Florida md august 2015

AUGUST 2015 • COVERING THE I-4 CORRIDOR

Florida Hospital Celebration Health

Thoracic Program to Improve Outcomes with Innovative Robotic Expertise

Krystal

professional basketball player coach loves the game

Our team of renowned orthopedic and sports medicine specialists helped Krystal get back on the court after a knee injury.

Now she’s back to grabbing rebounds and making lay ups. Orlando Health Physicians provide expert care for professional athletes and weekend warriors, and partner with you to manage your health – with convenient locations throughout Central Florida.

For your health. Choose Orlando Health Physicians.

Call 321.841.3724 or visit OrlandoHealth.com/Physicians ALTAMONTE SPRINGS • CLERMONT • CONWAY • DR. PHILLIPS • HUNTERS CREEK • KISSIMMEE L AKE MARY • L AKE NONA • LONGWOOD • MAITL AND • OCOEE • ORL ANDO • OVIEDO • ST. CLOUD

contents 4

AUGUST 2015 COVERING THE I-4 CORRIDOR

 COVER STORY

A revolutionary, robot-assisted thoracic surgery program at Florida Hospital Celebration Health is improving outcomes in the fight against lung cancer and esophageal cancer.

PHOTO: PROVIDED BY FLORIDA HOSPITAL

The new Thoracic Surgery Program provides minimally invasive surgical approaches, ongoing studies and lasting solutions. The advanced minimally invasive procedures offered expand treatment options for patients, including those who are elderly and frail and may otherwise not be candidates for traditional thoracotomy.

The program founder is renowned thoracic surgeon Farid Gharagozloo, M.D., F.A.C.S., an expert in robotic surgery, esophageal surgery and thoracic oncologic surgery. He specializes in minimally invasive surgical approaches for benign and malignant esophageal disorders and advanced thoracic malignancies.

The world of robotics has become truly a game changer in terms of outcomes, especially in thoracic surgery, much more so than ever imagined,” says Dr. Gharagozloo. “In the chest, the robot is an instrument that improves the risk of surgery, which is a huge thing.”

ON THE COVER: Renowned thoracic surgeon Farid Gharagozloo, MD, FACS, of Florida Hospital Celebration Health’s new Thoracic Surgery Program.

20 ANTERIOR CRUCIATE LIGAMENT (ACL) INJURY, REPAIR AND RECOVERY IN YOUNG ATHLETES 23 THE SPORTS PREPARTICIPATION EXAMINATION 26 EIGHT GOOD REASONS TO FINANCE YOUR MEDICAL OFFICE EQUIPMENT

PHOTO: PROVIDED BY FLORIDA HOSPITAL

12 CASE STUDY: HOW ONE MEDICAL GROUP SAVED OVER $500K IN MEDMAL BY SUPPORTING GOOD CAUSE-INDEPENDENT DOCTORS CAN GET $1000S BACK

DEPARTMENTS 2

FROM THE PUBLISHER

3

HEALTHCARE LAW

9

ORTHOPAEDIC UPDATE

10 PULMONARY & SLEEP DISORDERS 14 MARKETING YOUR PRACTICE 16 CANCER 18 BEHAVIORAL HEALTH

FLORIDA MD - AUGUST 2015

1

FROM THE PUBLISHER

I

am pleased to bring you another issue of Florida MD. As physicians, you know that providing a disability diagnosis can be difficult for a parent to hear; and these parents will rely on your guidance to identify the best plan for their child’s development. I am pleased to remind Florida physicians of the support, education and therapy services offered at UCP of Central Florida, a not-for-profit charter school and therapy clinic helping children ages birth to 21 achieve their optimal potential according to their abilities. UCP offers options for families such as integrated onsite therapy during the school day and/or outpatient therapy and rehabilitative services. Please join me in supporting this truly wonderful organization and the good work they do.

Best regards,

Donald B. Rauhofer Publisher

UCP’S EDUCATION AND THERAPY PROGRAMS UCP’s education and therapy programs are geared toward children with all kinds of disabilities and delays including cerebral palsy, spina bifida, Down’s syndrome, autism, speech and language delays, developmental delays and rehabilitative needs stemming from injury. UCP’s education and therapy teams collaborate closely with physicians and other professionals to provide each child with a comprehensive interdisciplinary approach where families are an essential part of the team.

In addition to the educational programs (available for infants through high school), UCP’s Physical Therapy focuses on preserving, developing and restoring physical function. Speech Therapy develops verbal and non-verbal communication skills, as well remediation of oral-motor and feeding challenges. Occupational Therapy programs aim to improve fine motor, self-help, sensory motor and visual perceptual skills. All three disciplines utilize diverse approaches, techniques, devices, physical agents and modalities to help each child reach their individual goals.

Services are provided at UCP’s six campuses as part of their in-house educational program, as well as on-site outpatient therapy, summer enrichment and services at some local community facilities. Many education programs are free of charge for eligible children. Therapy services most common funding sources are Medicaid, commercial insurances and private pay. You can positively impact the 65,000 Central Florida youth who have a least one disability by referring them to the ‘Experts for children with Special Needs.’ Learn more at www.ucpcfl.org.

COMING UP NEXT MONTH: The cover story is about The Digestive and Liver Center, PA. Editorial focus is on Pediatrics, Advances in NICU’s and Autism.

ADVERTISE IN FLORIDA MD

PREMIUM REPRINTS

For more information on advertising in Florida MD, call Publisher Donald Rauhofer at (407) 417-7400, fax (407) 977-7773 or info@floridamd www.floridamd.com

Reprints of cover articles or feature stories in Florida MD are ideal for promoting your company, practice, services and medical products. Increase your brand exposure with high quality, 4-color reprints to use as brochure inserts, promotional flyers, direct mail pieces, and trade show handouts. Call Florida MD for printing estimates.

Email press releases and all other related information to: info@floridamd.com

2 FLORIDA MD - AUGUST 2015

Publisher: Donald Rauhofer Photographer: Donald Rauhofer / Florida MD Contributing Writers: Heidi Ketler, Sajid Hafeez, MD, Jessica M. Frakes, MD, John Lovejoy III, MD, Syed Mobin, MD, Harrison Youmans, MD, Marni Jameson, Jennifer Thompson, Jeff Holt, Jason A. Zimmerman, G. Brock Magruder, 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.

HEALTHCARE LAW

Securing Health Information in Today’s High Tech World

By Jason A. Zimmerman and G. Brock Magruder The availability of information and the speed by which information is now transmitted are some of the most beneficial aspects of today’s technological world. There is always another side to every story, and that same availability and speed causes significant heartburn to entities in the healthcare space in relation to patient information, especially in those cases where the patient is a public figure.

For instance, on July 4, 2015, Jason Pierre-Paul, a defensive end for the New York Giants, injured his hand while lighting fireworks in South Florida. While Pierre-Paul suffered damage to his hand, including the amputation of one of his fingers, a troubling situation quickly arose when his medical chart leaked on ESPN Reporter Adam Schefter’s Twitter page to roughly 4 million people. Under the Health Insurance Portability and Accountability Act (HIPAA), Pierre-Paul’s medical chart clearly was protected health information, and should never have been released to the media, or anyone, without his consent.

Yet, who did what wrong and why were questions that many people could not address.

The initial public outcry was directed to Schefter and his audacity for publishing private information. Schefter’s post triggered an explosion of debate, criticism, contemplation of journalistic professionalism and ethics for publishing such sensitive, and potentially damaging information as Pierre-Paul is currently unsigned by his present team, costing him millions in future earning potential. However, legal scholars were quick to point out that third-parties, including reporters, investigators, media outlets and others are not bound by HIPAA and are under no obligation to protect the sanctity of protected health information.

HIPAA extends only to “covered entities,” which is defined as health plans, health care clearinghouses and health care providers who electronically transmit any health information. Of course, employees working for those “covered entities” would also be included.

Furthermore, when Congress enacted HIPAA in 1996, they provided only administrative recourse for a violation of the Act, and did not provide a private right of action for patients to sue in civil court. Courts around Florida and across the nation have routinely and consistently upheld the lack of a civil remedy under HIPAA, and while that may provide some comfort to companies working in the healthcare industry, there is still a level of vigilance needed by these entities when it comes to health information.

The Pierre-Paul incident, as well as the unfortunately high number of other leaks of health information of public figures in

recent years, demonstrate the control a covered entity has over its employees who actually possess the health inforJason A. Zimmerman mation and are in a position to leak the same info to third-parties is less than ideal. It is getting exponentially easier to transmit large quantities of information outside the confines of whatever security measures the entities have set up, and it takes constant updates, revisions and new policies to ensure adequate protections. While Schefter was forced to face down public outcry, and Pierre-Paul had his personal and private horror story broadcasted to the G. Brock Magruder world, Jackson Memorial Hospital, the entity where the leak occurred, could be the party left holding the “liability bag” and it is up to the covered entity to ensure their security policies are keeping up with the speed and ease by which information is transmitted.

Jason A. Zimmerman is an attorney with GrayRobinson, P.A. and member of its Litigation practice group. He has broad experience ranging from securities litigation to HIPAA to white collar and antitrust law. He can be reached at 407-244-5669 or jason.zimmerman@gray-robinson.com.

G. Brock Magruder III is an attorney in the Commercial Litigation and Insurance Defense Practice Groups with GrayRobinson, P.A. He can be reached at 407-843-8880 or brock.magruder@gray-robinson.com.



Be sure and check out our website at www.floridamd.com!

COMING UP NEXT MONTH:

The cover story is about The Digestive and Liver Center, PA. Editorial focus is on Pediatrics, Advances in NICU’s and Autism.

FLORIDA MD - AUGUST 2015 3

COVER STORY

Florida Hospital Celebration Health – Thoracic

Program to Improve Outcomes with Innovative Robotic Expertise

By Heidi Ketler A revolutionary, robot-assisted thoracic surgery program at Florida Hospital Celebration Health is improving outcomes in the fight against lung cancer, esophageal cancer and other thoracic diseases.

The new Thoracic Surgery Program provides minimally invasive surgical approaches, ongoing studies and lasting solutions.

The advanced minimally invasive procedures offered expand treatment options for patients, including those who are elderly and may otherwise not be candidates for traditional thoracotomy.

