsible for opinions expressed or facts expressed by its authors. Copyright 2012, Sea Notes Media. All rights reserved. Reproduction in whole or in part without written permission is prohibited. Annual subscription rate $45.

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Advanced medical care with life-changing benefits drives the medical staff of The Spine & Scoliosis Center. Compassion for those who are suffering fuels it. Photo: DONALD RAUHOFER / FLORIDA MD

The memory of the practice founder, orthopedic surgeon Joseph C. Flynn Sr., M.D., provides inspiration. Dr. Flynn Sr. founded The Spine & Scoliosis Center (SASC) in 1990, decades after his pioneering career began in 1958. Today, the thriving practice is comprised of a close-knit medical team led by Spine Surgeons Joseph C. Flynn Jr., M.D., who joined his father’s practice in 1993; and Geoffrey Stewart, M.D., who joined in 1996. Javier A. Placer, M.D., a Physical Medicine and Rehabilitation physician who joined the practice in 2006, leads the patient rehabilitation component. Francis K. Cheung, P.A-C.; and John F. Stoker, M.M.S., P.A-C., provide invaluable physician support.


ON THE COVER: Left to Right: Back Row: Dr. Javier A. Placer, Fran Cheung, PA-C, John Stoker, PA-C, Left to Right: Front Row: Dr. Joseph C. Flynn, Jr., Dr. Geoffrey Stewart

17 Capitol Hill: Independent Doctors Like Law that Would Make Facility Fees Transparent 18 Early Diagnosis and Treatment of Esophageal Cancer: A Reality at Last? 20 Scoliosis Detection and Treatment: A Checklist for Providers 22 The Heart Program at Miami Children’s Hospital Uses 3D Printing Technology to Plan Complex Heart Surgery on Pediatric Patient 24 West Florida Health Now Providing Home Care Services










The Spine & Scoliosis Center

Delivering Next-Generation Care with Compassion By Heidi Ketler Advanced medical care with life-changing benefits drives the medical staff of The Spine & Scoliosis Center. Compassion for those who are suffering fuels it.

called on to do the most complicated neck and spine surgeries, such as reconstructive surgery to correct severe structural deformities.

The memory of the practice founder, orthopedic surgeon Joseph C. Flynn Sr., M.D., provides inspiration. Dr. Flynn Sr. founded The Spine & Scoliosis Center (SASC) in 1990, decades after his pioneering career began in 1958.

Advanced Expertise

Today, the thriving practice is comprised of a close-knit medical team led by Spine Surgeons Joseph C. Flynn Jr., M.D., who joined his father’s practice in 1993; and Geoffrey Stewart, M.D., who joined in 1996. Javier A. Placer, M.D., a Physical Medicine and Rehabilitation physician who joined the practice in 2006, leads the patient rehabilitation component. Francis K. Cheung, P.A-C.; and John F. Stoker, M.M.S., P.A-C., provide invaluable physician support. All treatment is preceded by careful diagnostic and historical evaluation. Individualized treatment plans are shaped after consultation with the patient about the options and risks. Close coordination with the physician assistants assures an effective patient care process. “Providing advanced care and establishing good patient-physician relationships are part of carrying on a tradition,” says Dr. Flynn. The combined skill and expertise of the surgical team is unique in Central Florida, according to Dr. Flynn. So, SASC is often

Studies suggest that back pain affects about 90 percent of adults at some time in their lives, and about 67 percent of adults experience neck pain. These two ailments are among the most common reasons for physician visits and are major causes of disability, missed workdays and high health care costs. The Spine and Scoliosis Center’s surgical team gives Central Floridians relief with practical, high-quality solutions. Procedures include: • • • • • • • • • • •

Cervical disc replacement Cervical fusion Complex revision spine surgery (DLIF) XLIF lumbar surgery Facet joint denervation Lumbar fusion Lumbar disc replacement Lumbar microdiscectomy Minimally invasive spinal surgery Scoliosis surgery Spinal stenosis surgery “We have enough experience to use minimally invasive surgical A successful scoliosis correction surgery performed by Dr. Stewart and Dr. Flynn. The team approach is what makes The Spine and Scoliosis Center unique and one of excellence.



Dr. Stewart, an internationally recognized spine surgeon, discusses a recent surgery outcome with a patient. Each patient receives optimal and customized care by the doctors at the Spine and Scoliosis Center.




Dr. Javier Placer, assisted by Medical Assistant Tech, Ana Bentim, performs an interventional spinal procedure. The Spine and Scoliosis Center has an on-site, state-of-the-art pain center located in both their Clermont and Orlando offices. Patients can receive physician’s evaluations and procedures and rehabilitative care all in the same facility.

techniques when appropriate and rely on traditional techniques when appropriate for maximum patient benefit. Our experience encompasses non-surgical management to major reconstructive surgery,” says Dr. Stewart. The SASC surgical team recently operated on a 65-year-old woman to correct severe bilateral, vertical pain caused by degenerative spine disease and underlying scoliosis with instability that was exacerbated by an on-the-job injury. The otherwise healthy woman’s function had declined during the past five years to the point of hardly being able to walk 100 feet with a rolling walker. Dr. Stewart and Dr. Flynn performed a decompressive laminectomy to relieve pressure on the spinal nerve roots, and a few days later “the patient was able to walk further than before surgery, and the leg pain had dramatically improved. Her post-surgical back pain is improving on a daily basis, and she will be walking a mile without a cane or walker within another three to four weeks,” says Dr. Stewart. “We are fortunate enough to have the opportunity to do a lot of things that make a real difference in people’s lives. We were able to take someone who was in a wheelchair and give her the ability to walk again,” Dr. Stewart says. “It’s really about taking someone with pain and disability and offering them a dramatic improvement in both function and comfort level.”

practice to the next level,” says Dr. Placer. He recalls the 56-year-old patient earlier in the week who presented with acute radiculopathy and acute sciatica and was having trouble walking due to a herniated disk in the lower back. Dr. Placer saw the patient the day after he received the referral, and the patient was able to return to work the next day. “We are always able to help,” he says. For this patient, Dr. Placer’s pain management plan and physical therapy guidance made it possible for her to postpone surgery for five years, until she could retire. “Pain is very complex. You have to have a good understanding of how pain behaves and what exactly the source of the problem is to provide adequate treatment. To understand what is going on, the physician must understand the patient’s complaint and gain the patient’s trust. Once I am able to get that, I am able to provide a treatment plan. For patients on a pain management program, comfort, understanding and trust is 50 percent of the treatment before implementing a plan to address the source of the problem.”

Pain Management

Dr. Placer’s experience as a young athlete who suffered injuries whet his interest in pain management. “My first doctor’s visit as a teen was with a physiatrist. I was able to see how he worked with me and how he was able to gain my trust. Once I got into residency, the science of pain management intrigued me.”

