Florida Md December 2016

DECEMBER 2016 • COVERING THE I-4 CORRIDOR

HealthSouth Rehabilitation Hospital of Altamonte Springs Focusing on Personalized, Accelerated Care to Give Patients Back their Independence

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contents 4

DECEMBER 2016 COVERING THE I-4 CORRIDOR

 COVER STORY

PHOTO: DONALD RAUHOFER / FLORIDA MD

As a nationwide leader in rehabilitation services, HealthSouth Corporation has been known in the medical community for over three decades and operates 120 hospitals around the nation. In 2015, the company, already present in the state of Florida, expanded to Central Florida, bringing an exemplary level of post-acute care to the region with the opening of HealthSouth Rehabilitaion Hospital of Altamonte Springs. With 12 offices and hospitals located in other regions of Florida it had built a solid reputation for its comprehensive approach to rehabilitation of patients, including those dealing with traumatic injuries that require extensive rehabilitation services. With the opening in Altamonte Springs, HealthSouth provided new options to the Central Florida community, options to benefit patients with acute care needs and their families committed to getting them back home, getting them back their independence and living life to its fullest.

PHOTO: DONALD RAUHOFER / FLORIDA MD

ON THE COVER: HealthSouth Rehabilitation Hospital of Altamonte Springs

DEPARTMENTS 2

FROM THE PUBLISHER

3

PULMONARY & SLEEP DISORDERS

8

HEALTHCARE BANKING, FINANCE AND WEALTH

9

ORTHOPAEDIC UPDATE

11 MARKETING YOUR PRACTICE 12 CARDIOLOGY 18 HEALTHCARE LAW 20 DIGESTIVE AND LIVER UPDATE

FLORIDA MD - DECEMBER 2016 1

FROM THE PUBLISHER FROM THE PUBLISHER

II

am pleased to bring you another issue of Florida MD. . This time of year is special to all of us regardless of religious persuasion. It is especially important to children. However, it can be a particularly distressing Iam to bring you issueabandoned of Florida or MD hard toThe imagtimepleased for children that areanother neglected, liveMagazine. in abusiveIt’shomes.

Children’s Home Society of ine Florida trieswho to make better life children by finding loving either temporarily anyone is not afamiliar withforthethese March of Dimes and thethem workathey do home to through foster care or permanently through adoption. But there are a lot of children – nearly 20,000 – in Florida who can’t live safely with their families right now. They need more than Children’s Home Society always reinventing create newsome programs andcan services.

Coming next this very worthwhile of Florida … theythemselves need all oftous.

I hope of you find the time up to assist month is the annual Marchtofor Babies. a wonderful team-building for please visit www. organization in its efforts help theseIt’s special children.

To find out opportunity more information chsfl.org. Have a wonderful holiday season and a happy, healthy and prosperous New- Year.

Best regards, tions on how you and your family canNEXT join the march The or how to form team foron your COMING MONTH: cover storyafocuses The Florida Diabetes and Endocrine Center and Florida Hospital’s programs to address Prewhole practice. I hope to see some of you there.

Diabetes, Diabetes Management and Weight Loss. Editorial focuses on Donald B. Rauhofer Digestive Disorders and Diabetes.

Warm regards, Publisher The holiday season … a time for joy, for hope, for family.

But what about children who aren’t with their families this year … children who aren’t safe in their own homes?

Thankfully, these children have Children’s Home Society of Florida. Because of this 110-year organization, these kids can have hope during theRauhofer holidays – and throughout the New Year.

Donald B. You see, Children’s Home Society of Florida offers something thousands of kids have never before known: safety. When it’s not safe Publisher/Seminar for children to liveCoordinator at home anymore, at least for a little while – sometimes forever – Children’s Home Society of Florida embraces them, providing comfort, healing and security. But when the holidays come, it’s tough for these kids … they’re caught between painful pasts and uncertain futures … and they so desperately want to believe in something, to grasp onto that glimmer of hope.

When Join more than a million people walking in March of Dimes, March for Babies and They find it with Children’s Home Society of Florida.

Saturday, April 24th raising money to help give every baby a healthy start!

Invite your family and friends But there are a lot of children – nearly 20,000 – in Florida who can’t live safely with their families right now. They need more than 7am Registration 8am Walk to join you in March for Babies, or even form a Home FamilySociety Team. of You can also Children’s Florida … join they with need all of us.

It’s easy to help, to become a Champion The first step is to visit www. your practice and become a team captain. Together you’ll raise more money and sharefor Children.

Where chsChampionsForChildren.org to learn what it means to be a Champion – to be the voice for kids a meaningful experience.

Lakeinto Lily the Park, Maitland who can’t be heard without you. Take 90 seconds to glimpse plight of our community’s children – find out why they need you. Then, get involved. Register to become a Champion. Share Sometokeys success:kids.

AskBegin your friends, information on March Steps for New Users: your passion helptoFlorida’s the journey thatFor willmore change lives. family and colleagues to support you by for Babies please call: 1. Go to marchforbabies.org When we join together on behalf of kids, hundreds of thousands of voices will be heard. Our Phone: the (407) 599-5077 friends, family members and neighbors will better understand too-often hidden tragedy of 2. Click JOIN A TEAM Fax: (407) 599-5870 child abuse … and they’ll join the fight against it.

And, yes, funds will be raised so more children 3. Search for your team name in the why peopleand do prepared not donate that Central Florida Division can growreason up safe, healthy forislife. no one asked them to– and give we (don’t be shy)! search box.

341 N. Maitland Suitechildren 115 Our kids are not numbers cannot let them become statistics.

JoinAvenue, me in giving Emailing them is an easy way to ask.

Maitland, 4. Click on your team name hope and opportunities. Become a Champion for Children today. FL 32751 Learn more at www.chsChampionsForChildren.org, call (321) 397-3005 or email Paul.Soost@ 5.  done! Your personal page has been chsfl.org.You’re created for you and you are ready to begin fundraising! password for future reference.

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PULMONARY AND SLEEP DISORDERS

Halotherapy

By Daniel T. Layish, MD, FACP, FCCP, FAASM

The word Halotherapy comes from the Greek word “halos” meaning salt. While the potential benefits and therapeutic nature of salt has been known for centuries, it was not until the early 1800’s that the underground salt mines throughout Eastern Europe were noted to benefit various respiratory conditions. As the workers were mining the salt in these climate-enriched chambers, dry salt particles would be inhaled into the respiratory system.

The dry salt was discovered to be super absorbent, anti-bacterial and anti-inflammatory. Soon people with various conditions were spending time in these salt mines. In the mid-1900’s the Russians began working on a technology to replicate the dry salt particles in the air and developed the first halogenerator, a device that grinds pure sodium chloride into precise particles (several microns in diameter) and disperses the dry salt into a climate controlled room or chamber. This was the start of modern Halotherapy, which has been utilized for several decades throughout Eastern Europe and has begun to expand into many other countries including the United States and Canada. The small particle size is felt to be important to allow penetration deep into the lungs, since larger particles will simply be deposited in the nose, throat or large airways. The air in a halotherapy chamber is also filtered to remove contaminants and the temperature and humidity are well controlled.

As a pulmonologist, I initially became familiar with halotherapy through my care of individuals with Cystic Fibrosis. Cystic Fibrosis is a genetic disorder characterized by dehydration of the respiratory epithelial surface, resulting in impaired mucociliary clearance. In this disorder, thick tenacious secretions obstruct the lower airway and sinuses and provide an environment for chronic infection. Nebulized hypertonic saline has been shown (in well done randomized clinical trials) to improve pulmonary function and respiratory symptoms as well as reduce pulmonary exacerbation rate in individuals with cystic fibrosis. This may be referred to as “wet” salt therapy as opposed to halotherapy which is “dry” salt therapy. Nebulized hypertonic saline can sometimes cause bronchospasm, and not all patients can tolerate this therapy even when premedicated with a bronchodilator. In cystic fibrosis, halotherapy has some theoretical advantages over nebulized hypertonic saline. The prolonged duration of therapy (typically a 45-minute session) appears to be associated with a much lower incidence of bronchospasm then is seen in the setting of nebulized hypertonic saline. In addition, in the halotherapy mode of administration the salt particles are delivered to both the sinuses and the lower respiratory tract. After seeing anecdotal benefit in our patients with cystic fibrosis, we performed a clinical study, which confirmed that this therapy was well tolerated and the patients derived symptomatic benefit in terms of their sinus complaints. Other studies are planned to study this therapy further in individuals with cystic fibrosis.