The program founder is renowned thoracic surgeon Farid Gharagozloo, M.D., F.A.C.S., an expert in robotic surgery, esophageal surgery and thoracic oncologic surgery. He specializes Florida Hospital Celebration Health is dedicated to providing patients with comprehensive care.

in minimally invasive surgical approaches for benign and malignant esophageal disorders and advanced thoracic malignancies.

“The world of robotics has become truly a game changer in terms of outcomes, especially in thoracic surgery, much more so than ever imagined,” says Dr. Gharagozloo. “In the chest, the robot is an instrument that reduces the risk of surgery, which is a huge thing.”

In most cases robotic surgery allows the surgeon to access afflicted areas with minimal incisions and increased visibility for greater success. In thoracic and esophageal conditions, it enables precise surgery, which translates into better outcomes in terms of immediate operative survival, cancer control and long-term survival. Additionally, blood loss, pain, hospital stay and risk of infection are dramatically reduced.

Dr. Gharagozloo is fellowship trained in minimally invasive treatment of lung, thoracic, esophageal and gastrointestinal disorders. He earned his medical degree from Johns Hopkins Medical School and received additional training at Mayo Clinic and Harvard Medical School.

His vast experience in robot-assisted thoracic surgery spans 30 years. He has published more than 200 peer-reviewed articles and coauthored the internationally recognized Textbook of Robotic Surgery. A unique approach to research has led him to pioneer several innovative surgical techniques that provide patients with greatly improved survival rates.

“Experience matters greatly when it comes to minimally invasive, robotic-assisted surgery,” says Dr. Gharagozloo, who was recently appointed medical director of cardiothoracic surgery at Florida Hospital Celebration Health. “It is one of the main factors to achieving the many positive outcomes that can result when using this procedure.”

Problems occur, he says, when surgeons are not experienced enough in the use of the advanced technology. “It’s really not a matter of the robot; it’s a matter of experience.”

THORACIC SURGERY ENHANCES FOREMOST ROBOTIC SURGERY PROGRAM PHOTO: PROVIDED BY FLORIDA HOSPITAL

The Florida Hospital Global Robotics Institute at Celebration Health is the first and largest organization of its kind in the world. It offers robotic techniques for a broad spectrum of disciplines: urologic and prostate; bariatric surgery; abdominal surgery; head and neck; and now thoracic surgery.

“Robotic thoracic surgery is meant to change the story of lung cancer in Florida, where the population is increasingly elderly with borderline physiology.”

According to Dr. Gharagozloo, the Thoracic Surgery Pro4 FLORIDA MD - AUGUST 2015

COVER STORY gram is four-pronged. It offers advanced robotic surgery expertise in the form of: 1) Treatment for patients 2) Continuing education through Florida Hospital Nicholson Center for surgeons.

3) Training for medical students.

4) Research through the Florida Hospital Global Robotics Institute.

Dr. Gharagozloo uses advanced minimally invasive techniques to treat many benign and malignant disorders, including: • Achalasia • Barrett’s esophagus • Gastroesophageal reflux disease (GERD) PHOTO: PROVIDED BY FLORIDA HOSPITAL

• Hiatal hernias • Swallowing disorders • Thoracic outlet syndrome (TOS) • Hyperhidrosis (excess sweating) • Myasthenia Gravis • Lesions and tumors in the lung and esophagus • Lung and esophageal cancers • Mesothelioma • Thymoma

Several of Dr. Gharagozloo’s dedicated medical team moved with him from Arizona.

His collaborative approach involves a multidisciplinary team to diagnose, treat and care for thoracic patients. He typically works in close partnership with pulmonology, gastroenterology, medical oncology, radiation oncology and other medical specialists to determine the best course of action.

In addition, the thoracic program combines screening and advanced robotic surgery as part of multi-modality therapy.

it’s too late, according to Dr. Gharagozloo.

“The government and leading medical associations encourage lung cancer screening, and Medicare and medical insurance companies are paying for it. They realize that this is the only thing that’s going to change the number of people with poor outcomes.”

“Part of our mission for the Thoracic Surgery Program here at Florida Hospital Celebration Health is to be the place where we begin to change the story and the epidemiology of lung cancer, first by increasing awareness,” says Dr. Gharagozloo.

A low-dose, spiral computed tomography (CT) scan every year is recommended for people ages 55-74 who have a 30 pack-year history or greater of smoking (number of cigarettes smoked per day/20 × number of years smoked). Findings from the National Lung Cancer Screening Trial showed that screening with CT scans compared to chest X-rays reduced lung cancer deaths by 20 percent.4

“The combination of early detection and a minimally invasive robotic operation has every chance of changing the story of lung cancer, just like mammograms changed the breast cancer story.”

“Lung cancer is a disease of older people. If the patient is not strong enough, they will have a lot of pain and complications with open-chest surgery. Some cannot survive it.

Lung cancer is the second-most diagnosed cancer in men and women and the leading cancer killer in the United States. Lung cancer causes more deaths than the next three most-common cancers combined (colon, breast and prostate).

“Medicare now pays for cancer screening, but it doesn’t help to find the cancer, if you have no way of treating it. Robotic surgery is now an excellent alternative.”

INCREASING AWARENESS HELPS SAVE LIVES

Florida is a multicultural melting pot, with a high incidence of smoking. This contributes to one of the highest lung cancer rates in the United States.

Surgery is one of the main therapies for the treatment of lung cancer and if the disease is caught early can provide a cure. But about 70 percent of people are diagnosed with lung cancer when

If a CT scan detects a lung nodule, people now have the option for a minimally invasive surgical procedure with curative intent.

Using robot-assisted surgical techniques, Dr. Gharagozloo and his team are able to remove the nodule through a few tiny incisions between the ribs.

Cancer of the esophagus is the only cancer in this country that is increasing, according to Dr. Gharagozloo, and the incidence FLORIDA MD - AUGUST 2015

5

COVER STORY has risen greater than 350 percent among white men since the mid-1970s(1,2,3). It’s the reason that investigating esophageal cancer (EC) is a high priority for the National Cancer Institute, he says.

The two major kinds of EC are squamous cell cancer and adenocarcinoma. According to the National Cancer Institute, adenocarcinoma struck four people per million in 1975, but that rate rose to 23 people per million in 2001.5 Often esophageal cancer is diagnosed at an advanced stage because there are no early signs or symptoms. Smoking and heavy alcohol use increases the risk of esophageal squamous cell carcinoma. Gastroesophageal reflux disease and Barrett’s esophagus have been associated with increased risk of esophageal adenocarcinoma.

Contributing to the trend is reliance on medication. “For over 30 years we’ve been treating reflux with pills that relieve the symptoms rather than fix the problem. In the 60s and 70s, we treated chest pain by putting a nitroglycerin pill under the tongue. It didn’t fix the problem, just the symptoms.

“Now we’re treating reflux symptomatically with a purple pill. We feel better, because the gastric acid doesn’t hurt. But it’s still going into the esophagus and burning it. When you treat it chemically, you don’t know the damage is happening.”

Reflux is a “disease of the good life,” says Dr. Gharagozloo. “It is associated with obesity, which is an epidemic in America, and it’s worse in older people.”

He cautions that increased pressure in the abdomen, such as from obesity, pregnancy, coughing or straining during bowel movements, may increase the risk of hiatal hernia. Hiatal her-

nia is associated with an increased risk of Barrett’s esophagus, a condition in which the normal squamous esophageal lining is replaced by specialized or intestinal columnar epithelium.

“So if you’re going to reduce your risk of esophageal cancer, you need to change your diet, and the specialists need to fix hiatal hernias and reflux.”

MINIMALLY INVASIVE THORACIC SURGERY EXPANDS OPTIONS FOR FRAIL PATIENTS Thoracic surgery has recently emerged as a specialty unto itself, apart from cardiovascular surgery. “Today thoracic surgery is specialized in diseases that affect lungs, chest and esophagus, as opposed to heart. This differentiation is important, because this focus has led to greater sophistication in treatment and surgical techniques,” Dr. Gharagozloo says.

For the past 13 years, Dr. Gharagozloo has been a roboticsurgery pioneer, exploring new frontiers to achieve the benefits of traditional surgery using minimally invasive surgery – which results in the least disruption to normal body functions.

His specialization is rooted in the understanding of the human stress response to thoracotomy. He explains that when the chest is opened and boney and muscle tissue is cut, the stress response results in hypercoagulation. It is an evolutionary response in mammals created over millions of years to preserve life, but in surgery it is an undesirable side effect that can produce bad outcomes.

Dr. Gharagozloo recalls the experience that inspired his interest in minimally invasive surgery as a way to work around the phenomena. He was a new resident at Mayo Clinic watching in awe as surgeons performed lung surgery. “I felt I was watching the gods of surgery. They took the lung out, and it was like a ballet.”

State-of-the-art imaging technology helps diagnose Thoracic Outlet Syndrome.

The next day the patient inexplicably died of a pulmonary embolus.

“Now, 30 years later, we know it is because of a cascade of hormonal changes that triggers hypercoagulation during thoracotomy. After a lot of research, it became very clear to me that the patient would not have had that outcome if he hadn’t gotten the large incision.”

PHOTO: PROVIDED BY FLORIDA HOSPITAL

In hypercoagulation, there is an increased tendency for clotting of the blood, which may put a patient at risk for obstruction of veins and arteries (phlebitis or pulmonary embolism). Excessive clotting can cause heart attack, stroke, damage to the body’s organs or even death.

“This understanding is the foundation of everything we do in my practice. After our extensive study, it became very clear that if (a surgeon) is going to make a difference, you have to stay under the body’s 6 FLORIDA MD - AUGUST 2015

COVER STORY

“We do a lot of work on this in my lab, and we’ve found that when a surgeon makes three little holes in the chest, you are under the radar of body’s hormonal response. All of a sudden you are factoring out significant morbidity and mortality by doing robotic surgery. It’s a big game changer, because thoracic surgery has high risk.”

The research also revealed the limitations of conventional laparoscopy. Dr. Gharagozloo explains that the chest is a three-dimensional structure, and regular laparoscopy The Thoracic Surgery Program uses a multi-disciplinary approach in the treatment of thoracic conditions. is two-dimensional. “Depth perception is a problem in the lutionary procedure has been associated with a lower likelihood chest (using laparoscopy). It’s not good enough,” says Dr. Gharaof neurovascular complications and offers improved results with gozloo. less pain and a faster recovery.