Compassionate care at SASC is expedient care, especially when the patient is in discomfort. “Within two to three days, we are able to take care of the patient. It’s one of the things that takes a

Dr. Placer’s areas of specialized medical care includes physical medicine, rehabilitation, pain management, sports medicine, pain relief treatment via injection and electrodiagnostic medicine. FLORIDA MD - APRIL 2015



COVER STORY SASC is among the first Spine Surgery groups to use Jazz Bands. Born in France in 2007, the innovation is indicated for spinal pathologies requiring vertebral fusion. Used in combination with vertebral instrumentation, the sublaminar bands provide temporary stabilization as a bone anchor during the development of solid bony fusion and aid in repairing bone fractures. Dr. Placer’s participation in research as well as recent developments on the benefits of stem cell and amniotic fluid procedures may lead to its use at SASC. “Bringing it in-house would make it easier for the patients and reduce their discomfort, while reducing costs for patients,” he says. “We’re working on other new technologies all the time,” Dr. Flynn discusses MRI findings and treatment options with Physician Assistants John Stoker and Fran says Dr. Flynn. “After 23 years Cheung. Both PA’s are certified and exemplify compassionate and comprehensive care. of doing this, I see a lot of new Services include: devices and approaches come • Spinal injections (lumbar epidural, selective nerve root blocks, and go. So we watch and see how a new device works and what sacroiliac joint injections, lumbar facet blocks, radiofrequency problems it has before choosing to do that type of procedure or ablation) technique. We’re a little more conservative than some.” • Motor point blocks/phenol neurolysis The SASC Legacy • Peripheral joint injections The founder of The Spine & Scoliosis Center is considered a • Electromyography/nerve conduction studies pioneer of his time. Dr. Flynn Sr. made far-reaching contribu• Botulinum toxin injections tions to orthopedic medicine, through innovations and a lifelong • Acupuncture dedication to clinical research and teaching, according to Dr. • Kyphoplasty/vertebroplasty Flynn Jr. • Pain injections/discography Dr. Flynn Sr.’s most well-known contribution was a novel tech• Spinal cord stimulator placement nique for correcting elbow fractures in children using pins, which Training and Research to Stay Ahead he developed in the late 1950s. The opportunity to do that arose when, according to Dr. Flynn Jr., “one night something hapResearch and development and training are constant for the pened to a kid. Dad knew that the accepted method of the time medical professionals at The Spine & Scoliosis Center. frequently failed, so he used pins.” For example, Orlando Regional Medical Center recently pur“Dad followed his initial group of patients who received this chased the newest O-Arm Surgical Imaging System for use in surgery for 20 years or more and wrote a couple of papers on it. spine, orthopedic and trauma-related surgeries. Before the many Today, the technique is mentioned in most medical school texttechnological and patient outcome benefits can be realized, howbooks on pediatrics or orthopedics that include sections on fracever, considerable training is required. tures,” Dr. Flynn says. O-Arm technology provides more exacting visualization – realAccording to Dr. Flynn, his father’s great love of children and time, multiplane, multidimensional (two- and three-dimensional) interest in scoliosis developed at the Pennsylvania State Hospiimaging – to confirm hardware therapy placement. In addition to tal for Crippled Children, where he trained after his orthopedic being more intuitive for the physicians, surgical imaging allows residency and graduation with a medical degree from Jefferson for less-invasive surgery, reduced infection rates, shorter hospital Medical College, Philadelphia in 1951. stays (in some cases from weeks to days) and faster recovery time. “Back then, orthopedic physicians didn’t have a specialty; it It also may eliminate the need for revision surgeries. 6 FLORIDA MD - APRIL 2015

COVER STORY was more a concentration. So Dad’s concentration was on kids and scoliosis.” The combined interests led Dr. Flynn Sr. to spearhead the successful campaign to establish a statewide scoliosis screening program in Florida schools. In addition to general orthopedics, Dr. Flynn Sr. also had a special interest in the hip and spine. “He worked on anterior lumbar spine fusion and was one of the first to bring advances to the Orlando area, such as Harrington rods (the gold standard in the 1960s for fixation of a thoracic curve in idiopathic scoliosis using a posterior approach) and CDs (Cotrel-Dubousset instrumentation rods, which revolutionized spinal deformity surgery by providing stronger fixation and better three-dimensional correction),” says Dr. Flynn. The field of Spine Surgery has come a long way since those days, and The Spine & Scoliosis Center has kept pace, adopting leading-edge technologies and techniques that are backed by strong evidence of positive outcomes.

“Nowadays the focus is more on the business of patient care. Here we practice a more traditional patient care approach. We are compassionate and listen to a patient for understanding before we come up with an assessment or diagnosis.” His final question during an exam, he says, is ‘“Do you have any further questions.’ I want to make sure the patient understands the condition and what I am doing to help out.” At The Spine & Scoliosis Center, compassionate care and advanced technical expertise work together to improve quality of life for patients. The long list of annual awards presented to the SASC physicians testifies to that. Each has been recognized by his peers and patients, alike. For more information call Zelda Theophilus-Hanna, Practice Administrator, at (407) 849-1200 or visit online at www. spinedoctors.md. 

Strong Patient Relationships While advances in communication technology have greatly expedited the delivery of information, nothing can substitute for one-on-one relationships that are based on trust. Open and honest two-way dialogue facilitates understanding and ultimately better patient health outcomes and a higher level of patient satisfaction, says Dr. Placer.


Dr. Flynn teaching Residents in a cadaver lab. Both Drs. Flynn and Stewart pride themselves in teaching Residents throughout the year. Drs. Flynn, Stewart and Placer are also on Faculty at UCF Medical School.



Healthcare Law

Protecting Innovation in Telemedicine By Christopher M. Ramsey, PhD The Florida Legislature is considering two telemedicine bills this session, but those bills are not aimed at protecting innovations in telemedicine technology. There are three general categories of telemedicine services, including: (1) interactive, (2) remote monitoring, and (3) data storage services. Interactive services allow for real-time electronic interactions between providers and patients. Remote monitoring services allow providers to monitor their patients remotely. Data storage services give the provider remote access to the patient’s medical data. These services are all computer software-based. Today, much of the innovation in telemedicine is associated with how the software functions. Because it can be very expensive to develop new software for telemedicine, software developers should try to minimize their competition through intellectual property (IP) protection. This article outlines some of the IP protection available for telemedicine software. Patents. Software patents give their owners the ability to prevent others from copying the software’s inventive functions, but they are more expensive and harder to obtain than other forms of IP protection. The United States Patent and Trademark Office decides whether software inventions are patentable during an extensive examination process. If the software merely allows someone to perform a previously known task on a computer, it is not patentable. But if the software makes a technical improvement to that task, the software is patentable so long as the improvement is not obvious. Copyrights. Federal copyright protection is often the most useful source of IP protection for software. Owning a federal copyright registration permits the registrant to prevent others from copying the software’s source code, which is written in a human-readable programming language. The bar for registering a software copyright is much lower than the bar for obtaining a software patent, but the drawback is that the scope of copyright protection is generally narrower than patent protection. Because copyright law protects the source code, but not necessarily the software’s functions, copyrights are most useful against competitors that copy some or all of the copyrighted source code. Trade Secrets. A trade secret is information that has value based on the fact that it is a secret. A software trade secret, for example, might be a proprietary algorithm required to make the software function. A drawback to relying on trade secret protection is that fact that once the secret is public, others can use it for their own purposes. This drawback makes it extremely important for trade secret owners to have a strict policy in place for maintaining confidential information. Trade secret protection is very 8 FLORIDA MD - APRIL 2015

useful when (a) the software’s functions cannot be easily reverse engineered by a competitor and/or (b) to prevent software developers from disclosing one party’s trade secrets to another party. Non-Disclosure Agreements (NDAs). An NDA allows parties to share confidential information while restricting how the information is used and disclosed. NDAs work in conjunction with patents, copyrights, and trade secrets, and also when the confidential information is not otherwise protectable. Even though a party might have protected its IP through all other available means, that party should still use an NDA when the need arises to disclose valuable information to someone else.

Christopher M. Ramsey, Ph.D. practices intellectual property law and is a registered patent attorney at GrayRobinson, P.A. in Orlando, FL. He advises clients on patent, trademark, and copyright issues. Chris is a Ph.D. chemist whose research is published in more than twenty peer-reviewed articles. For additional information, Chris can be reached at 407-2445686; christopher.ramsey@gray-robinson.com; or by visiting www.gray-robinson.com. 

