Florida MD July 2021

JULY 2021 • COVERING THE I-4 CORRIDOR

Encompass Health Hospital Rehabilitation of Altamonte Springs

Providing Superior Outcomes Through Connected Care

TOMMY

IHERNIA CHOOSE EXPERTS FOR

MORE TIME WITH MY FAMILY. When a traumatic injury resulted in a hernia, Tommy needed expert care more than ever.

From the moment the Orlando Health Orlando Regional Medical Center team stepped in, he and his family knew he was in the best hands. Now he looks forward to pain-free days full of health, fun and family.

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contents 4

 COVER STORY

As a nationwide leader in rehabilitation services, Encompass Health Corp., formerly HealthSouth Corp., has been known in the medical community for over three decades. 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 Encompass Health Rehabilitation Hospital of Altamonte Springs in 2014. The hospital is part of a nationwide network of 130 inpatient rehabilitation hospitals and 220 home health locations and 58 hospice locations.

PHOTO: ENCOMPASS HEALTH

As Encompass Health, the hospital and its staff remain dedicated to guiding each patient through recovery and are committed to helping patients regain their independence.

By building a solid reputation for its comprehensive approach to rehabilitation of patients, including those dealing with traumatic injuries that require extensive rehabilitation services, Encompass Health Altamonte Springs provides options that 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.

ON THE COVER: Dr. Eliam Fuentes, medical director of Encompass Health Altamonte Springs

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STUDY- CANNABIS IS NOT A GATEWAY DRUG

16 HEALING ECZEMA: BEYOND SKIN DEEP PHOTO: ENCOMPASS HEALTH

17 CATCHING MULTIPLE SCLEROSIS EARLY 18 UCF LAKE NONA MEDICAL CENTER IS THE FIRST HOSPITAL IN CENTRAL FLORIDA TO OFFER INCISIONLESS BRAIN SURGERY AS ADVANCED TREATMENT FOR ESSENTIAL TREMOR

DEPARTMENTS 2

FROM THE PUBLISHER

8 PULMONARY 10 DERMATOLOGY 11 MARKETING YOUR PRACTICE 13 13 PEDIATRICS 14 HEALTHCARE LAW

FLORIDA MD - JULY 2021

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FROM THE PUBLISHER

I

am pleased to bring you another issue of Florida MD. Sometimes a patient may have the opportunity to participate in a clinical trial. Sometimes a patient may need specialized treatment that is not available in Central Florida. And sometimes there’s no money for that patient to get to those places. Fortunately there is Angel Flight Southeast to get those patients where they need to go. I asked them to tell us about their organization and how you, as physicians, can help. Please join me in supporting this truly wonderful organization.

Best regards,

Donald B. Rauhofer Publisher

ANGELS ON EARTH HELP PATIENTS GET TO LIFESAVING MEDICAL TREATMENT Everyone knows angels have wings! But did you know in Florida and many parts of the nation they have engines and tails with dedicated volunteers who donate lifesaving services every day? Leesburg, Fla.-based Angel Flight Southeast is a network of approximately 650 pilots who volunteer their time, personal airplanes and fuel to help passengers get to far-from-home medical care. A member of the national Air Charity Network, Angel Flight Southeast has been flying passengers since 1993.

Almost all of its passengers are chronic-needs patients who require multiple, sometimes 25-50 treatments.

Passengers may be participating in clinical trials, may require post-transplant medical attention or are getting specialized treatment that is not available near home. Each passenger is vetted to confirm medical and financial need and is often referred to Angel Flight Southeast by medical personnel and social workers.

Angel Flight Southeast “Care Traffic Controllers” arrange flights 24 hours a day, 365 days a year. In the event of a transplant procedure, the Care Traffic Controllers have precious minutes to reach out to its list of volunteer pilots who have agreed to be prepared on a moment’s notice to fly a patient to receive his or her potentially lifesaving organ.

The organization is completely funded through donations by individuals and organizations. A typical Angel Flight Southeast pilot donates $400 to $500 in services-per-trip. In fact, Angel Flight Southeast has earned the Independent Charities of America Seal of Approval as a good steward of the funds it generates from the public.

Each $1 donated generates more than $10 worth of contributed services by Angel Flight Southeast.

The charity always seeks prospective passengers, volunteer pilots and donations. For additional information, please visit https://www.angelflightse.org or call 1-888-744.8263.

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

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Publisher: Donald Rauhofer Photographer: Donald Rauhofer / Florida MD Contributing Writers: John “Lucky” Meisenheimer, MD, Joseph Cannizzaro, MD, Christopher Gregg, MD, Amy Gutierrez, MD, Daniel T. Layish, MD, Julie A. Tyk, JD, Sonda Eunus, MHA, Michael Patterson NHA, OTR/L, CEAS, Juan Lopez, Pharm D, John Meisenheimer, VII 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.

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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 2021, Sea Notes Media. All rights reserved. Reproduction in whole or in part without written permission is prohibited. Annual subscription rate $45.

Study- Cannabis is not a Gateway Drug

By Michael Patterson, NHA, OTR/L, CEAS For decades, prohibitionists have lived and died by the claim that cannabis is a “gateway” drug that will lead people onto harder drugs. However, there has not been widely accepted objective data to backup those claims. Now, based on a recent study published in April 2021 in the Journal of Experimental Criminology, claims that the initiation of marijuana use is independently linked to the later use of other controlled substances are not supported by longitudinal data. A link to the study is below.

Is marijuana really a gateway drug? A nationally representative test of the marijuana gateway hypothesis using a propensity score matching design | SpringerLink Researchers affiliated with Boise State University analyzed the relationship between self-reported marijuana use in late-adolescence and the use of other illicit substances later in life in a nationally representative sample. Using three waves of data from the National Longitudinal Study of Adolescent to Adult Health (1994–2002), eighteen propensity score-matching tests of the marijuana gateway hypothesis were conducted. Six of the eighteen tests were statistically significant; however, only three were substantively meaningful. These three tests found weak effects of frequent marijuana use on illicit drug use but they were also sensitive to hidden bias.

The researchers reported, “Political discourse advocating marijuana prohibition commonly hinges on the assumption that marijuana causes hard drug use. The MGH [marijuana gateway hypothesis] is by far the most common justification for prohibiting the use of cannabis. However, the current study provides further evidence that common liability arguments are more in line with substance use patterns observed in the USA.” Results from this study indicate that marijuana use is not a reliable gateway cause of illicit drug use. As such, prohibition policies are unlikely to reduce illicit drug use.