The fundamental defect in cystic fibrosis is related to chloride transport and therefore there is a strong rationale for halotherapy in this particular disease. Anecdotally, I have seen patients with other respiratory diseases derive significant benefit from Halo-

therapy including bronchiectasis, chronic bronchitis, chronic sinusitis and allergic rhinitis. The hypothesis is that Halotherapy may help with respiratory illnesses by liquefaction of airway secretions thereby enhancing expectoration. There seems to be very little risk to this therapy other than the financial and time investment. There is certainly a theoretical basis for the possible benefit of halotherapy, given the known antiinflammatory and anti-infective properties of salt.

Currently, halotherapy is not covered by medical insurance companies. However, it is hoped that this may change as research is planned to try to prove the benefits that many patients have reported. Many halotherapy institutions offer a monthly pass that can make therapy more affordable than purchasing individual sessions. There is also an effort to develop systems that can deliver halotherapy in the home setting, avoiding the need to travel to a salt room. This is important since many people do not live close to a halotherapy center. It is worth noting that many patients have also noticed benefits in non-respiratory conditions, particularly dermatalogic conditions such as acne and psoriasis and research is planned in this area as well.

References available upon request. I would like to thank Leo Tonkin and Ulle Pukk for reviewing this manuscript.

Daniel Layish, MD, graduated magna cum laude from Boston University Medical School in 1990. He then completed an Internal Medicine Residency at Barnes Hospital (Washington University) in St.Louis, Missouri and a Pulmonary/Critical Care/Sleep Medicine Fellowship at Duke University in Durham, North Carolina. Since 1997, he has been a member of the Central Florida Pulmonary Group in Orlando. He serves as Co-director of the Adult Cystic Fibrosis Program in Orlando. Dr. Layish serves as the medical advisor for the Salt Room Orlando and also sits on the board of the Salt Therapy Association. He may be contacted at 407-841-1100 or by visiting www.cfpulmonary.com. 

FLORIDA MD - DECEMBER 2016 3

COVER STORY

HealthSouth Rehabilitation Hospital of Altamonte Springs – Focusing on Personalized,

Accelerated Care to Give Patients Back their Independence

By Katie Dagenais As a nationwide leader in rehabilitation services, HealthSouth Corporation has been known in the medical community for over three decades and operates 120 hospitals around the nation. In 2015, the company, already present in the state of Florida, expanded to Central Florida, bringing an exemplary level of postacute care to the region with the opening of HealthSouth Rehabilitaion Hospital of Altamonte Springs. With 12 offices and hospitals located in other regions of Florida it had built a solid reputation for its comprehensive approach to rehabilitation of patients, including those dealing with traumatic injuries that require extensive rehabilitation services. With the opening in Altamonte Springs, HealthSouth provided new options to the Central Florida community, options to benefit patients with acute care needs and their families committed to getting them back home, getting them back their independence and living life to its fullest.

Dr. Eliam Fuentes tests a patient’s balance using the Biodex Balance System™ SD.

Leading the nation in rehabilitation, HealthSouth accounts for 20 percent of the beds in the nation. The 50-bed, all private room, hospital in Altamonte Springs is often close to capacity, with the hospital seeing over 1,800 patients since it opened its doors in the fall of 2015.

For Robert E. Kent, DO, PM&R, Medical Director of HealthSouth Rehabilitaion Hospital of Altamonte Springs, the numbers are not surprising, it was about filling very specific needs in this area. “We were able to shape our hospital to the population of Central Florida. Rehab beds were at a shortage here with the aging population and the stroke rehab need, those living with multiple sclerosis, local veterans as well as those battling Parkinson’s disease. We decided to keep our approach broad, but at the same time specialize in neurological rehabilitation to focus on these patient populations.”

Dr. Kent, a physiatrist with a subspecialty in interventional pain management, joined the HealthSouth team in 2015. A Central Florida native, he was drawn to the endless possibilities that would result in bringing an established hospital system to a growing and aging community. “Being such a large corporation, HealthSouth has rehab down to a science, we have resources and each hospital can function and operate and focus on specialties needed in our patient population.”

“THE UPSWING OF MEDICINE” The Altamonte Springs facility employs a staff of more than 170. Dr. Kent and physiatrists Dana Clark Kuriakose, MD, PM&R, and Eliam Fuentes, MD, PM&R, maintain individual private practices and extend their services to include patients at HealthSouth. They are quick to point out what sets their teams and their services apart. First is clearing up a the misconception, that because “rehab” is in the hospital name, that it is the same as a skilled nursing facility.

PHOTO: DONALD RAUHOFER / FLORIDA MD

“At a skilled nursing facility a patient’s stay is a lot longer and they have approximately three to five hours of rehab a week. At HealthSouth, we are a hospital and as such we are regulated to do three hours of therapy per day,” explains Dr. Kuriakose.

Because of the intensity and scope of services, the average patient stay at HealthSouth is just 10-14 days. The therapy is intentional, focused, multidisciplinary and effective. HealthSouth reduces the number of readmissions to acute hospitals up to 60% better than skilled nursing facilities and home therapies.

“The biggest thing is to educate our patients about is that they’re not going to spend all day in bed. The goal here is to be 4 FLORIDA MD - DECEMBER 2016

COVER STORY out of bed, in the gym and working towards independence. For some that is terrifying and for some that is a welcome change,” says Dr. Kuriakose. “We almost take a second seat as a physician, because the real goal is to get their therapies and ultimately transition them home.”

Most HealthSouth patients are admitted from local acute care hospitals, although some are referred from home or other long term care facilities. Patients admitted to HealthSouth face complex situations resulting from stroke, spinal cord injuries, amputations, traumatic brain injuries, ALS and neurologic cases.

HealthSouth Altamonte Springs is also one of the few facilities in Central Florida certified in LSVT programs designed for Parkinson’s Disease. In addition, the facility is currently seeking Joint Commission certifications in stroke and brain injury.

For all patients though, regardless of their injury, there is a common denominator. Patients and their families must be committed and able to handle the intense rehabilitation they will undergo at HealthSouth.

“If you have a complex patient with many medical co-morbidities, it is a challenge to do therapies outpatient or at home,” explains Dr. Fuentes. “Most patients cannot tolerate home therapies and some think they can’t tolerate three hours of therapy, but many can and they do.”

Before a patient is admitted, he or she undergoes preadmission screening. Nurses do a CMS guideline screening, patients

PHOTO: DONALD RAUHOFER / FLORIDA MD

THE HEALTHSOUTH PATIENT

Dr. Dana Kuriakose discusses the treatment plan with a stroke victim.

are then evaluated by a physiatrist and physical and occupational therapists.

“Every patient is exposed to multiple therapies. Patients engage in physical therapy and we see how they perform. If they can tolerate it, it’s a good predictor of their success in an inpatient rehabilitation facility,” says Dr. Fuentes.

PLANNING DISCHARGE AT ADMITTING For HealthSouth patients, discharge planning begins at admitting.

“What we want to do is make a roadmap at the highest and safest level possible. Our case managers begin planning ahead at

PHOTO: DONALD RAUHOFER / FLORIDA MD

The onsite gym features top of the line equipment to help patients achieve their rehab goals.

FLORIDA MD - DECEMBER 2016

5

PHOTO: DONALD RAUHOFER / FLORIDA MD

COVER STORY

Dr. Dana Kuriakose meets daily with staff in “team conferences” to discuss patient treatment plans.

day one. As soon as a patient is medically stable they begin therapy. Research shows that the sooner a patient begins therapy, and starts moving after an acute event, the better they will recover.

Ultimately, that is our goal,” says Dr. Kent.

This includes case managers planning ahead for everything from durable medical equipment to dialysis treatments, so that when patients can return home they have everything that they need to sustain their rehabilitation success.

PATIENT OUTCOMES For patients, being part of an acute care facility means that they will move around and benefit from it. HealthSouth prides itself on extremely low infection rates, half the benchmark for national rehab hospitals.

“This is exceptional, especially considering we are working with post surgical patients,” says Dr. Kent. “We also have very low wound rates, thanks to an excellent wound care team that rounds daily.”

THE “TEAM CONFERENCE” At HealthSouth the multi-disciplinary team is charged with executing a road map that will get patients out of their hospital bed and home. HealthSouth has all the specialties of an acute hospital including infectious disease, cardiology, gastroenterology, internal medicine, neurology, neuropsychology, psychology, wound care, nephrology and in house dialysis.

These specialists, comprising the team, meet two to three days per week in what is called the “Team Conference”. Working cohesively as a group in these “team conferences” they ensure that patients are getting all of the services they need to get them home faster, healthy and infection free.

6 FLORIDA MD - DECEMBER 2016

“The ‘team conference’ is similar to a tumor board in a cancer center.

We discuss the small things that will impact our patients,” explains Dr. Kent. “We all sit around the table and review a patient’s progress and their benefits and deficits.”

At the table you will find the entire team including the physician, a pharmacist, physical therapist, occupational therapist, speech therapist, registered dietitian, nurse and a case manager. The first team conference takes place within the first week of admission after the patient has fully been assessed. Together the 15-20 members of the team come up with one solidified idea to make a patient more functional with the ultimate goal to start addressing a patients needs early on.