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Orexin Antagonist Therapy:

A New Option for the Pharmacologic Treatment of Insomnia By Daniel T. Layish, MD and Kathleen Summo RN, MSN Insomnia can be divided into two categories: difficulty initiating sleep and/or difficulty maintaining sleep. Approximately 30 percent of the adult population is affected by insomnia at some point, thus creating a major risk factor for anxiety, depression and/or substance abuse. Current pharmacologic therapy options for insomnia include benzodiazepines and non-benzodiazepine gamma-amino butyric acid (GABA) acting hypnotics such as zolpidem and eszopiclone. Other options include antihistamines, sedating antidepressants and melatonin agonists. Orexin, a neurotransmitter (also known as hypocretin) was discovered in 1998. There are approximately 15,000 orexin neurons in the brain, primarily located in the perifornical lateral hypothalamus. Hypocretin deficiency is associated with decreased levels of epinephrine and histamine, important chemicals in promoting arousal, alertness and wakefulness. Ninety percent of patients with narcolepsy have been found to have decreased levels of orexin in their cerebrospinal fluid. Cataplexy, (the most common form of narcolepsy) causes sudden, transient episodes of muscle weakness triggered by emotions (such as crying or laughing). Seventy percent of narcoleptics have cataplexy, which is caused by the autoimmune destruction of orexin. The FDA recently approved suvorexant, a duel orexin receptor antagonist, as the first in a new class of pharmacologic agents for the treatment of insomnia. This new medication blocks both 0X1R and OX2R, has been shown to improve both sleep onset as well as sleep maintenance. One major advantage of suvorexant is its low potential for addiction or rebound. In gaining FDA approval, three Phase III studies were conducted. Two of these studies lasted three months and the largest evaluated more than 1200 elderly and non-elderly subjects for safety and efficacy. Plasma concentrations were unchanged in patients with moderate hepatic or renal dysfunction. However, suvorexant should be avoided in individuals with severe hepatic impairment. At doses of 15-20 mg, Suvorexant reduced latency to persistent sleep by about 10 minutes as compared to placebo. By the third month of therapy this was down to 5 minutes. Wakefulness after sleep onset (WASO) was about 35 minutes less than placebo (verified by polysomnography) at the 15-20 mg dose. This effect also lessens over time to a 23 minute improvement in WASO (versus placebo) by month three. Suvorexant may cause daytime sleepiness as well as some daytime confusion. The daytime sleepiness is dose dependent. There is also a potential for next day driving impairment at the higher doses. Suvorexant should be used cautiously in the setting of other moderate CYP3A medications and is contraindicated with severe CYP3A inhibitors. It is recommended that this medication be taken within 30 minutes of going to bed and by those ready to stay in bed for at least seven hours. Many of the studies that led to the FDA approval of suvorex-

ant looked at higher doses than were eventually approved. This fact should be kept in mind when interpreting Daniel T. Layish, MD these clinical studies. Suvorexant is now available under the brand name BelsomraÂŽ in 5, 10, 15, and 20 mg tablets. Suvorexant is a controlled substance (Schedule lV) and is contraindicated in narcolepsy. In addition to pharmacologic therapy for insomnia, it is important to remind patients about cognitive behavioral therapy, sleep hygiene, and other non-pharmaceutical treatments of insomnia (such Kathleen Summo RN, as avoidance of caffeine, nicotine, MSN alcohol, etc.). Perhaps in the future, there will be an orexin agonist available to treat excessive daytime sleepiness, as this is currently an active area of clinical research.

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/Sleep Medicine Fellowship at Duke University in Durham, North Carolina. Since 1997, he has been a member of the Central Florida Pulmonary Group in Orlando. He serves as Co-director of the Adult Cystic Fibrosis Program in Orlando. Dr. Layish may be contacted at 407-841-1100 or by visiting www.cfpulmonary.com. Kathleen Summo RN, MSN, CCP is the Clinical Director of Research and Cystic Fibrosis at the Central Florida Pulmonary Group, PA. She has a Masters degree in Nursing with a minor in Clinical Research and fifteen years of experience conducting clinical trials. î Ž




Stereotactic Laser Interstitial Thermal Therapy: A Minimally Invasive Innovative Approach for Difficult Brain Cancers By Arnold B. Etame, MD, PhD Surgery plays a major role in the management of brain cancers. Whenever the goal is solely for tissue-diagnosis, a stereotactic image-guided craniotomy for biopsy is often performed. However, in most cases the goals are surgery are centered on the principle of maximum-safe resection of tumors whenever feasible. There is also ample evidence within the cancer literature that local disease control in the brain is highly correlated with the extent of resection especially for tumors that primarily arise from the brain1-5.

Stereotactic Laser Thermal Therapy for Brain Cancers

Safe resection of tumors is a paramount objective since any significant deficits that result from surgery could significantly limit the patient’s ability to proceed with adjuvant therapies such as chemotherapy and radiotherapy. Furthermore, tumors in eloquent or critical areas of the brain such as speech, motor, basal ganglia, thalamus and brainstem regions present unique challenges given the potential morbidity of surgery. Hence innovative strategies are warranted to minimize morbidity. Advances with awake-craniotomies6-8 and image-guided navigational techniques9-11 have made resection of tumors in motor and speech regions feasible with minimal adverse effects. Furthermore, innovative minimally invasive stereotactic-guided techniques such as Laser Interstitial Thermal Therapy (LITT) have demonstrated recent success in treating brain tumors that were once considered be in inoperable locations through traditional surgery12.

Stereotactic LITT is minimally invasive when compared to craniotomy resections. The procedure can be accomplished through a 4 mm skin incision, which minimizes blood loss, postoperative pain, discomfort and wound complications. Furthermore the precise and focal ablation minimizes damage to surround brain tissue making it ideal for tumors adjacent to critical structures. Expectedly, the recovery time is markedly quicker with LITT compared to craniotomy with markedly lower complication rates and shorter hospital stay. Hence patients can quickly commence adjuvant therapies such as chemotherapy and radiotherapy.

Stereotactic LITT is a minimally invasive procedure whereby a laser fiber probe is used to focally destroy brain lesions with heat while sparing the surround normal brain13. Using the exquisite precision of image-guided navigation, the neurosurgeon can precisely target a tumor with a laser fiber probe placed to bisect the longest axes of the tumor (Figure 1). Placement of the laser fiber occurs in the operating room through a 3 mm burhole using a combination of high-resolution CT and MRI images for stereotactic localization of tumor and fiber placement. Next, the tumor ablation takes place under real-time MRI guidance using specialized software programs that provide real-time data on

The majority of LITT applications in Neuro-Oncology to date have been in the recurrent disease setting. LITT is effective for treating recurrent gliomas (glioblastoma) even in locations often considered inoperable12, 14, 15. Hence, LITT is emerging as a treatment paradigm for patients with thalamic glioblastomas. LITT is also effective for post-radiosurgery recurrence of brain metastases which minimizes interruption of systemic chemotherapy and other adjuvant therapies16-19. Such patients therefore experience very minimal interruption of systemic therapies when compared to craniotomy patients. Furthermore, LITT is effective for treating radiation necrosis 19-21 which is a post-radiotherapy inflamma-


brain temperatures and zone of ablation. In order to limit the extent of damage to surround brain tissue, the surgeon can place temperature threshold safeguard parameters which if realized in surrounding brain tissue, the laser would automatically shut off.

CANCER tion associated with brain swelling and neurological symptoms. Our Comprehensive Cancer Center is one of a few centers in the US that currently offer LITT in the form of Visualase® for brain cancer treatment. We currently employ LITT for the treatment of glioblastoma, metastatic tumors, radiation necrosis, cancers in deep or critical locations that make conventional craniotomy surgery risky, and for patients with substantial medical comorbidities. Our outcomes have been thus far excellent in terms of successful ablation of lesions without significant neurological deficits. Patients are typically observed overnight and discharged the day after surgery. LITT serves a new treatment that provides hope to our brain cancer patients who would otherwise have no other treatment options. Arnold B. Etame, M.D., Ph.D., is Assistant Member of the Neuro-Oncology Program at Moffitt Cancer Center. References available upon request

Arnold Etame MD, PhD is a Neurological Surgeon and Scientist specializing in Neuro-Oncology at the Moffitt Cancer Center, and Assistant Professor of Oncology at the University of South Florida, College of Medicine. He directs the awake-brain tumor surgery program, minimally invasive laser-guided ablation program, and image-guided surgery program at the Moffitt Cancer Center for brain tumors. In collaboration with Radiation Oncology, he co-directs the stereotactic radiosurgery program for brain and spine metastatic tumors. He completed his undergraduate degree at the State University of New York at New Paltz, medical degree at the University of Iowa, neurological surgery specialization at the University of Michigan, doctorate degree and fellowship at the University of Toronto. Patients can reach Dr Etame at 813745-3871 or 813-745-2011. 