They concluded: “In sum, the findings from the current study … provide further support of previous research questioning the causal claims of the MGH. While there is strong support for correlation and sequencing in marijuana and hard drug use, correlation and sequencing alone cannot provide sufficient evidence for causality. Factors other than marijuana use such as genetic predisposition, peer associations, or access to the illicit drug market could be the primary causes of hard drug use instead of marijuana use itself. As such, any public policy that prohibits the use of marijuana in an attempt to curb hard drug use is unlikely to succeed.”

ANALYSIS This study is based on objective data analysis. The Marijuana Gateway Theory is based on lies and fear. Lies and fear have been used by prohibitionists for almost 100 years to keep cannabis illegal and away from people who need this life saving medication.

This study is just the beginning of objective, clinical data coming out about the benefits of cannabis in our society and proving the claims of the prohibitionists of cannabis being bad for society as

false and misleading.

With the US Government recently approving over ten new research licenses to allow cultivation of cannabis for research purposes, more and more quality studies and data will continue to be published.

These studies will prove that cannabis is beneficial to patients and our society. With more objective and clear-cut data, prohibitionists will have to think of other lies and fearmongering techniques to keep cannabis illegal. Cannabis has been a part of human history for thousands of years. No matter what prohibitionists do, cannabis legalization is coming to the USA and most of the planet. It is not a matter of “if ”, but “when”.

Michael Patterson NHA, OTR/L, CEAS is CEO of US Cannabis Pharmaceutical Research and Development LLC. (uscprd.com). He is a healthcare executive with 25+ years experience in: Cannabis-Hemp investment, Law, Regulation, Compliance, Operations, & Management, Skilled Nursing, Pharmacy, Laboratory, Assisted Living, Home Healthcare, & Healthcare Analytics. He is a subject matter expert in the Global Cannabis and Hemp Industry with Gerson Lehrman Group (glg.it) & Guidepoint. He is an editorial board member of the American Journal of Medical Cannabis, licensed Nursing Home Administrator, & licensed Occupational Therapist in 4 states. 

Sea Notes Photography Donald Rauhofer – Photographer Head Shots • Brochures • Meetings Events • Portraits • Arcitectural

4O7-417-74OO FLORIDA MD - JULY 2021

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COVER STORY

Encompass Health Hospital Rehabilitation of Altamonte Springs – Providing Superior Outcomes Through Connected Care

By Staff Writer As a nationwide leader in rehabilitation services, Encompass Health Corp., formerly HealthSouth Corp., has been known in the medical community for over three decades. 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 Encompass Health Rehabilitation Hospital of Altamonte Springs in 2014. The hospital is part of a nationwide network of 130 inpatient rehabilitation hospitals and 220 home health locations and 58 hospice locations.

cated to guiding each patient through recovery and are committed to helping patients regain their independence. By building a solid reputation for its comprehensive approach to rehabilitation of patients, including those dealing with traumatic injuries that require extensive rehabilitation services, Encompass Health Altamonte Springs provides options that 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.

Based on 2016 data, Encompass Health accounts for 22 percent of licensed beds in the nation and provides rehabilitation services for 29 percent of Medicare Dedicated physical therapists are key to providing focused care to patients. patients. In November 2018, Encompass Health Altamonte Springs expanded its services to reach even more patients. The hospital added 20 new beds, giving it a total of 70. It also recently opened a new dialysis unit with four beds, allowing those in need of dialysis to continue their therapy and work toward their individual goals.

The hospital has seen over 1,800 patients since it opened its doors in the fall of 2015 and received a reaccreditation by The Joint Commission as a facility of care.

As Encompass Health, the hospital and its staff remain dedi-

For Dr. Eliam Fuentes, medical director of Encompass Health Altamonte Springs, it was not surprising; “Since our opening we have helped so many patients providing excellent rehabilitation care for many strokes, Parkinson’s, and other catastrophic injuries.”

PHOTO: ENCOMPASS HEALTH

Dr. Fuentes, began seeing patients at HealthSouth Altamonte Springs in 2014, after doing his residency in Cleveland, Ohio. 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, Encompass Health 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” Encompass Health Altamonte Springs employs a staff of more than 100 who are quick to point out what sets their teams and their services apart. First is clearing up the misconception, that because “rehabilitation” is in the hospital name, 4 FLORIDA MD - JULY 2021

COVER STORY

“At a skilled nursing facility a patient’s stay is a lot longer and they have approximately three to five hours of rehabilitation a week. At Encompass Health Altamonte Springs, we are a hospital and as such we are regulated to do three hours of therapy a day for five days each week,” explains Dr. Kuriakose.

The secret to the hospital’s success, he added, is its staff and the fact that it is 100 percent dedicated to rehabilitation. The therapy is intentional, focused, Patients participate in a variety of exercises which help strengthen motor skills. multi-disciplinary and effective.

With an average length of stay of about 12 days, compared to 38.5 days at a skilled nursing pital current holds disease-specific care certification from The home, Dr. Fuentes said Encompass Health can also get patients Joint Commission for its stroke rehabilitation program. back to their home, which is better for the patient and more For all patients though, regardless of their injury, there is a cost-efficient. For 2017, the company had a 79.4% discharge common denominator. Patients and their families must be comrate back to the community outperforming the Uniform Data mitted and able to handle the intense rehabilitation they will System for Medical Rehabilitation average of 75.9%. undergo at Encompass Health Altamonte Springs.

The therapy gym, located in the center of the hospital, is a fo“If you have a complex patient with many medical comorcal point of a patient’s time at the hospital and boasts the most bidities, it is a challenge to do therapies outpatient or at home,” advanced equipment. Patients can move easily from one modalexplains Dr. Fuentes. “Most patients cannot endure home theraity to the next during their multiple visits to the gym each day. pies and some think they can’t tolerate three hours of therapy, Modalities include partial weight bearing equipment, to gate but many can and they do.” training, to IREX, a new modality that is a virtual reality therapy Before a patient is admitted, he or she undergoes pre-admissystem which uses immersive video gesture control. sion screening. Nurses do a CMS guideline screening, patients “The biggest thing to educate our patients about is that they’re are then evaluated by a physiatrist and physical and occupational not going to spend all day in bed. The goal here is to be out of therapists. bed, in the gym and working toward independence. For some “Every patient is exposed to multiple therapies. Patients enthat is terrifying and for some that is a welcome change,” says Dr. gage in physical therapy and we see how they perform. If they Kuriakose. “We almost take a second seat as a physician, because can tolerate it, it’s a good predictor of their success in an inpathe real goal is to get their therapies and ultimately transition tient rehabilitation facility,” says Dr. Fuentes. them home.”