“It’s a meeting of the minds,” says Dr. Kent. “Every portion is so valuable and will help the patient turn the corner.”

PHYSIATRISTS - THE QUALITY OF LIFE SPECIALISTS Physiatry is a specialty that began during war time, caring for the military during the first and second World Wars. The physiatrists at HealthSouth point out that while not as well known in the United States as in other countries, it is a specialty that is growing exponentially.

“What we have found in this specialty is that not only do we learn valuable lessons from veterans, but overall better options and outcomes are due in great part to the patients who came before them. Battle wounds became a learning ground for those treating patients with the most profound and traumatic injuries,” says Kent.

For those who have made their careers in physiatry, such as Drs. Kent, Kuriakose and Fuentes, it is a specialty of the heart.

Each has a unique path that led them to this field.

Dr. Kent spent part of his residency at the poly trauma unit at James Haley Veterans’ Hospital in Tampa treating traumatic brain injuries. For him, overseeing a patient’s rehabilitation from a devastating injury and observing their strength, and the strength of their families recommitted him to the specialty.

“These patients made me fall in love with the specialty all over again. These patients had multiple traumatic injuries, from TBI’s to spinal injuries, burns and amputations. To be part of the team that helped them find their new normal was incredibly gratifying.

I consider physiatrists the quality of life specialists in medicine.”

For Dr. Kuriakose the speciality is incredibly rewarding because she can oversee a patient’s progress. “We get to see patients over a long period of time, their progression and as they move back into the community.”

It was while in residency at Harvard that she treated Boston Marathon bombing victims and witnessed first hand the strong sense of support within the rehab community.

“This support is invaluable for patients. I consider it a privilege to be a part of the team that gives them the physical and emotional tools to regain their independence.”

Dr. Fuentes understands first hand the life changing effects of rehabilitation. At the age of two his daughter suffered a stroke and became a patient at HealthSouth in Puerto Rico.

“I changed my career goals after that. Other specialities don’t have the ability to see the direct results of treating complex issues. My daughter was completely dependent when she became a patient at HealthSouth Puerto Rico. And now, here we are years later, she is a normal 11 year old and has recovered completely. I often share this Dr. Robert E. Kent tests a patient’s driving ability using the TRAN-SIT® Car Transfer story with my patients. It helps us create a rapSimulator which helps patients relearn and practice driving skills. port. I don’t presume to know what every patient is feeling, but I’ve been there in a hospital, crying and I have been ties include partial weight bearing equipment, to gate training, in their shoes.” to IREX, a new modality that is a virtual reality therapy system WHY HEALTHSOUTH? which uses immersive video gesture control.

At HealthSouth, the physiatrists and therapy teams work in For Dr. Fuentes and his colleagues time spent at HealthSouth tandem, providing an acute rehabilitation facility that offers pais a critical component to a patient making important strides in tients the ability to be monitored and have their therapy directed his or her recovery. from all angles. This aids in overall positive outcomes and pa“I would advise them to trust our care and providers. We have tients return to an independent, albeit perhaps new normal, life. the best therapy teams, we have the best nursing teams and we The gym, located in the center of the facility, is a focal point have an excellent team of doctors dedicated to our patients.” of a patient’s time at the facility and boasts the most advanced HealthSouth Altamonte Springs has plans to eventually expand beyond its 50 rooms, to meet the growing needs of the Central Florida community. For its current and future patients, and the Central Florida A therapy team member works with a patient using the GestureTek® IREX™ System. This cutting-edge therapeutic exercise program can be made specifically for individual patient needs. medical community, Dr. Kent hopes Patients’ movement data during various activities is then measured, recorded, and reported on they will embrace the incredible value a real-time basis by IREX’s sophisticated camera technology. of acute rehabilitation.

PHOTO: DONALD RAUHOFER / FLORIDA MD

equipment. Patients can move easily from one modality to the next during their multiple visits to the gym each day. Modali-

“It’s the upswing of medicine,” he says. “With the work we are doing here, we can make it so patients don’t have problems later on. Very very small things can make big differences later on - think of it as the butterfly effect with medicine.”

With the commitment of its staff, therapists and physicians, HealthSouth Altamonte Springs continues to spread its wings, and reach those with acute rehabilitation needs. In turn they provide patients with a road to recovery in order to return home, to a new normal and regain a level of independence despite their injuries.  FLORIDA MD - DECEMBER 2016

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PHOTO: DONALD RAUHOFER / FLORIDA MD

COVER STORY

HEALTHCARE BANKING, FINANCE AND WEALTH

Attracting and Keeping Your #1 Asset Invest in Finding the BEST Team!

By Jeff Holt, CMPE, VP, Senior Healthcare Business Banker with PNC Bank When my clients and I go to review their financials we tend to focus on the numbers from their financial statements to measure their success. But the largest Asset for their practice never shows up on any balance sheet, and needs their attention at all times. In most cases their success is driven by this key asset, which is their staff or better…. their Team!

As someone who works with people every day, you know how important it is to hire the right team members. But how do you find them? One way is to create an effective job listing. Here are some rules for writing a job description that works.

Think about your practice and what sort of person would work best there—specifically, not just generally. What makes the people in your practice different? Whether it’s that they’re ready for anything or are compassionate and caring, the clearer your listing is about the right person, the easier it is to find him or her.1 Ask them how they would describe what they do— especially if you’re looking to attract someone similar. Find out what they feel the job’s responsibilities are, and ask them what they’d search for if they were looking. They might have a clearer sense of what someone looking for a position like theirs might want or need to know.2 When you have a sense of who you want and what makes your practice special, write your job listing, which should include the job’s title, purpose, scope and duties. List the responsibilities and the job’s relation to other positions in your practice. The clearer you are at the outset, the easier it is to get worthwhile candidates.3 Note exactly what the job entails. It’s a waste of your time and job seekers’ time to call them in for an interview, only to find they’re not qualified or interested in the position once they know more about it. Your listing should do some of the culling for you.4 That means using keywords to cover the different ways a candidate might search, including variations on the job title itself.

For example, “office assistant” and “administrative assistant” tend to cover the same duties, so use both terms in your job description.

If you’re looking for particular areas of expertise, put them in the description, as someone skilled in those areas might be searching using those words.5 Hiring the right person—the one who will fit well and stay—is crucial to making your practice run smoothly so you can focus on your own work. Put time into getting the listing right, and you’ll have an easier time finding the person you need.

Who do you trust with helping you make sure that you attract and retain these high valued assets of the practice? Are they doing a great job at it, or do they / you need help?!

8 FLORIDA MD - DECEMBER 2016

If you need help…. just ask me for assistance!

References: 1- http://profitable-practice.softwareadvice.com/optimize-joblistings-to-attractcandidates-0214/ 2- Ibid.

3- http://hiring.monster.com/hr/hr-bestpractices/recruiting-hiring-advice/jobdescriptions/ sample-job-descriptions.aspx 4- Ibid.

5- http://profitable-practice.softwareadvice.com/optimize-joblistings-to-attractcandidates-0214/ The third-party trademarks referenced in these articles are owned by and are the registered trademarks of their respective third-party owners. There is no affiliation, sponsorship or endorsement relationship between PNC or its affiliates and any such third party.

PNC is a registered mark of The PNC Financial Services Group, Inc. (‘‘PNC’’) Business Insights for Dental Professionals/Business Insights for Healthcare Professionals is prepared for general information purposes by Manifest, LLC and is not intended as legal, tax or accounting advice or as recommendations to engage in any specific transaction, including with respect to any securities of PNC, and do not purport to be comprehensive. Under no circumstances should any information contained in the presentation, the webinar or the materials presented be used or considered as an offer or a commitment, or a solicitation of an offer or a commitment, to participate in any particular transaction or strategy, nor should it be considered legal advice. Any reliance upon any such information is solely and exclusively at your own risk. Please consult your own counsel, accountant or other advisor regarding your specific situation.

Neither PNC Bank nor any other subsidiary of The PNC Financial Services Group, Inc. will be responsible for any consequences of reliance upon any opinion or statement contained here, or any omission. The opinions expressed in these materials or videos are not necessarily the opinions of PNC Bank or any of its affiliates, directors, officers or employees. Banking and lending products and services, bank deposit products, and Treasury Management products and services for healthcare providers and payers are provided by PNC Bank, National Association, a wholly owned subsidiary of PNC and Member FDIC. Lending and leasing products and services, including card services and merchant services, as well as certain other banking products and services, may require credit approval.

Jeff Holt is a Senior Healthcare Business Banker and V.P. with PNC Bank’s Healthcare Business Banking and is a Certified Medical Practice Executive. He can be reached at (352) 385-3800 or Jeffrey.Holt@pnc.com. 