RAVENHEART GRAPHIC Design • Illustration • Photography •

407-292-6609 • 407-414-3359 FLORIDA MD - APRIL 2015 11

Marketing Your Practice

Making the Most Out of Phone Calls By Jennifer Thompson

We recently conducted a survey for one of our clients about overall patient satisfaction. Everything was rated relatively well... except one issue. Patients said phone calls were the worst part about the office experience. So, we thought, “How can we make phone calls better for our client and their patients?” Now that it’s not just about insurance anymore, patient satisfaction is front and center for medical practices.

night and over the weekend. Instead of having a staff member dedicate an entire morning to deciphering voicemails and calling patients back, she will have an inbox (or spreadsheet) with data neatly filled out. She can then mow down a list and

Below you’ll find a few tips and strategies you can use at your office to increase efficiency on the phone and improve patient satisfaction during phone calls.

Remind Staff How Important the Patient Is We’re all guilty of it. Sometimes we got lost in the day-to-day-mark-offtask-one-and-move-to-task-two mentality and we forget why we went into healthcare in the first place (it was to help people in case you need a reminder). Every phone call is a life choosing your office for help, and it’s up to you to make a difference for them. Call a quick meeting and remind staff answering the phones that we’re here to help, these people matter and they need us to improve their life. It’s often said you can hear someone smile through the phone; so take a few minutes and remind your phone operators that patients are listening for that smile and they deserve to hear it. Every. Time.

Incentivize Staff When the phone rings at your practice, do you have a goal in response time or are you just hoping it doesn’t go to voicemail? Set a goal and then incentivize staff to meet and exceed it. We suggest 80 percent of calls answered within 30 seconds or less. As a motivator, create a contest for front desk staff, appointment schedulers or whomever is responsible for answering your phones. Those that meet or exceed the goal should be recognized among their peers and rewarded. Take them out to lunch once a month or pick up a gift card the next time you’re at Target - anything to show their efforts matter. Oh, and be sure to be consistent with your rewards. If you start an incentive program, you can’t stop without good reason (and “I forgot” is not good reason).

Tweak Operations There are a few ways you can easily increase efficiency when it comes to phone calls from an operational standpoint. Consider: • Adding an appointment request form to your website to cut down on new patients calling in. This is especially handy at 12 FLORIDA MD - APRIL 2015

confirm appointments much faster than checking a few dozen voicemails on the office line. We’ve seen this form work for our clients, even generating 300+ appointments month over month that would have either been phone calls or folks that wouldn’t have scheduled at all. ª Answer the phone with, “Hello, when would you like to be seen?” This surprises the patient, but it gets the conversation rolling right away. Sure, sometimes the caller may not need to be seen, but about 90% of your calls are for appointments or follow ups, so you may as well jump right in. • Stagger staff members in the front so one is managing patients at the office and one is on the phone. This way, no one is left unattended and your team can work together to increase patient flow efficiency and get patients back to see their doctor as soon as possible.

Break Down What Your Medical Staff Should be Saying We hear it far too often. Physicians, especially those who tend to have a few more gray hairs, like to tell patients to call the office and let us know how you’re doing. Ugh. This creates a bottleneck at the front, which takes staff away from getting new patients scheduled and can lead to a negative experience from the patient on the line because of how much they have to wait just to let someone know how they feel.

Marketing Your Practice Instead, schedule a training session (or two) for your medical staff and explain why it’s important for them to tell patients to use the patient portal for messaging. Talk about how it slows the office down and may be hurting the bottom line. Present any hard numbers you can so the physicians can clearly see how they’re costing themselves money by creating inefficiencies - that should get them to do what you need right away. Looking for more ways to attract and retain more patients? Check out DrMarketingTips.com for free articles, webinars, ebooks, audio blogs and more for your practice. Jennifer Thompson is co-founder and chief strategist for DrMarketingTips.com, a website designed to help medical marketing professionals market their practice easier, faster and better. 

Coming UP Next Month: The cover story focuses on Gateway at Lake Nona. Florida Hospital and UCF Health joined forces to create Gateway at Lake Nona, an innovative and collaborative model of health care that brings a range of new providers and services to Medical City. Editorial focus is on Women’s Health and Advances in Cosmetic Surgery.

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Behavioral Health

Treating the Spirit STORY By COVER Sajid Hafeez, MD A safe assumption is that when a patient is involuntarily admitted to an acute crisis unit, he or she is probably not having a good day. Even those who are admitted there on a voluntary status are doing so because they see treatment as a last result. They are hopeless. They are helpless. Maybe their meds have stopped working. Maybe they have lost someone. Maybe they have been arrested. Maybe depression just slowly snuck up on them. While medication can treat the chemistry, and therapy can teach coping skills, a large part of recovery is treating the spirit. As any doctor will tell you, a vital part in the patient recovery is the restoration of hope. When a patient can see that there is the potential to return to a state of mental wellness, that patient begins to take an active investment in his or her treatment, which is a great indicator of success. The question is, how exactly does one conjure optimism where none exists? It starts by first validating the patient. Stigma against mental health runs deep through society, and often times those who struggle with issues compare themselves to people they feel are successful and without problems. The patient must be treated with the dignity and respect due any person, regardless of his or her behavior or condition. In showing common courtesy, understanding, and empathy, it helps the patient to feel like less of a failure or outcast. A trained staff of nurses, therapists, and techs

understand that most people in crisis will act as they do out of fear, the avoidance of pain, or to gain a sense of control over a new and potentially frightening environment. With this understanding it is easier to accept without judging so that together the staff and patient can focus on what can be instead of what is. A major part of hopelessness is the unknown. The patient is often completely unaware of how to begin the path to wellness. As such, a second facet of restoring hope is education. In conversation with the doctor, a patient is educated on the causes of his or her affliction, and what medicines can be used to treat it. Each potential plan of treatment or medication acts as an arrow to fill the patient’s quiver. Now unfortunately, some of these may miss the mark. Yet as long as that quiver remains full of different medications, ideas, and approaches, there always exists a chance to hit the bull’s-eye. In this the combined knowledge and optimism of the doctor translate to an optimism for the patient. Hope is amazing in that it can be borrowed by one in need from someone who has excess. This is also emboldened by a trust in the confidence of the doctor’s ability, trustworthiness, and knowledge. As such even if a doctor has doubts, it is vital to focus on the best potential in order to lend out that optimism.