THE ENCOMPASS HEALTH PATIENT

PLANNING DISCHARGE AT ADMITTING

Most Encompass Health Altamonte Springs patients are admitted from local acute care hospitals, although some are referred from home or other long-term care facilities. Patients admitted to Encompass Health Altamonte Springs face complex situations resulting from stroke, spinal cord injuries, amputations, traumatic brain injuries, ALS and neurologic cases. The hospital is also one of the few facilities in Central Florida certified in LSVT programs designed for Parkinson’s disease. In addition, the hos-

For Encompass Health Altamonte Springs patients, discharge planning begins at admission and includes patients and their families and caregivers every step of the way. “We work as a team. From day one, we establish realistic goals that involve patients, family, and the whole team. The whole idea is to set up a rehabilitation plan that includes the patient, and an interdisciplinary team aimed to guarantee a safe discharge home,” says Dr. Fuentes.

FLORIDA MD - JULY 2021

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PHOTO: ENCOMPASS HEALTH

that it is the same as a skilled nursing facility. The hospital also provides access to independent physicians specialized in rehabilitative medicine including Dr. Fuentes, and Dr. Dana Kuriakose.

COVER STORY 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. And if further care is needed after discharge, patients can choose to continue that high level of care they received in the hospital at home. In addition to inpatient rehabilitation, Encompass Health also has a home health and hospice segment available after discharge if needed.

“This is exceptional, especially considering we are working with post-surgical patients,” says Dr. Fuentes. “It is not only about function. As physiatrists we are trained in wound care, and our hospital is blessed to have a great wound care program that handle complex wounds on a regular basis.”

THE “TEAM CONFERENCE”

At Encompass Health Altamonte Springs, the multi-disciplinary team is charged with executing a road map that will get paPATIENT OUTCOMES tients out of their hospital bed and return home. The hospital For patients, being part of an acute care facility means that has all the specialties of an acute hospital including infectious they will move around and benefit from it. Encompass Health disease and cardiology to name a few. These specialists, comprisAltamonte Springs prides itself on extremely low infection rates, ing the team, meet two to three days per week in what is called half the benchmark for national rehabilitation hospitals. the “team conference.” Working cohesively as a group in these “team conferences” they ensure that patients are The goal at Encompass Health is to get patients out of bed and working toward their getting all of the services they need to get them independence. home faster, healthy and infection free.

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 is to start addressing a patients needs early on.

“These meetings help us to coordinate patients’ needs better,” says Dr. Fuentes. “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 Encompass Health Altamonte Springs point out that, while not as well known in the United States as in other countries, it is a specialty that is growing exponentially.

“As a specialty, physical medicine & rehabilitation focuses on function. We treat neurological and musculoskeletal conditions which can limit independence” says Dr. Fuentes.

PHOTO: ENCOMPASS HEALTH

For those who have made their careers in physiatry, such as Drs. Fuentes and Kuriakose, it is a specialty of the heart. Each has a unique path that led them to this field.

Dr. Fuentes did his residency at Case Western Reserve University at the MetroHealth Rehabili6 FLORIDA MD - JULY 2021

COVER STORY tation Institute of Ohio, where spent part of his residency at the trauma hospital and at the Veterans’ Hospital in Cleveland treating traumatic brain injuries and spinal cord 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.

“I changed my career goals after that. Other specialties 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 Encompass Health Puerto Rico. And now, here we are years later, she is a normal teenager and has recovered completely. I often share this story with my patients. It helps us create a rapport. I don’t presume to know what ever patient is feeling, but I’ve been there in a hospital, crying and I have been in their shoes.”

For Dr. Kuriakose, the specialty 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.”

PHOTO: ENCOMPASS HEALTH

Dr. Fuentes understands firsthand the life changing effects of rehabilitation. At the age of two, his daughter suffered a stroke and became a patient at the Encompass Health hospital in Puerto Rico.

Therapists review multi-disciplinary patient treatment plans.

“I would advise them to trust our care and providers. We have the best therapy teams, we have the best nursing teams and we have an excellent team of doctors dedicated to our patients.”

With the commitment of its staff, therapists and physicians, Encompass Health Altamonte Springs continues to spread its wings, and reach those with acute rehabilitation needs, providing patients with a road to recovery in order to return home, to a new normal and regain a level of independence despite their injuries. 

It was while in residency at Harvard that she treated Boston Marathon bombing victims and witnessed firsthand the strong sense of support within the rehabilitation 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.”

WHY ENCOMPASS HEALTH? At Encompass Health Altamonte Springs, the physiatrists and therapy teams work in tandem, providing an acute rehabilitation facility that offers patients the ability to be monitored and have their therapy directed from all angles. This aids in overall positive outcomes and patients return to an independent, albeit perhaps new normal, life.

For Dr. Fuentes and his colleagues, time spent at the inpatient rehabilitation hospital is a critical component to a patient making important strides in his or her recovery.

ENCOMPASS HEALTH REHABILITATION HOSPITAL OF ALTAMONTE SPRINGS 831 SOUTH STATE ROAD 434 ALTAMONTE SPRINGS, FL 32714 PHONE NUMBER: 407.587.8600

FLORIDA MD - JULY 2021

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PULMONARY AND SLEEP DISORDERS

Update on the Paradigm for Treating Pulmonary Arterial Hypertension: Significance of the AMBITION Trial By Daniel T. Layish, MD, FACP, FCCP, FAASM Without pharmacologic therapy, WHO Group I pulmonary arterial hypertension (PAH) is a progressive fatal illness. (Table 1).

There are three main pathways involved in the pathophysiology of PAH which currently offer treatment options. (Figure 1) These TABLE I: WORLD HEALTH ORGANIZATION CLASSIFICATION OF PULMONARY HYPERTENSION (2013 Nomenclature) WHO Group 1: Pulmonary arterial hypertension (PAH). a) Idiopathic. b) Genetic PAH. c) Drug and toxin induced PAH. d) PAH associated with connective tissue diseases, HIV infection, portal hypertension, congenital heart disease with right to left shunting, schistosomiasis WHO Group 2: Pulmonary venous hypertension: this can be seen in the setting of left ventricular systolic or diastolic dysfunction or valvular heart disease or left ventricular outflow tract obstruction WHO Group 3 Pulmonary Hypertension: This includes pulmonary hypertension secondary to hypoxia as can be seen in COPD, interstitial lung disease, sleep-disordered breathing, alveolar hypoventilation or chronic exposure to high altitude WHO Group 4 Pulmonary Hypertension: Chronic thromboembolic pulmonary hypertension, this occurs with chronic pulmonary emboli which do not resolve and lead to a mechanical obstruction; this is the only surgically curable form of pulmonary hypertension so it is critical to exclude WHO Group 5: Pulmonary hypertension secondary to miscellaneous disorders such as chronic hemolytic anemia, sarcoidosis and glycogen storage disease

include the endothelin, nitric oxide and prostacyclin pathways.