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ORTHOPAEDIC UPDATE

Outpatient Rotator Cuff Surgery Gets Patient Back to Work and Enjoying the Simple Things in Life

By Corey Gehrold Ronald Colletti isn’t one to sit around. When the pain in his shoulder started preventing him from doing ordinary, everyday activities, he knew he had to take action.

“It’s amazing, the simple little things that we all take for granted, like brushing your teeth or working on the computer, were taken away from me for a while,” says Ronald. “And you want to get back to work and get functional again.”

Ronald turned to Bradd G. Burkhart, M.D., a board certified orthopaedic surgeon specializing in sports medicine, knee and shoulder surgery at Orlando Orthopaedic Center, for evaluation and treatment. Together, they determined outpatient rotator cuff surgery was the best treatment option to get Ronald back on the job and enjoying the little things in life he cherishes.

“I actually had two surgeries; the right shoulder in 2013 and the left one two months ago,” says Ronald. “Pretty much I got almost full range of motion (back). I had a lot of help from the whole rehab team; just by doing the exercises and working hard, getting my arm over my head again.”

creases. Some studies have shown that rotator cuff tears may be as high as fifty percent in people aged sixty-five and older.

Bradd G. Burkhart, MD

WHAT EXACTLY IS THE ROTATOR CUFF? The shoulder joint is composed of three bones that make up a ball-and-socket: the upper arm bone (known as the humerus), the shoulder blade, and the collarbone. The head of the upper arm sits in a shallow space in the scapula. It’s kept in place by a group of muscles and tendons known as the rotator cuff. The cuff encapsulates and stabilizes the shoulder joint, enabling one to raise and rotate the arm.

HOW DOES THE ROTATOR CUFF GET DAMAGED? The tendons of the rotator cuff can get torn, resulting in significant pain and loss of arm mobility. Injury and degeneration over time are the two primary reasons for rotator cuff tears.

According to the American Academy of Orthopaedic Surgeons, every year about 200,000 Americans require shoulder surgery to repair their rotator cuff, and another 400,000 Americans undergo surgery for related rotator cuff tendonitis or for partial tears.

The natural wear and tear of the shoulder joint over the long term, especially in the dominant arm, can lead to a degenerative rotator cuff tear. Other factors leading to common rotator cuff injuries include:

Although not every patient will meet all requirements to have an outpatient rotator cuff surgery, those who do usually decide to undergo this minimally-invasive procedure.

• Repetitive stress: sports with repetitive motions such as tennis, baseball or weight lifting can increase the chances of a tear.

Manual jobs such as painting, carpentry and other overhead chores can put additional stress on the shoulder joint and lead to overuse tears.

“Surgeries performed in the outpatient setting are typically found to be safer, more convenient and less stressful for patients and their families,” says Dr. Burkhart.

Other benefits of outpatient rotator cuff surgery include: • Patients return home the same day as surgery, compared to several days in the hospital with an inpatient procedure

• Reduced blood supply: tendons need an ample supply of blood in order to replenish and to heal. In older individuals, the rotator cuff tendons receive less and less blood, which can result in tears.

• Easier access when checking-in and checking-out at an outpatient center when compared to a typical hospital • Decreased risk of infection • Recovery starts at home, often leading to increased comfort and a reduced period of time required to fully heal “My wife and I came to the center, the team greeted me, they told me what I was going to be up against,” says Ronald. “(The surgery lasted) 45 minutes. (Then) you’re out, you’re done. It’s amazing.”

Americans in general are living longer, healthier and more active lifestyles than ever before. As individuals get older, their risk of musculoskeletal problems, including rotator cuff injuries, in-

Ronald says his rotator cuff surgery with Dr. Burkhart helped him get back to work and his favorite activities.

FLORIDA MD - DECEMBER 2016

9

ORTHOPAEDIC UPDATE • Trauma: traumatic events/injury can also cause tears in the rotator cuff. Lifting a grandchild, placing the luggage in an overhead compartment, falls, and lifting heavy objects are just some of the ways to tear the rotator cuff Typical symptoms of a torn rotator cuff include: • Pain while resting at night, coupled with increased discomfort when lying on the concerned shoulder • Experiencing pain when raising or lowering the arm • A feeling of weakness in the arm when raising or rotating it • Cracking sounds or sensations when the shoulder is moved in certain ways

ROTATOR CUFF TREATMENT OPTIONS Both surgical and non-surgical alternatives exists for treating a torn rotator cuff.

Non-surgical options include: • Resting the damaged shoulder and/or using a sling to immobilize it • Stopping the activities that generate the shoulder pain • Over the counter anti-inflammatory medicine such as aspirin and ibuprofen

• Physical therapy and exercises to strengthen the shoulder.

Stretching and solidifying the muscles around the shoulder joint can reduce pain and limit further injuries • Steroid or cortisone injections may relieve pain and swelling if other non-surgical methods prove ineffective

RESULTS AND RECOVERY FOR ROTATOR CUFF SURGERY Surgery is the first step on the road to full recovery. Rehabilitation through physical therapy plays a crucial role in restoring the strength and mobility of the shoulder and allowing the patient to get back to their normal routine. It can take anywhere from three to six months after surgery for the shoulder to fully recover.

Ronald credits the rehabilitation staff at Orlando Orthopaedic for his swift post-surgical recovery.

“From Becky and Michelle and the therapy team, the admin team all the way up to the surgical team - Lynn and Dr. Burkhart are fantastic,” says Ronald. “Every time I called the office with a question, within a few hours, I had an answer. The experience has been fantastic. A tough experience made really easy by Orlando Orthopaedic.” 

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MARKETING YOUR PRACTICE

Why Content Marketing Matters to Medical Practices By Jennifer Thompson We hear it all the time.

Content is king. Content marketing really works. Seriously, guys. It really does.

Marketing professionals are always talking about how effective content marketing is, but does content marketing matter to medical practices? The short answer is yes, content marketing works just as effectively in the medical field as it does for all other consumer-focused businesses. According to NeilPatel.com, 78% of consumers believe that organizations providing custom content are interested in building good relationships. That’s probably something you want to develop with your patients, don’t you think?

So let’s start at the beginning… what is content marketing and how can you use it to fill empty appointment slots at your clinic?

Well, content marketing is the process of creating relevant, valuable content to attract new audiences. By distributing targeted content, you can clearly define your practice and establish yourself as a go-to source.

But wait there’s more. According to ContentMarketingInstitute.com, 90% of businesses currently use content marketing, and why wouldn’t they? Content Marketing Institute explains that content marketing leads to: • Increased sales • Cost savings • Better customers who have more loyalty So you see, content marketing does matter to your medical practice, but where do you start?

WHERE TO BEGIN

It is important to understand that content is not the only key to appearing high in search engine rankings, but it definitely helps.

You also need: • A strong Search Engine Optimization (SEO) strategy. This strategy is a guide to getting your site listed on the first page of google using specific keywords and phrases.

• A social media presence. Having a presence on top social networking sites including Facebook, Twitter and Google Plus will help you connect with millions of users. According to statista.com, “78 percent of U.S. Americans have a social media profile today.” So, by having a social media presence, you can connect with a large audience; and the more you you engage with users on social media, the higher you will be listed on search engine result pages.

• To constantly monitor your website via online reputation management. ORM is the process of understanding what patients are saying about your practice and then determining the best ways to improve what is being said online.

HOW TO GET YOUR SITE LISTED ON THE FRONT PAGE

1. Write about relevant content: Dragonsearch.com states that 61% of consumers’ decisions are influenced by custom content.

When it comes to creating content, you should write about what

you know. Some great examples to help get you started are: • Patient testimonials • Discussion of new treatment technology in your field • Risk factors for potential diseases • Quick top 10 lists - this is particularly effective when creating custom content.

These lists are short reads (something many patients will appreciate), but they still help you establish authority.

Also, it is important that you use meta keywords in your writing to link to other pages on your site. If your website doesn’t have the ability to do so then it’s time to build a new website that does have these features.

2. Set a schedule and stick to it: Creating content is a neverending process. It’s important to continuously generate new posts such as video testimonials, articles or blog updates on a weekly basis. Posting 2 to 3 pieces each week will help you boost your ranking.

3. Promote your hard work: At the end of the day, you’re not writing for your health, you’re writing to boost business, right?

So, why would you write, publish and then not tell anyone?

You can earn more patients by: • Spreading word of your website. Mention it to friends and family, at networking events, or have your doctors put a link to the website on their presentation slides when they host meetings.

• Posting about your website on social networking sites. Including a link on your social networking profiles can drive more traffic to your website.

If you need help spreading the message, you can always contact someone who specializes in the field. Ultimately, the goal is to spread news of your website to the world.