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Behavioral Health Next, it falls upon the techs and the therapists to buff the patient’s self esteem. Through guided existential evaluation, any patient can be walked through a path to discover what it is that he or she likes best about his or her self. In doing so, the staff is effectively breathing life back into a fading ember before it goes out. When that patient begins to recognize that there are aspects of life that they do enjoy, it is possible to fan those embers to glow a little brighter and a little hotter. While the process may not happen all at once, over time, this ember can be rekindled into a small flame of purpose. When a patient is able to regain a sense of purpose, it represents a turning point wherein a patient is able to cross that bridge of hopelessness into hopefulness. The solution to this problem is making the patient feel he or she is the star of his or her own story of recovery, and not just a supporting role. It is then that the patient can draw the connections between what it is that defines hope, and make a promise to his or her self that he or she does have value and that they have a sense of control in the outcome. Those patients who develop this understanding are those who are most likely to succeed. However, a hospital is a temporary escape from the real world where stressors, and problems often are temporarily placed on hold. It then falls upon the duty of the facility to provide a plan of action at discharge as opposed to releasing the patient with nowhere to go. Patients are then recommended to the next level of care. For some it may be a day program. For others it may simply be a follow-up therapy with med management. What is known is that success rates are shown to be higher when the follow up is carried out as soon as possible. With a plan in hand, a patient has less to fear of the unknown. As of yet, medical science has made no discoveries of how to put hope and optimism into a pill. Until that time, medical professionals will continue to use the kindness, empathy, and compassion to achieve the same results. Ultimately, when all is said and done these are the best medications that we as health professionals have to offer. Sajid Hafeez, M.D., is a child and adolescent psychiatrist who is serving as a Medical Director of the Acute Care Baker Act Unit at the University Behavioral Center. He also served as the Center’s Medical Director of the long term Residential Units: ASAPP Unit (for adolescent boys with inappropriate sexual behaviors), Solutions Unit (for adolescent boys with behavior problems), Promises and Stars Unit (for adolescent females with behavioral problems as well as victims of sexual abuse), and Discovery Unit (for children ages 5-13 with behavioral as well as inappropriate sexual problems). In addition, Dr. Hafeez also Served as an Assistant Professor of Psychiatry at the University of Central Florida (Voluntary Position). He was also the Chief of the Adolescent Psychiatry Unit, an Attending Psychiatrist of the Comprehensive Psychiatry Emergency Program and of the Mobile Crisis Team at the Westchester Medical College. At Vassar Brother’s Medical Center in New York. Dr. Hafeez was the Director of Outpatient Child & Adolescent and Adult Psychiatric Clinic as well as Director of Consultation and Liaison Psychiatry. Dr. Hafeez received his adult Psychiatry and Residency Training at the University of Kansas Medical Center in Kansas City. He received his Child and Adolescent Psychiatry fellowship training at the New York Medical College New York and at Children’s National Medical Center of George Washington University in Washington, DC. Dr. Hafeez can be reached at 407-281-7000 or by visiting www. universitybehavioral.com. 



Living With a SLAP Tear By Corey Gehrold Imagine cooking in your kitchen, going to reach for something out of a cabinet and not being able to grab it because of excruciating pain in your shoulder. That’s what patients experiencing a superior labrum anterior and posterior (SLAP) tear must live with every day. Pamela, a recent patient of Alan W. Christensen, M.D., a board certified orthopedic surgeon specializing in hand and upper extremity surgery, says getting treatment for her SLAP tear is one of the best thing she has ever done. “It has been absolutely amazing,” says Pamela who has had two shoulder surgeries ten years apart under the care of Dr. Christensen. “There has been very little medication, recovery time has been practically nothing and everything has been really great.” In 2004, Pamela had surgery to repair a SLAP tear. Over time, she began suffering from pain again and returned to Dr. Christensen for further treatment. With a decade of medical advances between procedures, she says the experience and recovery this time was far superior to her last surgery. What is a SLAP tear? A superior labrum anterior and posterior (SLAP) tear is an injury to the labrum of the shoulder. The labrum is the ring of cartilage that surrounds the socket of the shoulder joint that helps to deepen the socket and stabilize the shoulder joint. “When a SLAP tear occurs, the top part of the labrum becomes unstable and can lead to shoulder instability,” Dr. Christensen says. “The injury tears both the front and back of where the bicep meets the labrum, which can cause a lot of pain for a patient, even if the shoulder does not become unstable it can impair everyday function.” A SLAP tear can be caused by a motor vehicle accident, falling onto an outstretched arm, shoulder dislocation, repetitive overhead sports or repetitive motions over time. Most SLAP tears are caused by the slowly wearing down of labrum over time. Symptoms of a SLAP tear include: • A locking, popping, catching or grinding sensation ª Pain when lifting objects Pamela has had two shoulder surgeries ten years apart under the care of Dr. Christensen and she says she is back to full function and feels amazing following her latest procedure.


• Decreased range of motion • Feeling as if the shoulder is going to pop out of joint Pamela says she couldn’t move her arm without being in pain prior to her surgery, but now she has full mo- Alan W. Christensen, MD tion back within just 6 weeks time. What are SLAP tear treatment options? Generally, SLAP tears are first treated conservatively, meaning surgery is not the first option. Patients and physicians will work together to develop a plan involving medication and physical therapy depending on the severity of the injury. When those conservative measures fail, surgery becomes the only way to repair the tear. How can an arthroscopy help treat a SLAP tear? A surgical option that a surgeon will most likely use to treat a SLAP tear is an arthroscopy. During an arthroscopy, the surgeon inserts a small camera, called an arthroscope, into the shoulder joint to see what damage has been caused to the shoulder. From there, surgeons can diagnose and repair problems to a joint. “The arthroscope provides us with a minimally invasive, stateof-the-art method to see inside the joint,” Dr.Christensen says. “Once in the joint, we can repair or remove the torn section of the labrum.” In the case of Pamela, Dr. Christensen used the arthroscope to repair the labrum and remove three bone spurs that had developed as a result of a 2004 surgery in the same shoulder. Dr. Christensen used a nerve block to manage pain for Pamela during and after the surgery. “We use this short-term block, which usually lasts several days, to dull the pain for patients following surgery. This minimizes discomfort and allows them to start rehabilitation sooner,” says Dr. Christensen. “It didn’t even hurt when he put the [nerve] block in,” says Pamela. “I didn’t even know he was finished yet.” What is the recovery process like? Once the pain and swelling from surgery has diminished, your surgeon will prescribe a physical therapy protocol. Recovery time is anywhere from two to 12 weeks depending on the severity of the injury. “The last time when I had [surgery] in 2004, I couldn’t even start moving my arm for at least 8 weeks,” Pamela says. “This time, my first visit back in one week, I started my therapy doing my strengthening of my arm, moving around, doing all the activities at home.” After six weeks Pamela has regained full range of motion and she says she couldn’t be happier with the results. “It’s real simple, I wouldn’t go anywhere else. That’s why I came back 10 years later,” she says. “I’ve lived through it twice and can say, don’t wait for it - don’t be in pain.” Watch Pamela’s full story and see what she has to say about her experience with Orlando Orthopaedic Center at OrlandoOrtho.com. 

Capitol Hill: Independent Doctors Like Law that Would Make Facility Fees Transparent By Marni Jameson On Capitol Hill last month the National Physicians Council on Healthcare Policy convened and the mood was grim. Rep. Pete Sessions (R-Texas) had invited 50 physicians and lawmakers to meet in the Rules Committee Chamber of the Capitol building to discuss legislation that would impact them. While the news regarding the SGR repeal, ICD-10 and other regulatory changes was less-than-encouraging, there was one bright spot. When it was my turn to address the group, I opened my remarks by saying, “I hope after I’m done speaking, you will all see a little ray of hope.” Rays of hope are few and far between for independent physicians these days, but at the Association of Independent Doctors we are creating them. During the 15 minutes I was allotted to present, I gave three examples of what A.I.D. was doing nationwide on behalf of independent physicians. Each example was met by a round of applause. There is hope. One of the three examples I shared was A.I.D.’s work to advance a law recently passed in Connecticut. The law is a push for price transparency. Specifically, it requires hospital-employed physicians to disclose to patients before their appointments that they will be charged facility fees and how much. Moreover, it requires these doctors’ offices to tell patients that if they went to an office not owned by a hospital, they would not be charged facility fees. And it requires providers to tell patients in clear written language. We want this to be the law in every state. Hospitals charge facility fees for outpatient services performed by employed physicians that independent physicians and freestanding facilities do not charge. Facility fees are separate from professional fees, and can increase the total cost of a service by three to five times compared to the same service provided by an independent physician, according to the Medicare Payment Advisory Committee. Facility fees are why a Medicare patient can go to his doctor for a heart ultrasound one month and pay 20 percent of $189, Medicare’s contracted rate with the doctor’s office. The next month, if a hospital has bought the doctor’s practice, the same patient will pay 20 percent of $453 for the same test in the same building by the same doctor using the same equipment. Taxpayers, of course, pay the balance.