Additionally, the laparoscope is a straight instrument. “It’s as if the surgeons don’t have hands. The surgical robot brought the wrist back and turns out to be the instrument to do the surgery well,” he says.

RESEARCH LEADS TO REVOLUTIONARY TECHNIQUES

Other conditions where Dr. Gharagozloo has pioneered innovative robotic surgical techniques with significantly better results are achalasia and diseases affecting the muscle of the esophagus, and mesothelioma.

MEET DR. GHARAGOZLOO

Dr. Gharagozloo’s significant clinical and research interests include robotic thoracic surgery, surgery for advanced thoracic malignancies and surgery for benign and malignant esophageal disorders. They have led him to pioneer several innovative surgical techniques, including a new procedure for the treatment of gastroesophageal reflux disease (GERD) and robotic surgery for thoracic outlet syndrome.

Dr. Gharagozloo is among the world’s most experienced thoracic surgeons in robot-assisted surgery. He was one of the first to demonstrate the benefits of robotic thoracic surgery in 2003, while practicing in Washington, D.C. It was during his 18 years on the Georgetown and George Washington University Medical Center faculty and as head of the Washington Institute of Thoracic and Cardiovascular Surgery.

Robotic-assisted gastroesophageal valvuloplasty is a revolutionary surgical procedure that continues to show promise for severe GERD sufferers. The treatment minimizes or eliminates reflux symptoms in as little as three weeks after surgery. Dr. Gharagozloo is one of the leading surgeons in the world using this technique. He has been recognized for his innovative approach and the improved outcomes he has achieved for his patients.

Dr. Gharagozloo says he joined Florida Hospital Celebration Health for a number of reasons, including its location in a fastgrowing region of the country, where the population is older and has a high risk of lung cancer. His move was an opportunity to introduce new robotic thoracic surgery techniques as part of the elite Florida Hospital Global Robotics Institute at Celebration Health and the Florida Hospital Nicholson Center, which has provided training to more than 50,000 physicians from around the world.

The thoracic outlet is in an area between the base of the neck and armpit. Thoracic outlet syndrome occurs when the bundle of nerves and blood vessels that travel through it – from the chest to upper extremities – becomes pinched. For cases where pain and numbness are chronic, with little or no relief achieved through other methods, surgery may be recommended.

Because the surgical area can be difficult to reach using traditional methods, Dr. Gharagozloo pioneered a robotic-assisted approach that allows for partial removal of the first rib. This revo-

He also hopes to impact the future of medicine by sharing his knowledge with colleagues and students of the new University of Central Florida College of Medicine via multiple educational and training initiatives.

Dr. Gharagozloo’s Thoracic Surgery Program at Florida Hospital Celebration Health is his third such program. He developed the first at George Washington University Medical Center in FLORIDA MD - AUGUST 2015

7

PHOTO: PROVIDED BY FLORIDA HOSPITAL

hormonal radar,” says Dr. Gharagozloo.

COVER STORY Washington, D.C. The second is the University of Arizona (UA) Thoracic Oncology Program.

PHOTO: PROVIDED BY FLORIDA HOSPITAL

Prior to coming to Celebration, Dr. Gharagozloo was professor and chief of thoracic surgery, robotic cardiothoracic surgery and esophageal surgery and the Southwest Thoracic Oncology Program at the University of Arizona Medical Center. In 2012, the year he and his team moved from Washington, D.C., to Tucson, he says, there were about 4,000 robotic operations per year east of the Mississippi and 50 west of the Mississippi.

“We were very successful in instituting the University of Arizona. We went from 70 cases per year to over 800. That really shows that the patients are there. These people could not have had anything done for them in the past.”

Dr. Gharagozloo is a diplomate of the American Board of Thoracic Surgery and board member of the Society of Robotic Surgery. Other professional memberships include the Southern Thoracic Surgical Association, the Society of Thoracic Surgeons, the American College of Surgeons, the Society of Laparoendoscopic Surgeons, the Thoracoscopy Society of Arizona, the Priestly Society of Surgery and Clinical Robotic Surgery Association.

A dedicated care coordinator is available to help patients with navigating through the discharge planning process.

CELEBRATION IS A GREAT MOVE

PHOTO: PROVIDED BY FLORIDA HOSPITAL

Dr. Gharagozloo is thrilled that he and his team are now working at Florida Hospital Celebration Health.

“We’ve had the most amazing welcome by everyone. My team and I are so happy. Our jobs and careers are our life. This is family. This is everything for us, and we really treasure it,” he says, adding, “This is definitely the crowning move of my career.”

He notes that several on his dedicated medical team moved with him from Arizona. He praised his staff – from the nurse practitioner and thoracic care coordinator to the operating room staff to the office staff. “It does take a village; it’s not a one-person show at all.”

“This hospital is among the most technologically advanced in country. The patient rooms showcase the latest in technology. All is designed to accommodate the patient – from the luxury hotel approach to patient care to the fountains and music. This is truly a wonderful, healing place,” Dr. Gharagozloo says.

References available upon request.

For more information, visit www.Celebration Thoracic.com or call (407) 303-3827. 

8 FLORIDA MD - AUGUST 2015

Dr. Gharagozloo showcasing the technology used at Florida Hospital Celebration Health.

CENTER FOR ADVANCED THORACIC SURGERY 410 Celebration Place, Suite 302-B • Celebration, FL 34747 Office Phone: (407) 303-3827

ORTHOPAEDIC UPDATE

What is a Rotator Cuff Tear and How Can It Be Treated?

By Corey Gehrold Making the bed. Mopping the floors. Putting the dishes away.

Sure, they’re mundane tasks. But what happens when you have so much pain in your shoulder you can’t even complete the most common of household chores?

“I couldn’t work around the house, I couldn’t go to the gym and it was really affecting my overall quality of life,” remembers Troy Timberman, a recent rotator cuff repair patient of Bradd G. Burkhart, M.D., a board certified orthopaedic surgeon specializing in sports medicine, knee and shoulder surgery at Orlando Orthopaedic Center.

But that was before his surgery with Dr. Burkhart. Today, a mere 10 weeks later, he says his shoulder is almost back to 100 percent and it gets better by the day. “I’ve never been so happy to take a shower,” he jokes. “I can lift both my arms above my head and work out and swim without any pain whatsoever. I have full range of motion again and it’s great.”

WHAT IS A ROTATOR CUFF TEAR?

The rotator cuff is a group of muscles and tendons that surrounds the shoulder joint. These tendons and muscles connect the upper arm to the shoulder blade and provide stability while helping the shoulder rotate and function.

“A tear to one of these tendons can cause intense pain, a decrease in range of motion and instability in the shoulder,” says Dr. Burkhart. “When the patient has failed all nonsurgical, conservative treatment methods we recommend surgery to provide relief and a return to function.”

Dr. Burkhart explains that surgery to repair a torn rotator cuff involves reattaching the torn tendon to the head of the upper arm bone (humerus). Partial tears may only need a debridement, or trimming. He says tendons can tear as a result of overuse or injury; and most rotator cuff tears occur as the result of wear and tear, putting people over age 40 at a greater risk.

“Unfortunately, surgery is often the only treatment option for a complete tear, as was the case with Troy,” comments Dr. Burkhart.

Using this method, patients are in surgery for less than an hour and are able to return home the same day as Bradd G. Burkhart, MD the procedure.

“During surgery, we insert a small camera into the shoulder joint,” explains Dr. Burkhart. “Using the arthroscope and other precision tools, we reattach the torn tendon to the bone using small incisions which makes for a faster recovery time with less pain.”

What is the Recovery Process for Rotator Cuff Tears?

Following surgery, patients should experience gradual, progressive relief, however it may take three to six months for a patient to fully recover from the procedure.

“I felt better right after surgery,” says Timberman. “I’m still going through physical therapy and regaining my strength, but every day it gets a little easier and I know in the end the payoff is the great benefit.”

Most patients report improved shoulder strength and less pain after they are fully healed from rotator cuff repair surgery.

“Once healed, most patients regain shoulder strength and a range of motion that is the same as what they experienced before their injury,” says Dr. Burkhart.

For Troy, having his rotator cuff repaired has made an incredible difference in his everyday life.

“I’m so thankful I had this done,” he says. “If you’re experiencing shoulder pain, get in and see a specialist like Dr. Burkhart.

The sooner you’re done with surgery, the sooner you can start to feel better and you don’t have to worry about it anymore.”

To view Mr. Timberman’s full patient testimonial, visit OrlandoOrtho.com.  Bradd G. Burkhart, MD, performing an arthroscopic rotator cuff repair.

HOW ARE ROTATOR CUFF TEARS TREATED?

There are both nonsurgical and surgical options for treating rotator cuff tears.

Nonsurgical treatments for a rotator cuff tear include: • Rest • Avoiding activities that cause shoulder pain • Anti-inflammatory medications, such as Advil and Motrin • Strengthening exercises and physical therapy • Steroid injection If nonsurgical methods fail, surgery may be required.

“For most patients, strength will not improve without surgery” says Dr. Burkhart. “Luckily, advances in surgical techniques allow us to repair most rotator cuff tears arthroscopically using the latest minimally invasive techniques.”

�

Orlando Orthop�dic Center

JOINTcENTER

Troy Timberman, a recent patient of Bradd G. Burkhart, M.D., says his recent rotator cuff repair has allowed him to return to the gym and household chores without restriction and he couldn’t be happier. “I can work out and swim without any pain whatsoever. I have full range of motion again and it’s great.”

FLORIDA MD - AUGUST 2015

9

PULMONARY AND SLEEP DISORDERS

Central Sleep Apnea Sleep disordered breathing disorder is characterized by abnormal respiration during sleep. There are four major sleep related breathing disorders. Central sleep apnea, Obstructive sleep apnea, sleep related hypoventilation disorders and sleep related hypoxemia disorder. Central sleep apnea (CSA) is a disorder characterized by repetitive cessation or decrease of both airflow and ventilatory effort during sleep. Condition can be primary or secondary. Secondary CSA can arise in medical condition, drug or substance, or high altitude periodic breathing. Central sleep apnea associated with cheyne stokes breathing (CSB) is particularly common especially among patients who have heart failure or have had stroke. Central sleep apnea may emerge during titration of CPAP in patients previously diagnosed with obstructive sleep apnea. This syndrome termed complex sleep apnea (CCA) is a controversial topic in sleep literature and has been a difficult to treat obstructive sleep apnea. As many as 6.5% of patients with obstructive sleep apnea may develop emergent or persistent central sleep apnea with CPAP treatment. Central apnea can alternatively characterized by hyperventilation or hypoventilation.