THE TAKEAWAY Building good relationships with patients is essential for medical practices today. If you create custom content frequently and spread the word on it, then you will increase your position on search result pages and establish yourself as an expert in the community.

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.  FLORIDA MD - DECEMBER 2016 11

CARDIOLOGY

Soteria Cardiac Platform: New Technology for the Identification of Patients with Atherosclerosis and Guideline Management of Associated Risk Factors – Part 3

By Jeffrey K. Raines and Zoraida Catherine Navarro

Parts 1 and 2 appeared in FloridaMD October and November issues

1. Elevated Blood Lipids: The National Institutes of Health (NIH), specifically the National Heart, Lung, and Blood Institute (NHLBI) is responsible for the administration and direction of the National Cholesterol Education Program. A number

the NIH and other sources for the latest guidelines and drug information.

In Appendix 3 of this Booklet you Jeffrey K. Raines Zoraida Catherine will find in elecNavarro tronic format ATP III Guidelines At-A-Glance, which is the Quick Desk Reference distributed by the NIH National Cholesterol Education Program.

Before cosing this Section there is one final word. There are individuals that present with severe atherosclerosis, even heart attack and stroke, without obvious cardiovascular risk factors. When this occurs, abnormal lipids may be the reason. Therefore, in this setting, a more complete Lipid Analysis than presented in Table 4 is indicated.

Fig. 5 – Blood Lipids (Low Density Lipoprotein – LDL) Attacking the Arterial Wall

of years ago, the NHLBI convened a panel of experts which was referred to as the Adult Treatment Panel (ATP III). The charge for the panel was to develop and publish a consensus document which was called the ATP III Guidelines. This was actually published in May 2001 as NIH Publication No. 01-3305.

This publication, to this day, is the most complete treatise of Blood Lipids ever presented. However, it should be acknowledged that challenges and even changes to the ATP III Guidelines have been made and are even in-progress as this Booklet is written.

However, from the prospective of practical preventive medicine, the challenges and changes are minimal. For that reason, the authors have elected to use the ATP III Guidelines for this Booklet and inform the readership of said challenges and changes; we are steadfast in the belief that without an understanding of the initial ATP III Guidelines to enter the debate unarmed, would not be helpful.

The treatment of blood lipids as a risk factor for coronary heart disease and cardiovascular disease in general is clearly complex.

This complexity serves to prove and underline the importance of this risk factor, of which its importance and manipulation is still evolving. In the remainder of this section you will find Table 4 which is titled – Understanding, Evaluating, and Managing Blood Lipids. The table is constructed from ATP III. It is intended to give patients a glimpse of Blood Lipids and perhaps provide helpful information to physicians who do not deal in this arena on a daily basis. Anyone desiring to know the very latest should contact 12 FLORIDA MD - DECEMBER 2016

2. Obesity: In less than 1 hour, an individual in the United States with access to the Internet could easily identify 50 different diets promoted by individuals, public organizations, and commercial firms.

Despite this array of potential opportunities, two statements can be made without fear of contradiction: (i) obesity is a Fig. 6 – Ending Obesity is Difficult! serious cardiovascular risk factor and (ii) obesity is literally at epidemic proportions in the United States and many countries in the developed world. The term “epidemic” is formally defined as an abnormal increase in disease occurrence and is also related to timing of the process. Our numbers clearly suggest that over 25% of individuals with atherosclerosis have associated obesity.

The cost to society of obesity is so large as to be extremely difficult to measure, further, the process has been long-standing. The following short section, identified by dashes, is the Forward extracted from a major Guideline document sponsored by the National Institutes of Health (NILBI). The entire document is 110 pages long and is very comprehensive.

In June 1998, the Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: Evidence Report was released by the National Heart, Lung, and Blood Institute’s (NHLBI) Obesity Education Initiative in cooperation with the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The impetus behind the clinical prac-

CARDIOLOGY TABLE 4 – UNDERSTANDING, EVALUATING, AND MANAGING BLOOD LIPIDS Diagnosis LDL Cholesterol

< 100 Optimal 100 – 129 Near Optimal 130 – 159 Borderline High 160-189 High > 190 Very High Total Cholesterol < 200 Desirable 200 – 239 Borderline High > 240 High HDL Cholesterol < 40 Low, > 60 High Triglycerides < 150 Normal 150 – 199 Borderline High

200 – 499 High

> 500 Very High Coronary Heart Disease (CHD) (1) Clinical DHD, (2) Symptomatic and CHD Equivalents carotid artery disease, (3) Peripheral arterial disease, and (4) Abdominal aortic aneurysm (1) Abdominal obesity - Waist Metabolic Syndrome (Any 3 circumference confirms the Dx): The Tx for (Men: > 40 in, Women > 35 in) Metabolic Syndrome is: (i) Weight (2) Triglycerides - > 150 mg.dL, Management – see Section 8 of (3) HDL (Men , 40 mg/dL; this Booklet, (ii) Increased Physical Women < 50 mg/dL), Activity – see Section 9 of this (4) Blood pressure – (> 130/> 85 Booklet, (iii) Treat hypertension, mmHg), and and (iv) Treat elevated Triglycerides (5) Fasting glucose (>110 mg/dL) and/or low HDL Risk Factors (1) Tobacco Use, (2) Hypertension (BP > 140/90 mmHg or on antihypertensive medication), (3) Low HDL (< 40 mg/dL), (4) Family history of premature CHD (CHD in male first degree relative < 55 years; CHD in female first degree relative < 65 years), (5) Age (men > 45 years; women > 55 years), (6) HDL cholesterol > 60 mg/dL counts as a negative risk factor

Targets CHD or CHD Risk Equivalents Drug Rx: LDL > 130 mg/dL 2+ Risk Factors Drug Rx: LDL > 160 mg/dL 0 or 1 Risk Factors Drug Rx: LDL > 190 mg/dl Therapeutic Lifestyle Changes (TLC) – if LDL is above goal TLC Diet Saturated fat < 7% of calories, Cholesterol, 200 mg/day, Viscous (soluable fiber (10-25 g/day), and

plant stanois/sterois (2g/day) Weight Management See Section 8 of this Booklet Increased Physical Activity See Section 9 of this Booklet Management HMG CoA reductase inhibitors Example Rx: Lovastain (20-80 mg); expected reductions, LDL 18-55% and (statins) TG 7-30%, and HDL increase of 5-15%

Bile acid sequestrants Nicotinic Acid Fibric Acids

Example Rx: Cholestyramine (4-16 g);

expected reductions, LDL 15-30%, TG no change, and HDL increase of 3-5% Example Rx: Cholestyramine (4-16 g); expected reductions, LDL 15-30%, TG no change, and HDL increase of 3-5% Example Rx: Gemfibrozil (600 mg BID); expected reductions, LDL 5-20%, TG 2025%, and HDL increase of 10-20%

tice guidelines was the increasing prevalence of overweight and obesity in the United States and the need to alert practitioners to accompanying health risks.

The Expert Panel that developed the guidelines consisted of 24 experts, 8 ex-officio members, and a consultant methodologist representing the fields of primary care, clinical nutrition, exercise physiology, psychology, physiology, and pulmonary disease. The guidelines were endorsed by representatives of the Coordinating Committees of the National Cholesterol Education Program and the National High Blood Pressure Education Program, the North American Association for the Study of Obesity, and the NIDDK National Task Force on the Prevention and Treatment of Obesity.

This Practical Guide to the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults is largely based on the evidence report prepared by the Expert Panel and describes how health care practitioners can provide their patients with the direction and support needed to effectively lose weight and keep it off. It provides the basic tools needed to appropriately assess and manage overweight and obesity. The guide includes practical information on dietary therapy, physical activity, and behavior therapy, while also providing guidance on the appropriate use of pharmacotherapy and surgery as treatment options.

The Guide was prepared by a working group convened by the North American Association for the Study of Obesity and the National Heart, Lung, and Blood Institute. Three members of the American Society for Bariatric Surgery also participated in the working group. Members of the Expert Panel, especially the Panel Chairman, assisted in the review and development of the final product. Special thanks are also due to the 50 representatives of the various disciplines in primary care and others who reviewed the preprint of the document and provided the working group with excellent feedback.

The Practical Guide will be distributed to primary care physicians, nurses, registered dietitians, and nutritionists as well as to other interested health care practitioners. It is our hope that the tools provided here help to complement the skills needed to effectively manage the millions of overweight and obese individuals who are attempting to manage their weight.

David York, Ph.D. President North American Association for the Study of Obesity

Claude Lenfant, M.D. Director National Heart, Lung, and Blood Institute

Appendix 4 is the entire Obesity Guideline document. The remainder of this section will draw on simple facts associated with obesity. While the scope of this section cannot be complete or even considered broad, what is presented will work for the obese individual – if the individual is appropriately motivated.