Activation of the nitric oxide pathway leads to vasodilation and inhibition of cell proliferation. Endothelin receptor antagonists (ERA) inhibit the endothelin receptor, resulting in vasodilation and inhibition of vascular smooth muscle cell proliferation. Phosphodiesterase type 5 inhibitors (PDE-5i) augment the nitric oxide pathway by disrupting the breakdown of cyclic GMP. The prostacyclin pathway leads to vasodilation and inhibition of vascular smooth muscle proliferation. The first PAH-specific therapy was epoprostenol (Flolan®), which was approved by the FDA in 1995, but requires an indwelling catheter and a continuous intravenous infusion. Since 1995, there have been several approvals of other pharmacologic therapies for the treatment of PAH. Oral therapy was introduced when bosentan (Tracleer®), an ERA, was approved by the FDA in 2001. The second ERA approved by the FDA was ambrisentan (Letairis®) in 2007. There are two currently available PDE-5 inhibitors, sildenafil (Revatio®) and tadalafil (Adcirca®), approved by the 8 FLORIDA MD - JULY 2021

FDA in 2005 and 2009, respectively.

Traditionally, when patients progressed despite treatment with either an ERA or a PDE-5i, sequential combination therapy was offered. However, some of the combinations studied did not seem to result in an additive benefit. In addition, drug interactions can be problematic. For example, bosentan lowers the availability of sildenafil which may reduce the efficacy of this therapy, while sildenafil raises the availability of bosentan which may increase the risk of hepatotoxicity.

The rationale for the AMBITION trial was to determine if early aggressive therapy with two drugs targeting different pathways is more efficacious than monotherapy. It was a prospective, randomized, double-blind, multicenter study designed to evaluate safety and efficacy of upfront combination therapy with ambrisentan plus tadalafil versus ambrisentan or tadalafil alone in treatment naive patients with WHO Group I PAH. Overall, 500 patients were randomized 2:1:1 to receive either upfront combination therapy with ambrisentan and tadalafil (N=253) or monotherapy with ambrisentan (N=126) or tadalafil (N=121). Ambrisentan was titrated from 5 mg up to 10 mg once a day over an 8 week period, and tadalafil was titrated from 20 mg to 40 mg once a day over 4 weeks. The primary end point was time to first clinical failure event, which was a composite end point, incorporating both the traditional components of clinical worsening Figure 1

PULMONARY AND SLEEP DISORDERS (death, hospitalization and disease progression) with a component of unsatisfactory long-term clinical response. Upfront combination therapy with ambrisentan and tadalafil reduced the risk of clinical failure by 50% compared to monotherapy with ambrisentan or tadalafil. The study was not designed to compare ambrisentan versus tadalafil alone. The treatment effect for the composite primary end point of time to clinical failure was mainly driven by a reduced number of hospitalizations related to PAH. The risk of hospitalization due to PAH was reduced by 63% in the group which received upfront combination therapy. The reduction in clinical failure events were seen regardless of the etiology of PAH, WHO functional class, age, or gender. There were also improvements in the secondary end points including N-terminal pro-B-type natriuretic peptide and six minute walk distance. Overall the combination therapy was well tolerated.

Side effects were similar to that seen with monotherapy including peripheral edema, headache, and nasal congestion.

The results of the AMBITION trial have been received enthusiastically by pulmonary hypertension specialists and seem to confirm the hypothesis that upfront combination therapy targeted at more than one of the pathophysiologic pathways is beneficial. However, these results should not be extrapolated to other combinations, which were either not studied or were studied and did not show beneficial effects. The treatment algorithms for PAH continue to be rapidly evolving. For example, the recent approval of riociguat (Adempas®), macitentan (Opsumit®) as well as oral treprostinil (Orenitram®) and the oral prosGIFT CERTIFICATES ARE AVAILABLE tacyclin receptor agonist selexipag (Uptravi®). The pace of new drug development has really been fairly miraculous since epoprostenol was initially approved in 1995. It is certainly exciting to have more treatment options to offer our patients with this lifethreatening illness. However, much work still needs to be done to understand the specific role of various combination therapies.

ANTI-BACTERIAL | SIDE EFFECT FREE | ANTI-INFLAMMATORY Nevertheless, the AMBITION study is truly a landmark trial in our understanding of the optimal treatment strategy for PAH.

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versity 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 Codirector of the Adult Cystic Fibrosis Program in Orlando. He may be contacted at 407-841-1100 or by visiting www.cfpulmonary.com.

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DERMATOLOGY

Why I Wear Sunscreen

By John “Lucky” Meisenheimer, MD and John Meisenheimer, VII

Trying to explain to a fourteen-year-old why they should wear sunscreen typically falls on deaf ears. Pulling the “you will get skin cancer” card results in eye rolls, because they know that will never happen to them. Only old people, which they will never become, get skin cancer. My secret weapon is to warn them about “ugly spots” that will be fertilized by exposure to the sun. For some strange reason, this affects them more than being warned about skin cancer. Most fourteen-year-olds have never seen a skin cancer, but they all know what “ugly spots” are and fear them.

PHOTO: JOHN MEISENHEIMER, VII

Occasionally, there is push back. They respond saying their skin is excellent and “ugly spots” are a feature of time, not sun exposure. I ask them to consider the skin of their grandfather’s face. I remind them that the skin on his backside where the sun never shines is the same age, but is as spotless and unwrinkled as a teenagers face. This only works if the grandfather is not a practicing nudist.

So what are these nebulous “ugly spots” to which I am referring? Well, it can be a lot of things.

Below are photos of skin lesions that occur due to chronic exposure to ultraviolet radiation. So, forget about the anticancer benefits of using sunscreen, I use them to prevent “ugly spots” keeping me young and beautiful forever.

Below are some photos of conditions that await you if you don’t protect your skin from the sun.

PHOTO: JOHN MEISENHEIMER, VII

Disseminated porokeratosis. A benign condition of the skin on the arms and legs due to chronic solar damage.

Disseminated porokeratosis is sometimes mistaken for actinic keratoses and squamous cell carcinomas.

PHOTO: JOHN MEISENHEIMER, VII

PHOTO: JOHN MEISENHEIMER, VII

Rhytids (wrinkles) Both losses of subcutaneous fat and chronic solar damage contribute to the formation of static wrinkles.

Lentigo (liver spots) Folks spend millions on creams that don’t work to remove these annoying brown spots, which are found commonly on the face and hands.

10 FLORIDA MD - JULY 2021

PHOTO: JOHN MEISENHEIMER, VII

Seborrheic keratosis.

Benign growths found in a high percentage of folks over the age of 50. They appear more frequently in sunexposed areas.