Hyperventilation encompasses most of the type of central apnea.

Hypoventilation related to CSA occurs in condition like drug or substance abuse there is alveolar hypoventilation is so severe that central apneas occur when the patient falls asleep because the wakefulness stimulus to breathe disappears.

Predominant central apnea is uncommon and is seen in less than 10% presenting for PSG. In the general population, the prevalence of central sleep apnea is less than 1%. CSB-CSA has been reported in 25-40% of patients with heart failure and in 10% patients who have had a stroke.

Presence of CSA in heart failure is independent risk factor for higher mortality. One study showed the prevalence of CSA at 30% in a population of patients in stable methadone program. CSB-CSA is characterized by classic a cre-

scendo-decrescendo pattern that typically occurs periodicity of 45 seconds or greater cycles. ICSD-2 specifies that at least 10 central apneas and hypopneas per hour of sleep should occur, 10 FLORIDA MD - AUGUST 2015

By Syed Mobin, MD accompanied by arousals and derangement of sleep structure.

During polysomnography a central apnea event is conventionally defined as cessation of airflow for 10 seconds or longer without an identifiable respiratory effort. In contrast obstructive apneic event has ventilatory effort during the period of airflow cessation. Central sleep apnea appears to be higher among individual who are elderly, male, have certain co morbid conditions. Central sleep apnea associated with Cheyne Stokes breathing is prevalent among individuals with heart failure who are male, older than 60 years have atrial fibrillation or have daytime hypocapnea. (PCO2<38 mmHg).

CSA is common after stroke. This was illustrated by prospective study showing 70% patients develop sleep apnea within 72 hours after stroke. CSA was detected in only 7% of patients 3 months after stroke. There is no relationship of likelihood of CSA and location of stroke.

Patients with CSA typically present with symptoms with disrupted sleep, excessive sleepiness, poor sleep continuity, insomnia, inattention and poor concentration. In general daytime sleepiness is less than that observed with obstructive sleep apnea

and insomnia is more prominent. CSA is typically associated with another medical condition, and therefore, patients often report the symptoms of the coexisting condition. CSA is strongly associated with atrial fibrillation/flutter.

Management of CSA is controversial. No clear guidelines available on when or whether to treat central sleep apnea in the absence of symptoms, particularly when central sleep apnea is discovered after polysomnogram is performed for another reason.

Clearly when symptoms are present treatment is warranted. The decision to treat should be made on an individual bases. Up to 20% CSA patients, CSA resolve spontaneously. If patient is not symptomatic, observation may be only appropriate step. Since many patients with CSA improve spontaneously after several months of continuous positive airway pressure CPAP therapy, expectant management with CPAP is appropriate in most cases.

Patients who do not improve, options include changing the mode of positive airway pressure to either Adaptive Servo Ventilation ASV or bilevel positive airway pressure BIPAP with backup rate.

ASV may have a slightly larger magnitude of effect. In addition Re-emergence of central events may be of concern with BIPAP

PULMONARY AND SLEEP DISORDERS but not ASV. For these reasons ASV is generally preferred to BIPAP with a backup rate when available and affordable. ASV provides a varying amount of inspiratory pressure superimposed on a low level of CPAP, with backup rate. The magnitude of the inspiratory pressure provided by the device is reciprocal to changes in peak flow, determined over three to four minute moving window. Thus peak flow that are lower than the average peak flow induce an increase in the amount of inspiratiory pressure, conversely, peak flow that are higher than average peak flow induce a decrease in the amount of inspiratory pressure. The back up respiratory rate can be set automatically by the device or manually and is an important aspect of the ASV. Of note ASV should be avoided in patient with CSA due to symptomatic heart failure with reduce ejection fraction. This is based on preliminary results of SERVE-HF, a randomized trial of ASV versus standard medical therapy in patients with CSA due to symptomatic heart failure with a low ejection fraction < 45% in which ASV was associated with a 2.5% absolute increase in cardiovascular mortality compared with standard medical therapy. Supplemental oxygen may be effective in some patients with CSB-CSA due to heart failure and has been shown to improve ejection fracture. It is thought to work by decreasing the hypoxic drive and thus attenuating the hyperventilatory response to a change in PCO2. When comparing oxygen to ASV, CSA-CSR is reduced to greater extent by ASV than oxygen therapy over 8 weeks but oxygen therapy is better accepted. Any patient with central apnea and significant hypoxemia is a potential candidate for a trial with supplemental oxygen. Due to the heterogeneity of the central apnea syndromes, different medications aimed at improving central apnea include acetazolamide, theophylline and sedativehypnotic agents. Acetazolamide has been shown to be effective therapy in primary central apnea and CSB in patients with heart failure and in the treatment of high altitude periodic breathing. Theophylline has been found effective in attenuating CSB and high altitude periodic breathing. Hypnotic agents Temazepam and Zolpedem have been shown to be effective under in non hypercapnic CSA and believed to work by consolidating the sleep pattern thus minimizing the instability in ventilation induced by sleep wake transitions. In summary treatment of central apnea may involve treating existing conditions, using positive airway therapy to assist breathing or using supplement oxygen.

Syed L. Mobin, MD, completed his Fellowship at Mayo Clinic Rochester, MN and Mayo Clinic Jacksonville, FL and is board certified in Pulmonary Medicine, Critical Care Medicine and Sleep Medicine. He is Department Chairman of Internal Medicine at Florida Hospital and is Director of CFPG Institute of Sleep Medicine. Dr. Mobin is also the clinical assistant professor at University of Central Florida School of Medicine, a member of the American Academy of Sleep Medicine, the American College of Chest Physicians, the Society of Critical Care Medicine and a Mayo alumni. Dr. Mobin is practicing with the Central Florida Pulmonary Group and can be contacted at (407) 841-1100 or by visiting cfpulmonary.com. î Ž

FLORIDA MD - AUGUST 2015 11

CASE STUDY: How One Medical Group Saved over $500k in MedMal by Supporting Good Cause -- Independent Doctors Can Get $1000s Back

By Marni Jameson One of the biggest budget items in any medical practice is malpractice insurance. Depending on the specialty, annual premiums can run from $10,000 a year to $50,000 per provider. In a large group of 15 or more specialists, the cost can approach half a million dollars. Yet when renewal time comes around, many groups just hit the default button and renew the same policy with the same company. They get “invested” in one plan, and don’t take the time to shop.

“That complacency can cost independent doctors thousands of dollars a year,” said Tom Thomas, a certified public accountant whose Winter Park, Fla., firm represents many independent medical groups.

A strong proponent of independent doctors, Thomas co-founded the Association of Independent Doctors, a two-year-old, fast-growing national nonprofit which now has members in 12 states. AID works to help doctors stay independent, which includes helping them save money and thrive financially. “Keeping America’s doctors independent helps keep costs down, access to care up, and is better for our communities and our country,” Thomas says.

Last year, AID and MagMutual, a leading provider of medical malpractice insurance, joined forces. MagMutual began offering every Florida member of AID a 10 percent discount on medical liability insurance.

This has amounted to a huge savings for many practices who like the idea of joining a worthy cause and getting money back. And not just a little money. Dozens of groups (whose agents or practice managers did not just auto renew their policies without shopping) have joined AID this year and saved thousands of dollars. To drive home the point, Thomas provided this actual case study of a specialty group he represents. The group’s 15 specialists were already AID members, and had paid a total of $7,500 in dues to support the efforts of the growing national association. (An AID membership costs $500 a year for each doctor.)

The group, whose name Thomas must keep confidential, had been buying malpractice insurance from a leading provider for years.

Thomas encouraged them to get a quote from MagMutual, which cut the premium down by more than 30 percent, resulting in more than $500,000 in savings over the next five years. (See chart.) A return of $510,000 over five years for a tax-deductible contribution of $37,500 (Dues for 15 doctors for five years) is just one of the many ways AID is helping independent doctors stay that way.

So the next time your malpractice insurance comes up for renewal, ask your agent to bring you a few proposals. If your agent doesn’t mention that a membership in AID could save you while benefiting the future of independent doctors, educate him or her, or contact us for a referral.

Marni Jameson is the executive director for the Association of Independent Doctors. You may reach her at 407-865-4110 or marni@aid-us.org. 

COMPARISON OF MEDMAL RATES FOR SPECIALTY GROUP 2015-2019 Other Major Insurer Annual Premium: $ 304,886* Total over five years: Participation Plan Initial Balance: $ 95,198** Value in five years: Projected 4.2% Dividend: $ 12,097 Value in five years: Net 5-Year Cost: MagMutual Annual Premium (Includes AID discount):

$ 208,244 Total over five years: Owners Circle: $ 0 Value in five years: Projected 4% dividend:*** $ 8,330 Value in five years: Net 5-Year Cost: Net Projected 5-Year Savings Counting $95,000 Forfeiture***

$ 1,524,430 ( $ 216,237) ( $ 60,485) $ 1,247,708

$ 1,041,220 $( 261,622) $( 41,650) $ 737,948 $ 1,247,708 −737,948 $ 509,760

*When the original insurer learned the practice was getting another bid, it immediately reduced the premium by over $60,000. ** If the group switched insurance companies, it would have to forfeit this accrued $95,000 benefit. *** Case study analysis and the content herein is for illustrative and educational purposes only and is not an offer to sell, or solicitation to purchase, any insurance product or service.

12 FLORIDA MD - AUGUST 2015

Together we can make a difference.

The Breast Care Center of Osceola Regional Medical Center is an all-in-one breast imaging center committed to the prevention, early detection, diagnosis and treatment of breast disease through compassionate, coordinated care.