The caption for Fig. 6 shown above is true; it is very hard to defeat obesity! Consider how difficult it is to eat when you are not feeling well. The reverse is true in obesity – it is very difficult NOT to eat when you are well and used to eating! Every obese individual FLORIDA MD - DECEMBER 2016 13

CARDIOLOGY should read the following steps: A. How do you know for sure that you need to lose weight?

Fortunately, the answer to this questions is extremely easy. All that is required is the following: (i) an accurate weight scale, (ii) a method to measure height, (iii) a simple calculation (given below), and simple definitions of the one-parameter finding (also given below). a. Using an accurate scale measure your weight in pounds (lbs). When making this measurement limit your clothing and take-off shoes.

Typical weight in lbs for adults ranges from 90 to 300 lbs. b. Measure your height in inches. This can be done with a tape-measure and a vertical wall. Make the measurement with your shoes off; the measurement is from the bottom of your feet to the top of your head. Typical height in inches for adults ranges from 55 to 75 inches. c. Investigators have demonstrated for years that the measurement of Body Mass Index (BMI) is both an accurate and simple what to judge the weight distribution of an individual. The measurement takes weight and distributes the weight over height, using the following formula: W = Weight in lbs / 2.2: In an individual weighting 200 lbs, W = 200 / 2.2 = 90.9 H = Height in inches x 0.0254: In an individual with a Height of 70 inches, H = 70 x 0.0254 = 1.77 BMI = W / H / H: For our example, BMI = 90.9 / 1.77 / 1.77 = 29.01 d. With BMI known, please refer to Table 5. This table determines the weight (i.e. level of obesity) as a function of BMI.

TABLE 5 – WEIGHT CATEGORY AS A FUNCTION OF BMI

>

>

BMI < 20 20 to 25 25 to < 30 30 to 35 35

B. What is your current Calorie Intake?

Experience and the Laws of Thermodynamics clearly indicate that for an adult individual, without serious underlying disease, to maintain 1 pound of Body Weight, 12 calories are required over a 24 period. If 12 calories are not consumed over a 12 hour period, the body will take energy from internal storage to maintain the individual’s metabolism.

To further clarify, if an individual’s weight has been stable over a period of time (i.e.

4 to 6 weeks), by multiplying the individual’s weight in pounds over the preceeding month, times 12 will reveal the individual’s Average Daily Calorie Intake. For example, a 200 pound individual, on average, is consuming 2400 calories per day to maintain the current weight (200 x 12).

For the record, calorie is essentially a measure of heat, actually the heat of components that compose cells. Would you agree that a heated cell, as in the case of a liquid turned into a gas secondary to heating, would occupy more volume than a unheated cell still in the liquid state? Consider that a car radiator actually explodes when its internal heat causes its contents to change from liquid to gas. The same thing happens in the human 14 FLORIDA MD - DECEMBER 2016

Weight Category Underweight Normal Overweight Obese Morbidly Obese

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CARDIOLOGY cell. If the cell is stimulated by excessive calorie intake, cell volume expansion takes place. Please know that as an individual takes on girth, the number of body cells does not increase, they simply experiece volume expansion.

Whereas we know its takes 12 calories over a 24 period to maintain 1 pound of Body Weight, we also know it takes a 3500 Calorie Deficit for an individual to lose 1 pound of Body Weight. Consider this number and concept carefully as it will be used in the next step of this process.

C. What must be done to lose weight?

The answer to this section’s title is relatively easy to understand. The individual, through the combination of reduced Calorie Intake and increased Activity must produce a Calorie Deficit. You were told in the previous section that a 3500 Calorie Deficit will result in the loss of 1 pound of Body Weight. Since a day is a typical period of time to use in this discussion and a week is composed of 7 days, if we take the 3500 Calorie Deficint number and divide it by the number of days in a week, the result is a 500 Calorie Deficit per Day to lost 1 pound of Body Weight in a week. To make this more clear.

If an individual wanted to lose 1 pound in a week, without increasing Activity, and the individual weighed 200 pounds, the individuals Calorie Intake would have to be decreased from 2400 calories per day to 1900 calories per day. If the individual wanted to lose 2 pounds per week, the Calorie Intake would have to be reduced by 1000 calories per day or 1400 calories.

The Summary here is that weight can be lost by reducing Calorie Intake and that a 500 Calorie Deficit will result in 1 pound being lost in 1 week. A safe weight-loss-rate is between 1 pound and 1.5 pounds per week.

This is a daily calorie reduction range of 500 to 750 calories.

D. Can increasing Activity hasten weight loss?

The answer to the title of this section is a resounding YES! However, there are clear limitations which must be understood. Many individuals fail to understand the degree to which exercise will hasten weight loss. The first issue is that overweight individuals rarely have been currently active in a formal exercise program and further, are rarely physically able to participate immediately in extensive exercise or other taxing activities. This argues that reducing Calorie Intake initially will take on very significant proportions.

Consider the following, if a standard sized individual walks, jogs, or runs 5 miles, approximately 500 calories were be expended. If an individual played tennis at the professional level for 1 hour, approximtely 1000 calories would be expended. Table 6 illustrates the positioning of Activity versus Food Intake and points out the necessary bias toward reducing Calorie Intake over increasing Activity in successful weight loss programs continued on page16

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CARDIOLOGY TABLE 6 – CALORIES AS A FUNCTION OF ACTIVITY AND FOOD EQUIVALENCE

Calories Activity Equivalent

70 Walk 0.5 miles (10 minutes)

100 Walk 1 mile (20 minutes) > 250 Walk 2.5 miles (50 minutes)

500 Walk 5 miles (100 minutes)

Food Equivalen 1 Hard Boiled Egg 10 oz of Coke or 1 Apple 1 Snickers Candy Bar 1 Big Mac, 4.5 oz Cheese, or 4 pieces of Bacon

E. Calorie Counting The odds are good that any individual needing to lose weight has failed at previous attempts. This is another way of saying that the individual is most likely not an expert in weight loss and clearly needs help. Consider an individual that is asked to drive a vehicle from a current location to a city within the same state for which the individual has no idea as to its location. It is quite logical for that individual to seek advice to complete the desired trip.

This advice may come in the form of referring to a paper map or performing a MapQuest Search on the Internet. The important point is that to be successful, the non-expert MUST obtain additional information. This is just as true in losing weight. Here the reference is simple – know exactly what the individual is putting in his or her mouth! This is easily determined and learned rapidly by using a book or computer program that displays the relationship between food and calories. Consider in a complex road trip, information source can be used as a constant monitor of success.

Accurately counting calories must be done to be successful and can be accomplished by anyone with a little patience (The Calorie Counter. 6th Edition – Karen J. Nolan, PhD and Jo-Ann Heslin, MA, RD, CDN - Amazon.com - $7.99 or The Complete FOOD Counter. 3rd Edition – Annette B. Natow, PhD and Jo-Ann Leslin, MA, RD, CDN - $7.99).

F. How to set-up your Program The answer is to follow Table 7 given below

TABLE 7 – INDIVIDUAL PROGRAM TABLE Parameter Weight and (BMI) – Initial Weight and (BMI) – Goal Weight Loss Desired Weight Loss Rate per Week and (Program Period) Calories Allowed per Day (Per Week) Maximum Calories Allowed per Day at Goal

Example 200 lbs (29.01) 180 lbs (26.11) 20 lbs 1 lbs per week (20 weeks) 1900 (13300) 2160

The individual’s initial weight and BMI are known parameters.

The Weight Goal and BMI Goal are inputs. It is suggested that reachable goals be selected. Whereas an individual may need to loss 60 pounds, this could be divided into phases. The first phase must be something the individual is confident can be obtained.

Future phases will take care of themselves. For a first phase, do not select a Weight Loss Desired that exceeds 50 pounds and consider the individual’s BMI in selecting the goals.

From the Weight Goal the Weight Loss Desired is easily calculated, by subtracting the Weight Goal from the Weight Initial.

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Select a Weight Loss Rate between 1.0 and 1.5 pounds per week. Individuals that select rapid schedules have more difficulty in achieving goals and may experience symptoms secondary to rapid weight loss. The Program Period is determined by dividing the Weight Loss Desired by the Weight Loss Rate per Week.

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Please use the following formula to determine Calories Allowed per Day: Calories Allowed per Day = (Initial Weight x 12) – (Weight Loss Rate per Week x 500)

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For Our Example: Calories Allowed per Day = (200 x 12) – (1.0 x 500) = 2400 – 500 = 1900 The Calories allowed per Day MUST be carefully monitored by CALORIE COUNTING! When the Goal is reached the individual enters a Mantainance

16 FLORIDA MD - DECEMBER 2016

CARDIOLOGY Phase and should adher to the Maximum Calories Allowed per Day, calculated by multiplying the Current Weight by 12. As in the Table 7 example, the Phase 1 Weight Goal is 180 pounds, therefore, the maintainance calorie level is 180 x 12 or 2160 calories per day during maintainance.