Guttate Hypomelanosis. This condition is a loss of pigment in small, drop-like macules in chronically sun-damaged skin. Guttate hypomelanosis can occur in both fair-skinned and dark-skinned individuals and is mostly seen on the arms and legs.

Solar keratosis/Actinic Keratosis (precancers) Fertile ground for later development of squamous cell carcinomas.

PHOTO: JOHN MEISENHEIMER, VII

PHOTO: JOHN MEISENHEIMER, VII

PHOTO: JOHN MEISENHEIMER, VII

Lucky Meisenheimer, M.D. is a board-certified dermatologist specializing in Mohs Surgery. He is the director of the Meisenheimer Clinic – Dermatology and Mohs Surgery. John Meisenheimer, VII is a medical student at USF. 

Poikiloderma of Civatte. Chronic solar changes of the skin of the neck and chest. Notice the sparing of the skin under the chin where less sun hits.

Cutaneous horns. A buildup of thick keratin over both benign and malignant growths in sun-damaged skin.

MARKETING YOUR PRACTICE

Facebook Marketing for Medical Practices

By Sonda Eunus, MHA, CMPE For a medical practice, as for any business, it is now crucial to have a strong presence on social media platforms. However, it is often hard for medical practice leaders to know which social media platforms to focus on to get the greatest results. Whereas there are multiple great options to choose from, Facebook should always be the #1 platform to start with and to invest the most time on.

WHY FACEBOOK SHOULD BE #1 ON YOUR LIST: Facebook is currently the largest social media platform, with 2.6 BILLION monthly active users worldwide as of the first quarter of 2020 – with 1.73 billion of those using Facebook daily (1). Facebook is now the world’s 3rd most-visited website, after Google and Youtube (2). There are 90 million Facebook Business pages (2). This shows that 90 million businesses have found it beneficial to have a Facebook presence. Not only is it important because you are getting additional exposure to Facebook users, but it will also improve your online credibility and boost your search engine optimization. Social Media accounts show up in search results when someone searches for your practice – so make sure that your page is active, that you are sharing valuable content, and that you have a good amount of page followers for social proof that your business is liked and respected in the community.

If you are not sure that your target audience is on Facebook, consider this: 71% of American adults use Facebook, as compared to Instagram’s 38%, and Twitter’s 23% (2). The percentages of people in specific age ranges that are active on Facebook look like this: • 18-24: 76% • 25-29: 84% • 30-49: 79% • 50-64: 68% • 65+: 46% This is a good audience for any medical practice, as you can reach both young parents with newborns, older patients, and anyone in between.

OPTIMIZE YOUR FACEBOOK PAGE: To get started, make sure that your Facebook Business page is optimized. Here are some key steps to focus on: • You want to add as much information as possible and fill out all the sections available.

• Upload a clear copy of your logo as your profile picture.

• Add a nice cover photo – this could be a picture of your clinic, your staff, or another image that is relevant to your clinic and your target audience.

• Make sure that there is a clear way to contact you, visit your website, etc. and add the services that you provide • Add as many photos as possible, such as pictures of your waiting room, exam rooms, doctors, staff, etc.

• Ask your existing patients to add Facebook reviews to your page

GROW YOUR FACEBOOK AUDIENCE: Here are the best ways to start growing your Facebook audience: • Invite all your friends to like your new Business page • Ask the other page Administrators that you add to invite their friends to like your page • Ask your friends on Facebook to invite their friends to like your Facebook page After you have acquired an initial following by using these strategies, you will need to start focusing on more long-term strategies to engage with your existing audience and to grow your following. To do so, you will need to: • Post quality content regularly, at least once a day – you can use funny (tasteful) memes, motivational quotes, informative articles, etc.

• Invite the people that engage with the content you share to like your page, respond to any comments that you receive on your page • Use engaging posts to increase engagement, such as contests, raffles, photo share requests, etc.

• Share blog posts that you write • Ask your friends, staff, and business partners to share your posts • Be active in local Facebook groups • - Start your own Facebook group

LEVERAGE FACEBOOK GROUPS TO GROW YOUR AUDIENCE: There are over 10M+ groups on Facebook, and over 1.4 billion people now use Facebook Groups every month (1). It is a good idea to start a Facebook group in addition to your Facebook Business page in order to grow your following and get more page likes. To grow your group, post valuable resources and information relevant to your target audience – and, every now and then, make announcements regarding your practice, new services that you are offering, or other updates. However, make sure that you are not using this group solely to promote your practice, or you will lose group members. What is great about groups, is that when you share a post in a group, all of your members get a notification that you have posted in the group. This way, your posts get seen by more people than the posts that you share on your Business page.

Aside from creating your own Facebook group, make sure that your page also joins as many relevant local groups as possible.

There are groups for everyone, and you need to find the ones that FLORIDA MD - JULY 2021 11

MARKETING YOUR PRACTICE will help you gain exposure to your target audience. For example, a pediatric practice can join groups for local moms, or a specialist can join groups related to a specific ailment that they treat at their clinic.

To summarize, a Facebook presence is important for any medical practice. By utilizing the steps outlined below, you will be on your way to growing your practice exposure and building up your credibility as an expert in your field.

If you would like to outsource your Social Media Marketing to a team of Marketing experts, Leading Marketing Solutions can help you bring these strategies to life and grow your audience and social presence for you. Visit www.lms-plus.com for more information.

References: 1. https://zephoria.com/top-15-valuable-facebook-statistics/ 2. https://blog.hootsuite.com/facebook-statistics/ 3. https://www.websitehostingrating.com/facebook-statistics/

Sonda Eunus is the CEO of Leading Marketing Solutions, a Marketing Agency working with Medical Practices and other Businesses to help them identify the best marketing strategies for their business, create a strong online presence, and automate their marketing processes for a better return on their Marketing budget. Learn more about Leading Marketing Solutions at www.lms-plus.com.

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12 FLORIDA MD - JULY 2021

PEDIATRICS

Brachial Plexus in Newborns By: Christopher Gegg, MD Q: WHAT IS A BRACHIAL PLEXUS INJURY?

guide management decisions.

A: Brachial plexus injuries affect the nerve network that provides feeling and muscle control in the shoulder, arm, forearm, hand and fingers.

The specialist may also order: • x-rays

• the birth is complicated by a breech delivery

• nerve conduction study and EMG to test nerve and muscle function

• the mother has a very long labor

• MRI

• the baby’s shoulders are too wide to fit through the birth canal

Q: HOW IS A BRACHIAL PLEXUS INJURY TREATED?

• babies greater than or equal to 8 lbs birth weight

A: Most babies with a brachial plexus injury regain both movement and feeling in the affected arm. In mild cases, this may happen without treatment. Other babies might need daily physical therapy.