We are proud to provide the latest technology and professional expertise of an onsite board certified radiologist specializing in breast images. From digital mammography with the comfort of mammo pads, to the powerful 3T MRI and MRI-guided biopsy, we offer the most advanced treatments.

Breast Care Center at Osceola Imaging Center 730 West Oak Street Kissimmee, FL 34741

www.OsceolaRegional.com

- Tejal Patel, M.D Womenâ&#x20AC;&#x2122;s Imaging Specialist

Certified in Breast Cancer

To schedule your next mammogram, please call (407) 518-4200 or visit OsceolaRegional.com for online pre-registration.

ORMC-6164 Breast Cancer Ad_Florida MD Magazine_8.375x11.indd 1

9/10/14 10:27 AM FLORIDA MD - AUGUST 2015 13

MARKETING YOUR PRACTICE

3 Easy Ways to Capitalize on Back to School Time Without Much Effort

By Jennifer Thompson Did you know spending for back to school is expected to reach $74.9 billion this year according to the National Retail Federation?

We all know back to school time is right around the corner; so, how can you take advantage of this time of year to grow your medical practice and fill empty appointment slots?

Read on to find out some simple things you can do to reach a new audience and earn new patients during back to school season without spending much time and effort.

With very few exceptions, just about every medical subspecialty can be applied to kids or teens without a lot of thought.

Dentistry, dermatology, internal medicine, ophthalmology, orthopaedics, otolaryngology, neurology, urology – you name it.

The fact is, lots of kids need what you do, and lots of parents are open to messages about their kids this time of year (especially when it comes to their health).

Here’s how to reach them.

better be good. Your concept should be kid-focused and easy to read.

Here are a few sample headlines for concepts you can apply to your practice: • Acne Issues? Clear Them Up Before the First Bell. (dermatology) • Make Sure Not Being Able to See the Board is Not an Excuse. (optometry) • Does Your Child Have Straight A’s on Their Health Report Card? Get the Checkup. Get the Grade. (family medicine/ pediatrics) After you’ve got a concept and headline, there are a few other things you need to make sure your content is viewed and remembered.

Here are some tips to create a good, relevant piece of collateral for your medical practice: • Choose an arresting image (one that makes you stop and say, “Aww”) • Go light on copy and let the imagery do the talking • Create an easy call to action (“Schedule Now at MyWebsite. com”) • Include bullets to catch the “reader” who just scans the page There are plenty of ideas out there, so make sure yours is compelling enough to deserve a glance no matter where it is.

That’s step two: choose your medium wisely. Whether that’s an in-office flier, web or social media ad, print piece, poster in the window of local community partners, billboard, etc., you want to put it in a place where the maximum amount of relevant eyes will see it to get you the highest return on investment.

2. REPURPOSE CONTENT Do you already have content from previous back to school seasons? How about general patient education pieces or news items Rework content you have already created with a back to school theme and put it on your website.

Create something that will capture the attention of your target audience: the parents.

1. CREATE COLLATERAL If you want parents to listen to your back to school checkup message, you’ve got to create something to capture their attention. What that is will depend on your budget.

Step one is determining your concept and step two is applying to the medium of your choosing.

Choose your message carefully for your collateral. You’ve only got one shot to engage the parent of your target patient, so it 14 FLORIDA MD - AUGUST 2015

MARKETING YOUR PRACTICE about what you do?

Consider rewriting these and tweaking them to have a back to school theme to put on your website, throughout your office or available at checkout. There is no need to reinvent the wheel, but if you’ve already got the content, make sure you’re getting the most out of the wheel you’ve got.

Spend 10 minutes rewriting a piece of education material and tie it in with this time of year. Hint: this also works around pretty much any major holiday.

3. PUT TOGETHER A RESOURCE CENTER ON YOUR WEBSITE Can you modify your website? Even if you can only create a news (blog) post, put something together to act as a “resource center” for back to school season. If you can change out image sliders and create pages, that’s great. Do that, too.

If not, use whatever means you have to put something together for parents in need of information (or for current patients visiting your site to share with people they know).

WHAT SHOULD YOUR RESOURCE CENTER INCLUDE? • Any relevant content you have (see no. 1 and 2 above) • Helpful links (perfect if you don’t have the content – link to a reputable website or news outlet that does) • Videos of your physicians discussing procedures, trends, topics and things to be aware of this time of year (or general pro-

cedures that could be applied to a younger population) • New patient forms • Appointment request information • A motivating call to action

NOW WHAT? Overwhelmed? You shouldn’t be. Tackle the items found above in small, manageable chunks. Start with what you’re most comfortable doing and move from there. Keep in mind that designing a piece of collateral will probably take the longest however between getting the design just right and going through the approval process.

Even with little to no budget, you can create momentum around back to school time to build your medical practice and find new patients in your community.

Now get to work before you’re late for class.

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.



Central Florida Pulmonary Group, P.A. Serving Central Florida Since 1982

Specializing in: • • • • • • • •

Asthma/COPD Sleep Disorders Pulmonary Hypertension Pulmonary Fibrosis Shortness of Breath Cough Lung Cancer Lung Nodules

Our physicians are Board Certified in Internal Medicine, Pulmonary Disease, Critical Care Medicine, and Sleep Medicine Daniel Haim, MD, FCCP

Eugene Go, MD, FCCP

Jorge E. Guerrero, MD, FCCP

Daniel T. Layish, MD, FACP, FCCP

Mahmood Ali, MD, FCCP

Roberto Santos, MD, FCCP

Francisco J. Calimano, MD, FCCP

Steven Vu, MD, FCCP

Jean Tan Go, MD

Francisco J. Remy, MD, FCCP

Ruel B. Garcia, MD, FCCP

Hadi Chohan, MD

Ahmed Masood, MD, FCCP

Tabarak Qureshi, MD, FCCP

Syed Mobin, MD, FCCP

Kevin De Boer, DO, FCCP

Downtown Orlando:1115 East Ridgewood Street East Orlando:10916 Dylan Loren Circle Altamonte Springs: 610 Jasmine Road

407.841.1100 phone | www.cfpulmonary.com | Most Insurance Plans Accepted FLORIDA MD - AUGUST 2015 15

CANCER

Improving Value Based Care for Esophageal Cancer with Advanced Techniques: Getting Closer

By Jessica M. Frakes, MD Without effective screening methods to detect esophageal cancer at the earliest stages, the majority of patients present with locally advanced or metastatic disease. The predominant contemporary tumor histology is adenocarcinoma with a location in the lower esophagus/gastroesophageal junction (GEJ).

Treatment of patients with adenocarcinoma of the GEJ is challenging. First, patients present with significant dysphagia and odynophagia associated with weight loss that limits their performance status. Second, many patients have multiple comorbid medical conditions which may limit their fitness for surgical resection. Third, the majority of patients with locally advanced disease have bulky mucosal disease that may preclude placement of esophageal stents and favor placement of jejunostomy (J) tubes, in anticipation of potential future surgery, to ensure adequate nutrition.

Number of Episodes

In this setting, multidisciplinary oncology treatment teams can provide rapid assessment and management. At Moffitt Cancer Center, for example, our patients are evaluated with endoscopic ultrasound (EUS) to determine the tumor (T) and nodal (N) stage. Once we determine the patient will benefit from neoadjuvant therapy with chemoradiation (stage T2N0 and higher), our endoscopic oncologists will place radio-opaque markers called fiducial markers above and below the gross disease. Our group recently reported the stability and safety of these markers in a large series of >1000 placements for GI tumors.1 Since our physicians see the patients in a joint GI clinic, we coordinate same day appointments with our medical oncology and surgical oncology colleagues so that we can facilitate shared decision making of that individual patientâ&#x20AC;&#x2122;s intended treatment course. Our institutional

treatment pathway is to proceed in this setting with concurrent neoadjuvant chemoradiation followed by re-evaluation and consideration for surgery, trimodality therapy.

Delivery of radiation to a moving esophageal cancer target is complex. Since the majority of our patients will undergo resection, our intent is to avoid cardiopulmonary complications by minimizing the delivery of high dose radiation to the lungs and heart. Fortunately, in the modern era, we have more techniques than ever before to improve the exact targeting of the tumor while maximizing normal tissue avoidance with a technique called intensity modulated radiation therapy (IMRT). This precision can be further enhanced by daily image guided radiation therapy (IGRT). We have shown that the use of IMRT/IGRT in esophageal cancer is associated with a significant decrease in toxicity.2 Our practice is to start with a motion study after the fiducial markers are placed endoscopically. This allows us to determine the amount of respiratory associated tumor motion. Our group has shown that compression belts can decrease motion by 50%.3 Thus, for each individual patient, we personalize the motion management strategy since we want to decrease the amount of normal tissue irradiated. Then, we proceed with a 4D CT simulation which allows us volumetrically to identify the moving target for treatment planning. In addition, we often obtain a 4D PET/CT in the treatment position to confirm the extent of locoregional disease and ensure no occult micrometastatic disease which would alter management.

At Moffitt, we have been incorporating these treatment techniques in the last five years. We have reported our results showing a near doubling of the traditional 30% pathoTreatment Interruptions and Hospitalizations logical complete response (pCR) rates and have and Degree of Weight Loss hypothesized that this may be due to the integration of fiducial markers with advanced planning and delivery techniques.4 The absence of 45 any increased surgical complications despite an <5% weight loss 39 40 increased radiation dose may also be, in part, >5% weight loss due to our surgical colleagueâ&#x20AC;&#x2122;s improvements in 35 minimally invasive/robotic techniques.

30 25 20

21 14

15 of Episodes Number 10

7

5 0 Treatment interruptions 16 FLORIDA MD - AUGUST 2015

Hospitalizations

With such a high rate of pCR rates, there is more interest than ever in pursuing personalized patient selection strategies to determine which patients could reliably be treated with an organ preservation approach. One promising tool is the Radiation Sensitivity Index (RSI) which was developed at Moffitt by Drs. Javier Torres Roca and Steven Eschrich. This molecu-

CANCER

Degree of Weight Loss and IV Fluid Use Number of times patients received IV fluids

lar diagnostic tool can identify an individual tumor’s likely response to radiation and has been validated in esophageal cancer.5 The future question thus becomes whether RSI will one day soon be a routine part of the initial evaluation of these patients so that the multidisciplinary team can identify upfront which patients will derive cure from definitive chemoradiation. Similarly, RSI may predict which patients will not experience response (non-responders) such that they could proceed directly to surgery; our group has previously shown that non-responders have equivalent outcomes to patients matched to the same stage who received upfront resection.6

140

120

120

<5% weight loss >5% weight loss

100 80 60

54

40 Given the fundamental shift in healthcare from a volume based to a value based system, 20 maximizing the oncologic benefit of care while retaining the highest quality of life and minimiz0 Number of times patients received IV fluids ing costly complications will be more relevant IV fluids frequency of use and important than ever before. Strategies such as team based multidisciplinary care with integration of advanced radiation and surgical techniques on treatment pathways are promising. We all look forward to the day when radiosensitive patients can be treated non-surgically and non-responders can avoid the potential morbidity of futile neoadjuvant therapy.