The extra payment that hospitals get is part of what’s driving hospitals to buy up medical groups, a trend that is causing health-care costs to skyrocket. The bills that are three to five times higher are compounded by the downstream effect: Hospital-owned groups refer exclusively to other hospital-owned providers, which charge -- you guessed it -- facility fees. More transparency would not only spare consumers sticker shock and let them vote with their feet and their dollars, but it also might curb hospitals’ appetites for private practices. This Connecticut law has already had a markedly positive impact on independent physicians. And a version of the law is moving forward in Kansas, thanks to A.I.D. executive committee member Dr. Elizabeth Rowe, of Lenexa, Kansas, who got the bill into the Kansas Senate by sending information about the Connecticut bill to the appropriate committee chair. The bill has strong bipartisan support. In Florida, other A.I.D. members are working with local and state medical associations to push forward a similar proposal, one that would also require doctors to clearly disclose whether they are employed by a hospital or independent. “The point is very straightforward,” said Dr. Rowe in her testimony before the Kansas legislature. “If there are two offices reasonably close to each other, and one charges facility fees and one does not, then the hospital-owned office needs to notify patients about this cost difference before they use those services. As it is now, patients have no warning when they are going to be billed for an add-on facility fee.” At A.I.D., we believe patients have the right to know facts up front that will triple their bill and likely lead them to receive less access to care because their doctor must refer only to other hospital-employed doctors, who may or may not be the best providers. That’s what I told the National Physicians Council on Health Care in Washington last month. That’s when they applauded. However, this concept deserves more than a round of applause. It deserves to be the law. To continue fighting this fight for Americans, we need independent doctor everywhere to join our cause www.aid-us.org. Marni Jameson is the executive director for the Association of Independent Doctors. You may reach her at 407865-4110 or marni@aid-us.org. 


Early Diagnosis and Treatment of Esophageal Cancer: A Reality at Last? By Udayakumar Navaneethan, MD and Shyam Varadarajulu, MD Esophageal cancer makes up about 1% of all cancers diagnosed in the United States with the predominant type being adenocarcinoma followed by squamous cell cancer. More than 18,000 new cases of esophageal cancer and more than 15,000 disease-related deaths is expected nationally in 2014. Esophageal cancer is rare in young people and increases in incidence with age, peaking in the seventh and eighth decades of life. It is three to four times more common in men than in women. Over the past three decades, the rates of esophageal adenocarcinoma have been progressively increasing. Barrett’s esophagus (BE), the recognized precursor lesion for the development of esophageal cancer, is the major risk factor and can be detected by means of endoscopic screening. Because esophageal cancer is often asymptomatic in the early stages, it is oftentimes detected late making treatment more challenging. Therefore, early diagnosis is imperative for effective management. In BE, the precurFigure 1: Early esophageal cancer in the setting sor of esophageal of Barrett’s esophagus. adenocarcinoma, specialized intestinal columnar epithelium replaces the normal squamous epithelium. Dysplasia within BE signals a marked increase in cancer risk — the annual risk is approximately 1% for patients with low-grade dysplasia and more than 5% for patients with high-grade dysplasia. Endoscopic screening results in detection of BE in 6 to 12% of patients with prolonged acid reflux symptoms (figure 1). This is more commonly encountered in patients more than 50 years of age. Patients in whom adenocarcinoma is detected during endoscopic surveillance Figure 2: Narrow band imaging demonstrates neoplastic changes in Barrett’s esophagus. for BE are more likely to have earlystage cancer, receive curative therapy, and survive longer than symptomatic patients with late-stage adenocarcinoma. At Florida Hospital Center for Interventional Endoscopy (CIE), we use advanced en18 FLORIDA MD - APRIL 2015

doscopic techniques such as narrow band imaging and volumetric laser endomicroscopy for the detection of early cancer in the setting of BE (Figures 2, 3). Volumetric Laser Endomicroscopy (VLE) is a novel balloon-based optical coherence tomography (OCT) technique that provides circumferential scan of the esophageal wall layers to a depth of 3 mm with a resolution comparable to low-power microscopy. This system incorporates a through-the-scope, balloon-centered optical fiber that scans circumferentially a 6-cm segment of the lumen of the esophagus. A full-resolution scan can be performed in 90 seconds!

Udayakumar Navaneethan, MD

Shyam Varadarajulu, MD

The primary application of VLE appears to be for the imaging of BE with a potential to detect both surface Figure 3: Normal esophageal wall layers seen and subsquamous on VLE. dysplasia and laser marking for targeted therapy. Utilizing an advanced form of Fourier-domain optical coherence tomography (FDOCT) also known as OFDI (optical frequency-domain imaging), VLE pro- Figure 4: Early-stage malignant changes seen in the esophageal wall on VLE. vides cross-sectional, volumetric digital images of a patient’s organ. This information is used to aid decisions regarding targeted biopsies and treatment. Traditionally, high-grade dysplasia and intramucosal cancer arising from BE were treated with esophagectomy, while BE with low-grade dysplasia were managed with endoscopic surveillance. Problems associated with these approaches included significant morbidity and mortality from esophagectomy, and the risk of missed or interval development of cancer in patients undergoing surveillance. To address these concerns, less invasive endoscopic treatments have been developed and pioneered. Radiofrequency

Ablation (RFA) is an FDA-approved endoscopic technique in which the diseased tissue is ablated by heat energy. RFA is an option for the treatment of patients with dysplastic (low-and high-grade dysplasia) BE because RFA decreases the risk of malignant progression. Short to intermediate-term follow-up is promising, and five-year follow-up data suggest that the eradication of BE following RFA is maintained in more than 90 percent of patients with a lower risk of progression to cancer. An electrode mounted Figures 5 and 6: RFA of dysplastic Barrett’s esophagus (left) followed by complete healing as evident on a balloon catheter or a thin, flexible tube on follow-up endoscopy (right). (endoscope) is used to deliver heat energy directly to the diseased lining of the esophagus. The energy delivered by the electrode results in thermal ablation of the Barrett’s lining within 25 to 35 minutes. The ablated tissue sloughs off over 48 to72 hours and is replaced by normal (squamous) lining in 6 to 8 weeks. Endoscopic mucosal resection (EMR) is emerging as an effective treatment alternative for early- stage esophageal cancer. EMR involves the use of special tools that lift and cut tumors from the superficial lining (mucosal and submuscosal layers) of the esophagus. FH CIE Figures 7 and 8: EMR of early-stage esophageal cancer in the setting of Barrett’s esophagus. physicians employ advanced RFA and EMR techniques to treat BE and high-grade dysplasia. Our specialists work closely with cancer surgeons to select patients who are ideally suited for the endoscopic removal of pre-cancerous lesions versus those who would require surgery. The introduction of EMR with or without ablation has been a major advance in treating BE with high-grade dysplasia or adenocarcinoma that is limited to the epithelial (superficial) portion of the mucosa (category T1a). The risk of lymph-node metastasis is correlated with the depth of tumor invasion; the risk is close to zero among patients with BE who have only high-grade dysplasia and is only 1 to 2% among patients with stage I tumors. Several observational studies have suggested that cure and survival rates associated with endoscopic treatments are equivalent to surgery. Therefore, endoscopic therapy should be considered as the first-line therapy for patients with stage 0 or I esophageal adenocarcinoma. Although advances in diagnosis and treatment have resulted in progressive improvement in the overall survival of patients with esophageal cancer, more work is needed. As one of the few centers in Florida to offer early diagnosis and treatment options for esophageal cancer, CIE is a nationally recognized leader in this field. More research in basic, translational and advanced imaging techniques will further strengthen our efforts to fight esophageal cancer more effectively. Shyam Varadarajulu, M.D., is the Medical Director of the Center for Interventional Endoscopy at Florida Hospital Orlando. He is board certified in Internal Medicine and Gastroenterology-Hepatology. He specializes in the treatment of complex pancreatic and biliary disorders with particular expertise in Endoscopic Ultrasound (EUS) and Therapeutic ERCP. He is a Professor of Medicine at the University of Central Florida. He was formerly an Associate Professor of Medicine and Pediatrics and Chief of Endoscopy at the University of Alabama at Birmingham. He has published more than 200 peer reviewed articles, authored 35 textbook chapters and demonstrated endoscopic procedures in more than 25 countries. Udayakumar Navaneethan, M.D., has undergone advanced training in ERCP, EUS, Double Balloon Enteroscopy (DBE), chromoendoscopy, endoscopic mucosal resection (EMR) and other complex endoscopic procedures. He completed his Gastroenterology fellowship as well as an advanced endoscopy year at the Cleveland Clinic in Cleveland, Ohio. He has published more than 120 peer-reviewed articles and has authored several textbook chapters many focusing on the endoscopic management of Inflammatory Bowel Disease. For patient referrals please call 407-303-2570. The Center for Interventional Endoscopy is located at 601 East Rollins Street, Orlando, FL 32803.