In newborns, these injuries can happen if:

Q: WHAT ARE THE DIFFERENT KINDS OF BRACHIAL PLEXUS INJURIES?

A: There are different kinds of brachial plexus injuries. Depending on where the nerve damage is, the injuries sometimes are called neonatal brachial plexus palsy, brachial plexus birth palsy, or Erb’s palsy.

For a more severe injury, a child should be cared for by a team of specialists from: • neurology

Q: WHAT HAPPENS IN A BRACHIAL PLEXUS INJURY?

• neurosurgery

A: During childbirth, a brachial plexus injury can happen if the baby’s neck is stretched to one side.

• orthopedic surgery

The brachial plexus nerve network begins with nerve roots at the spinal cord in the neck and reaches to the armpit. Nerves branch out from there and continue down the arm to the forearm, hand, and fingers.

• occupational therapy

When a strong force increases the angle between the neck and shoulders, the brachial plexus nerves might stretch or tear. The injury may also pull the nerve roots of the brachial plexus from the spinal cord. Damaged nerves carry sensation poorly and make muscle movements weak or cause complete paralysis.

Q: WHAT ARE THE SIGNS AND SYMPTOMS OF A BRACHIAL PLEXUS INJURY?

A: Signs include: • full or partial lack of movement • a weakened grip • numbness • an odd position, internal rotated shoulder with lack of elbow flexion • drooping eye lid on the side of the injury Q: HOW COMMON IS A BRACHIAL PLEXUS INJURY IN NEWBORNS?

A: Neonatal brachial plexus injuries are a common type of birth injury (1 to 2 for every 1,000 births).

Q: HOW IS A BRACHIAL PLEXUS INJURY DIAGNOSED?

A: Because an infant’s motor control is generally coarse, it can be challenging to accurately assess the neurological status of a newborn’s upper extremities. Following a brachial plexus injury, subtle changes in the physical exam inform the prognosis and

• physical medicine and rehabilitation • physical therapy If pain, weakness or numbness continues, surgery can often help.

Surgical treatments include: • Nerve grafts. Autologous grafts, usually using the sural nerve (a sensory nerve to back of foot) or cadaveric nerve.

• Nerve transfer. Use of a healthy nerve or some of its fascicles to restore injured nerve pathways.

• Muscle transfer. Grafting of a muscle and its neurovascular bundle, usually from the patient’s thigh, to replace an atrophic muscle of the arm.

Q: WHAT ARE THE POST-SURGERY EXPECTATIONS AND RECOVERY PROCESS?

A: Initial benefits of a successful surgery are expected about eight months after the procedure. Improvement in your patient’s condition may continue for up to 18 months or more after surgery. Consistent physical and occupational therapy play a critical role in restoration of arm strength and dexterity.

Christopher Gegg, MD, is a fellowship-trained pediatric neurosurgeon at Nemours Children’s Health who specializes in treating a variety of neurological conditions, including brachial plexus, epilepsy/brain tumors, complex tethered spinal cords and spasticity.

Call (407) 650-7715 for more information. 

FLORIDA MD - JULY 2021 13

HEALTHCARE LAW

Understanding Exculpatory Clauses

By Julie A. Tyk, JD. An exculpatory clause purports to deny an injured party the right to recover damages from a person negligently causing his injury. Cain v. Banka, 932 So. 2d 575 (Fla. 5th DCA 2006).

They are disfavored in the law because they relieve one party of the obligation to use due care and shift the risk of injury to the party who is probably least equipped to take the necessary precautions to avoid injury and bear the risk of loss. Applegate v.

Cable Water Ski, L.C., 974 So. 2d 1112, 1114 (Fla. 5th DCA 2008). Such clauses are strictly construed against the party seeking to be relieved of liability. Sunny Isles Marina, Inc. v. Adulami, 706 So. 2d 920 (Fla. 3d DCA 1998). Thus, exculpatory clauses are enforceable, only where, and to the extent, that the intention to be relieved from liability is made clear and unequivocal. Tatman v. Space Coast Kennel Club, Inc., 27 So. 3d 108, 110 (Fla. 5th DCA 2009). The wording must be so clear and understandable that “an ordinary and knowledgeable person will know what he is contracting away.” Id. (quoting Gayon v. Bally’s Total Fitness Corp., 802 So. 2d 420 (Fla. 3d DCA 2001)).

The seminal Florida case on exculpatory clauses is the Florida Supreme Court case of Sanislo v. Give Kids The World, Inc., 157 So. 3d 256 (Fla. 2015). Give Kids the World, Inc. (“GKTW”) provided free vacations to seriously ill children and their families.

When applying for the vacation, the Sanislos executed a “wish request” form that contained a waiver of liability, also known as an exculpatory clause. When the parents arrived at the resort village they again signed a liability release form, also an exculpatory clause. The language of the exculpatory clause is reprinted below for reference: I/we hereby release Give Kids the World, Inc. and all of its agents, officers, directors, servants, and employees from any liability whatsoever in connection with the preparation, execution, and fulfillment of said wish, on behalf of ourselves, the above named wish child and all other participants.

The scope of this release shall include, but not be limited to, damages or losses or injuries encountered in connection with transportation, food, lodging, medical concerns (physical and emotional), entertainment, photographs and physical injury of any kind....

I/we further agree to hold harmless and to release Give Kids the World, Inc. from and against any and all claims and causes of action of every kind arising from any and all physical or emotional injuries and/or damages which may happen to me/us....

Sanislo at 258-259.

While participating in a horse-drawn wagon ride, a rear pneumatic lift designed to allow those in wheelchairs to participate failed, and Ms. Sanislo was injured. The Sanislos brought suit and GKTW filed a motion for summary judgment arguing that the signed releases precluded an action for negligence. The Sanislos filed a motion for partial summary judgment against GKTW’s affirmative defense of release. The trial court granted the Sanislo’s 14 FLORIDA MD - JULY 2021

motion and denied GKTW’s motion.

The jury found for the Sanislos and GKTW appealed. Id. The Fifth District reversed, finding the lower court erred in denying GKTW’s motion for summary judgment because the release signed by the Sanislos was unambiguous and did not contravene public policy. It ruled the exculpatory clause barred the negligence action despite the lack of a specific reference to “negligence” or “negligent acts” in the exculpatory clause.