With these encouraging developments, there is renewed hope for improving the outcomes of patients with locally advanced esophageal cancers.

References available upon request.

Jessica Frakes, MD, is an assistant member at Moffitt Cancer Center in the Department of Radiation Oncology. She specializes in the treatment of patients with gastrointestinal malignancies. Dr. Frakes received her MD from the University of South Florida College Of Medicine and completed her Radiation Oncology Residency at University of South Florida/Moffitt Cancer Center.

She is experienced in the personalized use of advanced radiation techniques that include stereotactic body radiation therapy (SBRT), intensity modulated radiation therapy (IMRT), imageguided radiation therapy (IGRT), and liver-directed therapies such as radiation embolization. Her research interest includes improving outcomes and decreasing toxicity for the treatment of gastrointestinal cancers, with a strong focus on esophageal cancer. Dr. Frakes is a key member of the esophageal cancer research team, and she is dedicated to the advancement of multimodality treatments and the expansion of clinical trials. 

HELPING YOUR PATIENTS

GET BACK TO WHAT THEY LOVE

ORTHOPAEDIC SUBSPECIALTIES • SPINE • ELBOW • FOOT & ANKLE • HAND & WRIST • HIP • KNEE • ONCOLOGY • PEDIATRICS • SHOULDER • SPORTS MEDICINE • PAIN MANAGEMENT • PHYSICAL THERAPY

SAME DAY, NEXT DAY APPOINTMENTS AVAILABLE OVIEDO SATURDAY WALK-IN CLINIC NO APPOINTMENT NECESSARY | 9AM - 1PM

Downtown Orlando | Winter Park | Sand Lake | Lake Mary | Oviedo | Lake Nona

REQUEST YOUR APPOINTMENT AT ORLANDOORTHO.COM 407.254.2500 FLORIDA MD - AUGUST 2015 17

BEHAVIORAL HEALTH

The Mental and Health Issues of Substance Abuse

By Sajid Hafeez, MD

According to the National Alliance on Mental Illness, 50% of those affected with severe mental disorders will also struggle with issues of substance abuse. When working in mental health, it is an ever present factor to be considered when deciding how best to treat the patient. The question is, what came first, the chicken or the egg? In truth there is no definitive answer. Some patients may turn to illegal drugs to manage the symptoms of substance abuse. Others may develop mental illness from the use of illegal drugs. Regardless of how it began, it is important to understand that they are linked and as such treat both.

When a patient is initially admitted, substance abuse habits are questioned by the admissions therapists as well as the nurse.

Because of the nature of substance abuse, it is important for these professionals to establish a good rapport and convey a nonjudgmental attitude in order to elicit a truthful response to these questions. The majority of patients will be forthright about their habits, but some will attempt to hide their habits. Knowing this, the treatment team must remain conscious of the idea that a patientâ&#x20AC;&#x2122;s behaviors could effectively be the result of substances in the sys-

tem or withdraw symptoms. This can also be confirmed with a routine urine drug test. Depending on the substances ingested, a patient can present with any variety of classic mental illness symptoms from depression, to mania, to psychosis.

As stated, many will turn to substance abuse to manage their symptoms. This type of substance abuse happens significantly in those who are unable to afford medical insurance or treatment to manage underlying issues of mental illness. Marijuana is commonly abused to manage anxiety. Alcohol can be used to calm someone potentially manic or high strung. Those who are depressed may use uppers to make them feel better. For many, it will distract them from these mental illnesses or other stressors of life. A large risk of these behaviors is that many of these substances can exacerbate the symptoms of the underlying mental illness, making it harder to manage until the illness and the abuse both spiral out of control to the point that the patient ends up being admitted to a mental health facility.

So too, are there the recreational users who are using the drugs not to manage symptoms, but simply because they enjoy the induced effects. Many will discount the usage as something casual and benign without realizing how concurrent drug usage may eventually lead to long term cognitive and psychological damage. A way to explain it to them is in terms of the brainâ&#x20AC;&#x2122;s ability to rebound from being exposed to external chemicals. Every chemical that we ingest affects the brains chemical balance in some way or another.

This includes drugs both legal and illegal: caffeine, alcohol, THC, Cocaine. The body will naturally always try to adjust itself back to what is known to be as its natural state.

Tolerances are developed that cause the user to use a larger quantity to maintain the desired effect. Each time a substance is used, it pushes a little further on the brainâ&#x20AC;&#x2122;s ability to rebound from the exposure. Often times the ability to rebound is damaged. This is why some substance abusers can do the same drug time and time again, and eventually have a permanently altered behavior.

The trouble is that there is no way for a person to know what this tolerance limitation is. Some patients may smoke marijuana daily

18 FLORIDA MD - AUGUST 2015

BEHAVIORAL HEALTH for years and have minimal lasting damage. Other patients may react adversely on a 2nd or 3rd usage.

This is compounded in the fact that in procuring drugs illegally, the casual user has no way to verify the composition or purity of the substance. Many times patients will unwittingly be pushed over that rebound limit from a laced substance and will be faced with a difficult return path to wellness. Given a high enough quantity, just about any substance can alter the mind, pushing it into a state of psychosis.

Visit Our Website at

FloridaMD.com Your Medical Business Resource

When treating these patients, the team must be pre• Practice Management Advice pared to address both issues, the mental health and • Financial Information the substance abuse. A doctor will prescribe the pa• Pod Cast Interviews with tient different medications to help abate the physical symptoms of withdraw in the form of a medical stepSpecialists and Professionals down. While the doctor is able to attempt to return a • Medical Classifieds certain level of lucidity or control with medication, it • Back Issues with Informative falls upon the therapist to address the mental dependency of substance abuse. Because of this, inpatient and Interesting Stories stays commonly include drug group therapy where patients are able to address their issues and investigate For Information Please the link between their habit and their mental wellness.

Due to the addictive nature of substance abuse, this is a disease that may have more incidences of relapse and failure when compared to a mental health issue that is primarily about chemical balance such as depression. As such, the discharge planner must anticipate the need for secondary substance abuse outpatient care in addition to a standard therapist and psychiatrist, and may refer to groups such as Alcoholics Anonymous or Narcotics Anonymous.

Email: info@floridamd.com or call 407.417.7400

Because of the prevalence of substance abuse within the realm of mental health, those who treat any issues of mental health should stay well versed in the signs and symptoms of substance abuse. What are the physical symptoms? What are the psychological symptoms? In addressing these concerns, a treatment team is better able to manage the mental health as well. Ultimately it doesn’t matter which came first, the chicken or the egg. What is important is that both are addressed and cooked up in the kitchen of mental wellness.

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.



FLORIDA MD - AUGUST 2015 19

Anterior Cruciate Ligament (ACL) Injury, Repair and Recovery in Young Athletes

By John Lovejoy III, MD Injury of the anterior cruciate ligament (ACL) is one of the most common serious knee injuries in children. The frequency of ACL injuries appears to be increasing, possibly due to the rising popularity of year-round sports activities. In fact, in the National High School Sports-Related Injury Surveillance Study from 2011-12, ACL injuries were almost a fourth of all knee injuries in high school athletes. The study also revealed an interesting trend based on gender. Although more boys had ACL injuries compared with girls (23,794 vs 19,547) an increasing percentage, almost one third, of all knee injuries in girls are due to an ACL injury. For boys ACL injuries represented one fifth of all knee injuries. This study also highlighted the fact that ACL injuries occur in almost all sports activities — from dance to rodeo to cycling. Among girls, the trend is for increasing ACL injuries while playing soccer. Generally, ACL injuries are an unavoidable risk of participation in sports activities. Knee braces have not been shown to offer any clear advantage in preventing injury or re-injury, although many athletes wear them. ACL injuries tend to occur late in the game when players are fatigued, so it’s possible that conditioning exercises aimed at increasing lower extremity strength around the knee and improving endurance may offer some advantage in helping to prevent ACL injuries.

An ACL injury is almost always associated with immediate pain, swelling and reduced range of motion. The athlete may also report a popping sound or sensation. Sometimes, athletes may have a more subtle injury or, in the interest of continued participation in the sport, disregard the initial injury and seek care long after the swelling and pain has subsided. Young athletes presenting late with a chronic ACL injury typically describe a feeling of knee instability or dislocation, particularly when climbing or descending stairs, cutting, or stopping abruptly; they may also report pops, clicks or locking. When a young athlete describes these symptoms of instability consistent with a chronic ACL injury, a referral for evaluation by an orthopedic surgeon is appropriate even if the patient cannot recall a specific traumatic event, acute pain or swelling.

When I suspect an ACL injury has occurred, in addition to a careful physical examination, I check plain radiographs to rule out an associated fracture. I also usually order an MRI scan to better define the injury to the ligament and to help determine whether significant meniscal damage has also occurred.

My first steps in treating any orthopedic injury are forming a partnership with the family and establishing clear goals for treatment. With the family fully informed about all the options for treatment and the importance of timing relative to bone 20 FLORIDA MD - AUGUST 2015

growth, we can agree on a treatment plan.

Since ACL injuries are often associated with cartilage damage — for which there is no easy fix — continued participation in the sport precipitating the injury may place optimal long-term joint health at risk, making full understanding of all of the treatment options essential. For children under age 9, that’s often physical therapy and bracing with a reassessment later for possible surgical reconstruction. When surgical reconstruction is appropriate and the child’s skeletal growth is incomplete, using a growth plate sparing approach, such as an all-epiphyseal fixation technique, is required to minimize the risk of growth plate damage. This is a very different approach from the usual adult repair techniques. If skeletal growth is complete or nearly so, an adult technique may be preferable.