Scoliosis Detection and Treatment: A Checklist for Providers By Robert Stanton, MD As an orthopedic surgeon I have treated children with scoliosis for over 35 years. Currently I serve at Nemours Children’s Hospital in Orlando’s Lake Nona Medical City. Although treatment has advanced, diagnosing the disorder has become more complicated for providers. The following are insights and tactics to best protect your patients.

1. There is no substitute for a visual exam. Scoliosis is more common than people realize, but it can be difficult to spot in a developing child. School-aged children should be checked routinely during annual and sports physicals. To be effective, put them in a gown that opens to the back — spinal curvature is easy to miss if a patient is not fully undressed for the examination. You’ll need a view of the entire back to look for asymmetry of shoulder height, scapula bones, and waist creases. Keep in mind that the task is more complicated when a patient is overweight. Significant spinal curves can be masked by obesity.

2. Start scoliosis screening early. Although boys can develop scoliosis, it is eight times more likely in females. As a result, screening has focused on prepubescent girls. Since bracing — the nonsurgical treatment for the disorder — is effective only for children who are still growing, catching scoliosis early is important. Once a girl is two years beyond her first menstrual period, it’s too late. We must keep in mind that the average onset of puberty is changing. Whereas age 14 was once quite typical, many girls today show signs of puberty at 8 or 9 years old. Be sure to factor this shift into your screening schedule.

3. Know when to refer, and limit the X-rays. A diagnosis of scoliosis requires a curve of greater than 10 degrees. Anything under that falls into the category of “normal human variation.” We observe curves of 10–20 degrees. It is only at 20 degrees and above, and only in children who are still growing, that bracing is prescribed. When the curvature is slight, meaning a single-digit discrepancy, there is no need to refer your patient for evaluation. A child with a more significant asymmetry should be seen by a specialist, but don’t worry about taking X-rays first. A typical scoliosis series includes multiple views that are usually not needed to evaluate the kind of curve that warrants treatment. One full length film is generally sufficient, saving the patient unnecessary exposure to radiation.

4. Rejoice in a new age of bracing management. A recent multi-center study showed that bracing is effective 85 percent of the time for controlling small curves. Here in Florida, with our hot, humid climate, we tend to use nighttime-only bracing with most of our patients. It means that bracing for scoliosis doesn’t impact a child’s life the way it used to.

5. Surgery is safer than it’s ever been. Surgery is indicated for advanced curves that exceed 40 degrees in a patient who is still growing. It’s indicated for those who have stopped growing primarily when serious asymmetry impacts lungs or other organs. With modern anesthesia and newer fixation devices, safe correction of spinal deformity can be offered to most patients with very low risk, and serious complications are quite rare. In fact, most patients do not require blood transfusions and a typical hospital stay is four days. Only in exceptional cases is bracing or casting after surgery required.

Summary • Scoliosis is more common than people think, but a curve of 10 degrees or less is not cause for alarm. • Since it’s always preferable to treat curves with braces rather than surgery, early detection is critical. • Traditional visual exams with the entire back exposed are still by far the best screening method. • Children, especially girls, should be checked for scoliosis during their annual exams and sports physicals. • Screening for scoliosis should begin well before puberty, so factor any chance for early puberty into your examination timeline. Robert Stanton, MD may be contacted at (407)567-4000. 20 FLORIDA MD - APRIL 2015



Florida MD is a four-color monthly medical/business magazine for physicians in the Central Florida market. Florida MD goes to physicians at their offices, in the thirteen-county area of Orange, Seminole, Volusia, Osceola, Polk, Flagler, Lake, Marion, Sumter, Hardee, Highlands, Hillsborough and Pasco 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.


Digestive Disorders Diabetes


Cardiology Heart Disease & Stroke


Orthopaedics Men’s Health


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Women’s Health Advances in Cosmetic Surgery


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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. FLORIDA MD - APRIL 2015 21

The Heart Program at Miami Children’s Hospital Uses 3D Printing Technology to Plan Complex Heart Surgery on Pediatric Patient Photo: Edgar Estrada with Miami Children’s Hospital

Photo: Edgar Estrada with Miami Children’s Hospital

Miami— The Heart Program at Miami Children’s Hospital (MCH) is believed to be the first in the region to use three-dimensional printing technology to create a model of a patient’s heart to support pre-surgical planning for a child who was born with a complex heart anomaly. Fouryear old Adanelie Gonzalez was born with total anomalous pulmonary venous connection (TAPVC), a complex congenital heart defect in the

catheterizations, the surgeries had only proven a temporary fix and her health was quickly deteriorating. From L to R: Dr. Redmond Burke, Director of Cardiovascular Surgery at MCH; Dr. Nancy Dobrolet, Pediatric Cardiologist at MCH; Dr. Juan Carlos Muniz, Director of Cardiac MRI at MCH and Chelsea Balli, Biomedical Engineer at MCH.

veins leading from the lungs to the heart. Although she has already undergone two complicated open-heart operations and multiple cardiac

Photo: Edgar Estrada with Miami Children’s Hospital

L to R: Dr. Juan Carlos Muniz, Director of Cardiac MRI at MCH; Dr. Redmond Burke, Director of Cardiovascular Surgery at MCH; Dr. Nancy Dobrolet, Pediatric Cardiologist at MCH.

The team at MCH turned to 3D printing technology to better visualize the patient’s complex anatomy and to explore potential options for repair. Magnetic resonance imaging (MRI) and computed tomography (CT) image files were collected and rendered by MCH’s cardiologists and the biomedical engineer, who reformatted the image files to be read by a 3D printer. The files were then printed by AdvancedRP, an Atlanta-based distributor of Statasys 3D printers.  “I think about heart repairs in three dimensions, imagining what I will do with my hands during each step of the operation,” said Dr. Redmond Burke, Director of Cardiovascular Surgery of The Heart Program at MCH. “I thought that holding and manipulating a flexible 3D replica of this child’s heart might allow me to plan an operation that hadn’t been done before, configuring the necessary patches to create the exact shapes and dimensions to match her deformed pulmonary veins.”  Dr. Burke was able to intricately study the heart model, manipulating the vessels and exploring possible repairs as he would employ in the operating room. Dr. Nancy Do-


Photo: Edgar Estrada with Miami Children’s Hospital

brolet, Pediatric Cardiologist at The Heart Program at MCH says, “3D printing adds another element in caring for extremely complex conditions where surgical intervention is not typically thought possible. In Adanelie’s case, the 3D model provided us with a way to create a surgical option for her survival.” The Heart Program at Miami Children’s Hospital is a regional referral center for care of children and newborns with heart disorders and is one of the topranked programs in the nation. It offers assessment, intervention and ongoing care management for children and adults born with a congenital heart condition, supporting continuity of care over a lifetime.