Before closing this section, we will leave the readership with an additional fact. Please look up Kleiber’s Law. You will find that Dr. Kleiber in the 1930s studied mammal metabolism. He found that the Metabolic Rate (MR) of mammals extending from mice to whales was related to the Mass (M); mass is weight of the mammal, by the following simple formula (MR ~ M3/4). Using a 200 pound individual and increasing weight in 10 pound increments, the amount of calories, to support that weight gain may be calculated using Kleiber’s Law. Further, the amount of calories to sustain the increasing weight may also be determined (Table 8).

TABLE 8 – KLEIBER’S LAW APPLIED TO HUMAN WEIGHT GAIN

Individual Weight (lbs) Daily Calories to Initially Daily Calories to Maintain

Expand Weight Expanded Weight 200 2400 2400 210 2489 2520 220 2578 2640 230 2664 2760 240 2750 2880 250 2837 3000 260 2921 3120 270 3005 3240 Here is the take-home message from Table 8. Your weight can balloon from 200 pounds to 270 pounds by increasing your daily Calorie Intake by only 605 calories and that weight will be maintained by consuming 840 additional calories when compared to baseline. The 605 figure can be added by eating the equivalent of a Big Mac Sandwich and a 10 oz Coke over a 24 hour period. The 840 calorie figure can be added by simply eating the equivalent of a Big Mac Sandwich, Snickers Bar, and a 10 oz Coke over a 24 hour period. This clearly demonstrates how we gain weight and how we must COUNT CALORIES if we are to be successful in losing unhealthy weight.

Professor Jeffrey K. Raines was responsible for the Soteria Cardiac Platform including its design and module development.

After attending Harvard Medical School and training in the Surgery Department of Massachusetts General Hospital, Dr. Raines received a PhD in Engineering from MIT. His thesis title was Diagnosis and Analysis of Arteriosclerosis in the Lower Limbs from the Arterial Pressure Pulse; this work outlined the construction and testing of a new medical device called the Pulse Volume Recorder (“PVR”). This device was built and distributed by Life Sciences, Inc. and became a central device in the diagnosis of peripheral vascular disease and in the development of vascular diagnostic laboratories around the world. Dr. Raines was Chief of Research at the University of Miami Department of Surgery until his retirement in 2004 and Director of the Miami Vein Center from 2004 to 2010. Dr. Raines has developed Soteria’s technology over a period of 43 years and now that it has FDA clearance, he looks forward to expanding the use of the Platform worldwide. Dr. Raines is Emeritus Professor of Surgery at Harvard Medical School and the University of Miami. Dr. Raines is a Senior Member of the Society of Vascular Surgery, was elected to American College of Cardiology in 1975 and the Harvard Surgical Society in 2006. Dr. Raines lives in Homestead, Florida with Glo, his wife of many years; they have four children and five grandchildren.

Zoraida Catherine Navarro, MD practices at the Vein Center of the Palm Beaches and Navarro Dermatology Skin & Vein Care. Dr. Navarro earned a B.S. from MIT and medical degrees from Boston University School of Medicine and later, the University of Miami School of Medicine. As a member of the Palm Beach County Medical Society, she helped establish the Women Physicians Medical Society. In 1986, after a year as Director of Medicine for the Wellington Regional Medical Center, Dr. Navarro established the Vein Center of the Palm Beaches in West Palm Beach, an internal medicine solo practice with specialties in varicose vein sclerotherapy, skin care, and holistic approaches. 

FLORIDA MD - DECEMBER 2016 17

HEALTHCARE LAW

Trump Was Elected: What Does That Mean for The Affordable Care Act?

By Jessica Kendrick, Esq. and Sarah Geltz, Esq. On November 8th, the GOP gained control of the White House, Senate and House of Representatives. What this means for the Affordable Care Act is uncertain. Most believe there will be changes to the program, but whether or not the President-elect will make good on his campaign promise of “Repeal and Replace” remains to be seen. Government works slowly, and any changes

to current healthcare legislation will likely not be appreciated until 2018.

The ACA had lofty goals and set new standards for virtually all private health plans. Some of those standards included a prohibition on exclusions based on pre-existing conditions and a requirement for private plans to extend dependent coverage to the age of 26. The law also established new marketplaces for the sale of individual insurance policies to all (excluding undocumented immigrants), and created new subsidies for individual coverage.

To finance these subsidies; new fees, taxes, and offsetting budget savings were adopted.

Including the controversial “Cadillac Tax” on high-cost employer-sponsored plans.

Repealing the ACA is a costly proposition.

The Congressional Budget Office (CBO) estimates a full repeal of the ACA would increase the federal deficit by $137 – $353 billion over 10 years (2016-2025).

WHAT CAN WE EXPECT FROM THE PRESIDENT-ELECT? During the campaign, Trump was short on details with respect to his plans. Experts speculate that “Trumpcare” will be modeled after Paul Ryan’s 2016 healthcare policy paper.

Trump advocates for a complete repeal of the ACA, including the individual mandate for coverage. He envisions a plan where the federal government works with states to create and fund a high risk pool of individuals who have not maintained continuous coverage, rather than requiring insurers to provide coverage to everyone regardless of health status.

Trump’s agenda includes a tax deduction for the purchase of individual health insurance in place of refundable tax credits.

Trump and the GOP believe competition amongst insurers will drive costs down, and allowing insurers to sell policies across state lines will facilitate this goal.

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HEALTHCARE LAW Underutilized Health Savings Accounts (HSA) could be expanded. The GOP proposal allows for tax-free transfer of HSAs to all heirs.

Healthcare costs have continued to skyrocket. Trump’s plan requires price transparency from all hospitals, doctors, clinics and other providers, enabling patient’s and insurers to seek out fair and affordable services.

MEDICAID AND LOW INCOME COVERAGE Nearly 70 million Americans are covered by Medicaid, our nation’s main public health insurance program. Medicaid provides coverage for low income individuals and families with low or no out-of-pocket costs for care, assistance to low-income Medicare beneficiaries, coverage for long-term services, as well as direct financing to safety-net hospitals, clinics and states. Trump supports imposing a ceiling on federal funds allocated for Medicaid as a solution to the enormous budget deficit or “block-grant.” Trump indicates his plan would cover the low-income uninsured through Medicaid after repealing the ACA, but does not address how he plans to do so. The House Republican plan would offer states a choice between a Medicaid per capita allotment or a block-grant in an effort to reduce overall healthcare spending.

MEDICARE AND SENIORS Almost 57 million seniors and young adults with permanent disabilities are covered by the Medicare program. Trump consistently speaks to modernizing Medicare. Talk of capping the government’s share of Medicare has been discussed, which would potentially and likely lead to a large increase of premiums for seniors.

Trump’s goal is not to destroy Medicare but simply change the aspects and financial burdens it brings on the American people.

That being vague at this moment; repealing the ACA would mean repealing the law’s Medicare provisions.

addiction services, end Medicaid policies that obstruct inpatient treatment, increase first responders’ access to naloxone, remove restriction on the number of patients that providers can treat with recovery medicines, and expand incentives for state and local governments to use drug courts and mandated treatment to respond to the addiction crisis.

REPRODUCTIVE HEALTH AND WOMEN’S HEALTH Reproductive health is an essential element of women’s healthcare. The Affordable Care Act (ACA) expanded coverage for reproductive services for millions of women. Trump calls for completely defunding Planned Parenthood if they continue to provide abortions; therefore, redirecting that funding to community health centers.

Trump in recent days, appears to have softened his stance on a full repeal indicating he would not remove the provisions forbidding insurers to deny coverage for pre-existing conditions or allowing Americans to remain on their parent’s plans until age 26.

Whether he can make good on his promises remains to be seen.

Jessica Kendrick, Esq. and Sarah Geltz, Esq. founded Concierge At-Law in 2016 with a primary focus on physicians and the principle of providing superior legal representation and practical guidance in a proactive manner.

Please contact us at 407-488-4371 for further discussion or a complimentary consultation.



PRESCRIPTION DRUGS AND PRICE TRANSPARENCY Prescription drug spending is the 3rd largest component of U.S. health spending. The Affordable Care Act (ACA) allows for fast-track approval of drugs that perform similarly to an existing biologic drug. Specialty drug approvals are on the rise and have outpaced traditional drug approvals. Unlike traditional drugs, specialty drugs require special administration or close observation by a physician; therefore, an increase in cost to patient’s, medical providers, and health insurance. Trump supports allowing countries to import safe and reliable drugs to the United States, generally priced lower than same/similar drugs in the U.S. He also supports price transparency from all health providers.