The Fifth District reasoned that exculpatory clauses are effective if the wording of the exculpatory clause is clear and understandable so that an ordinary and knowledgeable person would know what he or she is contracting away, and that the court had previously rejected “‘the need for express language referring to release of the defendant for “negligence” or “negligent acts” in order to render a release effective to bar a negligence action.’ ” On the public policy argument, the Court said the relative bargaining power of the parties should not be considered because it was outside of the public utility or public function context and the Sanislos were not required to request a vacation with GKTW or go on the vacation. Id. In affirming the Fifth District’s decision, the Supreme Court wrote that the conflict for the Court’s resolution was “whether an exculpatory clause is ambiguous and thus ineffective to bar a negligence action due to the absence of express language releasing a party from its own negligence or negligent acts.” Id. at 260.

The Florida Supreme Court wrote: .... we are reluctant to hold that all exculpatory clauses that are devoid of the terms “negligence” or “negligent acts” are ineffective to bar a negligence action despite otherwise clear and unambiguous language indicating an intent to be relieved from liability in such circumstances. Application of such a bright-line and rigid rule would tend to not effectuate the intent of the parties and render such contracts otherwise meaningless.

Id. at 270.

The Court found that the GKTW liability release form released GKTW and all of its agents, officers, directors, servants and employees from “any liability whatsoever in connection with the preparation, execution and fulfillment of said wish…” The release then provided that the scope of the agreement included “damages or losses or injuries encountered in connection with transportation, food, lodging, medical concerns (physical and emotional), entertainment, photographs and physical injury of any kind . . . .” The Court found that the release clearly conveyed that GKTW would be released from any liability, including negligence, for damages, losses, or injuries due to transportation, food, lodging, entertainment and photographs. Id. The determination of whether an exculpatory clause is en-

HEALTHCARE LAW forceable will be determined by the Judge as the enforceability of a pre-injury release is a question of law. The enforceability therefore, will depend on the Judge assigned to the matter. Physicians should not assume that because a patient signed a liability release form the patient does not have a viable cause of action. Physicians should consult with an experienced attorney who can examine the facts of the case and help you determine the best path forward. The Health Care Practice Group at Pearson Doyle Mohre and Pastis, LLP is committed to assisting Clients in navigating and defending medical malpractice claims. For more information and assistance, please contact David Doyle and Julie Tyk at Pearson Doyle Mohre & Pastis, LLP.

Julie A. Tyk, JD, is a Partner with Pearson Doyle Mohre & Pastis, LLP. Julie concentrates her practice in medical practice defense litigation, insurance defense litigation and health care law. She has represented physicians, hospitals, ambulatory surgical centers, nurses and other health care providers across the state of Florida. She may be contacted by calling (407) 951-8523; jtyk@pdmplaw.com.. 

Check out our newly redesigned website at www.floridamd.com!

FLORIDA MD - JULY 2021 15

Healing Eczema: Beyond Skin Deep

By Joseph Cannizzaro, MD Oftentimes the children we treat in our practice suffer from asthma, allergies, eczema and other comorbid conditions, which create a persistent inflammatory state in the body. In these cases, we apply a synergistic mix of healing factors: nutrition with dietary modifications, supplements, enhanced detoxification, and medications when necessary. We determine food intolerances, look for nutritional deficiencies, and analyze chemical exposures.

Additionally, salt therapy has proven to be a safe and effective healing modality that helps clear eczema completely.

HOW DOES SALT THERAPY HELP HEAL ECZEMA? In January 2018, our pediatric center became the newest location for The Salt Room® in Central Florida. Salt therapy is performed in this special spa-like room with salt-coated walls and floor, called a halochamber. Pharmaceutical-grade salt is pulverized into microscopic particles and pushed into the room by a halogenerator.

Salt therapy involves lounging in this cozy room and passively breathing in the particles while listening to soothing music, reading, or just relaxing in a zero-gravity chair. Toys are provided so children can play with the salt in the room, much like sand at the beach.

The salt particles enter the lungs and nasal passages, accelerating mucus clearance and improving lung function while killing harmful bacteria and soothing the respiratory system. The antibacterial, anti-fungal, and anti-inflammatory properties of salt have been documented to help with symptoms of both respiratory and skin conditions.

HOW SALT THERAPY PROVIDES RELIEF FOR ECZEMA: • Fortifies the skin’s protective barrier • Stimulates microcirculation • Reduces inflammation, redness and irritation • Has anti-bacterial and anti-fungal effects • Reduces IgE levels • Helps normalize the skin’s pH balance • Promotes healthy tissue regeneration • Facilitates deeper penetration of skin care products • Increases skin elasticity • Cleans impacted follicles • Promotes gentle exfoliation (cell turnover) For those suffering from eczema, salt therapy works by activating multiple physiological processes in the body. On the outside of the body, the salt particles kill bacteria and fungi, reduce inflammation on the skin, and improve circulation on the skin surface. Salt calms the itchy rash and heals cracks, which restores 16 FLORIDA MD - JULY 2021

the skin’s barrier against infections and allergens. The skin and respiratory tract are cleansed of allergens like pollen, dust, or smoke. Salt therapy also reduces stress and strengthens the body’s defense system. Salt therapy is a clinically-proven, natural, safe, and beneficial method of treatment for every age group.

Taking a holistic approach to eczema—identifying the underlying cause(s), applying the appropriate integrative protocol, and incorporating salt therapy—has yielded successful outcomes for our patients. This “beyond the surface” approach to a skin condition has proven to shorten the journey to lasting relief—with a side effect of smiles.

Joseph Cannizzaro, MD has been practicing pediatrics in Central Florida for over 40 years and is the author of “Answers for the 4-A Epidemic: Healing for Kids with Autism, ADHD, Asthma and Allergies.” As a classicallytrained primary care physician who practices functional integrative medicine, Dr. Cannizzaro believes that integrative medicine can bring conventional and complementary healing modalities together, creating a highly personalized and high-touch healing environment. Call the Cannizzaro Integrative Pediatric Center at 321-2805867 for a meet and greet or to book a session at The Salt Room® Longwood. www.MyCIPC.com. 

Catching Multiple Sclerosis Early

By Amy Gutierrez, MD, FAAN Multiple sclerosis (MS) is a disease of the nervous system that affects the brain, optic nerves and spinal cord. Early signs of MS are varied and can be similar to other illnesses, however, those symptoms are important to know since early detection and treatment of MS can help delay the progression of MS. Nearly one million adults in the U.S. have been diagnosed with MS, and most are diagnosed between the ages of 20 and 50. In MS, the immune system becomes misdirected and attacks the fatty tissue around nerve cells in the central nervous system. Scar tissue form, making it difficult for the nerve cells to communicate between the brain and the rest of the body.

Why the immune system attacks the nerve cells is unknown.

Some evidence connects exposure to the Epstein Barr virus with an increased risk of MS, but some experts dispute this. Being of northern European descent puts Americans at higher risk, and women are more likely to develop MS than men. While the disease is chronic, it is usually mild in most case at the beginning.