About Miami Children’s Hospital

Photo: Edgar Estrada with Miami Children’s Hospital

Founded in 1950 by Variety Clubs International, Miami Children’s Hospital® is South Florida’s only licensed specialty hospital exclusively for children, with more than 650 attending physicians and over 130 pediatric sub-specialists. The 289-bed hospital is renowned for excellence in all aspects of pediatric medicine. In fact, it is the only hospital in Florida to be ranked in all 10 pediatric specialties assessed by U.S. News & World Report in its annual Best Children’s Hospitals rankings for three consecutive years, 2011, 2012 and 2013-14. The hospital is also home to the largest pediatric teaching program in the southeastern United States and has been designated an American Nurses Credentialing Center (ANCC) Magnet facility, the nursing profession’s most prestigious institutional honor. 

Be sure andcheck out our website at www.floridamd.com!

From L to R: Patient Adanelie Gonzalez, Luis Rivera, Gabriella Alonso, Luis Rivera Jr. and Dr. Nancy Dobrolet.

Coming UP Next Month: The cover story focuses on Gateway at Lake Nona. Florida Hospital and UCF Health joined forces to create Gateway at Lake Nona, an innovative and collaborative model of health care that brings a range of new providers and services to Medical City. Editorial focus is on Women’s Health and Advances in Cosmetic Surgery.

Patient Assistance Resource Center To make sure people with CF have the support, information and access to resources they need to take advantage of the best treatments available, the CF Foundation has developed a network of access to care programs called the Patient Assistance Resource Center. •

CF Patient Assistance Foundation (CFPAF) helps patients meet their co-pay requirements and provides financial assistance to those in need.

CF Social Security Project provides support for patients applying for SSI or SSDI.

Case Management helps patients, their families and CF care centers understand and navigate insurance and reimbursement terms and coverage. It also provides guidance with coordination of benefits, prior authorizations, appeals and network exceptions.

CF Legal Information Hotline serves as a free information resource about the laws that protect the rights of individuals with CF.

Mutation Analysis Program (MAP) offers free genetic testing to people with a CF diagnosis who do not know both of their mutations.

Patient Assistance Resource Library (PARL) is a self-service online resource with up-to-date materials on coverage and care for patients, their families and CF care providers.

CoverMyMeds assists health care providers expedite and streamline the submission of prior authorization requests.

Patient Assistance Resource Center 888.315.4154 parc@cff.org www.cff.org/AssistanceResources

FLORIDA MD - APRIL 2015 23 PARC ad 7x8.5.indd 1

4/3/2015 12:08:12 PM

West Florida Health Now Providing Home Care Services Florida Hospital Home Care and Chapel Home Care have united to form West Florida Health Home Care, a Tampa General Hospital and Florida Hospital partnership. February 26, 2015 – The state has approved the home health agency licensure application from the bay area’s newest healthcare company, West Florida Health, to provide home care services in Hillsborough, Hernando, Pasco, Pinellas and portions of Sumter counties. West Florida Health is a partnership between Tampa General and Florida Hospital with a mission to build on the expertise of the two hospitals to provide accessible, affordable care to the greater Tampa Bay community.Hospitals charge facility fees for outpatient services performed by employed physicians that independent physicians and free-standing facilities do not charge. Facility fees are separate from professional fees, and can increase the total cost of a service by three to five times compared to the same service provided by an independent physician, according to the Medicare Payment Advisory Committee. “Home care is an important part of the healing process as it allows a patient to leave the hospital sooner and continue recovery in the comfort of their own home,” said Jim Burkhart, President and CEO of Tampa General Hospital. “Because we can provide specialized care needed for recovery, patients can often avoid being readmitted to the hospital.” West Florida Health Home Care will provide professional clin-

ical care, personal care, and a wide range of medical services that a patient might need after being discharged from a hospital. The home care agency also provides specialized care for medical issues like heart failure, respiratory diseases, orthopedics, and diabetes. “Through the collaboration of our two hospitals, our home care team can provide a direct and coordinated approach to home care. That means they will have the ability to assess a patient’s vitals and monitor treatment based on real-time medical information, historical and current, which enables them to more effectively manage and monitor the progress of patients after they leave the hospital,” said Mike Schultz, President and CEO of Florida Hospital West Florida Region. The West Florida Health Home Care team works with patients and physicians to develop a plan of care. The home care staff includes: Registered nurses (RNs) with MBA/MSN; licensed clinical social workers (LCSWs); wound care-certified RNs; certified ostomy nurses; infusion specialists; occupational therapists; speech language pathologists; licensed practical nurses (LPNs); nurses experienced in end-of-life care; licensed physical therapists; and home health aides. “Our existing home care patients will not experience an interruption in care as a result of our new home care agency and we will continue to provide the outstanding quality and service they have come to expect with us. Our home care nurses can manage all aspects of a patient’s care and our registered nurses are available 24 hours a day, seven days a week to answer questions,” said Cindy Higgins, RN, BS, MSM, and Regional AdministraORTHOPAEDIC tive Director for West Florida Health Home SUBSPECIALTIES Care. Higgins has been a registered nurse • SPINE for over 22 years, including 20 years of ex• ELBOW perience in home care and 13 years as an • FOOT & ANKLE administrator for home care. • HAND & WRIST • HIP West Florida Health Home Care has of• KNEE fices in Brooksville, Tampa and Zephyrhills • ONCOLOGY and plans to expand to Pinellas County in • PEDIATRICS the near future. The home care agency is ac• SHOULDER credited by the Joint Commission and is a • SPORTS MEDICINE Medicare-certified provider. To learn more, • PAIN MANAGEMENT please visit www.WestFloridaHealth.org or • PHYSICAL THERAPY call (844) 887-2851. West Florida Health is a jointly owned not-for-profit company and partnership between Florida Hospital and Tampa General Hospital. The vision SAME DAY, NEXT DAY APPOINTMENTS AVAILABLE of West Florida Health is to redefine health OVIEDO SATURDAY WALK-IN CLINIC and wellness through its mission to build on NO APPOINTMENT NECESSARY | 9AM - 1PM the expertise of Tampa General and Florida Downtown Orlando | Winter Park | Sand Lake | Lake Mary | Oviedo | Lake Nona Hospital to provide accessible, affordable REQUEST YOUR APPOINTMENT AT ORLANDOORTHO.COM 407.254.2500 care to the community. 






Florida Hospital Cancer Institute’s Best of ASCO® Meeting A Program Licensed by the American Society of Clinical Oncology ® The Florida Hospital Cancer Institute is proud to bring the highlights of the ASCO Annual Meeting to Orlando, Florida through its licensed Best of ASCO® meeting, to be held at Hyatt Regency Grand Cypress, Orlando, Florida.

June 27-28, 2015 | Hyatt Regency Grand Cypress One Grand Cypress Boulevard Orlando, FL 32836 Hotel Reservation Line: 1 (888) 421-1442 Each year, the ASCO scientific committee selects the highest-rated abstracts from the Annual Meeting to be available for licensed Best of ASCO meetings around the world. The Florida Hospital Cancer Institute has chosen specific abstracts for presentation, based on the needs of oncology professionals. For more information or to register, visit FloridaHospitalCancerInstituteEvents.com or call (407) 303-1495, toll free to (800) 375-7761 x831-303-1945. This activity has been approved for 8.25 AMA PRA Category 1 Credit(s)™. ASCO is not the CME provider for this activity.

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