Surgical ACL repair usually takes about two hours and is performed under general anesthesia. Blood loss, even without a tourniquet, is typically minimal. In most cases, an anesthetic nerve block is placed to help reduce postoperative pain.

My personnel preference is to use autograft tissue for reconstruction. This avoids the minimal risk of disease transfer from cadaveric tissue and typically my patients tissue is much younger then the typically donor graft. Also, using cadaver grafts has been reported to have a higher rate of rerupture of the ACL. My most common repair technique uses an autologous graft from the hamstring tendons, but autografts from the iliotibial band and quadriceps tendon are also well described. The graft is fixed in place with a titanium button and a bioabsorbable bone screw.

If there has been no meniscal injury, the patient can begin bearing weight and initiate passive range-of-motion exercises immediately after surgery. After completing a six-month rehabilitation program, the patient can return to unrestricted play. We follow patients for two years after surgery and collect data on the details of treatments and outcomes so we can continuously improve our management of ACL injuries.

MY PERSPECTIVE ON PEDIATRIC ORTHOPEDICS I’m very interested in sports injuries and enjoy working with the kids and seeing their passion and energy. It’s great to be able to help them get back to the sports they love, and my work in pediatric orthopedics goes well beyond sports injuries. I find it exciting and rewarding that there’s so much we can do for kids with a wide variety of musculoskeletal problems.

The right treatment at the right time can enhance their quality of life for the rest of their lives.

Continued on page 22

The promise of a life in motion.

Hip dysplasia, a common cause of hip pain in adolescents and young adults, belongs in the differential diagnosis for patients presenting with unilateral or bilateral activity-limiting pain localizing to the hip, groin, buttock or knee. Clicking or snapping may be reported; locking may occur if the acetabular cartilage has torn. Hip dysplasia may be missed on radiographs if recently updated measurement criteria aren’t applied.

Nemours is proud to offer Periacetabular Osteotomy (PAO), a single-incision surgical procedure practiced by only a few orthopedic surgeons in Florida including Dr. Ryan Ilgenfritz. PAO gives adolescents with hip dysplasia the potential to return to unrestricted activity.

By improving acetabular alignment to correct for cartilage overloading in the dysplastic hip, PAO can improve a youth’s quality of life by: • • • • •

Ryan Ilgenfritz, M.D., M.S. Orthopedic Surgeon

extending the life of the natural hip normalizing the anatomy and function of the natural hip delaying or avoiding prosthetic hip replacement removing or reducing activity restrictions increasing range of motion

PAO is appropriate for correction of hip dysplasia after pelvic growth is complete, which may be as early as age 10.

Although an eight-week offloading period is required after PAO to facilitate bone growth and healing, a return to unrestricted activity is usually feasible within six months.

For questions about hip dysplasia, PAO or to refer a patient for evaluation, call (407) 650-7715 or visit Nemours.org/PatientReferrals.

Your child. Our promise.

FLORIDA MD - AUGUST 2015 21

We tend to take good orthopedic care for granted in this country, but during my annual trips to Haiti as part of a mission team, I’m reminded that access to quality orthopedic care impacts children’s lives in profound ways — for better or worse. During Haitian trips, we treat a wide variety of chronic orthopedic problems that rarely go untreated here — things such as neglected fractures, growth disorders and congenital deformities. When we can fix something for a child, no matter which country they’re growing up in, it provides durable benefits. Whether we’re restoring basic function for a child in Haiti or helping a Florida kid get back to peak performance for a shot at a college scholarship and maybe a future spot on a professional team, the rewards are life-changing.

The long-term impact that orthopedic procedures can have on a child’s development and adult quality of life inspires my professional passion for continuous improvement. As the director of our orthopaedic continuous improvement program, I try to look beyond simple geometry at things like function, infection rates and costs, so we can be sure we’re doing our very best in all of the parameters relevant to the patient.

Continuous improvement of care doesn’t stop with the individual patient, though. When we follow our treatments and their outcomes carefully, others can learn from our data.

So, while we’re working to achieve the best possible outcomes for the kids here in Central Florida, kids all over the world can share the benefits.

To speak to a Nemours pediatric sports medicine specialist, call (407) 650-7715.

Dr. Lovejoy is a pediatric orthopedic surgeon with clinical expertise in sports medicine and spinal deformity.

Prior to joining Nemours, he was a staff physician at Children’s National Medical

Center

and

assistant

professor of orthopedic surgery and pediatrics at George Washington University. After earning his medical degree from the University of Florida College of Medicine, he completed a residency in orthopedic surgery at Atlanta Medical Center and a clinical fellowship in pediatric orthopedics at Texas Scottish Rite Hospital for Children in Dallas. Dr. Lovejoy is certified by the American Board of Orthopaedic Surgery.



RAVENHEART GRAPHIC DESIGN • ILLUSTRATION • PHOTOGRAPHY •

407-292-6609 • 407-414-3359 22 FLORIDA MD - AUGUST 2015

The Sports Pre-Participation Examination

By Harrison Youmans, MD

As summer begins to wind down and a new school year approaches, parents are beginning to check off boxes of the late summer to-do list. One of those boxes invariably leads them to the doctor’s office for the annual sports pre-participation evaluation (PPE). As primary care physicians, the responsibility for completing these exams often belongs to us. Some form of PPE is required for high school athletic competition in all states, and it can be an important part of the overall heath care of our pediatric and adolescent patients.

on the form. A concussion history can be obtained at this time. A targeted cardiac history should also be obtained. Personal and family cardiac history questions recommended by the AHA include the following:

The PPE has become a nearly universal requirement for participation in sports in the United States at both the school and recreational levels. Initially born from the 12-point recommendations from the American Heart Association (AHA) designed to prevent Sudden Cardiac Death (SCD), the PPE has evolved into many different variations, with many states, leagues, and other organizations having their own requirements.

The PPE is designed to be a stand-alone exam to determine an athlete’s fitness to participate in athletic activities, and it is not a substitute for a comprehensive annual exam. For many of our young athletes, however, this may be the only contact that they have with a health care provider over the course of the year. For this reason, it is certainly a relevant component to the overall heath care of the athlete.

2. Unexplained fainting or near-fainting

It is important to note that the goal of the PPE is not to exclude athletes from participation, but to attempt to ensure their safety. Exercise, recreational activities, and organized sports offer multiple benefits, including medical, psychological, and social.

The exam gives the practitioner an opportunity to assess for any occult conditions that may increase the risk of participation, to ensure that chronic medical conditions are appropriately managed, and to identify previous injuries and allow for proper rehabilitation.

Depending on the nature of the relationship between the Primary Care Physician with the athlete, league, school, etc., the setting of the PPE may vary. Private clinician office visits provide a more personalized environment for the history and exam, and these are often performed by the patient’s personal physician, allowing for continuity of care. If the physician will be examining groups of athletes, such as for a school or entire team, a stationbased approach may be more efficient. Stations such as check-in, vital signs, eye exam, musculoskeletal, medical, and check-out with final clearance allow for multiple providers to participate at the same session and evaluate many athletes at once.

The history should be the initial component of the PPE. If the athlete is not of legal age, the parents should help to complete the history questionnaire, and ideally should be present throughout the exam. Any chronic medical conditions, hospitalizations, surgeries, current medications, and allergies should be listed

PERSONAL HISTORY 1. Chest pain/discomfort upon exertion 3. Excessive and unexplained fatigue associated with exercise 4. Heart murmur 5. High blood pressure

FAMILY HISTORY 6. One or more relatives who died of heart disease (sudden/ unexpected or otherwise) before age 50 7. Close relative under age 50 with disability from heart disease 8. Specific knowledge of certain cardiac conditions in family members: hypertrophic or dilated cardiomyopathy in which the heart cavity or wall becomes enlarged, long QT syndrome which affects the heart’s electrical rhythm, Marfan syndrome in which the walls of the heart’s major arteries are weakened, or clinically important arrhythmias or heart rhythms.

Following a review of the medical history, a screening physical examination is completed. Requirements will vary based on the school, league, or organization, but should include vital signs, visual acuity testing, HEENT, cardiovascular, pulmonary, abdominal, GU (males only), and musculoskeletal examinations.

The physical exam elements below constitute the remaining four of the 12 point evaluation as recommended by the AHA:

PHYSICAL EXAMINATION 9. Heart murmur 10. Femoral pulses to exclude narrowing of the aorta 11. Physical appearance of Marfan syndrome 12. Brachial artery blood pressure (taken in a sitting position) Any abnormalities on the physical exam should be evaluated prior to granting clearance to participate. For this reason, it is ideal to perform the PPE a minimum of six weeks prior to beginning competition. No one is happy when an athlete presents for a PPE the day before practice starts, and he/she has to be withheld from practice while a work-up is completed.

At this time, there are no consensus recommendations for any screening blood testing prior to sports participation for asymptomatic individuals. However, the NCAA does require that FLORIDA MD - AUGUST 2015 23

matriculating student-athletes have a screening sickle cell trait test, or that they provide documentation of previous test results.

This is not for purposes of exclusion, but provides athletic trainers and coaches with the knowledge to take preventative measures.

Electrocardiogram (ECG) screening has become an increasingly controversial topic in the United States in recent years, and is routinely performed in some European countries. Evidence regarding use of ECG as a screening tool in the U.S. is lacking, but is a rapidly growing field of study. While a set of criteria for evaluating normal findings on ECG in athletes has been developed and published, it is certainly recommended that this interpretation be performed by a well-trained and experienced practitioner.

athlete. This fee can then be returned to the school’s athletic training department to aid with the purchase of supplies for the upcoming year.

Finally, as with any office-based evaluation or procedure, the final piece of the puzzle for primary care physicians is billing.