PAINKILLER EPIDEMIC In 2013, 1 in 20 adults used prescription painkillers for nonmedical use. Health care expenditures, workplace costs due to lost wages and utilization of sick days, and criminal justice costs related to the opioid epidemic are an estimated $55 billion annually. Trump proposes stopping of the flow of illegal drugs into the country and closing shipping loopholes that allow dangerous drugs to be mailed into the U.S. He would also enhance access to FLORIDA MD - DECEMBER 2016 19

DIGESTIVE AND LIVER UPDATE

What is New in Obesity Treatment?

By Srinivas Seela, MD In 2010, 36 states had obesity rates of 25 percent or higher, and 12 of those had obesity rates of 30 percent or higher. Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have a negative effect on health, leading to reduced life expectancy and/or increased health problems.

WHAT DOES IT ACTUALLY MEAN TO BE OVERWEIGHT OR OBESE? At their most basic, the words “overweight” and “obesity” are ways to describe having too much body fat.

The most commonly used measure of weight status today is the body mass index, or BMI. • BMI uses a simple calculation based on the ratio of someone’s height and weight (BMI = kg/m2). Decades of research have shown that BMI provides a good estimate of “fatness” and also correlates well with important health outcomes like heart disease, diabetes, cancer, and overall mortality.

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20 FLORIDA MD - DECEMBER 2016

HEALTHY BMI RANGES FOR ADULTS What’s considered a healthy BMI? • For adult men and women, a BMI between 18.5 and 24.9 is considered healthy.

Obesity complications: Overweight is defined as a BMI between 25.0 and 29.9; and a BMI of 30 or higher is considered obese. Obesity has been linked to a number of health complications, some of which are life-threatening: • Type 2 Diabetes • Heart Disease • High Blood Pressure • Certain Cancers (Breast, Colon, and Endometrial) • Stroke • Liver and Gallbladder Disease • High Cholesterol • Sleep Apnea and Other Breathing Problems.

Successful weight-loss treatments include setting goals and making lifestyle changes, such as eating fewer calories and being physically active. Medicines and weight-loss surgery also are options for some people if lifestyle changes aren’t enough.

SET REALISTIC GOALS Setting realistic weight-loss goals is an important first step to losing weight.

For Adults • Try to lose 5 to 10 percent of your current weight over 6 months. This will lower your risk for coronary heart disease (CHD) and other conditions.

• The best way to lose weight is slowly. A weight loss of 1 to 2 pounds a week is do-able, safe, and will help you keep off the weight.

It also will give you the time to make new, healthy lifestyle changes.

DIGESTIVE AND LIVER UPDATE • If you’ve lost 10 percent of your body weight, have kept it off for 6 months, and are still overweight or obese, you may want to consider further weight loss.

LIFESTYLE CHANGES

Lifestyle changes can help you and your family achieves longterm weight-loss success. Example of lifestyle changes include: • Focusing on balancing energy IN (calories from food and drinks) with energy OUT (physical activity) • Following a healthy eating plan • Learning how to adopt healthy lifestyle habits Over time, these changes will become part of your everyday life.

Calories Cutting back on calories (energy IN) will help you lose weight.

To lose 1 to 2 pounds a week, adults should cut back their calorie intake by 500 to 1,000 calories a day. All patients with a BMI greater than 25 who would benefit. For individuals with a body mass index (BMI) >30 kg/m2 or a BMI of 27 to 29.9 kg/m2 with comorbidities, who have failed to achieve weight loss goals through diet and exercise alone, we suggest pharmacologic therapy be added to diet and exercise (from weight loss should receive counseling on diet, exercise, and goals for weight management. For patients with a BMI ≥40 kg/m2 who have failed to lose weight with diet, exercise, and drug therapy, we suggest bariatric surgery. However recently FDA approved gastric balloon for the treatment of obesity. This type of weight loss treatment can help you lose weight without invasive surgery. One type of gastric balloon is known as Orbera™. During the procedure a soft balloon is inserted into your stomach through your mouth, using an endoscope (a thin, flexible telescope) The FDA say the new dual balloon device offers a non-surgical option that can be quickly implanted, is non-permanent and can be easily removed.

The device comprises two balloons that are inserted into the stomach and inflated without the need for surgery. The device is meant to be a temporary measure and should be removed after 6 months. Removal is also via a non-surgical procedure. “... Likely works by occupying space in the stomach, which may trigger feelings of fullness, or by other mechanisms that are not yet understood.”

The Dual Balloon does not alter the anatomy of the stomach.

To help achieve and maintain weight loss, patients implanted with the Dual Balloon are advised to follow a medically supervised diet and exercise plan both while the device is in place and then for 6 months after it is removed.

The device is inserted during an outpatient visit. The procedure lasts no more than half an hour and is performed while the patient is under mild sedation.

A trained physician inserts the deflated balloons using an endoscope. This is a tube with a camera on the end that goes into the mouth, down the throat and into the stomach. The camera allows the physician to guide the placement of the deflated balloons.

Once in the stomach, the physician inflates the balloons by filling them with a sterile salt solution and then releases them and removes the endoscope.

The device is for obese adults whose body mass index (BMI) lies in the range 30-40 kg/m2. It is intended for patients who have not

been able to lose weight through diet and exercise alone and is limited to those with one or more obesity-related conditions such as high blood pressure, high cholesterol and diabetes.

Trial participants lost 14 lbs on average For the approval, the FDA reviewed a clinical trial of 326 obese patients aged from 22 to 60 whose BMI was in the range 30-40 kg/m2 and who had at least one obesity-related condition.

The trial randomly assigned the patients to either have the Dual Balloon inserted, or to undergo an identical “dummy” endoscopic procedure but where the device was not fitted.

The results showed that at the end of 6 months, when the device was removed, the 187 patients who were fitted with the Dual Balloon on average lost 14.3 lbs (6.5 kg), equivalent to 6.8% of their body weight.

In contrast, the control group on average lost 7.2 lbs (3.3 kg, 3.3% of their body weight). And 6 months after the device was removed, the group that had it fitted managed to keep off an average of 9.9 lbs (4.5 kg) of the 14.3 lbs they lost.

The insertion procedure may have side effects. These include muscle pain, nausea and headache. In rare instances, this may also lead to severe allergic reaction, tearing of the esophagus, infection, breathing problems and heart attack. Once the Dual Balloon is inserted, patients may also experience nausea, vomiting, feelings of indigestion, abdominal pain and stomach ulcers.

Patients who have had bariatric or other kinds of gastrointestinal surgery should not be fitted with the device, and neither should patients diagnosed with inflammatory intestinal or bowel disease, who have symptoms of delayed gastric emptying or active H. pylori infection, or who have a large hiatal hernia. Pregnant women and patients taking aspirin every day should also avoid it, the FDA advises.

Srinivas Seela, MD moved to Orlando, Florida after finishing his fellowship in Gastroenterology at Yale University School of Medicine, one of the finest programs in the country. During his training he spent a significant amount of time in basic and clinical research, and has published articles in Gastroenterology literature. His interests include advanced and therapeutic endoscopic procedures, colorectal cancer screening, Gastro Esophageal Reflux Disease (GERD), metabolic and other liver disorders.

Dr. Seela is board certified in both Internal Medicine and Gastroenterology. He is a member of the American Gastroenterological Association (AGA), the American Society for Gastrointestinal Endoscopy (ASGE), the American Association for the Study of Liver Diseases (AASLD), and Crohn’s Colitis Foundation (CCF).

In addition to being an Assistant Professor at the University of Central Florida School of Medicine, he is also a teaching attending physician at both the Florida Hospital Internal Medicine Residency and Family Practice Residence (MD and DO) programs. Dr. Srinivas Seela is a gastroenterologist at Digestive and Liver Center of Florida.

Contact information 407-384-7388. 

FLORIDA MD - DECEMBER 2016 21

HealthSouth Rehabilitation Hospital of Altamonte Springs Offers a Higher Level of Care.

HERE’S HOW.

Our patients and families hear a lot about a higher level of care. What does this mean to you? Our rehabilitation teams work with patients and their families, providing superior care with quality outcomes to return patients to maximum independence at home and in the community.

To a patient recovering from an illness, injury or surgery, a higher level of care means: • Personalized goals for a faster return home • Comprehensive team approach to rehabilitative care • Advanced technologies for the latest treatments • Frequent physician* visits • Three hours of therapy over a day, five days a week • 24-hour certified rehabilitation nursing care Choose a rehabilitation leader that makes a difference for patients and families with a higher level of care. HealthSouth Rehabilitation Hospital of Altamonte Springs. *The hospital provides access to independent physicians

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831 South State Road 434 • Altamonte Springs, FL 32714 407 587-8600 healthsouthaltamontesprings.com ©2016:HealthSouth Corporation:452913

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