However, some people may become unable to walk, have normal sensation and balance and it may affect memory as the disease progresses. Treatment with MS medications has repeatedly shown to stop this progression.

EARLY SIGNS OF MS Symptoms of MS can come and go, so particularly in the early stages, it’s easy to dismiss these signs or attribute them to other causes. MS symptoms usually begin and get worse over a 24- to 48-hour period.

They include: • Blurred vision • Double vision • Fatigue • Muscle weakness • Difficulty with coordination and balance • Numbness, prickling or tingling • Thinking and memory problems • Pain • Depression • Slurred speech • Dizziness • Problems with sexual, bowel and bladder function • Tremors • Paralysis • Partial or complete loss of vision in one eye (especially with pain) If you have any of these symptoms, see your doctor. Even if it’s

not MS, it is important to find out the underlying causes of your symptoms.

HOW IS MS DIAGNOSED AND TREATED? MS is best detected by a neurological examination and painless imaging studies of the brain and spinal cord using magnetic resonance testing (MRI). An ophthalmologist also can use a test called an optical coherence tomography (OCT) to determine if the optic nerve has been affected

by MS. In some cases, a lumbar puncture is needed to make the diagnosis of MS. Based on your symptoms, history, neurological exam and findings on the MRI, your doctor may make the diagnosis of MS. Although there is not currently a cure for MS, more than 25 different medications — ranging from injections to pills to intravenous infusions — are available to treat MS. Physical, occupational and speech therapy can help manage the disease symptoms. Even if you are newly diagnosed or have few symptoms, therapy along with nutrition, exercise and lifestyle changes can help you maintain your health.

The most important goal in MS treatment is to stop the disease from attacking your brain and spinal cord as these structures control everything in your body. By preventing new lesions from forming, we delay and potentially prevent future disability and people with MS can live normal lives.

To make an appointment, call (407) 352-5434 Amy Gutierrez, MD, FAAN, is a neurologist with the Orlando Health Neuroscience and Rehabilitation Institute Neurology Group. She is a Diplomat of the American Board of Psychiatry and Neurology, American Board of Electrodiagnostic Medicine, and American Board of Neuromuscular Medicine. She also is a fellow of the American Association of Neurological Surgeons and American Academy of Neurology.

In 2010 Dr. Gutierrez was a founding member of the ALS Multidisciplinary Clinic at LSU Health Science Center. She worked collaboratively with the Muscular Dystrophy Association and ALS Association providing care to patients and their families. In addition, she was involved in research with the North Eastern ALS Society and as a member of the ALS Clinic at the New Orleans VA Clinic.

Dr. Gutierrez has been the principal investigator for many research trials related to MS. She has more than 20 years of clinical experience with MS and has held leadership roles with the National Multiple Sclerosis Society. 

FLORIDA MD - JULY 2021 17

UCF Lake Nona Medical Center is the First Hospital in Central Florida to Offer Incisionless Brain Surgery as Advanced Treatment for Essential Tremor – Cutting-Edge Procedure Significantly Improves Quality of Life for Patients with Debilitating Tremor

By Staff Writer UCF Lake Nona Medical Center recently announced it is the first hospital in Central Florida to provide incisionless brain surgery to treat essential tremor and tremor-dominant Parkinson’s disease unable to be controlled with medication.

Essential tremor (ET) is a progressive, neurological disease characterized by tremor, most often of the hands or arms, which can make daily activities challenging. Nearly 10 million Americans are estimated to have ET, which is 10 times the number of people living with Parkinson’s disease. Tremors are the primary symptom that has the most severe impact on the daily activities of Parkinson’s patients, with about 10 percent of patients experiencing them.

Using focused ultrasound guided by magnetic resonance imaging (MRI), the innovative, scalpel-free therapy directs targeted sound wave energy deep into the brain, treating the tissue that causes a tremor. No surgical incision or anesthesia are required, and many patients experience immediate improvement with minimal complications reported.

“For patients who qualify, MRI-guided focused ultrasound provides an incisionless treatment option, performed on an outpatient basis with short recovery time and often immediate results,” said Dr. Nizam Razack, MD, JD, FAANS, FACS, neurosurgeon at UCF Lake Nona Medical Center. “Not only are we the first hospital in Central Florida to offer focused ultrasound for essential tremor, we’re also one of the very few centers nationally capable of providing the procedure. By expanding access to this treatment here in our region, we can help restore independence and provide relief for individuals suffering from debilitating and progressive tremors.”

The U.S. Food and Drug Administration (FDA) approved this procedure in 2016 as an alternative to deep brain stimulation (DBS), a more invasive form of treatment. MRI-guided focused ultrasound benefits include: • Substantial and nearly instant reduction in hand tremors • Reduced risk of infection, as the outpatient procedure is incisionless • Quicker recovery time with patients return18 FLORIDA MD - JULY 2021

ing to daily activities within days “When we opened UCF Lake Nona Medical Center in March, we made a commitment to the residents of Lake Nona and surrounding communities to not only increase access to excellent, patient-centered care in the region, but also to bring innovative technology, treatments and tools to Greater Orlando,” said Wendy Brandon, CEO of UCF Lake Nona Medical Center. “The launch of our incisionless brain surgery program demonstrates that commitment. We are proud to bring this revolutionary procedure to Central Florida and look forward to the tremendous impact it will have on improving the lives of our patients.”

For more information on Incisionless Brain Surgery – including the story of Jen Stratton, one of the first patients to receive this procedure – please visit cflakenonamedicalcenter.com/service/neurological-services. UCF Lake Nona Medical Center is a

partnership between UCF Academic Health and HCA Healthcare North Florida Division.

2021

EDITORIAL CALENDAR

Florida MD is a monthly medical/business digital magazine for physicians..

Florida MD is emailed directly to healthcare providers in Orange, Seminole, Flagler, Volusia, Osceola, Polk, Brevard, Lake and Indian River 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.

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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 –

Neurology / Neuroscience Advances in Rehabilitation

AUGUST –

Sports Medicine Robotic Surgery

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Cancer Dermatology

NOVEMBER – Urology Geriatric Medicine / Glaucoma DECEMBER – Pain Management Occupational Therapy

Please call 407.417.7400 for additional materials or information.

FLORIDA MD - JULY 2021 19

Connected care.

Superior outcomes.

HealthSouth Corporation and Encompass Home Health & Hospice have combined our post-acute strengths into Encompass Health. As part of a nationwide network, we are redefining expectations for how providers work together to create better patient experiences and deliver unparalleled outcomes. As a coordinated care team, we set the standard for the future of rehabilitation.

ENCOMPASSHEALTH.COM/ALTAMONTESPRINGSREHAB 18

Rehabilitation Hospital of Altamonte Springs