Unfortunately, there is not a V-code designed to cover this particular type of examination. As mentioned before, this exam should also not inhibit the patient from obtained an annual comprehensive medical examination, so billing the sports PPE as such could be detrimental. Evaluation and management (E/M) code use is discouraged, as the PPE is a screening exam. Because of this complexity, the author’s practice has decided to simply charge a flat fee to the patient for completion of the service. Many PPEs are performed free of charge, especially if the physician has a relationship with the team. Another option if this is the case, especially for mass physicals, is to charge a small flat fee to each

loskeletal medicine- use of musculoskeletal ultrasound,

Harrison Youmans, MD joined the Orlando Health Orthopedic Institute in Summer 2014. Dr. Youmans is board certified in Family Medicine by the American Board of Family Medicine, with a Certificate of Added Qualification in Sports Medicine. His area of practice is Primary Care Sports Medicine, including non-operative muscuregenerative medicine, and treatment of concussion and other sports-related injuries and medical issues. Dr. Youmans can be contacted by calling (321) 843-5851.



Be sure and check out our website at www.floridamd.com!

DO YOU KNOW? Over 86,000 women and girls are diagnosed with a gynecologic cancer each year.

The Women’s & Girls’ Cancer Alliance (WGCA) has been offering support and education on gynecologic cancer for women in Central Florida for nearly 20 years.

WGCA’s social support groups and Teal Mentor network helps patients and survivors relieve stress which helps in their recovery.

Most women don’t know that the Pap smear ONLY detects cervical cancer. It does not detect ovarian, uterine, vaginal, or vulvar cancer.

Women’s & Girls’ Cancer Alliance 1855 West SR 434, Suite 282 Longwood, FL 32750

24 FLORIDA MD - AUGUST 2015

WGCancer.org info@wgcancer.org Ph:407.339.0024

FLORIDA MD - AUGUST 2015 25

Eight Good Reasons to Finance Your Medical Office Equipment

By Jeff Holt, PNC Healthcare Business Banking To provide your patients with high-quality care, you need to stay up-to-date on the latest advances. And to do so, that often means having the right equipment. You’re familiar with the hefty price tags attached to this equipment, which puts you in the position of having to decide whether to lease the equipment or buy it outright.

allow you to pay for what you use rather than tying up capital in a rapidly depreciating asset. Equipment Finance also provides possibilities for early replacement, easy moves, additions and changes where traditional financing can fall short or add significant expense.

Both leasing and purchasing have positives and negatives, and these vary according to the specific equipment you’re considering.

Renting is, at least at first, the more affordable option,1 but you need to think about the long term if you can. Here are some factors to help you make the decision.

4. A plan for staying on the cutting edge: Equipment Finance is not just a finance structure, it’s a plan; a plan to evaluate the assets required, how they are used and disposed of. And then develop a diverse finance strategy to acquire assets for a low monthly payment that supports your need to remain on the leading edge of technological advancement.

SOME OF THE PLUSES OF RENTING VERSUS BUYING: 1. Since you haven’t committed to ownership, you have the option to upgrade to newer technology as it becomes available.2 2. You can evaluate the equipment as you use it, and change to another brand or model without repercussions. (Note: You should examine your lease agreement carefully before signing it.3)

Broad asset coverage that can help drive better ROI across most asset classes and better financial performance in your new operating unit.

Some of the drawbacks of renting versus buying: • If this equipment is necessary to run your practice and you use it over many years, you’ll end up paying more in rental or lease fees than you would if you purchased it.7

3. Many leases include maintenance as part of the agreement, potentially saving you money and the hassle of finding someone to make repairs.4,5

• The equipment won’t count as an asset to your practice should you ever decide to sell.8

4. Buying equipment usually involves a time-consuming process of applying for credit.6 But when you start to consider how long you’re going to have and use this equipment, and how necessary it is to your practice, other issues may come to the forefront.

Once you determine that equipment finance might be a viable alternative, choosing a financial resource with deep healthcare experience is critical. More than in-depth knowledge of the assets, manufacturers and vendors of healthcare, an appropriate financial resource must demonstrate capital strength, depth of product offering and, perhaps most importantly, deep experience structuring financial transactions.

KEY BENEFITS OF EQUIPMENT LEASING Mark Tambussi, senior vice president and national manager of PNC Healthcare Finance said, “Providers across the country have discovered equipment leasing offers several benefits for the entrant into a new revenue stream, but we’ve found there are four key reasons to lease - 100% financing, improved cash flow, flexible structures and plans for technological advancement.”

Let’s break those benefits down: 1. 100% financing can preserve your precious capital and budget dollars. Also with a lower initial investment in new service lines, equipment financing can allow your new offering to be financially accretive…faster.

2. Improved cash flow can result. An affordable monthly payment for equipment/tenant improvement can support a separate P&L for the new service line.

3. Flexible structures, including leases and structured loans, can 26 FLORIDA MD - AUGUST 2015

CHOOSING A FINANCIAL RESOURCE

References available upon request.

Jeff Holt, vice president and local senior healthcare business banker for PNC Bank, has been with PNC for 28 years and has over eight years’ experience servicing only healthcare clients. Through this role, he supports medical, dental, and veterinary practices with revenue cycle reviews, specialized lending and healthcare banking services in Central Florida to the Gainesville area. He can be reached at 352.385.3800, or via email at jeffrey.holt@ pnc.com.



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 - AUGUST 2015 27

CURRENT TOPICS

Florida Hospital Tampa Expands Treatment Options for Patients with Pancreatic Cancer Using New Catheter Technology

Second site in the United States to use the RenovoCath™ Florida Hospital Tampa has started treating select pancreatic cancer patients using the RenovoCath,™ a novel catheter that was developed for targeted delivery of fluids to selected sites in the peripheral vascular system. Patients with locally-advanced pancreatic cancer are now being treated at Florida Hospital Tampa with the device that provides direct, local delivery of chemotherapy to the pancreas. This directed approach to therapy may help pancreatic cancer patients who were previously not candidates for surgery by reducing their tumor size and potentially providing a surgical option. Florida Hospital Tampa is only the second site in the country to offer this innovative, new procedure.

Dr. Alexander Rosemurgy, surgeon and co-founder of Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive and Robotic Surgery at Florida Hospital Tampa referred patients for the procedure. Dr. Rosemurgy is renowned for his experience, expertise and compassion in treating pancreatic cancer patients, and he and his team actively pursue new treatments for these patients.

“We are excited to have new ammunition to use in the fight for our pancreatic cancer patients with locally advanced disease,” said Dr. Rosemurgy. “These patients have a biologically unique type of pancreatic cancer. In treating the tumor itself directly, there is a much better chance for successful outcomes. Our patients who undergo direct chemotherapy treatment are on target to respond and do well.”

“Our team is focused on diagnosing and treating our patients with the most cutting edge medical technology for our patients,” Dr. Rosemurgy continued. “While the RenovoCath is an exciting new technology, physicians are familiar with the use of catheters and will not be confronted with new risks or a steep learning curve when using it clinically. This opens the door for widespread application of this technology, which offers an effective therapeutic option for patients with a unique type of cancer.”

According to the National Institute of Health, nearly 50,000 Americans will be diagnosed with pancreatic cancer in 2015. Florida Hospital Tampa is using the RenovoCath as a new tool for specific pancreatic cancer patients – those with locally advanced pancreatic cancer – whose options are often limited. Many therapeutic agents, including chemotherapy, have proven to be less effective when delivered systemically for cancer of the pancreas. The RenovoCath delivers chemotherapy directly to the pancreas via the arteries that feed the tumor. The ultimate goal with this approach is to increase the effectiveness of treatment and reduce side effects.

Dr. Paul Vitulli, an interventional radiologist at Florida Hospital Tampa led their first procedure. “The difficulties surrounding the diagnosis and treatment of pancreatic cancer are well known. It is very rare that pancreatic cancer is detected in its early stages. It is estimated that only 20 percent of patients diagnosed with pancreatic cancer can be considered for surgical resection. Treatment options for those with advanced disease commonly include radiation and/or systemic chemotherapy,” said Dr. Vitulli.

Patients with locally advanced, unresectable pancreatic cancer would benefit from the development of alternative treatment options.

“The RenovoCath is an exciting new tool to treat cancer,” Dr. Vitulli continued.

Patients benefit by administering a local intra-arterial infusion of chemotherapy directly in the region of the tumor itself. Benefits of a local intra- arterial chemotherapy infusion, in contrast to systemic IV infusion, potentially include less bone marrow suppression and fatigue, and less gastrointestinal problems such as nausea. A lower dose of chemotherapy may be required, and a greater tumor response is expected.

RenovoRx (www.renovorx.com) has developed the RenovoCath RC120 catheter, which is specifically designed for the isolation of blood flow and delivery of fluids, including diagnostic material and therapeutic agents, into selected sites in the peripheral vascular system. The ability to deliver these materials at high concentration to specific vasculature, safely and without perfusion overlap to other regions, is a central paradigm of the company’s technology. The company’s first product to market is the RenovoCath,™ which is currently being introduced in the U.S. RenovoRx is an early stage startup based in Silicon Valley, California, and its top financial backers include Golden Seeds, Astia Angels, Sand Hill Angels, The Angels’ Forum and The Halo Fund III, L.P. 

COMING UP NEXT MONTH: The cover story is about The Digestive and Liver Center, PA. Editorial focus is on Pediatrics, Advances in NICU’s and Autism.

28 FLORIDA MD - AUGUST 2015

2015

EDITORIAL CALENDAR

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.

JANUARY –

Digestive Disorders Diabetes

FebRUARY –

Cardiology Heart Disease & Stroke

MARCH –

Orthopaedics Men’s Health

ApRil –

Surgery Scoliosis

MAY –

Women’s Health Advances in Cosmetic Surgery

JUNe –

Allergies pulmonary & Sleep Disorders

JUlY –

imaging Technologies interventional Radiology

AUgUST –

Sports Medicine Robotic Surgery

SepTeMbeR – pediatrics & Advances in NiCU’s Autism OCTObeR –

Cancer Dermatology

NOveMbeR – Urology geriatric Medicine / glaucoma DeCeMbeR – pain Management Occupational Therapy

Please call 407.417.7400 for additional materials or information.

FLORIDA MD - AUGUST 2015 33

LIFE is AMAZING .

Within each nurse lives a story.

A story made of amazing moments. Uplifting lives with extraordinary medical skill and compassion. We thank them for their limitless strength and talent.

Because when you have what it takes to fight to save lives, youâ&#x20AC;&#x2122;re amazing.

-SYSTEM-00104

Explore more amazing stories at FloridaHospital.com